Acute palliative care unit-initiated interventions for advanced cancer patients at the end of life: prediction of impending death based on Glasgow Prognostic Score.

PURPOSE: Unexpected death occurred in an unexpectedly high proportion of advanced cancer patients in the acute palliative care unit (APCU) setting and associated with fewer signs of impending death. Recognition of patients at high risk of approaching death, especially immediately after admitting APCU among clinicians, can improve the end-of-life trajectory. Our objective was accurate prognostication within a few days of admission. METHODS: Patients admitted to an APCU of the NTT Medical Center Tokyo, Tokyo, Japan, between April 2009 and December 2016 were retrospectively examined. The Glasgow Prognostic Score (GPS) was optimized with concomitant neutrophilia, lymphocytopenia, thrombocytopenia, anemia, and monocytosis. Kaplan-Meier survival curves were estimated, and independent predictors for 3-day mortality were identified using univariate and multivariate analyses. The sensitivity, specificity, and likelihood ratios (LRs) associated with imminent death were also assessed. RESULTS: Nine hundred ninety-one patients were included; 52.9% was male. The median age was 72 years. The median survival was 13 days (IQ range 6 to 26), and 11.7% died within 3 days of admission. Significant difference in survival with a GPS of 2 was observed in GPS optimized with concomitant thrombocytopenia, and it was the only significant predictor associated with 3-day mortality (p = 0.004), which had high specificity (> 95%) and high positive LR (> 5). CONCLUSION: The prognostic value of the GPS was enhanced by adding thrombocytopenia. The concurrent use of the GPS and platelet count improved the prognostication of limited time of survival and could assist in the personal and clinical decisions for advanced cancer patients.

[Distal gastrectomy for initially unresectable gastric cancer with pyloric stenosis following gastrojejunostomy and S-1 plus CDDP chemotherapy].

We report a case of advanced gastric cancer with pyloric stenosis, in which a curative resection was performed following gastrojejunostomy and S-1 based chemotherapy. A 46-year-old female presenting with vomiting was diagnosed with unresectable gastric cancer with pyloric stenosis after a detailed examination. She underwent laparotomy, which revealed a T4 tumor invading the pancreas head and involving the gallbladder. A gastrojejunostomy was performed. After the operation, chemotherapy of S-1(100mg/body, days 1-21)plus cisplatin(85mg/body, day 8)was administered. After 4 courses, the tumor size was markedly reduced upon imaging examinations. Six months after gastrojejunostomy, distal gastrectomy was curatively performed. The pathological findings were type 3, por1, pT4a(SE), pN1, M0, pStage III A. After 5 courses of S-1(100mg/day, days 1-28)as adjuvant chemotherapy, she had a recurrence at a lymph node behind the pancreas head. Despite irinotecan+cisplatin following docetaxel therapy, she had no effective benefits and died from the cancer 17 months after the first operation. The prognosis of unresectable gastric cancer with pyloric stenosis is not promising; however, gastrojejunostomy following S-1-based chemotherapy could lead such patients to curative resection and a longer survival time.

Laparoscopic excision of the cystic lymphangioma occurred in the lesser omentum: report of a case and review of literature.

Intraperitoneal cyst occurring in the lesser omentum is extremely rare entity. Because of the absence of abdominal symptoms, omental cyst is occasionally found accidentally in imaging examination performed during health screening. We experienced a case of cystic lymphangioma that occurred in the lesser omentum, which was successfully resected under complete laparoscopic procedure. A 50-year-old Japanese woman was admitted to our hospital because a cystic mass was found in the abdomen. Abdominal computed tomography scan was performed because she had a traffic accident, despite complaining no abdominal symptoms. The abdominal computed tomography scan and magnetic resonance imaging revealed a large cystic mass in the lesser omentum adjacent to the lesser curvature of the stomach, which was resected with a complete laparoscopic procedure. As the cystic wall was closely attached to the lesser curvature of the gastric wall, an ultrasonic coagulating shear was quite helpful to entirely mobilize the cyst from the surrounding structure such as lesser curvature of the stomach. After placing clips to the feeding vessels to the cyst branched from the accessory hepatic vessels, the entire cyst was mobilized without leakage of cystic content. The postoperative course was uneventful with slight delayed gastric emptying due to partial denervation of the lesser curvature of the stomach. The patient was discharged on eighth day after surgery without any postoperative complications. This is the first case of cyst of lesser omentum resected under complete laparoscopic procedure and certainly highlights advantage and feasibility of laparoscopic approach for cases with abdominal cystic lesions. Laparoscopic excision of cystic lymphangioma in the lesser omentum provides all the advantage of minimally invasive procedure.

Thrombopoietin in postoperative thrombocytopenia following living donor hepatectomy.

Thrombocytopenia is a frequent finding following living donor hepatectomy. It appears more pronounced in right graft donors than in left graft donors. This study analyzed postoperative thrombocytopenia in 20 living liver donors and examined the change of endogenous thrombopoietin (TPO) in its recovery. Platelet count, TPO level, fibrinogen degradation product (FDP), and D-Dimer were measured before surgery and on postoperative days (PODs) 1, 2, 3, 5, 7, and 14. Concurrently, liver and spleen volumes were calculated by computed tomography. Platelet count on POD 3 was significantly lower in right graft donors than in left graft donors (13.0 +/- 3.7 x 10(4)/microL vs. 16.8 +/- 4.0 x 10(4)/microL, P = 0.039) but recovered by POD 7 in all donors. Postoperative elevations of FDP and D-Dimer were significantly higher in right graft donors than in left graft donors. TPO level rose immediately after surgery, peaked on POD 5 in left graft donors and on POD 7 in right graft donors, and fell nearly to preoperative levels by POD 14. Postoperative TPO level per liver volume was significantly higher in right graft donors than in left graft donors. In conclusion, thrombocytopenia following living donor hepatectomy resolved within the first week regardless of graft type and was mainly associated with increasing consumption of circulating platelets, possibly due to intrahepatic and splenic congestion. With a reduced number of circulating platelets, TPO level rapidly increases. Also, with reduced consumption of platelets related to recovery from surgery, thrombocytopenia should resolve. As a consequence, TPO level would be expected to fall.

[Liver regeneration in living-donor liver transplantation].

Liver regeneration in living-donor liver transplantation is summarized from the authors' data. In donors, liver function tests recovered to within the normal range 2 weeks after surgery regardless of graft type. At 2 weeks, the volumetric recovery of the remnant liver was 65% and 80% of the original volume in right and left lobe donors, respectively. These results suggest that functional recovery occurs earlier than morphologic restoration in donors. In recipients, the factor that affected the regeneration rate in size 4 weeks after transplantation was only implanted graft size; the rate was greater in patients in whom smaller grafts were implanted. In recipients with a rate of two or more, however, high portal vein pressure and flow were observed. Further, persistent low platelet counts and hyperbilirubinemia were seen in those patients. These results indicate that size enlargement may be caused by engorgement, and functional recovery is not achieved concurrently with morphologic restoration, especially in patients with smaller grafts. In patients with fulminant hepatic failure who receive auxiliary partial orthotopic liver transplantation, sequential histopathologic observations of the diseased liver revealed that liver regeneration initiates from cytokeratin 17-positive ductules and at least 1 year is necessary for complete recovery.

Evaluation of malignancy using Ki-67 labeling index for gastric stromal tumor.

BACKGROUND: Assessment of malignant potential in gastrointestinal stromal tumors (GISTs) is still problematic. The maximum tumor diameter and the mitotic index are generally used as an index of malignancy of GISTs. The Ki-67 labeling index has recently been used as an index of cell growth, and the prognosis of GISTs was reported to be significantly poor when the value of this index was 10% or higher. METHODS: Clinicopathological and immunohistological factors were analyzed in 15 patients who underwent surgical resection of gastric stromal tumors at our department between April 1997 and July 2002. The patients were divided into "metastasis/recurrence" and "benign" groups. Also, the relationship of changes in the Ki-67 labeling index to the degree of malignancy in recurrent lesions was assessed in an 84-year-old woman who underwent five reoperations because of recurrences in the peritoneum. RESULTS: Significant differences were noted between the metastasis/recurrence and benign groups in relation to the mean maximum tumor diameter (186.7 +/- 80.8 mm vs 41.3 +/- 22.9 mm), mitotic index (88.3 +/- 5.0/50 high-power fields [HPF] vs 3.0 +/- 2.9/50 HPF), and the Ki-67 labeling index (11.4 +/- 2.5% vs 0.01 +/- 0.51%). In the patient who had metastasis to the liver 3.5 years after initial operation and underwent five reoperations before death, the intervals until detection of recurrence tended to be shortened gradually. The Ki-67 labeling index varied with each operation, and tended to be higher at the time of reoperations than at the initial operation. CONCLUSION: The maximum tumor diameter, mitotic index, and Ki-67 labeling index were useful as an index of malignancy for gastric stromal tumor. The efficacy of surgical resection alone may be insufficient in patients with disseminated metastasis to the peritoneum.