Prognostic factors in T4b gastric cancer after surgery: A more balanced and sequential therapy for patients?

INTRODUCTION: This study aimed to evaluate the prognostic factors in T4b gastric cancer (GC) in order to improve future therapeutic strategies. METHODS: We retrospectively analyzed the medical records of 43 patients with advanced GC who underwent surgery and were surgically or pathologically diagnosed with T4b GC. The overall survival (OS) rate of patients with T4b GC was analyzed, and univariate and multivariate analyses were performed to identify clinicopathological factors that were independently associated with OS. In addition, we assessed the relationship between postoperative chemotherapy and laboratory parameters 4 weeks post-surgery. RESULTS: The proportion of patients with invasion of cancer in organs, including the pancreas, transverse colon, and liver, were 58.1%, 18.6%, and 14.0%, respectively. The proportion of patients who exhibited distant metastases was 44.2%, and R0 resection was achieved in 30.2% of patients. A total of 69.8% of patients underwent postoperative chemotherapy. The median survival rate was 12.3 months. Upon multivariate analysis, the presence of distant metastases (P = 0.01, HR; 3.48), the use of postoperative chemotherapy (P = 0.0004, HR; 0.12), and R0 resection (P < 0.0001, HR; 0.14) were significantly correlated with OS. Patients who did not undergo postoperative chemotherapy showed significantly higher levels of inflammatory parameters and lower levels of nutritional parameters 4 weeks after surgery than those who did. CONCLUSIONS: We evaluated that the presence of distant metastases was significantly associated with a poor prognosis, and the use of postoperative chemotherapy and R0 resection was significantly associated with a better prognosis in patients with T4b GC. It would be more important for a T4b GC treatment to balance between therapeutic tolerance for postoperative chemotherapy and surgical therapeutic effect.

Non-Alcoholic Fatty Liver Disease May Be a Risk Factor for Liver Metastasis After Radical Surgery for Colorectal Cancer: A Retrospective Study.

PURPOSE: Distant metastasis develops in approximately one-third of patients with colorectal cancer (CRC) who undergo radical surgery, and colorectal liver metastasis (CRLM) is the most common form of distant metastasis in CRC. Hepatectomy is the only potentially curative treatment for CRLM, but few patients with metastatic CRC meet the criteria for this radical resection, and the 5-year survival rate is poor. Identifying risk factors for CRLM is critical. Non-alcoholic fatty liver disease (NAFLD) is an independent risk factor for CRC. However, the effect of NAFLD on CRC liver metastasis after radical surgery remains unclear. Therefore, we examined the impact of NAFLD-associated hepatic fibrosis on liver metastasis after radical surgery for CRC. METHODS: We retrospectively analyzed data from 388 patients who underwent curative surgery for CRC at our hospital between April 2008 and March 2015. The patients' clinical results, surgical procedures, postoperative course, and pathological and survival data were collected from the hospital records. The NAFLD fibrosis score was calculated and used to divide the patients into two groups (NAFLD and non-NAFLD). RESULTS: Recurrence was observed in 83/388 (21.4%) patients after a mean follow-up of 65.6 ± 15.1 months. Twenty-five patients had liver metastasis: 8 in the NAFLD group (8/45; 17.8%) and 17 in the non-NALFD group (17/343; 5.0%) (p = 0.004). Liver metastasis-free survival was significantly worse in the NAFLD than non-NAFLD group (p < 0.001). NAFLD and cancer stage were independent risk factors for liver metastasis recurrence. CONCLUSION: NAFLD may be a risk factor for liver metastasis in patients with CRC who undergo curative surgery.

Adrenocortical Carcinoma with a Renal Vein Thrombus Extending to the Inferior Vena Cava Successfully Resected with the Left Kidney and Distal Pancreatectomy: A Case Report.

Introduction: Adrenocortical carcinoma (ACC) is an extremely rare and aggressive tumor, and its clinical characteristics are poorly defined because of its rarity. Case Presentation: We report a 64-year-old man who presented with upper abdominal pain and weight loss. Computed tomography revealed a 15 cm left adrenal tumor compressing the pancreas ventrally and a tumor thrombus in the inferior vena cava (IVC) originating from the left renal vein. Positron emission tomography-computed tomography revealed 18F-fluorodeoxyglucose uptake only in the tumor and tumor thrombus, and radical surgery was planned. Intraoperatively, the tumor was visible on the posterior stomach wall, and the tumor adhered to the pancreas and left kidney. We excised the tumor with part of the pancreas and the left kidney and excised the thrombus from the IVC after clamping. The final diagnosis was ACC, tumor-node-metastasis grade T3N1M0, stage III. The patient received chemotherapy and radiotherapy postoperatively; however, two liver metastases appeared 6 months after surgery. Chemotherapy was continued, and no exacerbation of the liver metastases was observed. Posterior segment resection of the liver was performed 16 months after the initial surgery. Conclusion: This report of a rare case of ACC involving the pancreas with tumor thrombus extension to the IVC stresses that this combination of conditions does not preclude radical surgery. However, more data are needed regarding chemotherapy and radiotherapy, as well as relapse treatment, and further research on ACC is essential for a favorable prognosis.

Multidisciplinary treatment of advanced cervical esophageal adenocarcinoma derived from a gastric inlet patch: A case report.

A gastric inlet patch (GIP) is an ectopic gastric mucosal lesion usually arising at the cervical esophagus that may rarely cause esophageal adenocarcinoma (EAC). To the best of our knowledge, this is the first case of a GIP-derived EAC that was successfully treated using a multidisciplinary treatment approach. A 64-year-old man was referred to the Department of Gastrointestinal Surgery, Kanazawa University Hospital (Kanazawa, Japan) for surgical treatment of refractory recurrent cervical EAC derived from GIP who had previously been treated with induction chemotherapy, definitive chemoradiotherapy and photodynamic therapy (PDT). Esophagogastroduodenoscopy revealed a stenotic tumor at the GIP site in the cervical esophagus and submucosal tumors with suspected multiple intramural metastases in the anal side of the thoracic esophagus. The patient underwent robot-assisted thoracoscopic esophagectomy with laryngopharyngectomy and cervical lymphadenectomy as radical salvage surgery 4 months after the last PDT procedure. After postoperative adjuvant chemotherapy using oral administration of tegafur/gimeracil/oteracil (oral 5-fluorouracil prodrug) for 1 year; at present, the patient is alive without recurrence 3 years after the operation.

A case of anaplastic carcinoma of the pancreas with intrasplenic huge mass formation.

Anaplastic carcinoma of the pancreas (ACP) is an aggressive pancreatic tumor that grows rapidly, and its clinical characteristics are poorly defined because of its rarity. Thus, preoperative diagnosis is difficult and most definitive diagnoses are generally made by surgery, highlighting the importance of collecting more cases of ACP. We report a case of a 79-year-old woman with ACP that was difficult to diagnose preoperatively. Abdominal enhanced computed tomography revealed a large and expansive tumor in the spleen containing multilocular cystic and solid components. The first preoperative diagnosis was splenic angiosarcoma, and the tumor could be resected by distal pancreatectomy, total gastrectomy and partial transverse colectomy. ACP was first diagnosed based on postoperative histopathological findings. ACP that spreads to the spleen and forms an intrasplenic mass is rare. However, ACP should be included in the differential diagnosis of such patients, and further research of ACP is essential for a favorable prognosis.

Recurrent malignant peritoneal mesothelioma treated by a second resection: A case report.

Key Clinical Message: Malignant peritoneal mesothelioma, a rare and poor prognosis disease, is seldom treated surgically, especially for recurrence. However, early diagnosis and aggressive treatment of primary and recurrent tumors can achieve long-term patient survival. Abstract: Malignant peritoneal mesothelioma (MPM) is a rare and aggressive tumor, and rarely indicated for surgery, especially for recurrence. In the present case, we report a rare case who could survive long-term after two surgeries in 4 years for MPM.

[A case of acalculous gangrenous cholecystitis due to artery dissection].

A 62-year-old male presented with right intercostal muscle pain. Clinical examination revealed muscular defense in the same area. Abdominal ultrasonography revealed a distended gallbladder and ascites effusion, but no gallstones or polyps were present. Contrast-enhanced computerized tomography was performed, which revealed luminal obstruction due to arterial dissection of the celiac artery and intrinsic hepatic artery. This finding suggested gangrenous cholecystitis; thus, urgent cholecystectomy was performed. Only a few cases of celiac artery dissection and only one case of gangrenous cholecystitis without stones have been reported. We report here an extremely rare case of celiac artery dissection.

Prognostic significance of p16, p21, and Ki67 expression at the invasive front of colorectal cancers.

Cancer cells at the invasive front are believed to be responsible for invasion/metastasis. This has led to examining various morphological features and protein expressions at the invasive front. However, accurate assessment of the pathological section requires long-time training, and inter-observer disagreement is problematic. Immunohistochemistry and digital imaging analysis may mitigate these problems; however, the choice of which proteins to stain and the best analysis method remains controversial. We used the "go-or-grow" hypothesis to select markers with the greatest prognostic relevance. Importantly, nonproliferating cells can migrate. We used Ki67 as a proliferation marker, with p16 and p21 designating nonproliferating cells. We established a semi-automated quantification workflow to study protein expression in serial pathological sections. A total of 51 patients with completely resected colorectal cancer (stages I-IV) were analyzed, and 44 patients were followed up. Patients with cancer cells with p16-high/p21-low or p21-low/Ki67-low at the deepest invasive front demonstrated a significantly worse prognosis than those who did not display these characteristics. These results suggest that the nonproliferating cancer cells at the invasion front possess invasion/metastatic property with heterogeneity of senescence.

A Case of Spontaneous Remission of Membranous Nephropathy After the Removal of Nerve Epidermal Growth Factor-Like 1 Positive Sigmoid Colon Carcinoma.

Recently, the association between membranous nephropathy (MN) and malignancy has been recognized in about 30% of epidermal growth factor-like 1 (NELL-1) positive cases. However, the mechanism of association with MN and malignancy remains under search. In this report, we present a unique case of MN with positive staining for both thrombospondin type-1 domain-containing 7A (THSD7A) and NELL-1. An 80-year-old Japanese woman with nephrotic syndrome (NS) was diagnosed as an immunoglobulin (Ig)G1 subclass predominant secondary MN with weakly positive for THSD7A staining. Then, advanced cancer in the sigmoid colon was found during screening tests for malignancy. After the removal of colon carcinoma, complete remission was achieved at 28 weeks follow-up after operation. Five years later, she remained in remission and passed without recurrence. Thereafter, we examined again newly reported NELL-1 in renal biopsy specimens and found very strong staining along the glomerular capillary walls. Moreover, in resected tumor tissues, NELL-1 was strongly positive at the basal side of adenocarcinoma cells, but THSD7A staining was negative. This case report provides clinical details and highlights the utility of autoantibodies, especially NELL-1, in the diagnosis and treatment of secondary MN with malignancy.

Intra-tumoral FGFR2 Expression Predicts Prognosis and Chemotherapy Response in Advanced HER2-positive Gastric Cancer Patients.

BACKGROUND/AIM: This study aimed to evaluate the relationship between clinical outcomes and intra-tumoral fibroblast growth factor receptor 2 (FGFR2) expression in human epidermal growth factor receptor 2 (HER2)-positive gastric cancer (GC) patients who had undergone HER2-targeted chemotherapy. PATIENTS AND METHODS: A retrospective analysis was performed in 22 patients with HER2-positive GC, who had undergone systemic chemotherapy. We performed immunohistochemistry staining of FGFR2 expression using surgically resected specimens or biopsied samples and evaluated clinicopathological characteristic and overall survival (OS) in the FGFR2-negative and -positive GC groups. RESULTS: A total of 8 and 14 patients were placed in the FGFR2-negative and -positive group, respectively. The median OS rates were 56.2 and 16.0 months in the FGFR2-negative and -positive groups, respectively. The FGFR2-negative group had a significantly better prognosis after HER2-targeted chemotherapy [p=0.027 (log-rank test)]. The univariate analysis revealed that performing gastrectomy, response to combination chemotherapy with trastuzumab, and FGFR2 positivity were significantly correlated with OS. In a multivariate analysis, the response to combination chemotherapy with trastuzumab (p=0.008) was significantly correlated with OS. In addition, the proportions of patients who showed CR or PR in response to chemotherapy were 87.5 and 42.9% in the FGFR2-negative and -positive groups, respectively (p=0.031). CONCLUSION: HER2-positive GC patients, without overexpression of FGFR2, exhibited an improved prognosis and response rate to trastuzumab combination chemotherapy. Assessment of intra-tumoral FGFR2 expression could be helpful in predicting the prognosis and response to trastuzumab in HER2-positive GC patients.

Hyaluronic Acid May Be a Predictive Biomarker for Thrombocytopenia and Liver Dysfunction After Oxaliplatin-based Chemotherapy.

Background/Aim: Following oxaliplatin-based chemotherapy, approximately half of all colorectal cancer patients develop sinusoidal obstruction syndrome (SOS). SOS can be monitored by measuring splenic volume; however, obtaining this measurement is not a simple process. In this study, we evaluated changes in hyaluronic acid (HA) concentrations as a simpler marker of SOS. Patients and Methods: We measured splenic volume and laboratory data, including hyaluronic acid concentration, liver enzymes, and platelet counts, in 34 patients with colorectal cancer who underwent radical resection and who received capecitabine plus oxaliplatin (CapeOx) chemotherapy. Results: A strong correlation was identified between ≥30% increase in splenic volume and significantly elevated HA concentrations. Affected patients also had persistent thrombocytopenia and liver dysfunction compared to patients without elevated HA concentration. Conclusion: HA concentration may predict SOS in patients who receive CapeOx adjuvant chemotherapy.

Preoperative diagnosis of gallbladder torsion by magnetic resonance cholangiopancreatography: A case report.

Gallbladder torsion is a rare and potentially fatal condition presenting with acute abdominal pain. Gallbladder torsion requires early diagnosis and treatment; however, preoperative diagnosis is difficult. In the present case, magnetic resonance cholangiopancreatography provided definitive imaging findings and was very useful in making the preoperative diagnosis.

Conservative management of spontaneous isolated superior mesenteric artery dissection: A case report.

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare and potentially fatal cause diagnosis presenting with acute abdominal; however, because of its rarity, the pathogenic factors of SISMAD remain unknown and no clear cause has been found. Moreover, there is a lack of evidence-based treatment guidelines.

Laparoscopic intraperitoneal mesh repair of a large incisional hernia in a kidney transplantation patient: A case report.

A 73-year-old woman presented to our hospital because of painful bulging in the right lower abdomen, and developed a 17 × 12 cm incisional hernia after kidney transplantation using right oblique incision. Laparoscopic intraperitoneal onlay mesh (IPOM) repair was performed. Since a transplanted kidney is close to the abdominal wall defect, the space between the transplanted kidney and the abdominal wall was peeled off to secure enough space for the mesh to be place. After that the fascial defect was detected precisely, and the polypropylene-polyglycolic acid composite mesh was fixed with 3 cm overlapping of the hernia ring by non-absorbable tacks. The patient was discharged 9 days after surgery. In general, abdominal incisional hernias after kidney transplantation are relatively large with boundary defect of abdominal wall ensuing between the abdominal and allograft. However, laparoscopic IPOM repair of incisional hernia after kidney transplantation can be performed safely and effectively.

Relationship between fatty liver change and nutritional status after total gastrectomy in gastric cancer patients: a retrospective study.

BACKGROUND: The relationship between chronological nutritional changes and development of fatty liver after total gastrectomy (TG) in gastric cancer (GC) patients is still unclear. This study aimed to evaluate relationship between development of fatty liver and chronological changes of nutritional parameters during 12 months after TG. METHODS: We retrospectively analyzed medical records of 59 patients with GC who underwent TG at the Kanazawa Medical University Hospital between January 2009 and December 2017. We defined fatty liver change as a mean liver-to-spleen attenuation ratio (L/S ratio) of less than 1.2 in the computed tomography images at 12 months after TG and divided the patients into fatty liver (FL) and non-FL groups from the L/S ratio. We analyzed serum levels of total protein and albumin, and psoas muscle index (PMI) before TG and at 6 and 12 months after TG in the non-FL and FL groups. RESULTS: Six patients showed an L/S ratio of less than 1.2 at 12 months after TG and were included into FL group. There was no significant difference between the groups in serum parameters, L/S ratio, and PMI before TG. In the FL group, the mean levels of total protein and albumin decreased after TG and were significant lower at 6 months, compared with the non-FL group. And then, these levels in the FL group recovered at 12 months. In contrast, the mean levels of total protein and albumin in the non-FL group did not decrease below the preoperative levels throughout the year after surgery. As with laboratory parameters, all patients in the FL group showed decrease of PMI at 6 months after TG. This proportion was significantly higher than that in the non-FL group (100% vs. 40.8%, P = 0.006). CONCLUSIONS: We evaluated that the patients with fatty liver occurring after TG had significantly lower levels of serum nutritional parameters and skeletal muscle index at 6 months, not but 12 months, after TG.

Risk Factors for Overall Complications and Remote Infection After Gastrectomy in Elderly Gastric Cancer Patients.

BACKGROUND/AIM: A significant predictive factor for the occurrence of complications after gastrectomy in elderly gastric cancer patients is yet to be determined. We aimed to evaluate the clinical factors associated with overall complications including remote infection after gastrectomy in elderly gastric cancer patients. PATIENTS AND METHODS: We retrospectively analyzed data of 101 patients aged over 80 years, who underwent curative gastrectomy. We analyzed the clinicopathological factors that were independently associated with the occurrence of overall complications or remote infection by a logistic regression model. RESULTS: The overall complication rate was 24.8%. We identified pneumonia as a remote infection, and the occurrence rate of remote infections was 5.9%. On multivariate analysis, hemoglobin (<11 g/dl) and operation time (>240 min) were significantly correlated with the occurrence of overall complications. Regarding the occurrence of remote infection, performing total gastrectomy and a hemoglobin level <11 g/dl were identified as significant risk factors. CONCLUSION: Preoperative anemia and intraoperative factors, including the surgical procedure, could affect the occurrence of postoperative complications in elderly patients.

Advanced gastric cancer with abdominal wall invasion treated with curative resection after chemotherapy: a case report.

INTRODUCTION: In patients with gastric cancer, 6-27% of patients are diagnosed with T4b disease that invades adjacent organs, and curative resection can improve the prognosis of these patients. CASE PRESENTATION: A 70-year-old Japanese man presented with an abdominal tumor and was diagnosed with advanced gastric cancer (L-Circ type 3 T4b N2 M0 H0 stage IVA, based on the 15th edition of the Japanese Classification of Gastric Carcinoma) with extensive abdominal wall invasion. We performed open gastrojejunal bypass for gastric obstruction and initiated a chemotherapeutic regimen comprising S-1 (120 mg/day) and oxaliplatin (100 mg/m2). Upper gastrointestinal endoscopy performed after the administration of six courses of the S-1 and oxaliplatin regimen revealed a persistent primary lower gastric wall lesion; however, the diameter of the abdominal wall invasion and metastatic lymph nodes was significantly reduced, in addition to decreased serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels. Subsequently, the patient underwent distal gastrectomy with D2 lymphadenectomy combined with transverse colon and abdominal wall resection. We performed radical en bloc resection and achieved a tumor-free resection margin. Simple abdominal wall closure was performed without mesh or musculocutaneous flap placement. Histopathological examination of the resected tumor specimen showed direct invasion of the mesocolon and rectus abdominis muscle. The patient was postoperatively diagnosed with L Gre-Ant type5 T4b (SI: rectus abdominis muscle) N2 PM0 DM0 Stage IIIA R0 Grade 2a gastric cancer based on histopathological findings and received S-1 as adjuvant chemotherapy, 2 months postoperatively. No recurrence was detected 6 months postoperatively. CONCLUSIONS: We report a case of advanced gastric cancer with extensive abdominal wall invasion that was successfully treated with gastrectomy combined with resection of adjacent organs showing tumor invasion after effective systemic chemotherapy. A therapeutic approach comprising curative surgery combined with perioperative chemotherapy is useful in patients with T4b gastric cancer.

[Role of Surgical Resection after Chemoradiotherapy in Locally Advanced Pancreatic Cancer].

We investigated 34 cases of preoperative chemoradiotherapy(CRT)for locally advanced pancreatic cancer including resectable pancreatic cancer in our department during the past 11 years. For resectable(R)or borderline resectable(BR)pancreatic cancer, survival curves were generally higher in the CRT plus S-1 group treated after CRT than in the CRT group treated with post-CRT chemotherapy, but there was no statistically significant difference. In non-resected cases, local exacerbation was observed, which was one of the causes of a decline in terminal QOL. From the above, at present, it is desirable to remove R or BR pancreatic cancer after CRT, but the significance of surgery may change in the future due to the improvement of multidisciplinary treatment.

[Significance of Preoperative Chemoradiotherapy for Resectable Pancreatic Cancer].

We investigated the effect of chemoradiotherapy(CRT)on pancreatic cancer and the significance of preoperative chemoradiotherapy( NACRT)on resectable pancreatic cancer. The subjects were 36 patients who underwent CRT for locally advanced pancreatic cancer experienced in our department in the past 12 years(. 1)Regarding the antitumor effect of CRT, tumor diameter, tumor marker, and FDG for PET examination were reduced in 72%, 81%, and 96% of cases, respectively. In addition, the effect of Grade 1b plus 2 was observed in 10 of 16 patients who were resected after CRT(response rate 63%). In these successful cases, irradiation of 40 Gy or more and oral administration of S-1 1,500 mg or more were performed during this period. In addition, the survival rate of the NACRT plus S group(16 cases)was the same as that of the SF group (20 cases)of cStage ⅡA or lower at the same time, 50% survival was longer, and local recurrence was less. Based on the above, preoperative chemoradiotherapy combined with S-1 for resectable pancreatic cancer may be a promising preoperative treatment in the future.

Predictive factors for developing acute cholangitis and/or cholecystitis in patients undergoing delayed cholecystectomy: A retrospective study.

BACKGROUND: /Objective: We evaluated the risk of acute cholangitis and/or cholecystitis while waiting for cholecystectomy for gallstones. METHODS: We retrospectively enrolled 168 patients who underwent cholecystectomy for gallstones after conservative therapy. We compared clinical data of 20 patients who developed acute cholangitis and/or cholecystitis while waiting for cholecystectomy (group A) with 148 patients who did not develop (group B). We investigated surgical outcomes and risk factors for developing acute cholangitis and/or cholecystitis. RESULTS: Preoperatively, significant numbers of patients with previous history of acute grade II or III cholecystitis (55.0% vs 10.8%; p < 0.001) and biliary drainage (20.0% vs 2.0%; p = 0.004) were observed between groups A and B. White blood cell counts (13500/µL vs 8155/µL; p < 0.001) and C-reactive protein levels (12.6 vs 5.1 mg/dL; p < 0.001) were significantly higher in group A than in group B; albumin levels (3.2 vs 4.0 g/dL; p < 0.001) were significantly lower in group A. Gallbladder wall thickening (≥5 mm) (45.0% vs 18.9%; p = 0.018), incarcerated gallbladder neck stones (55.0% vs 22.3%; p = 0.005), and peri-gallbladder abscess (20.0% vs 1.4%; p = 0.002) were significantly more frequent in group A than in group B. A higher conversion rate to open surgery (20.0% vs 2.0%; p = 0.004), longer operation time (137 vs 102 min; p < 0.001), and higher incidence of intraoperative complications (10.0% vs 0%; p = 0.014) were observed in group A, compared with group B. CONCLUSION: A history of severe cholecystitis may be a risk factor for acute cholangitis and/or cholecystitis in patients waiting for surgery; it may also contribute to increased surgical difficulty.