[A Case of Squamous Cell Carcinoma of the Lung from Gastrointestinal Perforation Due to Small Intestinal Metastasis].

An 80s male, with a medical history of hypertension, hyperuricemia, and atrial fibrillation, visited our emergency outpatient department with vomiting and diarrhea as the chief complaint in August 2017. The blood examination revealed a high level of inflammatory reaction. The plain abdominal CT revealed fluid retention contacting the small intestine and intraabdominal free gas. We diagnosed the case as a small intestinal perforation, following which we performed emergency surgery. The small intestine was perforated, and an abscess cavity was formed between the transverse mesocolon and mesentery proper. Thus, the abscess was removed, and about 30 cm of the small intestine, including the perforated site, was resected, followed by the reconstruction. The resected specimens revealed squamous cell carcinoma at the small intestinal perforated site. Lung squamous cell carcinoma was diagnosed by subsequent chest CT and immunostaining. We administered 3 courses of chemotherapy combined with carboplatin and albumin-bound paclitaxel. Although the effect was partially observed, interstitial pneumonia occurred, which was inferred to be drug-induced. The patient died in 195 days following the surgery. Herein, we reported a case of lung cancer, which was diagnosed on the detection of gastrointestinal perforation caused by a small intestinal metastasis.

[Two Cases of Laparoscopic Partial Resection of Stomach Using a Trans-Gastric Wall Approach for Submucosal Tumors].

We performed laparoscopic partial resection of the stomach with a trans-gastric wall approach for submucosal tumors. Case 1: A 67-year-old woman was referred to our hospital because of tarry stool. Upper gastrointestinal endoscopy revealed a well demarcated, round, 45mm intraluminal-type submucosal tumor with delle on the anterior wall of the gastric upper body. Case 2: An 86-year-old woman was referred to our hospital because of anemia. Upper gastrointestinal endoscopy revealed a well demarcated, round, 25mm intraluminal-type submucosal tumor on the posterior wall of the gastric upper body. Laparoscopic partial resection of the stomach with a trans-gastric wall approach was performed. The operation times were 58 minutes and 73 minutes, respectively, and blood loss was low in both cases. This operative procedure is safe and easy and allows for resection resected with a direct view for surgeons without endoscopists.

[Two Cases of Resectable Intra-Abdominal Desmoid Tumor after Laparoscopic Gastrectomy for Gastric Cancer].

Case 1: A 52-year-old man underwent laparoscopic total gastrectomy for gastric cancer. After 2 years, a follow-up computed tomography(CT)scan showed a large, solid 10 cm-sized mass in his left upper abdomen. Under the diagnosis of a suspected mesenchymal tumor, a tumor resection with a partial resection of the upper jejunum and transverse colon was performed. Case 2: A 61-year-old man underwent laparoscopic pylorus-preserving gastrectomy for gastric cancer. After 1.5 years, follow-up CT showed a tumor of 2 cm in diameter near the greater curvature side of the upper stomach. Under the diagnosis of a suspected gastrointestinal stromal tumor(GIST), a laparoscopic partial resection of the stomach was performed. Histologically, spindle-shaped cells without atypia and rich collagen fibers were observed, and the sample was positive for b-catenin by immunostaining in both cases; from this evidence, the patients were diagnosed with desmoid tumors. Desmoid tumors have invasive proliferation characteristics, and treatment requires consideration of the balance between securing a surgical margin and increasing surgical stress.

[Laparoscopic Lymphadenectomy without Gastrectomy for Lymph Nodes Recurrence after Endoscopic Submucosal Dissection (ESD)].

A case oflaparoscopic lymphadenectomy in a patient with lymph node recurrence after endoscopic submucosal dissection (ESD)is presented. A 77-year-old man underwent ESD for gastric cancer. After 2 years, the patient was referred to our hospital with the diagnosis of lymph node recurrence. We offered radical surgery, including gastrectomy and lymphadenectomy; however, this suggestion was denied by the patient because ofstrong anxiety for gastrectomy. As an alternative therapy, laparoscopic lymphadenectomy for the limited area of high recurrence, without gastrectomy, was performed. Postoperative course was uneventful. The patient was discharged on the 10th postoperative day and remains cancer-free over 2 years after the operation. Laparoscopic lymphadenectomy for high risk area of recurrence may be considered in frail elderly patients to avoid the high burden ofgastrectomy.

[A Case of Curatively Resected Goblet Cell Carcinoid of the Appendix Diagnosed via Intraoperative Frozen Sectional Examination].

A 52-year-old patient presented with epigastric pain.An enhanced CT scan showed a strongly enhanced appendix with abscess formation.Appendectomy was performed under the diagnosis of acute appendicitis with perityphlitic abscess.The stump of the appendix was white and hard, suggesting malignant transformation.Intraoperative frozen sectional examination indicated goblet cell carcinoid(GCC)of the appendix.Thereafter, we performed ileocecal resection with lymphadenectomy (D3).The final pathological diagnosis was GCC, pSS, pN1, Stage III a by the Japanese classification of colorectal carcinoma. Immunohistochemical examination was consistent with GCC including synaptophysin(+), chromogranin A(+), somatostatin receptor(SSTR)2(±), SSTR5(+), and cytokeratin 20(+).The patient received adjuvant chemotherapy and remains cancer-free over 5 years after the operation.

[Simultaneous Laparoscopic Resection of Gastric Cancer and Hepatocellular Carcinoma].

A report of simultaneous laparoscopic resection for a patient with synchronous gastric cancer and hepatocellular carcinoma (HCC)is presented.A 76-year-old man was referred to our hospital for gastric cancer located in the antrum.In the preoperative examination, enhanced CT and MRI revealed a liver tumor located at S2 that had high contrast enhancement in the arterial phase but that was not washed out in the delayed phase.An early HCC was suspected, and simultaneous laparoscopic distal gastrectomy and partial resection of the liver was performed.The postoperative course was uneventful, and the patient was discharged on the 14th postoperative day.Simultaneous laparoscopic resection of gastric cancer and HCC is possible with special attention to surgical procedures and port settings.

[A Case of Advanced Gastric Cancer with Extensive Lymph Node Metastases Treated by Capecitabine plus Cisplatin plus Trastuzumab Chemotherapy,Followed by Conversion Surgery].

An 82-year-old woman underwent upper gastrointestinal endoscopy to evaluate upper abdominal pain.A type 2 tumor (adenocarcinoma, por, HER2+)was found in the lesser curvature of the gastric antrum.Abdominal CT showed bulky lymph node metastases and pancreatic invasion of lymph node No.6 , resulting in a diagnosis of cT3N3M0, Stage III B.Radical resection was not possible by gastrectomy, and chemotherapy(capecitabine plus cisplatin plus trastuzumab)was administered. The primary lesion and lymph node showed significant regression on CT after the administration of 8 courses of chemotherapy, which also clarified the border between the lymph node and pancreas.At this stage, it was determined that radical resection was feasible; distal gastrectomy(Roux-en-Y reconstruction)and D2 dissection and cholecystectomy were performed.No cancer cells were found in the primary lesion on histopathology.The therapeutic effect of preoperative chemotherapy was assessed as Grade 3, pCR, and retained tumor was only found in lymph node No.5 . On follow-up observation, the patient is alive 11 months after surgery, with no evidence of recurrence without neoadjuvant chemotherapy.

NF-E2-related factor 2 promotes compensatory liver hypertrophy after portal vein branch ligation in mice.

UNLABELLED: Hepatectomy is a standard therapy that allows liver cancer patients to achieve long-term survival. Preceding hepatectomy, portal vein embolization (PVE) is frequently performed to increase the remnant liver size and reduce complications. Although the clinical importance of PVE is widely accepted, molecular mechanisms by which PVE leads to compensatory hypertrophy of nonembolized lobes remain elusive. We hypothesized that NF-E2-related factor 2 (Nrf2), a master regulator of cytoprotection, promotes compensatory liver hypertrophy after PVE. To address this hypothesis, we utilized three mouse lines and the portal vein branch ligation (PVBL) technique, which primarily induces the redistribution of the portal bloodstream in liver in a manner similar to PVE. PVBL was conducted in Kelch-like ECH-associated protein 1 (Keap1) conditional knockout (Keap1-CKO) mice in which Nrf2 is constitutively activated, along with Nrf2-deficient (Nrf2-KO) mice. We found that hypertrophy of nonligated lobes after PVBL was enhanced and limited in Keap1-CKO and Nrf2-KO mice, respectively, compared to wild-type mice. In Keap1-CKO mice, Nrf2 activity was increased, consistent with transient activation of the phosphoinositide 3-kinase/protein kinase B (PI3K/Akt) pathway, and reactive hepatocyte proliferation was significantly prolonged after PVBL. Importantly, Nrf2 activation by a chemical inducer was also effective for enhancement of hypertrophy after PVBL. CONCLUSION: Nrf2 supports compensatory liver hypertrophy after PVBL. This finding is particularly intriguing, because the primary effect of PVBL is limited to the alteration of bloodstream; this effect is much milder than changes resulting from hepatectomy, in which intrahepatic bloodstream and bile production cease. Our results suggest that premedication with an Nrf2 inducer may be a promising strategy to improve the outcome of PVE; this approach expands the indication of hepatectomy to patients with poorer liver function.

[A long term survival case of hilar cholangiocarcinoma with multiple metastases treated with chemotherapy and operation].

A 40-year-old woman presenting with hilar cholangiocarcinoma and multiple liver metastases was admitted to our hospital. Initially, she underwent an extended right hepatectomy, 1 segmentectomy, and partial resection of the liver. After adjuvant chemotherapy with gemcitabine (1,000 mg/m² days 1, 8, and 15, of a 28-day cycle), multiple liver metastases (1 lesion in S2 and 2 lesions in S4) were detected by computed tomography (CT). As a result of the impaired response to gemcitabine, the chemotherapy regimen was changed to include combined chemotherapy with gemcitabine (1,000 mg/m² days 1 and 8, of a 21-day cycle), and S-1 (120 mg/body/day days 1 through 14). After 5 courses of combined chemotherapy, the liver metastases reduced in size; subsequently, a left internal sectionectomy and radiofrequency ablation were performed. Thereafter, the patient continued to receive adjuvant chemotherapy with S-1 for an additional 3 years; she is alive, without recurrence, 5 years after the initial operation. We propose that aggressive surgery should be considered for patients presenting with chemotherapy-responsive cholangiocarcinoma with multiple metastases.

Solid pseudopapillary neoplasms of the pancreas: an 18-year experience at a single Japanese Institution.

PURPOSE: This study investigated the clinicopathological features and surgical management of solid pseudopapillary neoplasms at a single institution in Japan. METHODS: Seventeen patients (the largest series in Japan) those underwent surgery for pathologically confirmed solid pseudopapillary neoplasms were retrospectively reviewed. RESULTS: Sixteen patients were women and their mean age was 34.1 years. Most patients were asymptomatic (n = 11), and the average tumor diameter was 51.8 mm. The most common imaging characteristic was tumors of solid and cystic type (n = 10), which were most commonly located in the pancreatic body (n = 7). All patients underwent surgical exploration, i.e., distal pancreatectomies in 7 patients (laparoscopically performed in 2); middle pancreatectomies, 4; pancreaticoduodenectomies, 4; enucleation, 1; and liver resection, 1. No surgical mortalities occurred, and postsurgical complications occurred in 9 patients. Four patients had malignant tumors. One patient with liver metastases experienced recurrence, which was well controlled by paclitaxel. The remaining patients were disease free at a median follow-up of 51 months. CONCLUSIONS: Solid pseudopapillary neoplasms can be treated by complete tumor resection with limited resection or a minimally invasive approach when applicable. The combination of surgical resection and chemotherapy may therefore prolong survival, even in malignant cases.

Nm23/nucleoside diphosphate kinase-A as a potent prognostic marker in invasive pancreatic ductal carcinoma identified by proteomic analysis of laser micro-dissected formalin-fixed paraffin-embedded tissue.

BACKGROUND: Pancreatic cancer is among the most lethal malignancies worldwide. This study aimed to identify a novel prognostic biomarker, facilitating treatment selection, using mass spectrometry (MS)-based proteomic analysis with formalin-fixed paraffin-embedded (FFPE) tissue. RESULTS: The two groups with poor prognosis (n = 4) and with better prognosis (n = 4) had been carefully chosen among 96 resected cases of pancreatic cancer during 1998 to 2007 in Tohoku University Hospital. Although those 2 groups had adjusted background (UICC-Stage IIB, Grade2, R0, gemcitabine adjuvant), there was a significant difference in postoperative mean survival time (poor 21.0 months, better 58.1 months, P = 0.0067). Cancerous epithelial cells collected from FFPE tissue sections by laser micro-dissection (LMD) were processed for liquid chromatography-tandem mass spectrometry (LC-MS/MS). In total, 1099 unique proteins were identified and 6 proteins showed different expressions in the 2 groups by semi-quantitative comparison. Among these 6 proteins, we focused on Nm23/Nucleoside Diphosphate Kinase A (NDPK-A) and immunohistochemically confirmed its expression in the cohort of 96 cases. Kaplan-Meier analysis showed high Nm23/NDPK-A expression to correlate with significantly worse overall survival (P = 0.0103). Moreover, in the multivariate Cox regression model, Nm23/NDPK-A over-expression remained an independent predictor of poor survival with a hazard ratio of 1.97 (95% CI 1.16-3.56, P = 0.0110). CONCLUSIONS: We identified 6 candidate prognostic markers for postoperative pancreatic cancer using FFPE tissues and immunohistochemically demonstrated high Nm23/NDPK-A expression to be a useful prognostic marker for pancreatic cancer.