[A Case of Advanced Gastric Cancer Accompanied with Skip Lymph Node Metastasis in the Retro Portal Region].

We report a case of advanced gastric cancer accompanied with skip lymph node metastasis in the retro portal region only. An 81-year-old man was referred to our hospital because of epigastric pain. CT examination of the abdomen revealed a gastric tumor and a tumor of 3.5 cm in diameter behind the portal vein and pancreatic head, which had high concentrations of FDG(SUVmax=8.5)on PET-CT examination. Thus, we diagnosed lymph node metastasis of the gastric cancer. We performed distal gastrectomyand en bloc resection of regional lymph nodes(D2 plus retro portal and retro pancreatic head nodes). In pathological examinations, the gastric tumor was diagnosed as poorlydifferentiated adenocarcinoma(por1, T3, INF b, ly1, v0). There were no metastatic nodes in perigastric lymph nodes, but the only metastasis was observed in the bulky lymph node, which was indicated by preoperative examinations. Postoperative course was uneventful. The patient is living recurrence-free without adjuvant chemotherapyfor more than 6 years after the operation.

[Tricuspid Valve Repair in a Patient with Isolated Tricuspid Valve Infective Endocarditis with Pulmonary Embolism;Report of a Case].

We report a case of 39-year-old man who developed tricuspid valve infective endocarditis with a complication of pulmonary embolism. He was transferred to our institution because of intermittent fever and enlargement of the vegetation of the tricuspid valve in spite of optimal antibiotics treatment. Computed tomography revealed pulmonary embolism, and transesophageal echocardiography showed a large and mobile vegetation (22×10 mm) on the tricuspid valve with moderate regurgitation. In addition, Streptococcus agalactiae was identified in blood cultures. The patient underwent surgical resection of the vegetation followed by tricuspid valve repair including De Vega's annuloplasty. Antibiotic therapy was continued for 4 weeks after surgery, and he was discharged on the 31st postoperative day. No endocarditis nor tricuspid valve dysfunction has re-occurred.

[A Case of Huge Colon Cancer Accompanied with Severe Hypoproteinemia].

We report a case of huge colon cancer accompanied with severe hypoproteinemia. A7 4-year-old woman was referred to our hospital because of abdominal fullness. Blood examinations revealed anemia(hemoglobin 8.8 g/dL)and sever hypopro- teinemia(total protein 4.5 g/dL, albumin 1.1 g/dL). Computed tomography examination of abdomen revealed ascites and large tumor(12.5×10.5 cm)at the right side colon. By further examinations ascending colon cancer without distant metastasis was diagnosed, then we performed right hemicolectomy and primary intestinal anastomosis by open surgery. Ahuge type 1 tumor(18×12 cm)was observed in the excised specimen, which invaded to terminal ileum directly. The tumor was diagnosed moderately differentiated adenocarcinoma without lymph node metastasis(pT3N0M0, fStage II ). Postoperative course was uneventful and serum protein concentration recovered gradually to normal range. Protein leakage from the tumor cannot be proved by this case, so we can't diagnose as protein-losing enteropathy, but we strongly doubt this etiology from postoperative course in this case.

[A Case of Locally Advanced Gallbladder Cancer That Developed Early Multiple Liver Metastasis after Curative Resection, and Achieved Long-TermPartial Remission Using S-1 and Gemcitabine].

A 76-year-old woman was referred to our hospital because of an abdominal tumor in September 2009. An irregularly shaped large tumor was detected in the right subcostal abdominal cavity on computed tomography, and was diagnosed as advanced gallbladder cancer without distant metastasis following further examination. We then performed a laparotomy. The tumor had invaded directly into the descending portion of the duodenum and transverse colon. We performed a curative resection of the tumor macroscopically. Pathological findings were moderately differentiated tubular adenocarcinoma derived from gallbladder cancer(T3N0M0, Stage III ). Postoperative antineoplasticc hemotherapy was not administered. At least 4 metastaticregions in the liver(segments 1, 5, 7, and 8)were detected using computed tomography 3 months after the operation, and we then initiated oral administration of S-1. After beginning treatment, we observed partial remission at 3 months and continued treatment. We changed the regimen of chemotherapy to gemcitabine 11 months later because of a drug-induced corneal disorder. One after treatment change also continues advertising, and treatment has ended 5 years after the operation. The patient has not received any treatment for the last 6 years and 7 months, and is now in the follow up period.

[A Case of Anorectal Amelanotic Malignant Melanoma].

We report a case of primary anorectal amelanotic malignant melanoma (MM), treated with a laparoscopic abdominoperineal resection (APR). A 75-year-old woman was referred to our hospital because of anal bleeding and pain. A finger-tip sized, dark reddish tumor, which protruded from her anus, was observed. After a tumor biopsy, the diagnosis was MM. No cutaneous pigmented regions were observed, and distant metastases and regional lymphadenopathy were not detected by computed tomography and magnetic resonance imaging. Therefore, we performed laparoscopic APR in order to relieve her symptoms. The resected specimen showed a partially pigmented tumor with a diameter of 6.0×4.1 cm in the anorectal junction. Histopathological examination of the specimen showed an amelanotic MM (negative for melanin pigmentation, and positive for HMB-45, Melan-A, and S-100). The post-operative course was uneventful, and we could not find any obvious evidence of recurrence of the disease 11 months after surgery. The prognosis of anorectal MM is extremely poor, thus a less invasive surgical procedure is recommended for treatment of anorectal MM. Laparoscopic APR is useful for treating anorectal MM due to its minimally invasive nature.

Predictors of prolonged laparoscopic cholecystectomy in the treatment of low-grade acute cholecystitis: a single-center, retrospective, observational study.

Aim: Laparoscopic cholecystectomy is frequently used to treat low-grade acute cholecystitis. Improvements in technical skills have reduced the rate of conversion from laparoscopic to open surgery. In this study, we sought to identify factors that might predict the surgical time of laparoscopic cholecystectomy as possible markers for surgical difficulty. Methods: We carried out a single-center retrospective analysis of a Japanese medical insurance database. Data were retrieved for 87 patients with acute cholecystitis. The analyzed factors included age, sex, body mass index, medical history, blood laboratory data, computed tomography findings, and time from disease onset to surgery. Multiple regression analysis was used to identify factors associated with surgical time. Results: Edema of the gallbladder wall on computed tomography, neutrophil sequestration, body mass index, and history of acute cholangitis were significantly associated with surgical time (P = 0.014, 0.027, 0.043, and 0.047, respectively). The conversion rate from laparoscopic surgery to open surgery was 2%. Conclusions: Our results suggest that edema of the gallbladder wall on computed tomography, neutrophil sequestration, body mass index, and history of acute cholangitis are associated with surgical time of laparoscopic cholecystectomy in the treatment of acute cholecystitis in our hospital.

[A case of multiple intestinal lymphomas accompanied by rapid growth of cutaneous infiltration after surgery].

We report a case of multiple intestinal lymphomas accompanied by rapid growth of cutaneous infiltration after surgery. An 86-year-old woman visited our hospital complaining of lower abdominal pain. Multiple tumors in the sigmoidal and ascending colon were detected by using colonoscopy and computed tomography; therefore, we performed surgery. Postoperative pathological examination identified the sigmoidal colon tumor as an adenocarcinoma and the ascending colon tumor as a B cell lymphoma. The tumors in the ileum and the ileal diverticulum, which were simultaneously excised, were also diagnosed as B-cell lymphomas. After surgery, rapid appearance of multiple light purple nodules on the skin of the right thigh was observed. Histological examination of biopsied skin nodules led to a diagnosis of B-cell lymphoma, similar to the previously removed tumors. Although radiotherapy and chemotherapy were administered to the dermatological lesion that reached an advanced stage, the disease condition was progressive. The patient was transferred to another hospital to receive medical treatment 3 months postoperatively. We consider these dermatological lesions to be dermal infiltration of B-cell lymphomas originating from tumors in the intestinal tract.

[A case of far-advanced colon cancer with extraluminal progression that required urgent surgical treatment].

A 60-year-old man was admitted to our hospital because of right flank pain. An irregular cystic mass region with calcification was detected in his right abdomen on computed tomography( CT). On the fifth day after admission, the patient's abdominal pain suddenly worsened. Based on a diagnosis of panperitonitis, we performed an urgent laparotomy on the same day. A bulky tumor involving the right colon, duodenum, and retroperitoneum was found in his abdominal cavity. We performed right hemicolectomy and partial resection of the duodenum but could not completely excise the tumor. The manipulation caused a serious duodenal injury; and therefore, pyloric antrum transection, gastrojejunostomy, and cholecystostomy were performed to reduce the inflow of gastric content and bile. Histological examination of the surgical specimens revealed a moderately differentiated adenocarcinoma that originated from the ascending colon. Many cancer cells were detected in the excised margin; thus, the surgical maneuver of choice was absolute noncurative resection. If peritonitis had not been observed, preoperative chemotherapy would have been more appropriate.

[A case of locally advanced rectal cancer successfully resected after preoperative chemotherapy].

We present the case of a patient who was admitted because of acute pan-peritonitis but was found to have locally advanced rectal cancer that was successfully excised after preoperative chemotherapy. A 68-year-old man was transferred to our hospital via an ambulance because of severe lower abdominal pain. His abdominal computed tomography scan showed a huge tumor in the pelvis. An emergency sigmoid colostomy was performed because of panperitonitis. However, his postoperative examinations indicated locally advanced rectal cancer accompanied with extensive urinary bladder invasion but without distant metastasis, and chemotherapy was started. Eventually, the tumor reduced to 47% of its maximum size after 4 courses of FOLFOX6 and 2 courses of FOLFOX6+panitumumab, and radical excision( low anterior rectal resection, partial urinary bladder resection, D3 lymph node dissection, and total mesorectal excision) was performed on the 154th day since the first operation. No cancer cells were detected on microscopic analysis of the margins of the excised specimen. Thus, preoperative chemotherapy is useful for treating locally advanced rectal cancer.

[A case of remnant gastric cancer with afferent loop syndrome treated by left upper exenteration].

A 64-year-old man with sudden upper abdominal pain and emesis was admitted to our hospital. Forty years ago, he had undergone distal gastrectomy and reconstruction by Billroth II anastomosis for gastric cancer. Abdominal computed tomography revealed a dilated afferent loop and anastomotic tumor. Gastrofiberscopy showed crookedness and edematization of the afferent loop anastomosis. A biopsy revealed a poorly differentiated adenocarcinoma. He was operated on under the diagnosis of remnant gastric cancer. Left upper exenteration was performed because the transverse colon, lateral segment of the liver, pancreas, and left renal hilus were involved. Liver metastasis and abdominal dissemination were not observed. Histopathological findings revealed severe invasion of poorly differentiated adenocarcinoma to other organs, and intraoperative peritoneal lavage cytology was positive. He was discharged from our hospital; however, adjuvant chemotherapy was impossible because of his poor condition. Four months after the operation, he died from peritoneal carcinomatosis. Remnant gastric cancer with afferent loop syndrome has a poor prognosis. Therefore, it is necessary to select surgical resection or palliative care after immediate chemotherapy, considering each patient's condition and cancer stage.

[Two cases of asymptomatic ruptured hepatocellular carcinoma].

We describe 2 cases of asymptomatic ruptured hepatocellular carcinoma diagnosed for the first time after the start of the operation. The first case is a 62-year-old woman. A tumor with a diameter of 3.6 cm was observed in the liver lateral segment on the abdominal computed tomography(CT) scan. She had not reported any subjective symptoms. Although we started operation using the laparoscope, we recognized a tumor burst and continuous bleeding. Bleeding was reduced by detaching the left hepatic artery from the left gastric artery, and left lateral hepatectomy was completed using the laparoscope. The second case is an 82-year-old man. A tumor with a diameter of 13 cm was observed in the left liver on the abdominal CT scan. He had also not reported any subjective symptoms. At the start of the operation, we observed about 200 mL of blood and a hematoma in the circumference of the liver. We intercepted the left Glisson's pedicle promptly and performed a left hepatectomy. Although it was unclear when these tumors were ruptured in both cases, they were bleeding from the burst part continuously at the time of the operation. The tumors were safely excised by controlling blood inflow as much as possible in the early stages of the operation.

[Two cases of retroperitoneal liposarcoma].

We report 2 cases of retroperitoneal liposarcoma. Case 1: A 53-year-old woman with severe abdominal distension and dyspnea was admitted to our hospital. Abdominal computed tomography(CT) and magnetic resonance imaging(MRI) revealed a large mass that occupied almost the entire abdominal cavity. She underwent surgery under the diagnosis of retroperitoneal liposarcoma. The tumor originated from the left lower pelvis. The tumor weighed 18 kg, and the histopathological diagnosis was well-differentiated liposarcoma. Seven years after the operation, local recurrence was found without any complaints. The operation was performed again. The tumor weighed 750 g, and it originated from the same area as observed in the first operation. The histopathological diagnosis was well-differentiated liposarcoma. Case 2: An 82-year-old woman complained of abdominal distension. A new dumbbell-like solid tumor was identified as retroperitoneal liposarcoma by CT and MRI findings, and it was growing rapidly. The tumor was removed with the cecum and right kidney in a curative operation. The tumor weighed 2.6 kg, and the histopathological diagnosis was dedifferentiated liposarcoma. The best treatment for retroperitoneal liposarcoma is curative resection. However, dedifferentiation occasionally occurs over time and in recurrent cases. It is important to follow-up strictly for retroperitoneal liposarcoma.

Development of an optical fiber flow velocity sensor.

A new optical fiber flow velocity sensor was developed by using an optical fiber information network system in sewer drainage pipes. The optical fiber flow velocity sensor operates without electric power, and the signals from the sensor can be transmitted over a long distance through the telecommunication system in the optical fiber network. Field tests were conducted to check the performance of the sensor in conduits in the pumping station and sewage pond managed by the Tokyo Metropolitan Government. Test results confirmed that the velocity sensor can be used for more than six months without any trouble even in sewer drainage pipes.

Integrin alpha2 mediates selective metastasis to the liver.

Cancers display distinct patterns of organ-specific metastasis. Comparative analysis of a broad array of cell membrane molecules on a liver-metastasizing subline of B16 melanoma versus the parental B16-F0 revealed unique up-regulation of integrin alpha2. The direct role of integrin alpha2 in hepatic metastasis was shown by comparison of high versus low-expressing populations, antibody blockade, and ectopic expression. Integrin alpha2-mediated binding to collagen type IV (highly exposed in the liver sinusoids) and collagen type IV-dependent activation of focal adhesion kinase are both known to be important in the metastatic process. Analysis of primary colorectal cancers as well as coexisting liver and lung metastases from individual patients suggests that integrin alpha2 expression contributes to liver metastasis in human colorectal cancer. These findings define integrin alpha2 as a molecule conferring selective potential for formation of hepatic metastasis, as well as a possible target to prevent their formation.

Biotransformation of raspberry ketone and zingerone by cultured cells of Phytolacca americana.

The biotransformation of raspberry ketone and zingerone were individually investigated using cultured cells of Phytolacca americana. In addition to (2S)-4-(4-hydroxyphenyl)-2-butanol (2%), (2S)-4-(3,4-dihydroxyphenyl)-2-butanol (5%), 4-[4-(beta-d-glucopyranosyloxy)phenyl]-2-butanone (19%), 4-[(3S)-3-hydroxybutyl]phenyl-beta-d-glucopyranoside (23%), and (2S)-4-(4-hydroxyphenyl)but-2-yl-beta-d-glucopyranoside (20%), two biotransformation products, i.e., 2-hydroxy-4-[(3S)-3-hydroxybutyl]phenyl-beta-d-glucopyranoside (12%) and 2-hydroxy-5-[(3S)-3-hydroxybutyl]phenyl-beta-d-glucopyranoside (11%), were isolated from suspension cells after incubation with raspberry ketone for three days. On the other hand, two compounds, i.e., (2S)-4-(4-hydroxy-3-methoxyphenyl)but-2-yl-beta-d-glucopyranoside (17%) and (2S)-2-(beta-d-glucopyranosyloxy)-4-[4-(beta-d-glucopyranosyloxy)-3-methoxyphenyl]butane (16%), together with (2S)-4-(4-hydroxy-3-methoxyphenyl)-2-butanol (15%), 4-[4-(beta-d-glucopyranosyloxy)-3-methoxyphenyl]-2-butanone (21%), and 4-[(3S)-3-hydroxybutyl]-2-methoxyphenyl-beta-d-glucopyranoside (24%) were obtained upon addition of zingerone. Cultured cells of P. americana can reduce, and regioselectively hydroxylate and glucosylate, these food ingredients to their beta-glycosides.

Expression of tropomyosin alpha 4 chain is increased in esophageal squamous cell carcinoma as evidenced by proteomic profiling by two-dimensional electrophoresis and liquid chromatography-mass spectrometry/mass spectrometry.

To identify proteins associated with esophageal carcinogenesis, we performed protein profiling of 16 esophageal squamous cell carcinomas (ESCCs) and paired noncancerous tissues by 2-DE and MS/MS. In cancerous tissues, three spots showed significant up-regulation in the amount of protein, while eight spots were significantly down-regulated. The identities of the spots were determined by PMF with LC-MS/MS and were confirmed by immunoblotting. The up-regulated proteins were tropomyosin alpha 4 chain, transgelin, and pyruvate kinase. The down-regulated proteins were serum albumin precursor, isoforms of annexin A1, tropomyosin beta chain, 14-3-3 protein sigma, and isoforms of serotransferrin precursor. In all 16 cases, up-regulation of the tropomyosin alpha 4 chain was confirmed by immunoblotting. Localization of the tropomyosin alpha 4 chain in ESCC cells and adjacent fibroblasts was confirmed by immunohistochemistry.

Proteomic analysis of autoantibodies in patients with hepatocellular carcinoma.

To detect autoantibodies that could be diagnostic markers for hepatocellular carcinoma (HCC), we analyzed serum autoantibodies comprehensively that showed immunoreactivity to proteins in tumor tissue obtained from patients with HCC. Fifteen paired samples of HCC tissue and corresponding nontumorous liver tissue as well as five normal liver tissue samples were used in the study. A combination of proteomics and SEREX (serologic analysis of recombinant cDNA expression libraries) technique was used. Tissue proteins were separated by 2-DE, transferred onto PVDF membranes, and immunoblotted with autologous sera. By comparing each immunoblot pattern, we identified four immunoreactive spots with stronger staining intensity in tumorous tissues than in corresponding nontumorous tissues and in normal liver tissues. Matched proteins on 2-DE gels were identified by LC-MS/MS. These immunoreactive proteins were heat shock 70 kDa protein 1 (HSP70), glyceraldehyde 3-phosphate dehydrogenase, peroxiredoxin, and manganese superoxide dismutase (Mn-SOD). In HCC sera, occurrences of autoantibodies against these proteins were 7/15 (46.7%), 5/15 (33.3%), 5/15 (33.3%), and 6/15 (40.0%), respectively, whereas 2/20 (10.0%), 7/20 (35.0%), 0/20 (0.0%), and 2/20 (10.0%) were in control sera. Immunoblot analysis using commercially available purified proteins was performed to confirm the specificity of autoantibodies. By statistical analysis, autoantibodies against HSP70, peroxiredoxin, and Mn-SOD showed significantly high-frequency immunoreaction in HCC sera. The three antibodies were considered patient-specific antibodies in HCC and may be candidate diagnostic biomarkers for HCC.

Increased expression and phosphorylation of liver glutamine synthetase in well-differentiated hepatocellular carcinoma tissues from patients infected with hepatitis C virus.

Hepatocellular carcinoma (HCC) is one of the most common fatal cancers, and chronic infection with hepatitis C virus (HCV) is thought to be one of the main causes in Japan. To identify diagnostic or therapeutic biomarkers for HCC associated with HCV (HCV-HCC), we tried to elucidate the factors related to the products from cancerous tissues of HCV-infected patients. From proteomic differential display analysis of liver tissue samples from HCV-HCC cancerous tissues and corresponding non-cancerous tissues from patients, three protein spots of the same molecular mass (42 kDa), whose expression increased in well-differentiated cancerous tissues, were detected. Although their pI were different, they were identified as glutamine synthetase (GS) by PMF with MALDI-TOF MS and by Western blotting using anti-GS specific mAb. Immunohistochemical analysis showed that tumor tissue consists of two parts, GS-positive cell and GS-negative cell regions, suggesting that GS-producing cells grew in the tumor tissue as a nodule in nodules. The tryptic peptides of the most acidic GS isoform lost the signal of 899.5 Da, corresponding a peptide of SASIRIPR, and gained a signal of 1059.5 Da, which was submitted to PSD analysis. PSD analysis showed the neutral loss by elimination of two phosphate groups, supposed to be on serine residues of the 899.5-Da peptide, from serine 320 to arginine 327 in GS. PMF followed by PSD analysis is thought to be useful for the determination of phosphorylation sites of proteins showing molecular heterogeneity.

Patent ductus venosus in children: a case report and review of the literature.

A 10-year-old girl with a patent ductus venosus associated with multiple autoimmune disorders presented with hypoxia, cyanosis of her lips, and exertional dyspnea. Ultrasonography and abdominal computed tomography of the liver showed a communication between the portal vein and the inferior vena cava through a patent ductus venosus. Portography showed flow from the portal vein directly into the inferior vena cava via the portosystemic shunt. The portosystemic venous shunt ratio was estimated to be 71.8% by scintigraphy using 123I-IMP. Intraoperatively, the authors diagnosed this portosystemic shunt as patent ductus venosus because of the absence of the ductus venosus on real anatomic position. The portal venous pressure was 8.2 cm H2O, which increased to 17.7 cm H2O when the ductus venosus was temporarily occluded. After surgical ligation of the ductus venosus, the color of liver improved, indicating restored liver circulation. The postoperative course was uneventful, and the patient has been asymptomatic for 6 months.

A serous oligocystic adenoma of the head of the pancreas successfully treated by dome resection and chemocautery: a new approach to serous oligocystic adenoma.

Serous oligocystic adenoma (SOA) is an extremely rare benign tumor and ill-demarcated large cyst. We report a case of pancreatic SOA. During abdominal ultrasonography (US) for a routine health examination and computed tomography (CT), a 69-year-old woman was found to have a 9-cm unilocular cyst located in the head of her pancreas. After a 2-year follow up, the cyst was seen to increase in size. The results of US, CT, magnetic resonance imaging, endoscopic retrograde cholangiopancreatography (ERCP), and angiography led to suspicion of a benign or low grade malignancy cystadenoma of the pancreas adjacent to the peripheral organs. Fluid analysis and frozen section pathological studies revealed a serous oligocystic adenoma with no malignancy. Dome resection, chemocautery, and omental filling were performed, and the postoperative course was uneventful. SOAs are difficult to diagnose without surgery. When the cyst exists in the head of the pancreas, adjacent to the biliary tract, portal system, or visceral vessels, it is also difficult to perform complete resection without the threat of morbidity or mortality. We have developed a new approach to SOA diagnosis and treatment that involves minimally invasive procedures.