Extended double sleeve lobectomy combined with thoracic wall resection to treat a huge lung cancer.

A 58-year-old man came to our hospital with numbness of the left arm, fatigue, and fever. A huge solid mass with necrotic changes located in the left upper lobe was noted on the computed tomography scan. The tumor directly invaded the extrathoracic wall, the left main pulmonary artery, and the superior segment of the lower lobe. To avoid pneumonectomy, a combination of an extended double sleeve lobectomy and thoracic wall resection was performed. The postoperative course was uneventful. The patient has survived without any recurrence for 6 months postoperatively.

Adjuvant chemotherapy can prolong recurrence-free survival but did not influence the type of recurrence or subsequent treatment in patients with colorectal liver metastases.

BACKGROUND: Although liver resection is the only potentially curative treatment for colorectal liver metastases, recurrence is frequent. We previously published the early results of a randomized controlled phase 3 trial showing that adjuvant therapy with uracil-tegafur and leucovorin significantly prolongs recurrence-free survival. This study sought to elucidate the impact of adjuvant chemotherapy on patient survival after an additional follow-up period, building upon the results of our previous study. METHODS: After resection for colorectal liver metastases, patients were randomly assigned in a 1:1 ratio to receive adjuvant uracil-tegafur and leucovorin or surgery alone. Patients assigned to the uracil-tegafur and leucovorin group received 5 cycles of uracil-tegafur and leucovorin within 8 weeks after surgery. RESULTS: Patients were assigned to an adjuvant uracil-tegafur and leucovorin (n = 90) or a surgery alone (n = 90) group; 3 patients were excluded because of protocol violations. After a median follow-up period of 7.36 years (95% confidence interval, 6.93-7.87), 60 (68.2%) patients in the uracil-tegafur and leucovorin group and 61 (68.5%) patients in the surgery alone group developed recurrences. The median recurrence-free survival was 1.45 years (95% confidence interval, 0.96-2.16) in the uracil-tegafur and leucovorin group and 0.70 years (95% confidence interval, 0.44-1.07) in the surgery alone group. The locations and treatments of the first recurrences did not differ between the groups, nor did the overall survival (hazard ratio, 0.86; 95% confidence interval, 0.54-1.38; P = .54). The overall survival was significantly longer in patients who underwent curative repeated resection than in patients who received non-surgical treatment (hazard ratio, 0.25; 95% confidence interval, 0.15-0.40; P < .0001). CONCLUSION: Adjuvant uracil-tegafur and leucovorin significantly prolonged the recurrence-free survival but not the overall survival. The repeated resection was the most important factor influencing overall survival.

Adjuvant Oral Uracil-Tegafur with Leucovorin for Colorectal Cancer Liver Metastases: A Randomized Controlled Trial.

BACKGROUND: The high recurrence rate after surgery for colorectal cancer liver metastasis (CLM) remains a crucial problem. The aim of this trial was to evaluate the efficacy of adjuvant therapy with uracil-tegafur and leucovorin (UFT/LV). METHODS: In the multicenter, open-label, phase III trial, patients undergoing curative resection of CLM were randomly assigned in a 1:1 ratio to either the UFT/LV group or surgery alone group. The UFT/LV group orally received 5 cycles of adjuvant UFT/LV (UFT 300mg/m2 and LV 75mg/day for 28 days followed by a 7-day rest per cycle). The primary endpoint was recurrence-free survival (RFS). Secondary endpoints included overall survival (OS). RESULTS: Between February 2004 and December 2010, 180 patients (90 in each group) were enrolled into the study. Of these, 3 patients (2 in the UFT/LV group and 1 in the surgery alone group) were excluded from the efficacy analysis. Median follow-up was 4.76 (range, 0.15-9.84) years. The RFS rate at 3 years was higher in the UFT/LV group (38.6%, n = 88) than in the surgery alone group (32.3%, n = 89). The median RFS in the UFT/LV and surgery alone groups were 1.45 years and 0.70 years, respectively. UFT/LV significantly prolonged the RFS compared with surgery alone with the hazard ratio of 0.56 (95% confidence interval, 0.38-0.83; P = 0.003). The hazard ratio for death of the UFT/LV group against the surgery alone group was not significant (0.80; 95% confidence interval, 0.48-1.35; P = 0.409). CONCLUSION: Adjuvant therapy with UFT/LV effectively prolongs RFS after hepatic resection for CLM and can be recommended as an alternative choice. TRIAL REGISTRATION: UMIN Clinical Trials Registry C000000013.

Transverse carcinoma after Miles operation: a case in which preoperative evaluation was assisted by computed tomographic colonography.

BACKGROUND: There were only few case reports in which CTC was performed in patients with colostomy. CASE PRESENTATION: A 68-year-old man was admitted with right abdominal pain and bloody stool that had been present for 2 weeks prior to admission. His medical history included abdominoperineal rectal resection with permanent sigmoid stoma (Miles operation). Colonoscopy showed a sub-occlusive tumor in the transverse colon but provided no information about the proximal colon. Thus, computed tomographic colonography (CTC) was planned to assist our examination of the proximal colon under sigmoid colostomy. CTC revealed the apple core sign in the hepatic flexure, without any evident tumor in the proximal colon. Therefore, we performed transverse colectomy and lymph node dissection, preserving a part of the ascending colon and Bauhin valve. CONCLUSION: CTC examination can be an effective means of preoperatively evaluating the proximal colon in patients with occlusive tumor. Further, CTC examination was technically feasible through a sigmoid stoma.

Intraoperative air leak test was useful for the detection of a small biliary fistula: A rare case of non-parasitic hepatic cysts with biliary communication.

INTRODUCTION: Symptomatic non-parasitic hepatic cysts with biliary communication are rare and no standard treatment has been established yet. Careful attention should be paid to avoidance of postoperative bile leakage during surgical treatment. PRESENTATION OF CASE: We report the case of a 74-year-old man who visited our department complaining of right upper abdominal pain and elevated serum levels of the liver enzymes. Computed tomography revealed hepatic cysts including a large one measuring 16cm in diameter in Segments IV and VIII. Percutaneous drainage of the cyst revealed bile-staining of the cyst fluid. Endoscopic retrograde cholangiography demonstrated the presence of a cyst-biliary communication. We performed open deroofing of the cyst. During the operation, the biliary fistula was invisible, however, air injection into the bile duct through the stump of the cystic duct caused release of air bubbles from the cyst cavity, which allowed us to detect the small biliary orifice and repair it successfully by suture. DISCUSSION: We utilized the intraoperative air leak test, which has previously been reported to be effective for preventing postoperative bile leakage in patients undergoing hepatectomy to detect of a small cyst-biliary communication in a case undergoing non-parasitic hepatic cyst surgery. CONCLUSION: An intraoperative air leak test may be a useful test during surgical treatment of non-parasitic hepatic cysts with biliary communication.

Cecal volvulus caused by endometriosis in a young woman.

BACKGROUND: Cecal volvulus is relatively rare. Moreover, to the best of our knowledge, a case of cecal volvulus caused by endometriosis has not yet been reported. CASE PRESENTATION: A 41-year-old woman was admitted to our hospital with a 14-day history of subacute intermittent right lower quadrant abdominal pain. Simple abdominal radiography and abdominal computed tomography findings were suggestive of sigmoid volvulus, and she underwent an emergency colonoscopy. Following colonoscopic reduction, the patient's symptoms resolved quickly, and elective laparoscopic surgery was scheduled 2 weeks after admission. Intraoperative examination revealed a significantly distended cecum and ascending colon, which was twisted around a short rope-like adhesion that connected the cecum and the mesentery of the transverse colon, whereas the sigmoid colon was neither twisted nor extended. We laparoscopically performed an ileocecal resection. The postsurgery histopathological examination revealed the presence of endometrial tissue in the short rope-like adhesion. This finding confirmed that cecal volvulus in this patient was caused by endometriosis. CONCLUSION: Cecal volvulus should be considered in relatively young women who present with atypical right lower abdominal pain. Whenever possible, secondary factors should be evaluated preoperatively, especially in relatively young patients.

Clinical and computed tomography findings of appendiceal diverticulitis vs acute appendicitis.

AIM: To study the clinical features and computed tomography (CT) findings of appendiceal diverticulitis vs acute appendicitis. METHODS: We retrospectively reviewed the records of 451 patients who had undergone appendectomy in our institution from January 2007 to September 2012. Patient demographics, clinical features, pathological findings, and surgical outcomes were analyzed. We also compared preoperative CT images of 25 patients with appendiceal diverticulitis with those of 25 patients with acute appendicitis. RESULTS: Among 451 patients, 44 (9.7%) were diagnosed to have appendiceal diverticulitis and 398 (86.9%) to have acute appendicitis. Patients with appendiceal diverticulitis were older (59 vs 37 years, P < 0.001) and had a longer duration of the illness (4.0 d vs 1.0 d, P < 0.001). Perforation rates in patients with appendiceal diverticulitis were higher (68% vs 27%, P < 0.001). The appendix could be visualized in only 13 patients (52%) among the appendiceal diverticulitis cases, but in all acute appendicitis cases. CT findings suggestive of appendiceal diverticulitis included the absence of fluid collection in the appendix (84% vs 12%, P < 0.001), absence of appendicolith (92% vs 52%, P = 0.005), and formation of abscess (68% vs 16%, P < 0.001). Appendiceal diverticula were identified in 6 patients (24%). CONCLUSION: Among patients who had undergone appendectomy, 9.7% had appendiceal diverticulitis. Patients with appendiceal diverticulitis had different clinical features and CT findings from patients with acute appendicitis.

Amebiasis presenting as acute appendicitis: Report of a case and review of Japanese literature.

INTRODUCTION: Outside of these high-risk regions, acute amebic appendicitis is considerably rarer and the mortality rate is much higher than with non-amebic appendicitis. PRESENTATION OF CASE: A 31-year-old woman presented with fever and right lower abdominal pain with no history of traveling abroad or sexual infection. Computed tomography revealed a dilated appendix and thickened cecal and ascending colon walls. She underwent an appendectomy for appendicitis. Owing to a lack of symptom resolution, we performed a pathologic examination of the appendix again that revealed multiple Entamoeba histolytica trophozoites; the serum amebic antibody was positive. She was treated postoperatively with metronidazole for amebiasis and discharged on postoperative day 12. DISCUSSION: The mortality rate and frequency of severe postoperative intraabdominal complications were higher in the Japanese literature (1995-2013) (25% and 33%, respectively) than in other developed countries (3.3% and 19.4%, respectively). Japan is a low-risk area for amebiasis; many physicians fail to consider amebiasis in the differential diagnosis of acute abdomen. It is important to conduct further examinations, including those for amebiasis, when appendectomy does not resolve acute appendicitis. CONCLUSION: We report a case of acute amebic appendicitis in a 31-year-old woman and review the ages at presentation, causative factors, treatments, and outcomes of 11 cases reported in Japan between 1995 and 2013.

Combined evaluation of the Glasgow prognostic score and carcinoembryonic antigen concentration prior to hepatectomy predicts postoperative outcomes in patients with liver metastasis from colorectal cancer.

BACKGROUND/AIMS: Little is known about the ability of the inflammation-based Glasgow prognostic score (GPS). METHODOLOGY: 106 patients who underwent curative resection for colorectal liver metastasis (CRLM) were analyzed. Patients with an elevated Creactive protein concentration (>10 mg/L) and hypoalbuminemia (<35 g/L) at admission were assigned a GPS 2, those with only 1 of these biochemical abnormalities were assigned a GPS 1, and those without either abnormality were assigned a GPS 0. RESULTS: Multivariate analysis showed that 2 variables, carcinoembryonic antigen (CEA) concentration > 30 ng/mL and a GPS 1 or 2, were independently prognostic of survival. Patients were classified into 3 groups on the basis of these 2 variables. Patients with GPS 1 or 2 and CEA concentration > 30 ng/mL were assigned a new score of 2, those with either 1 factor were assigned a new score of 1, and those with neither factors were assigned a new score of 0. The 5-year overall survival rates of new scores of 0, 1, 2 were 71.5%, 31.6%, and 0%, respectively (P < 0.0001). CONCLUSIONS: This simple staging system may be able to identify a subgroup of patients who are eligible for curative resection but show poor prognosis.

A combination of oral uracil-tegafur plus leucovorin (UFT + LV) is a safe regimen for adjuvant chemotherapy after hepatectomy in patients with colorectal cancer: safety report of the UFT/LV study.

The use of adjuvant systemic chemotherapy for resectable liver metastases from colorectal cancer (CRC) is controversial because no trial demonstrated its benefit. We conducted the phase III trial to evaluate UFT/leucovorin (LV) for colorectal liver metastases (CRLM). The primary endpoint has not been available until 2014, we first report the feasibility and safety data of UFT/LV arm. In this multicenter trial, patients who underwent curative resection of liver metastases from colorectal cancer were randomly assigned to receive surgery alone or surgery followed by adjuvant chemotherapy with UFT/LV. The primary endpoint was relapse-free survival. Secondary endpoints included overall survival and safety. A total of 180 patients were enrolled, 90 were randomly assigned to receive UFT/LV therapy. Eighty two of whom were included in safety analyses. In the UFT/LV group, the completion rate of UFT/LV was 54.9%, the relative dose intensity was 70.8% and grade 3 or higher adverse events occurred in 12.2% of the patients. Elevated bilirubin levels, decreased hemoglobin levels, elevated alanine aminotransferase levels, diarrhea, anorexia were common. Most other adverse events were grade 2 or lower and tolerable. In conclusions, UFT/LV is a safe regimen for postoperative adjuvant chemotherapy in patients who have undergone resection of liver metastases from colorectal cancer. Further studies are warranted to improve completion rate, but UFT/LV is found to be a promising treatment in this setting.

Index of convexity: a novel liver function index using Tc-GSA scintigraphy.

AIM: To investigate the clinical usefulness of a newly developed index, the "index of convexity (IOC)", for evaluating liver functional reserve using technetium-99m-diethylenetriaminepentaacetic acid-galactosyl-human serum albumin (Tc-GSA scintigraphy). METHODS: In total, 349 patients underwent Tc-GSA scintigraphy. Dynamic planner images were obtained, and time activity curves of the liver and heart were generated and analyzed. Our focus was on the convex shape of the liver accumulation curve. We developed a method for evaluating the extent of convexity and calculated an index that we named the IOC. Clearance index and receptor index were also calculated. The correlations between each GSA index with other liver function tests and liver histopathology were evaluated. RESULTS: Among the 3 indices generated by Tc-GSA, the IOC had the highest correlation with all other liver function tests (indocyanine green R15, albumin, prothrombin time, cholinesterase level, platelet count, and total bilirubin level). IOC can also differentiate between normal liver, chronic hepatitis, and liver cirrhosis with highest F ratio among GSA indices as determined by one-way analysis of variance. Receiver operating characteristic analysis demonstrated high diagnostic performance of IOC in the diagnosis of cirrhosis. CONCLUSION: IOC is a very simple and reliable index for assessing liver functional reserve, which may prove to be useful in combination with the indocyanine green test for preoperative assessment of hepatic resection.

Elevated C-reactive protein and hypoalbuminemia measured before resection of colorectal liver metastases predict postoperative survival.

BACKGROUND: Few studies have investigated whether the Glasgow Prognostic Score (GPS), an inflammation-based prognostic score measured before resection of colorectal liver metastasis (CRLM), can predict postoperative survival. PATIENTS AND METHODS: Sixty-three consecutive patients who underwent curative resection for CRLM were investigated. GPS was calculated on the basis of admission data as follows: patients with both an elevated C-reactive protein (>10 mg/l) and hypoalbuminemia (<35 g/l) were allocated a GPS score of 2. Patients in whom only one of these biochemical abnormalities was present were allocated a GPS score of 1, and patients with a normal C-reactive protein and albumin were allocated a score of 0. RESULTS: Significant factors concerning survival were the number of liver metastases (p = 0.0044), carcinoembryonic antigen level (p = 0.0191), GPS (p = 0.0029), grade of liver metastasis (p = 0.0033), and the number of lymph node metastases around the primary cancer (p = 0.0087). Multivariate analysis showed the two independent prognostic variables: liver metastases > or =3 (relative risk 2.83) and GPS1/2 (relative risk 3.07). CONCLUSIONS: GPS measured before operation and the number of liver metastases may be used as novel predictors of postoperative outcomes in patients who underwent curative resection for CRLM.

Inflammation-based prognostic score and number of lymph node metastases are independent prognostic factors in esophageal squamous cell carcinoma.

BACKGROUND/AIMS: Few studies have investigated whether the Glasgow Prognostic Score (GPS), an inflammation-based prognostic score, is useful for postoperative prognosis of esophageal squamous cell carcinoma. METHODS: GPS was calculated on the basis of admission data as follows: patients with elevated C-reactive protein level (>10 mg/l) and hypoalbuminemia (<35 g/l) were assigned to GPS2. Patients with one or no abnormal value were assigned to GPS1 or GPS0. A new scoring system was constructed using independent prognostic variables and was evaluated on whether it could be used to dictate the choice of clinical options. RESULTS: 65 patients with esophageal squamous cell carcinoma were enrolled. GPS and the number of lymph node metastases were found to be independent prognostic variables. The scoring system comprising GPS and the number of lymph node metastases was found to be effective in the prediction of a long-term outcome (p < 0.0001). CONCLUSIONS: Preoperative GPS may be useful for postoperative prognosis of patients with esophageal squamous cell carcinoma. GPS and the number of lymph node metastases could be used to identify a subgroup of patients with esophageal squamous cell carcinoma who are eligible for radical resection but show poor prognosis.

Inflammation-based prognostic score, prior to neoadjuvant chemoradiotherapy, predicts postoperative outcome in patients with esophageal squamous cell carcinoma.

BACKGROUND: Recent studies have revealed that Glasgow prognostic score (GPS), an inflammation-based prognostic score, is associated with poor outcome in a variety of tumors. However, few studies have investigated whether GPS measured prior to neoadjuvant chemoradiotherapy (nCRT) is useful for postoperative prognosis of patients with advanced esophageal squamous cell carcinoma (ESCC). METHODS: GPS was calculated on the basis of admission data as follows: patients with both an elevated C-reactive protein (>10 mg/L) and hypoalbuminaemia (<35 g/L) were allocated a GPS score of 2. Patients in whom only 1 of these biochemical abnormalities was present were allocated a GPS score of 1, and patients with a normal C-reactive protein and albumin were allocated a score of 0. All patients underwent radical en-bloc resection 3-4 weeks after nCRT. RESULTS: A total of 48 patients with clinical TNM stage II/III were enrolled. Univariate analyses revealed that there were significant differences in cancer-specific survival in relation to grade of response to nCRT (P = .004), lymph node status (P = .0065), lymphatic invasion (P = .0002), venous invasion (P = .0001), pathological TNM classification (P = .015), and GPS (P < .0001). GPS classification showed a close relationship with lymphatic invasion, venous invasion, and number of lymph node (P = .0292, .0473, and .0485, respectively). GPS was found to be the only independent predictor of cancer-specific survival (odds ratio, 0.17; 95% confidence interval, 0.06-0.52; P = .0019). CONCLUSIONS: GPS, measured prior to nCRT, is an independent novel predictor of postoperative outcome in patients with advanced ESCC.