[A Case of Stage â £ Cholangiocarcinoma with an Improved Quality of Life after Resection of a Symptomatic Giant Ovarian Teratoma].

An 82‒year‒old female presented to our hospital with abdominal fullness and loss of appetite. Abdominal computed tomography revealed a cholangiocarcinoma(Stage Ⅳ)with liver metastases and multiple lymph node metastases. In addition, we found a left ovarian teratoma(approximately 33 cm in diameter)occupying most of the abdominal cavity. She did not want an aggressive treatment for cholangiocarcinoma, but hoped to receive the best supportive care. She was treated with a fentanyl patch, although there was no symptomatic improvement. We explained that resection of the giant ovarian tumor may improve the symptoms. As a result, she accepted the surgery. The laparotomy was performed, and a left ovarian tumor(approximately 10,600 g in weight)was resected. Operation time was 2 hours and 35 minutes, and the amount of blood loss was small. No postoperative complications were observed. She started oral intake at POD 2. The abdominal symptom was relieved by the surgery, and she was discharged to her own home on POD 12. She was readmitted on POD 46 for general malaise, and died of advanced cholangiocarcinoma on POD 66. It was suggested that the QOL may be improved by resecting symptomatic benign tumors even in terminal cancer patients.

Management of an obstructed recurrent inguinal hernia using a hybrid method: a case report.

BACKGROUND: For recurrent incarcerated and strangulated hernias, the optimal treatment strategy for each case is needed. CASE PRESENTATION: The study patient was a 70-year-old man. TAPP repair was performed for a left inguinal hernia (JHS Classification II-1) 7 years earlier. The patient experienced transient pain and swelling of the left inguinal region for 5 months and visited our emergency department for abdominal pain and vomiting. A CT scan showed a recurrent left inguinal hernia and small bowel incarceration, and emergency surgery was performed. Laparoscopic observation of the abdominal cavity revealed recurrent left inguinal hernia (Rec II-1) with small bowel incarceration. The small bowel was reduced after pneumoperitoneum, and no findings suggested intestinal tract necrosis. Adhesions around the herniated sac were dissected using an extraperitoneal approach and then shifted to mesh plug repair. No perioperative complications or hernia recurrence were observed in the 10 months after the surgery. CONCLUSIONS: This report describes a novel, successful surgical treatment for a recurrent incarcerated hernia. In our patient, we could easily perform dissection and understand the positional relationship by hybrid surgery using the TEP method. Additionally, in patients with incarcerated hernias, we believe that performing hybrid surgery by combining the TEP method would be useful because bowel dilation caused by intestinal obstruction would not disturb the operative field.

A Case of Strangulation Ileus Due to a Low-Grade Appendiceal Mucinous Neoplasm.

BACKGROUND Strangulation ileus is caused by external obstruction to the small bowel, which results in ischemia and loss of bowel peristalsis. Low-grade appendiceal mucinous neoplasm (LAMN) is a low-grade adenocarcinoma that arises in the appendix. LAMN is usually asymptomatic but can present with appendiceal rupture and pseudomyxoma peritonei (PMP). This report is of a rare presentation of LAMN with strangulation ileus in a 92-year-old man. CASE REPORT A 92-year-old man was admitted to the emergency room with sudden onset of lower abdominal pain and abdominal distension. Laboratory investigations showed a leukocytosis with a white blood cell (WBC) count of 14.6×10³/µL with 85.5% neutrophils, blood urea nitrogen (BUN) of 26.6 mg/dL, and serum creatinine of 2.6 mg/dL, consistent with acute renal failure. Arterial blood gas analysis showed lactic acidosis (pH of 7.11) with a base excess of -20.8 mmol/L and lactate of 13.7 mmol/L. Abdominal computed tomography (CT) showed ascites and a dilated obstructed closed loop of the distal ileum associated with an external mass (3.9×2.8 cm). An initial diagnosis was of strangulation ileus due to Meckel's diverticulum. Emergency ileocecal resection was performed. Histopathology showed a low-grade mucinous tumor arising from the mucosa of the appendix, consistent with LAMN. At a 13-month follow-up, the patient was well with no tumor recurrence. CONCLUSIONS This report is of a rare case of LAMN that presented as a surgical emergency with strangulation ileus.

Valproic acid inhibits irradiation-induced epithelial-mesenchymal transition and stem cell-like characteristics in esophageal squamous cell carcinoma.

Esophageal carcinoma is one of the most aggressive malignancies, and is characterized by poor response to current therapy and a dismal survival rate. In this study we investigated whether irradiation induces epithelial-mesenchymal transition (EMT) in esophageal squamous cell carcinoma (ESCC) TE9 cells and whether the classic histone deacetylase (HDAC) inhibitor valproic acid (VPA) suppresses these changes. First, we showed that 2 Gy irradiation induced spindle cell-like morphologic changes, decreased expression of membranous E-cadherin, upregulated vimentin expression, and altered the localization of ß-catenin from its usual membrane-bound location to cytoplasm in TE9 cells. Irradiation induced upregulation of transcription factors including Slug, Snail, and Twist, which regulate EMT. Stimulation by irradiation resulted in increased TGF-ß1 and HIF-1α expression and induced Smad2 and Smad3 phosphorylation. Furthermore, irradiation enhanced CD44 expression, indicating acquisition of cancer stem-like cell properties. In addition, irradiation enhanced invasion and migration ability with upregulation of matrix metalloproteinases. These findings indicate that single-dose irradiation can induce EMT in ESCC cells. Second, we found that treatment with 1 mM VPA induced reversal of EMT caused by irradiation in TE9 cells, resulting in attenuated cell invasion and migration abilities. These results suggest that VPA might have clinical value to suppress irradiation-induced EMT. The reversal of EMT by HDAC inhibitors may be a new therapeutic strategy to improve the effectiveness of radiotherapy in ESCC by inhibiting the enhancement of invasion and metastasis.

[The present status of CapeOX as adjuvant chemotherapy for colorectal cancer].

We report on treatment with capecitabine plus oxaliplatin (CapeOX) as adjuvant therapy for patients with colorectal cancer. Twenty patients were treated. The mean age was 69 years; 15 patients were male and 5 were female. Thirteen patients with colon cancer and 7 patients with rectal cancer were enrolled after curative surgery. In total, 55% of patients completed the planned number of treatment cycles. Dose modifications were required for oxaliplatin in 60% of patients and for capecitabine in 67% of patients. The median relative dose intensities of oxaliplatin and capecitabine were 86% and 88%, respectively. Treatment-related Grade 3/4 neutropenia and Grade 3/4 thrombocytopenia were documented in 2 and 3 patients, respectively. Grade 3/4 hand-foot syndrome occurred in 1 patient. Treatment with CapeOX as adjuvant therapy for patients with colorectal cancer seems to be safe.

[A case of advanced colon cancer successfully treated with combination therapy of cetuximab and oxaliplatin, leucovorin, and 5-fluorouracil].

A 65-year-old woman was referred to our hospital for examination of anemia. Colonoscopy showed a type 1 tumor in the ascending colon with nearly complete stenosis that was diagnosed as a tubular adenocarcinoma. Computed tomography (CT) revealed swelling of the regional, periaortic, and celiac lymph nodes and lymphangitis carcinomatosa. The patient was diagnosed as having Stage IV ascending colon cancer, and neoadjuvant chemotherapy was administered to avoid non-curative resection. The patient was treated with cetuximab and oxaliplatin, Leucovorin, and 5-fluorouracil( mFOLFOX6) combination chemotherapy. After 6 courses of chemotherapy, the primary lesion and multiple lymph node swellings greatly reduced in size and lymphangitis carcinomatosa improved. Accordingly, right colectomy with D3 nodal dissection was performed. The patient was recurrence free at her 8-month follow-up examination. Neoadjuvant chemotherapy with molecular targeted drugs is useful in the treatment of patients with unresectable primary cancer.

[A case of locally advanced rectal cancer successfully treated by laparoscopic intersphincteric resection and effective neoadjuvant chemoradiation therapy].

A 74-year-old woman was diagnosed as having lower rectal cancer. Colonoscopy revealed a type 2 circular tumor over 15 cm from the port side close to the dentate line. The patient was diagnosed as having a moderately differentiated adenocarcinoma by biopsy. Computed tomography (CT) and fluorodeoxyglucose (FDG)-positron emission tomography (PET) revealed thickening of the wall from near the anus to the rectosigmoid junction and an increase in the concentration of the surrounding adipose tissue as well as swelling of the left internal iliac lymph nodes with FDG accumulation. The patient was diagnosed as having cSE, cN3, cM0, cStage IIIb rectal cancer. Because the tumor was very close to the anus with advanced extramural invasion and because the patient desired anal sphincter preservation, we performed preoperative chemoradiation therapy( CRT) combined with capecitabine plus oxaliplatin( XELOX) and bevacizumab( BV). Radiation therapy was performed with a linear accelerator( LINAC) for stereotactic radiation therapy( Novalis®). Partial response (PR) was achieved by this therapy. Five weeks after CRT, the patient underwent laparoscopic-assisted intersphincteric resection( total ISR). Pathological examination revealed minimal residual cancer cells( Grade 2, pPR, pA, N0, M0, pPM0, pDM0, pRM0, pStage II). Increased implementation of anus-preserving surgery can be expected owing to the successful control of regional and distant metastases by neoadjuvant CRT. Based on these encouraging findings, we should consider the challenges posed by neoadjuvant CRT for the treatment of lower rectal cancer.