Predictive Ability of the Combination of White Blood Cell and C Reactive Protein Levels for Infections Following Laparoscopic Hysterectomy.

OBJECTIVE: In the present retrospective study, we evaluated potentially predictive factors and determined receiver operating characteristic (ROC) curve cut-off values for effective detection of patients at higher risk of re-hospitalization due to postoperative infection after total laparoscopic hysterectomy. MATERIALS AND METHODS: We included 168 patients who had undergone laparoscopic hysterectomy. Data were collected from medical records. Patients were classified into non-infection (n = 161) and infection (n = 7) groups based on whether they developed fever after hospital discharge. We evaluated factors conventionally known to affect postoperative infection in general, and values of white blood cell (WBC) and C-reactive protein (CRP) determined on postoperative days 1 and 3-5. RESULTS: There were significant differences in WBC 3-5 days postoperatively (WBC POD3-5) (p = 0.049), CRP 3-5 days postoperatively (CRP POD3-5) (p = 0.018) and CRP POD3-5 × WBC 1 day postoperatively (WBC POD1) (p = 0.002). Area under the ROC curves for CRP POD3-5 and CRP POD3-5 × WBC POD1 were 0.81 and 0.84, and cutoffs were 4.46 mg/dL and 46885.5, respectively. CONCLUSION: If CRP POD3-5 or CRP POD3-5 × WBC POD1 is high, the physician should be alert to postoperative infection, and the patient should be under careful management and supervision.

[A Case of Gastric Cancer with Pericardial Effusion as an Immune-Reactive Adverse Events].

A 67-year-old man diagnosed with clinical Stage Ⅳ gastric cancer was administered nivolumab as fourth-line chemotherapy. After 9 courses, he was emergently admitted with complaints of low blood pressure and general malaise. On the fourth hospital day, he had high-grade fever and elevated serum C-reactive protein. Computed tomography showed a moderate amount of pericardial effusion. He was administered 1.7 mg/kg of methylprednisolone and improved rapidly. A hormonal blood examination showed his adrenal gland disorder. This is the first case in our country of pericardial effusion as an immune-reactive adverse event, which is not well known in Japan.

Comparison of various risk scores for the prognosis of hemorrhagic upper gastrointestinal mucosal disorder.

BACKGROUND: Various risk scores have been proposed that are useful for the management of upper gastrointestinal bleeding (UGIB), which is an important disease in emergency medicine. Few studies have examined the usefulness of Charlson Comorbidity index (CCI) in this disease, which evaluates the patient's general condition by scoring the patient's underlying disease. There have been no studies investigating the efficacy of CCI compared to other risk scores in the management of UGIB requiring endoscopic hemostasis. METHODS: In addition to the Glasgow-Blatchford score, AIMS65 score, and Rockall score, we investigated the efficacy of the outcome prediction obtained by the original CCI and the updated CCI, scored only with respect to the underlying disease. We also examined the cutoff value when using the risk score. This retrospective study included 265 patients with hemorrhagic upper gastrointestinal mucosal lesions who underwent emergency endoscopic hemostasis during a 6-year period between 2011 and 2016 in our hospital. RESULTS: The updated CCI and AIMS65 score correlated with prognosis in multivariate analysis (p = 0.002 and p = 0.003, respectively). In clinical practice, the prognosis might be worse if both updated CCI and AIMS65 score were 3 point or more. CONCLUSION: In addition to the AIMS65 score, the updated CCI can be a useful tool for managing upper gastrointestinal mucosal disorder bleeding that requires endoscopic hemostasis.

Successful resection of complicated bleeding arteriovenous malformation of the jejunum in patients starting dual-antiplatelet therapy just after implanting a drug-eluting coronary stent.

We report a case of a 57-year-old man who started dual-antiplatelet therapy with aspirin and clopidogrel following implantation of drug-eluting coronary stent and developed persistent active gastrointestinal bleeding. After detecting the origin of bleeding by double-balloon enteroscopy, successful laparoscopy-assisted partial jejunal resection was performed and the patient condition was promptly recovered, without any thrombotic or bleeding complications. Pathology revealed arteriovenous malformation of the jejunum without any malignancy. We should care for and be aware of this lesion as a rare cause of gastrointestinal bleeding when strong antithrombotic therapy is initiated. Under rigorous assessment and perioperative management, as well as meticulous intraoperative dissection and haemostasis, satisfactory outcome was achieved even in this complicated situation.

[A case of unresectable hilar cholangiocarcinoma successfully treated by gemcitabine and S-1 combination chemotherapy].

A 52-year-old male was presented with obstructive jaundice and liver dysfunction. He was diagnosed as hilar cholangiocarcinoma involving the confluence of the right and left hepatic duct and bifurcation of the main portal vein trunk. Swollen lymph nodes in the hepatoduodenal ligament were also detected. ERBD tubes were placed in each B2, 3, and 5 branch. GEM and S-1 combination chemotherapy was carried out for four months. As a reduction in the primary tumor and lymph nodes was observed on CT scan surgical exploration was conducted, and an extended left hepatectomy with partial resection of the portal vein and regional lymph node dissection was achieved. The postoperative course was uneventful, and the patient remained free of recurrence, 34 months after the original diagnosis was made, and 29 months after surgical resection. Thus, GEM and S-1 combination chemotherapy is one of the options for the management of advanced hilar cholangiocarcinoma.

Undifferentiated carcinoma of the common bile duct with intraductal tumor thrombi: report of a case.

We report a case of undifferentiated carcinoma of the common bile duct with intraductal tumor thrombi. A 73-year-old man presented with general malaise. Abdominal computed tomography and magnetic resonance imaging revealed a mass in the distal common bile duct, accompanied by dilatation of the intra- and extrahepatic bile ducts. The patient underwent pancreaticoduodenectomy with regional lymphadenectomy. Gross examination revealed that the distal common bile duct was obstructed by an elastic hard mass, 3.2 × 2.6 cm, accompanied by intraductal tumor thrombi. Microscopically, the nodule was well defined and composed of atypical large tumor cells with bizarre nuclei and little cytoplasm. Immunohistochemically, the tumor cells were diffusely positive for cytokeratin-7 and CAM5.2, but negative for CD56, chromogranin A, and synaptophysin. Thus, a histological diagnosis of undifferentiated carcinoma of the common bile duct was made. The patient recovered uneventfully and has remained free of any signs of recurrence for 18 months since the operation. Undifferentiated carcinomas of the extrahepatic bile duct can be detected early, with the chance of a good prognosis; however, because their biologic growth behavior is still considered aggressive, careful observation after surgery and the initiation of multidisciplinary treatment against recurrence are necessary.

Factors predicting incomplete endoscopic hemostasis in bleeding gastroduodenal ulcers.

BACKGROUND/AIMS: To investigate the factors contributing to failure of initial hemostasis in patients undergoing endoscopic hemostasis. METHODOLOGY: A total of 316 patients underwent endoscopic hemostasis for bleeding peptic ulcers in a period of 4 years. RESULTS: For hemostatic procedures, application of hemostatic clips, band ligation, injection of hypertonic saline epinephrine solution, soft coagulation, and argon plasma coagulation were employed either singly or in combination. Patients were divided into the following 2 groups for multivariate analysis: durable hemostasis (n = 268) and failed initial (incomplete) hemostasis (n = 48). Hemodialysis was a risk factor of incomplete hemostasis (Odds Ratio [OR] = 2.306, 95% confidence interval [CI] = 1.033-5.147; p = 0.041). Compared with the duodenal 2nd portion, the following bleeding sites had significantly lower risk of incomplete hemostasis (approximately 5 times less likely): The duodenal bulb (D), OR = 0.215, 95% CI = 0.058-0.797 (p = 0.022); the L region, OR = 0.207, 95% CI = 0.046-0.919 (p = 0.038); the M region, OR = 0.132, 95% CI = 0.036-0.482 (p = 0.002); and the U region, OR = 0.164, 95% CI = 0.041-0.649 (p = 0.01). CONCLUSIONn: Hemodialysis and a bleeding site located in the duodenal second portion were the factors strongly associated with incomplete hemostasis in bleeding gastroduodenal ulcers.

Effect of a late evening snack on outpatients with liver cirrhosis.

AIMS: We have reported that one-week administration of a late evening snack (LES) improved not only malnutrition but also glucose intolerance in hospitalized patients with liver cirrhosis. Thus, we investigated whether long-term LES administration to outpatients for 3 months could reproduce the results obtained from hospitalized patients, especially improved glucose intolerance. If this treatment aggravated glucose intolerance, we tried to find any marker predicting this aggravation before the treatment. METHODS: Outpatients were prescribed one pack of oral supplementation of a branched-chain amino acid (BCAA)-enriched nutrient, Aminoleban EN (210 kCal) as a LES without dietician supervision. Both before LES administration and after 3 months, glucose tolerance and liver function were examined using a 75 g oral glucose tolerance test (OGTT), biochemical parameters in blood and the relationship between glucose tolerance (area under the curve (AUC)) and the following serum markers. RESULTS: Branched-chain amino acid/tyrosine ratio (BTR), the number of red blood cells (RBC), and hematocrit (Ht) significantly increased, with significant reduction of blood NH(3) level in patients with a blood glucose level less than 200 mg/dL 2 h after 75 g OGTT. However, the increase of AUC was seen after 3 months of LES administration in patients who had blood glucose higher than 200 mg/dL 2 h after 75 g OGTT. AUC weakly correlated positively with serum 7S collagen and negatively with choline esterase (ChE) and albumin (Alb). CONCLUSION: 75 g OGTT is a useful marker to predict the worst outcome and avoid the adverse effect of LES treatment in liver cirrhosis patients if performed without adequate nutrient conduct by a dietician.

[A case of gastric cancer with multiple liver metastases responding completely to TS-1].

We report a case of a 65-year-old male with stage IV gastric cancer accompanied by liver metastases, which showed a significant response after administration of TS-1. One hundred and twenty mg/body/day of TS-1 was orally administered without hospitalization. After 3 months, upper GI endoscopy showed improvement of primary gastric lesion, and cancer cells could not be detected under biopsy. After 2 months, computed tomography (CT) showed a reduction in the multiple liver metastases. Moreover, after 15 months, CT showed a complete regression of the multiple liver metastases, for a complete response (CR). The serum level of carcinoembryonic antigen (CEA) was reduced from 115 to within normal range. Noticeable critical adverse effects did not appear. Treatment on an outpatient basis, therefore, greatly contributed to his quality of life. We judged that TS-1 might be a candidate anti-cancer drug for first-line chemotherapy for advanced gastric cancer.

Vascular endothelial growth factor-C expression in human gallbladder cancer and its relationship to lymph node metastasis.

Lymph node metastasis is a major prognostic factor in human cancer. Vascular endothelial growth factor C (VEGF-C) is a lymphangiogenic polypeptide that has been implicated in several human solid tumors. However, the clinical significance of VEGF-C has remained unknown in gallbladder carcinoma. Paraffin-embedded tumor specimens of 52 surgically resected gallbladder cancers were immunohistochemically stained for VEGF-C, VEGF, and CD34. The correlations among VEGF-C expression, VEGF expression, microvessel density (MVD), clinicopathologic features, and clinical outcomes were statistically analyzed. Thirty-three (63%) of the 52 gallbladder cancers were highly positive for VEGF-C protein by immunohistochemistry. VEGF-C expression was significantly correlated with lymphatic vessel involvement, lymph node metastasis, and worse outcomes after operation (p<0.001, p<0.001, p<0.001, respectively), but not with MVD. By the Cox regression model, lymphatic vessel involvement emerged as an independent prognostic parameter. These results suggest that VEGF-C may play a role in tumor progression via lymphangiogenesis and lymph node metastasis in human gallbladder cancer.

Detection of genetic alterations in pancreatic cancers by comparative genomic hybridization coupled with tissue microdissection and degenerate oligonucleotide primed polymerase chain reaction.

The aim of this study was to elucidate cytogenetic changes in pancreatic cancers (PCs) and to examine their clinical implications. We screened for genetic alterations in 32 primary PCs including 4 cases with distant organ metastasis using comparative genomic hybridization coupled with tissue microdissection and degenerate oligonucleotide primed polymerase chain reaction (DOP-PCR). The present study revealed frequent gains of chromosomes 13q and 15q and a loss of Xq in addition to a high prevalence of chromosomal imbalances. The average number of total genetic alterations and gains tended to be higher in N1 tumors (TNM classification) than in N0 tumors. The average number of amplifications was significantly higher in M1 tumors than in M0 tumors (p = 0.024). Gain/amplification of 20q was more frequently observed in M1 tumors than in M0 tumors (p = 0.016), and this change was also detected in all of 4 distant metastatic lesions. Losses of 6q, 8p, 9p, 17p, and 18q were recurrent in N0 and M0 tumors, and these alterations were also retained in N1 and M1 tumors. These observations suggest that these genetic losses contribute to the development of PCs and that increases in the DNA copy number confer an aggressive character on cancer cells. Especially, gain/amplification of 20q was associated with the potential of distant organ metastasis of tumor cells.

Chromosomal imbalances detected by comparative genomic hybridization are associated with outcome of patients with hepatocellular carcinoma.

BACKGROUND: Biologic characteristics of tumors are greatly affected by genetic aberrations. However, to the authors' knowledge there is no study that shows that cytogenetic information is useful for estimating prognosis of patients with hepatocellular carcinoma (HCC). METHODS: Comparative genomic hybridization (CGH) analysis was performed in 41 HCCs to examine whether the analysis of cytogenetic aberrations allows us to estimate biologic behavior of HCC. RESULTS: Tumor recurrence was linked to the loss at 13q (P = 0.0027) and to the number of DNA copy number aberrations (DCNAs; P = 0.0003). The decrease in DNA copy number at 8p and 13q and amplification at 11q13 were significantly associated with unfavorable outcome of patients (P = 0.017, P = 0.012, and P = 0.00081, respectively). The number of DCNAs was significantly different between favorable and poor prognosis patients with HCC; 5.78 +/- 2.7 versus 11.13 +/- 4.8 (P = 0.004), and it was an independent prognostic marker in HCCs. CONCLUSIONS: The current study indicates that cytogenetic information provided by CGH is useful for estimating prognosis of patients with HCC.

Interglandular cytogenetic heterogeneity detected by comparative genomic hybridization in pancreatic cancer.

The aim of this study is to explore the mechanisms of intratumoral cytogenetic heterogeneity (ICH) in pancreatic cancer. Using comparative genomic hybridization (CGH) analysis, we investigated interglandular variation in 20 primary invasive ductal adenocarcinomas of the pancreas. Three or four adjacent neoplastic glands were individually microdissected from a tumor specimen. Extracted DNA from each gland was amplified by degenerate oligonucleotide primed-PCR, followed by CGH. In addition, DNA index (DI) was measured by laser scanning cytometry in each case. CGH profiles displayed a wide variety of differences between glands within the same tumor in all cases, i.e., interglandular cytogenetic heterogeneity was distinct in pancreatic cancers. In this study, genetic changes detected in all regions of a tumor were classified as "region-independent" alterations, whereas changes seen in at least one, but not all regions were designated as "region-dependent" alterations, which resulted in ICH. The degree of ICH, which was manifested as the ratio of these two types of alterations, correlated closely with DI (Spearman rho = 0.842; P = 0.0002). Therefore, DI might be a surrogate marker for ICH. These results suggest that with tumor progression, ICH and DNA aneuploidy result from the successive appearance of region-dependent alterations attributable to chromosomal instability in tumor cells. Our data support a concept of individual cell heterogeneity in pancreatic cancer.