[A Case of Double Cancer of Squamous Cell Carcinoma of the Rectum and Adenocarcinoma of the Sigmoid Colon].

A 72-year-old male was transported to our hospital with complaints of heart palpitations and dyspnea since a month earlier and was immobile. Blood examination showed severe anemia, and colonoscopy revealed circumferential tumors in the rectum and the sigmoid colon. Histopathologic examination revealed the tumors as squamous cell carcinoma of the rectum and adenocarcinoma of the sigmoid colon. Therefore, they were diagnosed as double colorectal cancers. CT and MRI showed that rectal cancer invaded the seminal vesicles and the prostate; therefore, the patient underwent neoadjuvant chemoradiotherapy(oral capecitabine and concomitant radiation therapy: a total dose of 50.4 Gy/28 Fr)followed by total pelvic exenteration. Subsequent specimen pathology revealed a tumor regression grading of Grade 2 for the rectal and sigmoid colon cancers, and both were staged as ypT3N0M0, ypStage Ⅱa. Herein, we report a rare case of double cancer of adenocarcinoma of the sigmoid colon and squamous cell carcinoma of the rectum with a literature review.

Social implementation of a remote surgery system in Japan: a field experiment using a newly developed surgical robot via a commercial network.

PURPOSE: In recent years, the expectations for telesurgery have grown with the development of robot-assisted surgical technology and advances in communication technology. To verify the feasibility of the social implementation of telesurgery, we evaluated the communication integrity, availability, and communication delay of robotic surgery by remote control under different communication conditions of commercial lines. METHODS: A commercial line was used to connect hospitals 150 km apart. We had prepared guaranteed-type lines (1Gbps, 10Mbps, 5Mbps) and best effort-type lines. Two types of robotic teleoperations were performed, and we evaluated the round-trip time (RTT) of communication, packet loss, and glass-to-glass time. RESULTS: The communication delay was 4 ms for the guaranteed-type line and 10 ms for the best effort-type line. Packet loss occurred on the 5 Mbps guaranteed-type line. The mean glass-to-glass time was 92 ms for the guaranteed-type line and 95 ms for the best effort-type line. There was no significant difference in the number of errors in the task according to the type of line or the bandwidth speed. CONCLUSIONS: The social implementation of telesurgery using the currently available commercial communication network is feasible.

Pharmacological Inhibition of mTORC2 Reduces Migration and Metastasis in Melanoma.

Despite recent advances in therapy, liver metastasis from melanoma is still associated with poor prognosis. Although targeting the mTOR signaling pathway exerts potent anti-tumor activity, little is known about specific mTORC2 inhibition regarding liver metastasis. Using the novel mTORC2 specific inhibitor JR-AB2-011, we show significantly reduced migration and invasion capacity by impaired activation of MMP2 in melanoma cells. In addition, blockade of mTORC2 induces cell death by non-apoptotic pathways and reduces tumor cell proliferation rate dose-dependently. Furthermore, a significant reduction of liver metastasis was detected in a syngeneic murine metastasis model upon therapy with JR-AB2-011 as determined by in vivo imaging and necropsy. Hence, our study for the first time highlights the impact of the pharmacological blockade of mTORC2 as a potent novel anti-cancer approach for liver metastasis from melanoma.

[Improvement of QOL by Surgery in Two Patients for Brain Metastasis from Esophageal Carcinoma with Paralysis-A Report of Two Cases].

Brain metastasis from esophageal cancer is rare. Symptoms such as paralysis caused a decline in quality of life(QOL)and activity of daily life(ADL)and required emergency treatment. We report 2 cases in which QOL was improved by emergency resection for brain metastasis from esophageal carcinoma with paralysis. Case 1: A 50's male was diagnosed esophageal carcinoma and underwent esophagectomy(pT3N2M0, Stage Ⅲ). Brain metastasis was detected owing to development of left hemiparesis. Craniotomy and tumorectomy were performed, left hemiparesis was improved. He died 10 months after diagnosis of brain metastasis due to progression of other metastatic lesions. Case 2: A 61-year-old female was diagnosed esophageal carcinoma and underwent esophagectomy(pT3N1M0, Stage Ⅲ). She developed right hemiparesis 5 months after esophagectomy, admitted to our hospital. Brain and lung metastases were detected, craniotomy and tumorectomy and were performed, right hemiparesis was improved. Although systemic chemotherapy was administered, she died 10 months after diagnosis of brain metastasis due to progression of lung metastasis. Conclusion: Aggressive surgical treatments for brain metastasis were one good treatment option to maintain QOL and ADL.

[Postoperative Bile Leakage Following Liver Resection Due to Stenosis of a Choledochojejunostomy Anastomosis after Pancreaticoduodenectomy - A Case Report].

We report a rare case of intractable bile leakage after liver resection due to stenosis of the anastomosis of a choledochojejunostomy after pancreaticoduodenectomy. A 65-year-old woman was diagnosed with pancreatic and right breast cancer, and underwent pancreaticoduodenectomy and right mastectomy with simultaneous axillary lymph node dissection. Adjuvant chemotherapy and follow-up were performed in our department. After 18 months, computed tomography revealed a liver metastasis of 2.5 cm in segment 8. Because the primary nest of liver metastasis was unknown and performing a biopsy was difficult due to the location, partial resection of the liver was performed. Pathological examination confirmed liver metastasis from the breast cancer. She was rehospitalized due to a right subdiaphragmatic abscess 33 days post-surgery. Abscess drainage revealed bile leakage, and the cause was believed to be stenosis of the anastomosis created by the choledochojejunostomy. Percutaneous transhepatic cholangiographic drainage was performed, and the bile leakage disappeared immediately. However, it was difficult to release the anastomotic stenosis by choledochoscopy; therefore, a retrograde drainage tube was placed in the hepatic duct using enteroscopy, and it formed an internal fistula. The patient has continued to undergo chemotherapy for recurrence in the remnant liver that was observed 16 months after the hepatectomy. In conclusion, when hepatic resection is performed after pancreaticoduodenectomy, attention should be paid to the possible occurrence of bile leakage.

[Radical Operation Performed on a Gastric Cancer Patient with Cold Agglutinin Disease - A Case Report].

A 56-year-old man with no abnormalmedicalhistory was admitted to our hospitalfor gastric cancer surgery. The preoperative laboratory tests indicated anemia, hyperbilirubinemia, hemagglutinin reaction, and a markedly high cold agglutinin titer; thus, we diagnosed the patient with cold agglutinin disease(CAD). Although perioperative complications caused by cold stimulation were suspected, we decided that it was possible to perform the operation under robust intraoperative conditions avoiding exposure to cold temperatures, and thus performed the radical operation. Intraoperatively, we performed blood transfusion because the anemia of the patient progressed owing to bleeding; however, no other complications were noted. Postoperatively, the clinical course was good without any complications, and the patient was discharged 13 days after the operation. The present case demonstrated that CAD patients requiring surgery can safely be operated on if their conditions, including perioperative body temperature management, are adequately considered during surgical preparation.

[A Case of Neuroendocrine Carcinoma of the Esophagus Treated with Neoadjuvant Chemotherapy Comprising 5-Fluorouracil plus Cisplatin].

Esophageal neuroendocrine carcinoma is relatively rare and the prognosis is poor owing to its aggressive malignancy. We experienced a case of neuroendocrine carcinoma of the esophagus treated with neoadjuvant chemotherapy of 5-fluorouracil plus cisplatin. A 71-year-old man was diagnosed with esophageal carcinoma(clinical T3N1M0, Stage III ). He received neoadjuvant chemotherapy comprising 5-fluorouracil plus cisplatin, followed by subtotal esophagectomy with dissection of 3 regional lymph nodes. Immunohistochemical findings were synaptophysin-positive, CD56-positive, Ki-67(labeling index) B90%. The final diagnosis was neuroendocrine carcinoma, categorized as CT-pT1a-MM, pN0, Stage 0. The pathological response to neoadjuvant chemotherapy was Grade 2. The patient is alive 8 months after esophagectomy without metastasis.

[A Case of Laparoscopic Surgery for Rectal Cancer with Synchronous Lung Metastases after Chemotherapy].

A woman in her 70's presented with the predominant complaint of bloody stools. She was diagnosed with rectal cancer, and bilateral lymph node and pulmonary metastases were detected on computed tomography(CT). The patient was diagnosed with cT3N3M1a, cStage IV disease. After undergoing a colostomy, the patient was treated with S-1 plus oxaliplatin (SOX), and bevacizumab(Bev). A second CT scan obtained after completion of 7 courses of chemotherapy revealed that the lung metastases had significantly reduced or disappeared. Approximately 7 months after initial treatment, the patient underwent a laparoscopic Hartmann procedure to remove the tumor. The patient is currently under observation while being administered postoperative adjuvant chemotherapy as an outpatient in our department. There is currently no evidence of the safety of laparoscopic-assisted rectal cancer surgery for first-time Stage IV cases. However, when tumor regression has been achieved with chemotherapy, it may be an effective option.

[A Case of Pathological Complete Response after Neoadjuvant Chemotherapy(S-1 plus Oxaliplatin)and Laparoscopic Low Anterior Resection for Rectal Cancer].

We report a case of pathological complete response after neoadjuvant chemotherapy(NAC)(S-1 plus oxaliplatin)for rectal cancer. The patient was a 50-year-old man who had type 3 circumferential rectal cancer. An abdominal CT scan revealed locally advanced rectal cancer(cT3N2H0P0M0, cStage III b)with severe stenosis and oral-side intestinal dilatation. The patient was treated with NAC after loop-ileostomy. After 3 courses of chemotherapy, a CT scan revealed significant tumor reduction. Laparoscopic low anterior resection and bilateral lymph node dissection were performed 5 weeks after the last course of chemotherapy. The pathological diagnosis was a pathological complete response(no residual cancer cells). This case suggests that laparoscopic low anterior resection after NAC with S-1 plus oxaliplatin for locally advanced rectal cancer is a potentially effective procedure.

[A Case of Solitary Brain Metastasis from Stage 0 Esophageal Carcinoma after Neoadjuvant Chemotherapy Followed by Surgery].

Esophageal carcinoma rarely metastasizes to the brain. We experienced a case of solitary brain metastasis from Stage 0 esophageal carcinoma after surgery. A 54-year-old man was diagnosed with esophageal carcinoma (clinical T3N2M0, cStage Ⅲ). He received neoadjuvant chemotherapy consisting of 5-fluorouracil plus cisplatin followed by subtotal esophagectomy with dissection of 3 regional lymph nodes. The pathological diagnosis was poorly differentiated squamous cell carcinoma, CTpT1a- EP (T2), pN0, sM0, fStage 0. The pathological response of neoadjuvant chemotherapy was Grade 2. Eight months after surgery, abnormality of the right frontal lobe was identified with positron emission tomography(PET). Brain magnetic resonance imaging (MRI) uncovered a solitary 25 mm lobular tumor at the right frontal lobe, although no evidence of local recurrence or other metastatic sites was found. Gamma knife therapy was performed for the brain metastasis.He has survived for 35 months after esophagectomy without other metastases.

[A Case of Long-Term Survival after Surgeries for Gastric Cancer and Metachronous Ovarian Metastasis].

The patient was a 57-year-old woman. In October 2011, she underwent distal gastrectomy, D2 lymphadenectomy, and Roux-en-Y reconstruction for gastric cancer (pT4a, pN3b, Stage ⅢC [JCGC 14th Edition]). She then received S-1 plus CDDP combination therapy and S-1 monotherapy as postoperative adjuvant chemotherapies for 1 year, and was followed up as an outpatient. In April 2013, a significant increase in the CA19-9 level was noted, and CT indicated a right ovarian tumor. Ovarian metastasis from the gastric cancer was diagnosed, and the response to 3 courses of weekly PTX was stable disease. No findings indicated metastasis to other organs. In July 2013, a salpingo-oophorectomy was performed, after which her CA19-9 level returned to the normal range. Follow-up was adopted as the postoperative strategy in part due to the desires of the patient. Presently, 3 years and 6 months after the initial surgery and 1 year and 9 months after the last surgery, no recurrence has been detected. Generally, ovarian metastasis from gastric cancer is considered to be associated with a poor prognosis. However, our patient showed long-term survival after surgeries for gastric cancer and asynchronous ovarian metastasis. Here, we report the details of our case and review the relevant literature.

[A case of metastatic liver tumor arising from gastric cancer resected after second-line chemotherapy].

A man in his 60s was diagnosed with gastric cancer and underwent distal gastrectomy and D2 lymph node dissection. The histological diagnosis was adenocarcinoma (T3, N1, StageIIB). He was treated with S-1 as adjuvant chemotherapy for 1 year. One year and 2 months after gastrectomy, a computed tomography (CT) scan revealed liver metastasis (S8, 38 mm). The patient was diagnosed with liver metastasis(refractory to S-1), and administered combination chemotherapy with irinotecan and cisplatin. After 4 courses of treatment, a CT scan detected a progressive liver tumor (55 mm). Combination chemotherapy with docetaxel and S-1 was selected as second-line chemotherapy. After 6 courses of treatment, the tumor size reduced to 40 mm in diameter, and no other metastasis was detected. Nine months after the diagnosis of liver metastasis, partial resection of the liver (S8) was performed. A pathological diagnosis of metastatic adenocarcinoma was determined, and the pathological therapeutic effect was rated as Grade 1b. Combination chemotherapy with docetaxel and S-1 was found to be effective, and was thus administrated after the operation. There have been no signs of recurrence for 6 months after the operation. Surgery with perioperative chemotherapy can be an effective treatment for liver metastasis from gastric cancer.

[Salvage gastrectomy and radiotherapy for R-CHOP-refractory gastric malignant lymphoma].

A man in his seventies presented with a stomach abnormality that was revealed upon physical examination.Following workup, he was diagnosed with gastric diffuse large B-cell lymphoma (DLBCL)StageII1 (Lugano staging system for gastrointestinal lymphoma) with low risk as defined by the International Prognostic Index criteria.The entire stomach showed an intense, abnormal FDG uptake by FDG-PET evaluation.He was treated with rituximab plus CHOP (R-CHOP).The patient's body weight decreased by 12 kg during the treatment period.Post -treatment evaluation by gastroscopy and FDG-PET following 5 courses of R-CHOP therapy revealed a residual lesion in the stomach.Total gastrectomy was performed for R-CHOP refractory gastric DLBCL.The pathological diagnosis was DLBCL, and the pathological therapeutic effect was Grade 1a.Lymphoma cells were detected at the duodenal margin of the resected specimen, and an FDG-PET scan showed abnormal FDG uptake in the duodenal stump necessitating salvage chemotherapy (DeVIC therapy)and radiotherapy.The patient's body weight increased by 5 kg after gastrectomy and there were no signs of relapse for 14 months after the operation.Salvage therapy including gastrectomy may be effective for chemotherapy-resistant gastric DLBCL.

[A case of pneumatosis cystoides intestinalis after neoadjuvant chemotherapy for esophageal cancer].

A man in his 60s was diagnosed with esophageal cancer (T3, N0, StageII) and treated with 5-fluorouracil and cisplatin as neoadjuvant chemotherapy (NAC). On day 18 of the second NAC course, the patient developed febrile neutropenia, and a computed tomography (CT) scan showed pneumatosis cystoides intestinalis (PCI) of the ascending and transverse colon, free air around the ascending colon, thickening of the gallbladder wall, pleural effusion, and ascites. Because there were no signs of peritoneal irritation and intestinal perforation was ruled out, conservative treatment was selected. Seven days after PCI was diagnosed, CT showed improvement in PCI and the free air had disappeared, and 26 days after the diagnosis, a subtotal esophagectomy was performed. Observation of the abdomen did not show a thickened wall or stenosis of the ascending or transverse colon. PCI could be treated conservatively, even with free air in the abdominal cavity, by comprehensively assessing not only the imaging but also the physical findings. We were able to perform radical resection of the esophageal cancer without excessive treatment for PCI.

[A case of malignant peritoneal mesothelioma without deletion of p16].

The patient was a man in his 60s with a history of 2 operations for the treatment of malignant neurogenic tumors. Partial resection of the stomach and liver was performed in December 2006, followed by chemotherapy with adriamycin and interferon; resection of a recurrent tumor in the left subphrenic space was performed in December 2007. In June 2011, recurrent tumors were detected in the lesser curvature of the stomach body and left inferior quadrant of the abdomen (12 mm [SUVmax 7.9] and 23 mm [SUVmax 10.5], respectively)by using 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET). The tumors resected in August 2011 were diagnosed as malignant peritoneal mesothelioma on immunohistochemical analysis. In February 2013, FDG-PETrevealed a 20-mm tumor of in the mesentery with a SUVmax of 7.6, and the tumor was resected. This secondary tumor had the same features of the previously resected malignant mesothelioma. Fluorescence in situ hybridization revealed no deletion of the p16 gene, and the patient had had no other recurrence during follow-up. Malignant peritoneal mesothelioma is a rare disease, accounting for 10% of all malignant mesothelioma cases, with low rates of p16 gene deletion compared with malignant pleural mesothelioma. Previous studies have reported that the lack of p16 deletion is associated with better prognosis in malignant pleural mesothelioma. Herein, we report of a patient diagnosed with malignant peritoneal mesothelioma, without deletion of the p16 gene, who survived for over 2 years and 10 months after initial diagnosis of malignant mesothelioma.

[Conversion therapy for synchronous colorectal liver metastases].

Conversion therapy, a treatment strategy that facilitates the conversion of unresectable colorectal liver metastases (CRLM) to resectable CLRM after chemotherapy, has been reported to be effective. We assessed the applicability of treatment strategies for conversion therapy in 93 patients with synchronous CRLM encountered at our department. Of the 93 patients, 12 underwent conversion therapy and there was no significant difference in the clinicopathological factors of CRLM. The first-line regimen for 67% of the 12 patients who underwent conversion therapy was multidrug therapy with oxaliplatin and the number of courses administered ranged from 3 to 24. The 5-year survival rate of patients who underwent conversion therapy was 46%,and there was no significant difference when compared with the 5-year survival rate of patients who underwent hepatectomy for resectable CRLM. In order to improve the survival rate of patients with synchronous CRLM, it is important that more patients undergo conversion therapy with effective chemotherapy. Moreover, we believe that it is necessary to assess the appropriate balance in treatment between chemotherapy and hepatectomy in the future.

Skeletal muscle mass and quality before preoperative chemotherapy influence postoperative long-term outcomes in esophageal squamous cell carcinoma patients.

BACKGROUND: Previous reports have focused on muscle mass as a prognostic factor in esophageal cancer. AIM: To investigate how preoperative body type influences the prognosis of patients with esophageal squamous cell carcinoma who underwent neoadjuvant chemotherapy (NAC) and surgery. METHODS: The subjects were 131 patients with clinical stage II/III esophageal squamous cell carcinoma who underwent subtotal esophagectomy after NAC. Skeletal muscle mass and quality were calculated based on computed tomography images prior to NAC, and their statistical association with long-term outcomes was examined retrospectively in this case-control study. RESULTS: The disease-free survival rates in the low psoas muscle mass index (PMI) group vs the high PMI group were 41.3% vs 58.8% (P = 0.036), respectively. In the high intramuscular adipose tissue content (IMAC) group vs the low IMAC group, the disease-free survival rates were 28.5% vs 57.6% (P = 0.021), respectively. The overall survival (OS) rates for the low PMI group vs the high PMI group were 41.3% vs 64.5% (P = 0.008), respectively, and for the high IMAC group vs the low IMAC group, they were 29.9% vs 61.9% (P = 0.024), respectively. Analysis of the OS rate revealed significant differences in patients aged 60 years or older (P = 0.018), those with pT3 or above disease (P = 0.021), or those with lymph node metastasis (P = 0.006), aside from PMI and IMAC. Multivariate analysis demonstrated that pT3 or above [hazard ratio (HR): 1.966, 95% confidence interval (CI): 1.089-3.550, P = 0.025), lymph node metastasis (HR: 2.154, 95%CI: 1.118-4.148, P = 0.022), low PMI (HR: 2.266, 95%CI: 1.282-4.006, P = 0.005), and high IMAC (HR: 2.089, 95%CI: 1.036-4.214, P = 0.022) were significant prognostic factors for esophageal squamous cell carcinoma. CONCLUSION: Skeletal muscle mass and quality before NAC in patients with esophageal squamous cell carcinoma are significant prognostic factors for postoperative OS.

Strangulated bowel obstruction caused by an ileo-ileal knot: a rare case report.

BACKGROUND: Intestinal knot formation is a condition wherein two segments of the intestine are knotted together; however, reports of small-intestinal ileo-ileal knot formation are rare. CASE PRESENTATION: The patient was a 62-year-old Asian male with a history of endoscopic colorectal adenoma resection and a spontaneous pneumothorax. The patient had no history of a laparotomy. He consulted his local doctor with the chief complaint of abdominal pain and was admitted to our hospital with suspicion of an acute abdomen. The abdomen had muscular guarding with tenderness and rebound tenderness. Contrast-enhanced computed tomography (CT) showed torsion of the mesentery of the small intestine with poor contrast filling. The patient was referred to our department with strangulated bowel obstruction and underwent an emergency laparotomy. Intraoperative findings revealed that two segments of the ileum were wrapped around each other to form a knot, and the strangulated small bowel was necrotic. After the release of the knot, partial resection of the small intestine was performed from 220 cm distal to the ligament of Treitz to 80 cm proximal to the cecum. The patient had a good postoperative course and was discharged on the 11th postoperative day. CONCLUSION: Ileo-ileal knots should be considered as part of the differential diagnosis when treating strangulated bowel obstruction.

Reappraisal of telesurgery in the era of high-speed, high-bandwidth, secure communications: Evaluation of surgical performance in local and remote environments.

Aim: Communication and video transmission delays negatively affect telerobotic surgery. Since latency varies by communication environment and robot, to realize remote surgery, both must perform well. This study aims to examine the feasibility of telerobotic surgery by validating the communication environment and local/remote robot operation, using secure commercial lines and newly developed robots. Methods: Hirosaki University and Mutsu General Hospital, 150 km apart, were connected via a Medicaroid surgical robot. Ten surgeons performed a simple task remotely using information encoding and decoding. The required bandwidth, delay time, task completion time, number of errors, and image quality were evaluated. Next, 11 surgeons performed a complex task using gallbladder and intestinal models in local/remote environments; round trip time (RTT), packet loss, time to completion, operator fatigue, operability, and image were observed locally and remotely. Results: Image quality was not so degraded as to affect remote robot operation. Median RTT was 4 msec (2-12), and added delay was 29 msec. There was no significant difference in accuracy or number of errors for cholecystectomy, intestinal suturing, completion time, surgeon fatigue, or image evaluation. Conclusion: The fact that remote surgery succeeded equally to local surgery showed that this system has the necessary elemental technology for widespread social implementation.

Verification of delay time and image compression thresholds for telesurgery.

INTRODUCTION: Telerobotic surgery relies on communication lines, causing delays, and video information requires pre-transmission compression. Such delays and video degradation will continue to be unavoidable making communication conditions verification essential. Understanding the network specification values required for telerobotic surgery entails determining acceptable levels of delay and degradation due to the video compression and restoration processes during surgery. METHODS: The hinotori™ surgical robot from Medicaroid was used. Eight surgeons, skilled in robotic surgery, performed gastrectomy or rectal resection on pigs. Image compression (bitrate: 120, 60, 30, 20, 10 Mbps) was random, changing encoder settings during surgery, and delay times (30, 50, 100, 150 milliseconds) were pseudo-randomly inserted, changing emulator settings. Acceptable video levels were evaluated. Subjective evaluations by surgeons and evaluators regarding image degradation and operability, and objective evaluations of image degradation and operability were given five-point ratings. RESULTS: Regarding delay time, 30 and 50 millisecond periods garnered average ratings of 3.6 and 4.0, respectively, signifying that surgery was feasible. However, at 100 and 150 millisecond, average ratings were 2.9 and 2.3, respectively, indicating surgery was not feasible for the most part in these cases. The average rating for image compression was 4.0 or higher for bitrates of 20, 30, 60, and 120 Mbps, suggesting that surgery is possible even at bitrates as low as 10 Mbps, with an average rating of 4.0. CONCLUSION: In remote robotic surgery using the hinotori™, image compression and delay time are largely acceptable, so surgery can be safely performed.