Concomitant pancreatic and duodenal metastases 12 years after nephrectomy for renal cell carcinoma: a case report.

In selected patients with metastatic renal cell carcinoma, metastasectomy can achieve prolonged survival. Herein we report a patient with concomitant pancreatic and duodenal metastases occurring 12 years after total right nephrectomy for a renal cell carcinoma. The metastases were successfully treated by a pancreas-sparing duodenectomy and distal pancreatectomy. A 66-year-old man was referred to our hospital with a chief complaint of right upper abdominal pain. He had undergone laparoscopic total right nephrectomy for renal cell carcinoma 12 years before. Enhanced computed tomography showed hypervascular tumors in the pancreatic body and the descending duodenum near the papilla of Vater. Histopathological examination of endoscopic ultrasonography-guided fine needle aspiration cytology specimens revealed metastatic clear cell renal cancer. The patient underwent pancreas-sparing duodenectomy and distal pancreatectomy. He developed a pancreatic fistula after surgery that improved with conservative treatment, and has been free of evidence of recurrence up to 20 months postoperatively.

Right paraduodenal hernia presenting with strangulated obstruction with intestinal malrotation: a case report.

A paraduodenal hernia is a rare cause of an internal hernia that may require massive bowel resection; prompt diagnosis and surgical treatment are essential. In cases of malrotation, strangulation may occur both inside and outside the hernial sac. Strangulation outside the hernial sac makes the preoperative diagnosis more difficult. Herein, we report a patient with a right paraduodenal hernia, intestinal malrotation, and strangulation outside the hernia. An 86-year-old woman was admitted to our hospital with abdominal pain. Enhanced computed tomography showed a closed-loop obstruction of the hypo-enhancing small bowel and absence of a horizontal duodenal leg. The patient underwent an emergency laparotomy and was diagnosed with strangulated bowel obstruction due to a right paraduodenal hernia and malrotation. The patient underwent resection of the ischemic ileum, closure of the hernial orifice, and repositioning of the intestine. The postoperative course was uneventful. The patient reported no abdominal discomfort after 7 months of follow-up.

An incarcerated internal hernia of the sigmoid colon through a defect in the broad ligament: A case report.

INTRODUCTION AND IMPORTANCE: Hernias through a defect of the broad ligament are rare, accounting for only 1.6-5% of internal herniations [1]. This report describes a rare case of sigmoid colon obstruction due to hernia through a defect of the broad ligament, which was diagnosed before surgery. CASE PRESENTATION: A 78-year-old multiparous woman presented with lower abdominal pain and nausea. Contrast-enhanced multi-detector CT (MDCT) demonstrated a dilated sigmoid colon and edematous mesentery of the sigmoid colon in the left Douglas' fossa, the uterus was compressed dorsally to the right and the left ovary was compressed ventrally. We diagnosed an internal broad ligament defect hernia with incarceration of the sigmoid colon, and performed emergency laparotomy. The necrotic sigmoid colon was resected and anastomosis was performed by the double stapling technique. The postoperative course was uneventful. CLINICAL DISCUSSION: We consider the treatment of hernia of sigmoid colon through a broad ligament defect. CONCLUSION: We recognize that there is a possibility that, in addition to the small intestine, proximally located organs may be incarcerated. In the case of the colon, we should choose the treatment method carefully according to whether or not the colon is expected to be necrotic.

Lobulated esophageal schwannoma resected with concurrent approach from the thorax and cervix.

BACKGROUND: Esophageal schwannomas are rare esophageal submucosal tumors. We herein report a case of a lobulated esophageal schwannoma resected with concurrent approach from the thorax and cervix. CASE PRESENTATION: A 74-year-old woman visited our hospital with complaint of loss of consciousness, and a lobulated mediastinal tumor was discovered by chance in computed tomography. Upper gastrointestinal endoscopy showed a smooth elevated lesion at a position of 23-28 cm from the incisor teeth. A hypermetabolic appearance was noted on positron emission tomography. Based on these data, a gastrointestinal stromal tumor was suspected. The tumor was enucleated at the thoracic cavity while being pushed from the cervical incision. Pathological examination showed an esophageal schwannoma. CONCLUSIONS: We experienced a case of lobulated esophageal schwannoma with fluorodeoxyglucose accumulation. We resected the tumor with concurrent approach from the thorax and cervix.

A case of carcinoma of the papilla of Vater in a young man after subtotal colectomy for familial adenomatous polyposis.

BACKGROUND: Carcinoma and adenoma of the duodenum, including the papilla of Vater, are problematic diseases in patients with familial adenomatous polyposis (FAP). CASE PRESENTATION: A 36-year-old man underwent a periodic medical examination for early colon cancer originating from FAP for which laparoscopic-assisted subtotal colectomy with a J-shaped ileal pouch-rectal anastomosis was performed 3 years earlier. A tumor was detected at the papilla of Vater along with elevation of total bilirubin and hepatobiliary enzymes. Although cytology did not determine the tumor to be an adenocarcinoma, we suspected adenocarcinoma due to its hypervascularity shown by contrast-enhanced computed tomography. Pylorus-preserving pancreaticoduodenectomy with modified Imanaga reconstruction and regional lymph node dissection (D2) was performed. The pathological study showed that the tumor was a papillary and moderately differentiated tubular adenocarcinoma. The patient is currently in good health without recurrence, weight loss, or severe diarrhea at 12 months after surgery. CONCLUSIONS: Awareness of biliary-pancreatic symptoms and periodic gastroduodenoscopy might contribute both to the early detection of duodenal or periampullary polyps and cancer and to the radical treatment of FAP. Modified Imanaga reconstruction has the potential to become one of the more effective procedures for providing good quality of life to FAP patients with duodenal or periampullary cancer.

Preoperative diagnosis of an asymptomatic cancer restricted to the cystic duct.

INTRODUCTION: Even now, cystic duct cancer (CDC) as defined by Farrar is rare and has a better prognosis than gallbladder cancer, although CDC as defined by Ozden et al., the definition of which could apply to early and advanced cases of CDC, is not rare and has a poorer prognosis than the CDC defined by Farrar. PRESENTATION OF CASE: A 78-year-old woman with no complaints was found to have a tumor restricted to the cystic duct. Three cytology examinations of the patient's bile could not establish that the tumor was an adenocarcinoma. However, adenocarcinoma was suspected due to the hypervascularity shown on contrast-enhanced computed tomography. Cholecystectomy and extrahepatic bile duct resection with D2 lymph node dissection was performed. The pathological study revealed it to be CDC. Her postoperative course has been uneventful and without recurrence for 21 months. DISCUSSION: At their first medical examination, many CDC patients are found to have such advanced spread of the cancer to adjacent organs that an extended operation might be necessary. As in our case, better patient outcome results when no lymph node or remote metastasis is present. CONCLUSION: Diagnosing CDC as early as possible contributes to curative resections and favorable patient outcomes and also allows surgeons to recommend a mini-invasive procedure to their patients rather than extended resection including that of adjacent organs.

Predictive value of orotate phosphoribosyltransferase in colorectal cancer patients receiving 5-FU-based chemotherapy.

Pretreatment knowledge of chemosensitivity and side-effects of chemotherapy for colorectal cancer (CRC) patients are likely to ensure the best chemotherapeutic outcome. The aim of this study was to identify additional predictive factors of chemosensitivity to the key CRC treatment drug 5-fluorouracil (5-FU). Surgically obtained specimens from 106 patients treated for CRC were immunohistochemically assessed to investigate the correlation between the protein expression of the 5-FU metabolic enzymes orotate phosphoribosyltransferase (OPRT), thymidylate synthase (TS) and dihydropyrimidine dehydrogenase (DPD), and clinicopathological characteristics as well as the correlation between the protein expression and outcomes of 5-FU-based chemotherapy. A correlation was detected between the high expression of the 5-FU metabolic enzyme OPRT and negative lymph node metastasis (P=0.0496), as well as between DPD and advanced Tumor-Node-Metastasis (TNM) grade cases (IIIA-IVB) and positive lymph node metastases (P=0.0414, respectively). In all 106 patients and in 79 patients undergoing 5-FU-based chemotherapy, survival was improved in those patients with a positive OPRT expression (P=0.0144 and 0.0167, respectively). OPRT expression was higher in the 79 patients with no recurrence (P=0.0179) as well as in patients treated with R0 surgery and 5-FU-based chemotherapy without side-effects (P=0.0126). Disease-free survival (DFS) rate was higher in patients without side-effects, and in patients with a positive OPRT expression without side-effects (P=0.0021 and 0.0031, respectively). Findings of this study demonstrated that OPRT expression positively correlated with fewer side-effects of 5-FU-based chemotherapy and longer patient survival.

Novel strategy with gemcitabine for advanced pancreatic cancer.

5-fluorouracil (5-FU) is widely used in chemotherapy for gastric and colorectal cancer, but gemcitabine (GEM), and not 5-FU, is approved as a standard drug for use in pancreatic cancer. Interindividual variation in the enzyme activity of the GEM metabolic pathway can affect the extent of GEM metabolism and the efficacy of GEM chemotherapy. Human equilibrative nucleoside transporter 1 (hENT1) is recognized as a major transporter of GEM into cells. In addition, a factor that activates hENT1 is the inhibition of thymidylate synthase (TS), one of the 5-FU metabolic enzymes; TS inhibition mediates depleting intracellular nucleotide pools, resulting in the activation of the salvage pathway mediated through hENT1. In this paper, the role of 5-FU in GEM-based chemotherapy for pancreatic cancer is discussed with special emphasis on enzymes involved in the 5-FU and GEM metabolic pathways and in the correlation between GEM responsiveness and the expression of 5-FU and GEM metabolic enzymes.

A case of esophageal adenocarcinoma arising from the ectopic gastric mucosa in the thoracic esophagus.

A 75-year old man was detected with a pediculate tumor in the upper esophagus. A biopsy determined that it was an adenocarcinoma. A subtotal esophagectomy with dissection of three-fields of lymph nodes was selected. The pathological study revealed it to be an esophageal adenocarcinoma arising from ectopic gastric mucosa of the fundus of the stomach. His post-operative course was uneventful and without sign of recurrence for 3.5 years.

Contribution of thymidylate synthase to gemcitabine therapy for advanced pancreatic cancer.

OBJECTIVES: Thymidylate synthase (TS) inhibitors activate human equilibrative nucleoside transporter 1. We evaluated the contribution of TS expression to determine a treatment method providing an effect from gemcitabine (GEM). METHODS: The expression of 5-fluorouracil (5-FU) and GEM metabolic factors (5-FU: TS, dihydropyrimidine dehydrogenase, orotate phosphoribosyltransferase; GEM: human equilibrative nucleoside transporter 1, deoxycytidine kinase, cytidine deaminase, 5'-nucleotidase) were studied in 7 pancreatic cancer cell lines by Western blotting, and drug resistance was evaluated by 3-[4,5-dimethylthiazol]-2,5-dephenyl tetrazolium bromide assay. The expression of 5-FU factors was observed immunohistochemically in resected pancreatic cancer specimens. RESULTS: Gemcitabine concentrations that inhibited colony formation by 50% correlated with TS protein expression (P = 0.0169). With a 5-FU non-growth-inhibiting dose, GEM concentrations that inhibited colony formation by 50% were significantly reduced by one fourth to one tenth. Knockout of TS expression by small interfering RNA decreased resistance to GEM in the cell lines (P = 0.0019). Immunohistochemically, TS expression related to disease-free survival time of patients treated with GEM (P = 0.0224). A high expression of 5-FU factors was detected: orotate phosphoribosyltransferase: differentiated cases (P = 0.0137), lower T factor (P = 0.0411); dihydropyrimidine dehydrogenase: nerve invasion (P = 0.0188), lymph node recurrence (P = 0.0253); TS, positive N factor (P = 0.0061). CONCLUSIONS: The expression of TS provides an alternative source of substrate for DNA synthesis and positively correlates with GEM resistance and shortened patient survival.

Clinical significance of aggressive hepatectomy for colorectal liver metastasis, evaluated from the HGF/c-Met pathway.

Liver metastasis is one of the most critical factors in deciding the prognosis of patients with colorectal cancer (CRC). Hepatectomy is the most curative treatment for liver metastasis of CRC. The high amount of hepatocyte growth factor (HGF) is produced to promote liver regeneration by hepatectomy. Theoretically, HGF produced after hepatectomy stimulates the progression of CRC cells with c-Met in residual liver. This study was aimed to evaluate the value of hepatectomy towards liver metastasis of CRC in relation to the HGF/c-Met pathway. Ninety-four patients with CRC (including 24 liver metastasis cases) were operated at Gifu University Hospital (2002-2004). For these cases, the expression of c-Met in the primary and liver metastatic sites was evaluated by immunohistochemistry and Western blot. Experiments were also conducted on CT26 murine CRC cell line and a mouse liver metastasis model. In clinical study, the c-Met expression in liver metastatic sites was lower than in the primary sites in 87% of 24 cases. In basic study, the expression of c-Met protein in the liver tumor was significantly lower than in culture cells according to Western blot (p=0.033). The growth of residual liver tumors was not significantly different between 30% hepatectomy group and no operation group. The over-expression of c-Met was closely associated with CRC liver metastases. On the other hand, in liver metastatic lesions, the c-Met expression was reduced in comparison to primary lesions. Therefore, even if serum HGF levels increased due to liver resection during the regeneration period, residual liver metastases of CRC was not promoted in its progression. Aggressive hepatectomy would still be acceptable and favorable as a curative therapy.

Effect of hepatocyte growth factor on progression of liver metastasis in colorectal cancer.

BACKGROUND/AIMS: Colorectal cancer (CRC) is one of the most common cancers worldwide, and a strategy to assess and control liver metastasis will be critical to control patient prognosis. To evaluate therapeutic approaches, the biological responses associated with hepatectomy were studied with a focus on hepatocyte growth factor (HGF). METHODOLOGY: In 54 patients with metastatic liver tumors due to CRC, c-Met expression was estimated by western blotting from resected tissue specimens. Serum HGF levels were measured by an ELISA method and compared with other liver function serum factors. RESULTS: The preoperative serum level of HGF was found to be related to ICGR15, ALP, CHE and AST, but after hepatectomy, the change was not correlated with other liver function factors. From an evaluation of pre-operative liver condition using ICGR15, an increasing rate (post/pre) of AST, ALT, ALP and HGF was observed to be higher in cases with positive outcomes. In cases with normal pre-operative levels of serum HGF, the increasing rate (post/pre) of HGF after surgery was higher than in cases with abnormally high pre operative values (3.07 +/- 0.87 and 2.38 +/- 0.74, respectively; p = 0.0102). In cases where tumors recurred within 6 months (early recurrence cases), the c-Met value in tumor tissue was higher than in cases with no recurrence, even in cases where there was no tendency for an increasing rate of HGF. In addition, multiplying data serum HGF increasing rate by c-Met value in tissue was significantly higher in early recurrence cases than in cases with no recurrence, (3.96 +/- 0.62 and 3.00 +/- 1.16 respectively; p = 0.0135). A similar finding was also detected following curative operations involving multiple tumor resection (3.93 +/- 0.64 vs. 2.84 +/- 1.24 for early and no recurrence, respectively; p = 0.0147). CONCLUSION: The present study demonstrated that cancer with high c-Met expression and under high level of its ligand, HGF, led to recurrence soon after hepatectomy, leading to unfavorable patient prognosis. If pathological or biochemical factors from resected specimens could help identify patients with a high risk of relapse, innovative adjuvant chemotherapy protocols could be initiated.

Extracellular signal-regulated kinase phosphorylation due to menadione-induced arylation mediates growth inhibition of pancreas cancer cells.

BACKGROUND: Cytotoxicity of Vitamin K3 (VK3) is indicated to have the same mechanism with oxidative stress (H(2)O(2)). In the present study, we analyzed the differences and/or similarities in the cellular responses to oxidative stress and VK3 to clarify the mechanism of growth inhibition. METHODS: Cell viability was determined by a test method with 3-[4, 5-dimethyl-thiazol]-2, 5-dephenyl tetrazolium bromide (MTT). Expressions of cellular proteins were evaluated by Western blot analysis. RESULTS: The IC50 was calculated to be 47.3 +/- 4.1 microM for VK3 and 2.2 +/- 1.2 microM for H(2)O(2). By Western blot analysis, VK3 or H(2)O(2) was shown to induce rapid phosphorylation of extracellular signal-regulated kinase (ERK), and c-Jun N-terminal kinases (JNKs). H(2)O(2)-induced phosphorylation of ERK and JNK was almost complete inhibited by more than 100-muM genistein. VK3-induced JNK phosphorylation was blocked by 100-microM genistein, but ERK phosphorylation was not inhibited completely even if 400-microM genistein was used. H(2)O(2)-induced inhibition of cell proliferation was completely blocked by 400-microM genistein, but the VK3 effect was reduced 72.8 +/- 5.4% by the same concentration of genistein. H(2)O(2)-induced JNK phosphorylation and ERK phosphorylation were inhibited by staurosporine, protein kinase C (PKC) inhibitor. VK3-induced JNK phosphorylation was also blocked, but ERK phosphorylation was not affected. Staurosporine had no effect on VK3- or H(2)O(2)-induced growth inhibition. Treatment with a non-thiol antioxidant agent, catalase, completely abrogated H(2)O(2)-induced JNK and ERK phosphorylation, but a thiol antioxidant, L: -cystein, had no effect on phosphorylation of them. The VK3-induced JNK phosphorylation was inhibited by catalase, but not L: -cystein. But ERK phosphorylation was not inhibited by catalase and was abrogated completely by the thiol antioxidant. Catalase, but not L: -cystein, blocked H(2)O(2)-induced growth inhibition, and L: -cystein, but not catalase, blocked VK3-induced effects on cell proliferation completely. CONCLUSION: VK3-induced ERK phosphorylation occurs by a different mechanism from oxidative stress, and it might have an important role to induce growth inhibition.