[A Resectable Case of Highly Locally Advanced Cecal Cancer in an Elderly Patient after Bypass Surgery and Chemotherapy].

An 83-year-old woman underwent an examination for right lower abdominal pain and was diagnosed with highly advanced cecal cancer. CT showed no metastasis; thus, we attempted resection or bypass surgery. While no liver metastasis or peritoneal dissemination was observed intraoperatively, the circumflex region was highly infiltrated to the peritoneum and retroperitoneum. Considering the patient's age, resection was deemed overly invasive, so an ileum and transverse colon bypass surgery was performed. To downsize and safely remove the primary lesion, capecitabine plus bevacizumab was started. A CT examination performed after 3 courses revealed that the tumor had decreased in size. After the 4th course, surgery was performed. Intraoperative findings showed no obvious peritoneal dissemination, the tumor size was reduced, and the tumor was movable. A laparoscopic right hemicolectomy plus D3 dissection was performed. She was discharged on postoperative day 5. No obvious recurrence has been observed 6 months after surgery.

[Efficacy of Laparoscopic Gastrojejunal Bypass for Unresectable Gastric Cancer with Pyloric Stenosis].

In general, gastrojejunal bypass is performed for unresectable gastric cancers with stenosis. It enables patients to take food and be discharged from the hospital earlier. Previously, we used to primarily perform open gastrojejunal bypass; however, recently, we perform laparoscopic gastrojejunal bypass because it is minimally invasive. We evaluated 31 patients who underwent gastrojejunal bypass for unresectable gastric cancer in our department between December 2009 and December 2019. We retrospectively compared the laparoscopic surgery group(n=7)with the open surgery group(n=24). No significant difference in patient background was found between the study groups. Compared to patients in the open surgery group, those in the laparoscopic group had significantly shorter postoperative hospital stay and time until initiation of oral intake, relatively lesser blood loss, and no postoperative complications. Moreover, more patients in the laparoscopic group than in the open surgery group were administered postoperative chemotherapy. Further, postoperative chemotherapy was administered sooner in the laparoscopic group than in the open surgery group. Laparoscopic gastrojejunal bypass is a safe and less invasive treatment for unresectable gastric cancer with stenosis. It may be superior to the conventional open surgery with regard to early postoperative chemotherapy for cancer.

[Successful Treatment with Nab-Paclitaxel for Stage â £ Gastric Cancer in an Elderly Patient on Hemodialysis].

An 84-year-old man on hemodialysis was referred to our department for an advanced gastric cancer with pyloric stenosis. Pre-operative CT showed thickening of the stomach wall at the primary lesion and regional lymph node metastasis, while no clear peritoneal metastasis was found. However, we found peritoneal disseminations during the operation, so gastrojejunal bypass was performed. After the operation, he hoped chemotherapy despite risk factors such as renal failure and old age. We introduced a reduced dose of weekly nab-paclitaxel to him. After 3 courses, CT showed the primary lesion had decreased in size, and after 6 courses, serum CA19-9 level decreased to 61.8 U/mL from 2,343 U/mL at the before treatment. No serious adverse events were observed during the chemotherapy. However, after 8 courses, the tumor markers was gradually re-increased, and CT showed the primary tumor re-increased after 9 courses. Therefore, he received irinotecan alone as the second-line. He is still alive 1 year and 8 months after diagnosis of gastric cancer. It is generally said that the risk of cancer chemotherapy for dialysis patients and the elderly is high. However, we suggest that it could be safely performed by examining the appropriate drug and dose. Weekly nab-paclitaxel regimen could be one of the promising options for these patients.

Docetaxel, cyclophosphamide, and trastuzumab as neoadjuvant chemotherapy for HER2-positive primary breast cancer.

BACKGROUND: The standard primary systemic therapy for human epidermal growth factor receptor 2-positive (HER2+) breast cancer is anthracyclines and/or taxanes combined with trastuzumab, which demonstrates a high pathological complete response (pCR). A pCR is a predictive marker of prognosis. However, results slightly differ, depending on the hormone receptor status. The efficacy and tolerability of docetaxel, cyclophosphamide, and trastuzumab (HER-TC) as neoadjuvant chemotherapy (NAC) remain unclear. We performed a prospective multicenter study of HER-TC NAC for HER2+ primary breast cancer. METHODS: Eligible patients had a clinical diagnosis of HER2+ invasive breast cancer greater than 1 cm but less than 7 cm and a tumor stage of N0 or N1. T hey were diagnosed between July 2011 and February 2014. For NAC, four cycles of HER-TC (6 mg/kg loading dose, 8 mg/kg, 75, and 600 mg/m2) were administered intravenously every 3 weeks. We investigated the pCR of the primary breast tumors. A pCR was defined as no histological evidence of invasive carcinoma or the appearance of only ductal carcinoma in situ. RESULTS: We enrolled 42 patients. The completion rate for four cycles of HER-TC was 97.6 % (41/42 patients). The overall pCR rate was 43.9 % (18/41 patients). The pCR rate for patients with the luminal HER2 subtype [estrogen receptor (ER)-positive+, HER2+] and the HER2-enriched subtype (ER-, HER2+) was 40.0 % (8/20 patients) and 47.6 % (10/21 patients), respectively. A pCR was achieved with nearly the same probability for each subtype. CONCLUSIONS: Four cycles of HER-TC may be a NAC option for HER2-positive breast cancer.

[A Case of Synchronous Multiple Liver Metastases from Ascending Colon Cancer Showing Pathological Complete Response to CapeOX Treatment].

The patient was a 30-year-old man who underwent a medical examination for shortness of breath.An abdominal computed tomography(CT)scan revealed advanced ascending colon cancer with multiple metastases to the liver.We performed a laparoscopic right hemicolectomy first, due to the obstruction.Postoperatively, the patient received capecitabine plus oxaliplatin( CapeOX)chemotherapy.After 10 courses of CapeOX, the multiple liver metastases had reduced remarkably in size. Colectomy of the anastomosis and partial hepatectomy were then performed.Histological examination of the resected tissue revealed no residual cancer cells, suggestive of a pathological complete response.

Docetaxel and cyclophosphamide as neoadjuvant chemotherapy in HER2-negative primary breast cancer.

BACKGROUND: Docetaxel plus cyclophosphamide (TC) has recently been established as a standard adjuvant chemotherapy regimen for HER2-negative (HER2-) operable breast cancer. However, the efficacy and tolerability of TC as neoadjuvant chemotherapy (NAC) remain unclear. We, therefore, conducted a prospective study to evaluate the efficacy of TC NAC in HER2- primary breast cancer. METHODS: Patients who were diagnosed with HER2-, N0-N1, invasive breast cancer between July 2011 and February 2014 and had tumors measuring 1-7 cm were eligible. The subtypes were classified using a core-needle or vacuum-assisted breast biopsy. The efficacy and safety of NAC comprising TC (75 mg/m2 docetaxel and 600 mg/m2 cyclophosphamide, four cycles every 3 weeks) were investigated in a prospective study in patients with HER2- breast cancer. RESULTS: Fifty-two patients were enrolled. Of these, 94.2 % (49/52) completed four cycles of TC. The overall pCR rate was 16.3 % (8/49). The pCR rates for patients with luminal A-like breast cancer [estrogen receptor-positive (ER+), Ki67 index of <20 %, and HER2-], luminal B-like breast cancer (ER+, Ki67 index of >20 %, and HER2-), and triple-negative breast cancer [ER-negative (ER-) and HER2-] were 0 % (0/12), 4.3 % (1/23), and 50.0 % (7/14), respectively. Almost all pCRs occurred in triple-negative breast cancer patients. CONCLUSIONS: The pCR rate of TC NAC was not very high despite the high completion rate. TC NAC was effective against the triple-negative subtype, resulting in a higher pCR rate. Therefore, our results indicated that TC NAC showed limited efficacy in luminal subtype breast cancer with the exception of the triple-negative subtype.

Giant cell arteritis of the breast: a case report with a review of literatures.

Although giant cell arteritis (GCA), clinically designated as temporal arteritis, is recognized as a systemic disease, the breast may be the primary organ in which it is manifested. GCA of the breast is a rare disease that mainly occurs in postmenoposal elderly women. It manifests as nodules or pain in the breast, with or without tenderness, and is associated with significant constitutional symptoms that resemble those of polymyalgia rheumatica (PMR). These symptoms can be treated with or without prednisone therapy and can improve without the development of organ dysfunction. The clinical manifestations can often be recognized only by retrospective analysis after excisional biopsy. GCA of the breast occasionally mimics carcinoma, and its initial manifestations may be similar to those of other forms of vasculitis involving the breast, such as polyarteritis nodosa and Wegener granulomatosis. Biopsy is indispensable for establishing a definitive diagnosis. Thus far, the findings of imaging procedures, such as mammography and ultrasonography, for patients with mammary GCA have not been reported in detail, and no distinctive findings associated with this condition have been identified. Considering this and the fact that spontaneous remission may occur in some cases, mammary GCA probably often goes undiagnosed or may be misdiagnosed as an ordinary mammary disease. GCA of the breast should be considered as a potential diagnosis in the case of elderly women presenting with PMR-like symptoms and tenderness, lumps, or pain in the breast. We report a case of GCA affecting the breast and review previous reports on this condition in an attempt to summarize the features that distinguish this disease from other vascular diseases of the breast.

Clinicopathological evaluation of renal allograft treated with anti-CD25 monoclonal antibody.

Twenty-seven living-donor kidney recipients were treated with the antibody against CD25 as the induction immunosuppressive agent. They did not develop acute rejection within 1 month after transplantation, and mean serum creatinine level at 1 month was 1.0 +/- 0.4 mg/dL. There were no findings of acute rejection or drug-induced nephrotoxicity in protocol biopsies at 1 month following transplantation. After 1 month had passed, acute rejection occurred in three cases. The pathological grade of acute rejection varied from borderline to grade III by Banff classification. The careful inspection is necessary to find out the occurrences of acute rejection more than 2 months after transplantation because immunological situation has been changing around this period.

Management and outcome of living kidney grafts with multiple arteries.

PURPOSE: Kidney allografts with multiple renal arteries (MRAs) have been used with increasing frequency since the advent of laparoscopic live donor nephrectomy. To determine if MRA grafts affect the short- and long-term outcomes of grafts and patients, we analyzed 340 grafts procured by open nephrectomy. METHODS: We divided the graft recipients into five groups according to the methods used for vascular reconstruction. We compared patient and graft survival, serum creatinine levels, total (rewarm) ischemic times (TIT), incidence of acute tubular necrosis (ATN), need for antihypertensive drugs, incidence of acute rejection episodes, and vascular and urologic complications, between the MRA group and a control group of patients with single-artery renal grafts. RESULTS: In patients who underwent multiple anastomoses in situ, prolonged TIT resulted in an increased incidence of ATN, but there was no significant difference between the MRA groups and the control group (P = 0.45). The incidence of vascular complications was higher in the MRA groups (P < 0.01), but there were no significant differences in the other variables among the groups. CONCLUSION: Multiple renal artery grafts procured by open nephrectomy can be transplanted as successfully as those with single arteries, by using meticulous suturing techniques.

Expression of cyclooxygenase-1 and -2 in human breast cancer.

PURPOSE: We investigated the expression of cyclooxygenase (Cox-1 and Cox-2) in mammary tissues from patients with breast cancer. METHODS: We used reverse transcriptase-polymerase chain reaction (RT-PCR) and immunohistochemistry. RESULTS: The cancer cells showed very weak expression of Cox-1, but strong expression of immunoreactive Cox-2. In contrast, immunoreactive Cox-2 was very weak in all of the benign mammary tumors examined, including fibroadenoma (FA) and mastopathy (MP). Immunoreactive Cox-1 was also very weak in these benign tumors. The extent and intensity of immunoreactive Cox-2 polypeptides was significantly greater in the cancer cells than in the FA cells or MP cells. RT-PCR analysis showed enhanced expression of Cox-2, but not Cox-1 in breast cancer tissue, and faint expression of Cox-2 in benign tissue. CONCLUSIONS: These results demonstrated that human breast cancer cells generated Cox-2, indicating that Cox-2 might play an important role in the proliferation of breast cancer cells.

Tissue factor antisense oligonucleotides prevent renal ischemia-reperfusion injury.

BACKGROUND: Tissue factor (TF) expression is induced on macrophages and endothelial cells during the immune response. We designed an antisense (AS) phosphorothioate oligodeoxynucleotide (ODN) to specifically inhibit the expression of rat TF to study the effects of the AS ODN on renal ischemia-reperfusion injury in the rat. METHOD: AS-1 ODN for TF was delivered intravenously to inhibit the expression of TF in endothelial cells. After 8 hr, the right kidney was harvested and the left renal artery and vein were clamped. The kidney was reperfused after 90 min of ischemia, and rats were killed at 0, 1.5, 5, 12, and 24 hr after reperfusion. TF expression was analyzed by immunohistochemical staining using monoclonal antibody. RESULTS: In the untreated ischemic group, 0 of 20 rats survived beyond day 3. However, treatment with AS-1/TF led to 12 of 20 rats surviving beyond day 4. TF was detected on distal tubular epithelial cells, endothelial cells, and blood vessels but not on necrotic and proximal tubular epithelial cells. The necrotic area extended and encompassed nearly all of the ischemic kidney within 12 hr after reperfusion. The necrotic area and the grade of TF staining were more significantly reduced in the AS-1/TF-treated group than in the control group. Furthermore, fluorescein isothiocyanate-labeled AS-1/TF was significantly intense in tubular epithelial cells 8 hr after intravenous administration. CONCLUSIONS: The results indicate that AS-1/TF inhibited the ischemia-reperfusion injury of the kidney. Microcirculatory incompetence resulting from microthrombus may cause the formation and development of necrosis.

Clinicopathological evaluation of renal allografts of four patients by 20-year protocol biopsies.

Twenty-year protocol biopsies were performed in four cases of renal transplant recipients with grafts that had survived 20 years or more. All four recipients received transplants from their parents, and never had episodes of acute rejection. They were maintained with the conventional immunosuppressive protocol including azathioprine, mizoribine, and prednisolone. Three of them had past history of malignant diseases such as breast cancer and tongue cancer. In spite of fair graft function, the microscopic findings of 20-year protocol biopsy showed various degrees of histological damage; e.g. obsolescence of the glomeruli, glomerulosclerosis, arteriole wall thickening, interstitial fibrosis and tubular atrophy. Although two of the four grafts were functioning with low serum creatinine levels (1.3-1.4 mg dL-1) at 24 years and 26 years following transplantation, respectively, the function of the other two grafts had decreased more than 20 years after transplantation. In the two grafts with decreased function, glomerulosclerosis and arteriole wall thickening tended to be more severe (Banff classification of chronic allograft nephropathy [CAN] grade II and III) at the 20-year protocol biopsy compared with the two well-functioning grafts (CAN grade I and II). We conclude that the protocol biopsies even at 20 years can contribute to predict the fate of renal allografts.

Pulmonary embolism in a living-related kidney transplantation donor.

Living-related renal transplantation is the optimal therapy for patients with end-stage renal disease (ESRD). Normally, complications are rare in living-related donor nephrectomy. However, we experienced a case of pulmonary embolism (PE). The incidence of PE in living donor nephrectomy is rare, but the total incidence of PE in surgical operations has recently increased. The patient in the case reported here was diagnosed relatively early and recovered with appropriate treatment. It is very important for surgeons to realize that serious complications such as PE can develop in any case of living donor nephrectomy.

Antisense oligonucleotide for tissue factor inhibits hepatic ischemic reperfusion injury.

Tissue factor (TF) is an initiation factor for blood coagulation and its expression is induced on endothelial cells during inflammatory or immune responses. We designed an antisense oligodeoxynucleotide (AS-1/TF) for rat TF and studied its effect on hepatic ischemic reperfusion injury. AS-1/TF was delivered intravenously to Lewis rats. After 10 h, hepatic artery and portal vein were partially clamped. Livers were reperfused after 180 min and harvested. TF expression was studied using immunohistochemical staining. One of 10 rats survived in a 5-day survival rate and TF was strongly stained on endothelial cells in non-treatment group. However, by treatment with AS-1/TF, six of seven survived and TF staining was significantly reduced. Furthermore, we observed that fluorescein-labeled AS-1/TF was absorbed into endothelial cells. These results suggest that AS-1/TF can strongly suppress the expression of TF and thereby inhibit ischemic reperfusion injury to the rat liver.

The role of tissue factor in renal ischemic reperfusion injury of the rat.

BACKGROUND: Tissue factor (TF) is a membrane-bound glycoprotein that is the primary cellular initiator of the blood clotting cascade and its expression is induced on macrophages and endothelial cells during the inflammatory or immune response. Tissue factor pathway inhibitor (TFPI) regulates the extrinsic pathway of blood coagulation through its ability to inhibit tissue factor activity. We studied the role of TF in the kidney following warm ischemic reperfusion and studied the effect of TFPI in vivo. MATERIALS AND METHODS: After laparotomy of Lewis rats, the right kidney was harvested and left renal artery and vein were clamped. The kidney was reperfused after 60, 120, and 180 min of ischemia. Rats were sacrificed at 0, 1.5, 5, 12, and 24 h after reperfusion with or without TFPI treatment, and the kidney was harvested. Blood samples were collected at 0, 5, 12, and 24 h after reperfusion from the abdominal aorta. Blood urea nitrogen and kalium were monitored. TF expression was also studied by immunohistochemical staining with a monoclonal antibody (HTF-K108). RESULTS: Histologically, the necroses of the tubular epithelial cells were observed 1.5 h after reperfusion. Immunohistochemically, TF staining was positive on the glomerular endothelial cells and stimulated monocytes but negative on the tubular epithelial cells. The necrotic area extended and encompassed almost all of the ischemic kidney by 12 h after reperfusion. TF was stained on the glomerular base membrane, the glomerular endothelial cells, and the stimulated monocytes but was not evident on the necrotic tubular epithelial cells. Fibrinogen was also observed in the glomerular endothelial cells at 5-12 h after reperfusion, while it was slight in normal tissue. With TFPI treatment, the necrotic area was narrow and TF was slightly stained on the endothelial cells. CONCLUSIONS: These results suggest that TF plays an important role in the development of renal injury after ischemia and reperfusion. The microcirculatory incompetence due to microthrombus might cause the formation and development of the necrosis. These results also suggest that TFPI plays a key role in modulating tissue factor-dependent blood coagulation, therefore TFPI is a strong medication for prevention of ischemic reperfusion injury.