[A Case of Laparoscopic Repair for Hiatal Hernia Occurred Five Years after Esophagectomy for Esophageal Cancer].

A 70s man underwent minimally invasive esophagectomy and gastric conduit reconstruction via the posterior mediastinal route for early esophageal cancer 5 years ago. Three days prior to hospital visit, he presented with abdominal fullness, left chest pain, and vomiting. A CT revealed a postoperative hiatal hernia, and emergency surgery was performed laparoscopically. The laparoscopic findings showed that the transverse colon had prolapsed into the left thoracic cavity through the esophageal hiatus on the left side of the gastric conduit. The transverse colon had no sign of necrosis. The diaphragmatic defect was closed with unabsorbable suture. Increased bowel motility due to postoperative fat loss in the mesentery and intra-abdominal pressure are thought to be causes of the hernia. In addition, decreased adhesion formation due to endoscopic surgery may be a contributing factor. Although there is no unanimous opinion regarding the suture fixation of the conduit to the diaphragm after esophagectomy, it should be performed to prevent a herniation. Postoperative hiatal hernia occurs more than 5 years after the surgery is relatively rare, but its occurrence should be noted.

[A Case of Intrahepatic Cholangiocarcinoma Confused with a Recurrent Hepatocellular Carcinoma Treated by RFA at Diagnosis].

Intrahepatic cholangiocarcinoma(ICC)is the second most common malignant liver tumor after hepatocellular carcinoma (HCC). ICC is usually ischemic; however, it has variable findings and may be difficult to differentiate from HCC. We report about a case of ICC that was difficult to distinguish from HCC treated by radiofrequency ablation(RFA). A 79‒year‒old woman underwent RFA for HCC of the caudate lobe. Two years after RFA, a spindle‒shaped tumor was identified near the previous treatment site using contrast‒enhanced MRI. Images showed posterior segment bile duct dilation, posterior segment atrophy of the liver parenchyma, and posterior segmental portal vein disruption. We performed surgery because of the suspicion of a recurrent HCC invading into the bile duct. Intraoperative findings showed posterior segment atrophy. Intraoperative echocardiography could not identify the tumor but revealed a tumor plug and portal vein disruption in the posterior segment. The patient underwent post‒enlargement segmentectomy, caudate lobectomy of the liver, and biliary neoplastic resection. Histopathological findings showed no malignant findings in the hepatocytes. A moderately differentiated adenocarcinoma was found in the expanded bile duct, which was diagnosed as an intrahepatic cholangiocarcinoma. Here, we report about the case along with a discussion and a bibliographical consideration.

[A Case of Internal Hernia into a Reconstructed Pelvic Floor and Torsion of Jejunum near the Treitz Ligament after Laparoscopic Abdominoperineal Resection].

A 50s women underwent laparoscopic abdominoperineal resection(APR)for rectal cancer. Laparotomy was performed on the 8th postoperative day because of intestinal obstruction. An internal hernia was observed at the pelvic floor and the hernia orifice was found at the retroperitoneum that was sutured in the initial operation. On the other hand, the jejunum near the Treitz ligament was twisted, resulting in ischemic necrosis. The reason of the internal hernia is considered that a suction drain placed during the initial operation may have caused the rupture of the fragile part of the sutured peritoneum. Furthermore, increase of intra-abdominal pressure due to the internal hernia may have exacerbated the torsion of the jejunum near the Treitz ligament. This is probably due to the failure to the adequate reposition of the small intestine at the end of the initial operation. There is no consensus of the need for retroperitoneal sutures for APR. Currently, we only spray anti-adhesion agents on the pelvic floor without retroperitoneal reconstruction. Although the mobilization of small intestine is important to provide a good operative view in laparoscopic colorectal surgery, it is also important to confirm the reposition of the small intestine at the end of surgery.

[Gastric Complications in Stomach-Preserving Procedures on Total Pancreatectomy].

Whether the stomach should be preserved during total pancreatectomy(TP)is controversial. Therefore, we examined the correlation between stomach-preserving procedures on TP and postoperative gastric complications. Seven consecutive cases underwent TP(standard TP: 1 case, SSPTP: 3 cases, PPTP: 3 cases)for pancreatic cancer during the time period 2011-2019 at our hospital. There was no clinical case of postoperative gastric ulcer nor bleeding. Delayed gastric emptying(DGE)was observed in 4 cases of Grade A and 2 cases of Grade C. One of the Grade C cases was considered to be secondary DGE due to postoperative intestinal necrosis. The other was SSPTP case whose left gastric artery(LGA)was ligated. The patient had difficulty of food intake after the surgery and gastrointestinal endoscopy showed widespread hemorrhage and erosion of the gastric mucosa, considered to be ischemic gastropathy. Regarding primary DGE, most of cases were within Grade A even in stomach-preserving cases. Whereas, stomach-preserving procedure should be avoided when the LGA is ligated, because ischemic gastropathy may occur.

[Adenosquamous Carcinoma in the Remnant Pancreas after Pancreatoduodenectomy for Invasive Pancreas Cancer-A Resected Case with Five-Year Relapse-Free Survival].

A 52-year-old man underwent pancreatoduodenectomy(PD)for invasive cancer of the pancreatic head, with a histopathological diagnosis of moderately to poorly differentiated invasive ductal carcinoma. One year and 2 months after PD, follow- up CT revealed a mass 3 cm in diameter in the remnant pancreas without distant metastasis. Therefore, total remnant pancreatectomy was performed with a histopathological diagnosis of adenosquamous carcinoma. Five years after re-excision, the patient remains alive without recurrence. Although no tumor component was found at the anastomotic site of the pancreatojejunostomy, squamous metaplasia with chronic inflammation with carcinogenic potential was diffusely observed in the main pancreatic duct. Clinical cases of remnant pancreatic resection after PD for invasive cancer are relatively rare. Furthermore, this case of adenosquamous carcinoma with long-term recurrence-free survival is extremely rare.

[A Rare Case of Gastric Metastasis from Cholangio Carcinoma].

An 80-year-old man was referred to our hospital because of jaundice and fatigue. Abdominal computed tomography(CT) scan revealed an extrahepatic bile duct tumor, and biliary cytology detected adenocarcinoma; therefore, subtotal stomachpreserving pancreaticoduodenectomy was performed. Histological analysis showed that the tumor was a well-differentiated adenocarcinoma without lymph node metastasis. Two years after the initial surgery, blood examination detected an elevated serum CA19-9 level and submucosal tumor which is 2.5 cm diameter with an ulcer at the gastrojejunostomy anastomosis. Tumor biopsy was performed, and histological analysis revealed a recurrent cholangiocarcinoma. The tumor directly invaded the transverse colon mesentery; therefore, distal gastrectomy and right hemicolectomy were performed. The patient survived 12 months postoperatively without recurrence. Gastric metastasis from cholangiocarcinoma rarely occurs. Intraoperative exposure of bile juice may have caused gastric metastasis in this case.

[A Three-Year Survival Case of Extrahepatic Cholangiocarcinoma Treated with Palliative Bile Duct Resection and S-1 Monotherapy].

We report a 3-year survival case of cholangiocarcinoma treated with S-1 monotherapy despite positive margins after palliative bile duct resection. A 66 year-old man visited our hospital for jaundice. Because a smooth round defect was observed in the middle bile duct on ERCP, an impacted stone was suspected. Bile duct incision was performed, but the suspected stone was a tumor that was pathologically diagnosed as cholangiocarcinoma. Although pancreaticoduodenectomy was recommended, the patient decided to undergo palliative bile duct resection. Postoperative pathological examination showed moderately tubular adenocarcinoma with lymph node metastasis. The surgical margins of the hepatic side, duodenal side, and exfoliated surface were all positive. Subsequently, the patient chose to undergo S-1 monotherapy for maintaining his lifestyle. S-1 was orally administered at 100mg/day for 4 weeks, followed by 2 weeks of rest. He has continued S-1 monotherapy and survived for 3 years without evidence of recurrence.

[A retrospective study of tegafur/uracil compared with cyclophosphamide, methotrexate, and fluorouracil as adjuvant chemotherapy in patients with node-negative, triple-negative breast cancer].

Japanese clinical trials of a tegafur/uracil(UFT)-based postoperative chemotherapy regimen compared with cyclophosphamide, methotrexate, and fluorouracil(CMF)treatment have shown that UFT is not inferior to CMF for the treatment of hormone receptor-positive breast cancer patients. However, the usefulness of UFT for hormone receptor-negative breast cancer, including the triple-negative subtype(hormone receptor-negative, human epidermal growth factor receptor 2 [HER2]-negative), is unknown. The aim of this retrospective study was to examine the effectiveness of postoperative, adjuvant UFT compared to CMF when these regimens were given to women with node-negative, triple-negative breast cancer. We analyzed 50 women with node-negative, triple-negative breast cancer who were treated with six cycles of CMF(n=33) or two years of UFT(n=17)after surgery between January 2000 and December 2010. Although no significant differences were observed in relapse-free survival or overall survival in all patients, subset analysis of tumors of larger size(t2), higher nuclear grade(NG3), and with positivity for lymphovascular invasion showed that UFT was inferior to CMF. These results encourage caution regarding the choice of adjuvant UFT for node-negative, triple-negative breast cancer.

Ultrasonic Cleaning for Irrigating Purulent Substances during Laparoscopic Gastrointestinal Surgery.

To improve the outcome of laparoscopic gastrointestinal surgery, improvement in the technology for removing purulent substances from the abdominal cavity is required. Ultrasonic cleaning technology may be suitable for the task. However, it is necessary to examine cleaning efficiency and safety through model tests that can lead to clinical trials for practical use. Nine surgical specialists first estimated the distribution of the actual attachment of purulent substances using videos of removing pus-like model dirt as an evaluation scale. Subsequently, cleaning tests were conducted using a small-size shower with model dirt that was somewhat difficult to remove, and its suitability as a model sample was confirmed. A mixture of miso and other substances was attached to a silicon sheet to prepare a test sample. The model dirt could be removed within a few seconds by cleaning using a probe-type ultrasonic homogenizer while the test sample was submerged in water. This performance greatly surpassed that of water flow cleaning under increased water pressure. An ultrasonic cleaner that is useful for irrigation during laparoscopic surgery will be suitable for practical use in laparoscopic surgery.

Aldehyde dehydrogenase 1-positive cells in axillary lymph node metastases after chemotherapy as a prognostic factor in patients with lymph node-positive breast cancer.

BACKGROUND: Aldehyde dehydrogenase 1 (ALDH1)-positive cells exhibit stem-like or progenitor ability and have been considered a clinically important diagnostic and therapeutic target in patients with breast cancer. In this study, the authors evaluated responsiveness to chemotherapy of ALDH1-positive cells in primary and metastatic lesions and its relation to prognosis for patients with lymph node-positive breast cancer. METHODS: In total, 115 patients who had breast cancer with cytologically confirmed lymph node metastases and who underwent surgery after neoadjuvant chemotherapy (NAC) were evaluated. By using ALDH1 immunohistochemistry in core-needle biopsy specimens of the primary tumor, cytology samples of axillary lymph nodes before NAC, and pathologic samples of each after NAC, the clinical significance of ALDH1-positive cell status was evaluated in primary and metastatic lesions before and after NAC. RESULTS: The presence of ALDH1-positive cancer cells, but not ALDH1-negative cancer cells, in primary and metastatic lesions after NAC was associated with a worse prognosis. In multivariate analysis, only ALDH1-positive cells in metastatic lesions after NAC correlated with overall survival. The responsiveness of ALDH1-positive cells to chemotherapy differed between primary and metastatic lesions, and the findings indicated that ALDH1-positive cells in metastatic lesions after NAC may clinically precede those in the primary lesion. CONCLUSIONS: The responsiveness of ALDH1-positive cells to chemotherapy in primary and metastatic lesions and its prognostic significance were clarified in patients with breast cancer. The authors concluded that ALDH1-positive status may represent a surrogate marker as a new concept in patients with lymph node-positive breast cancer.

[Utility of CPT-11 as salvage chemotherapy for progressive or recurrent breast cancer patients with multiple drug resistance].

Salvage chemotherapy is necessary to maintain QOL among progressive or recurrent breast cancer patients with multiple drug resistance. We reported seven Japanese patients who received CPT-11 as salvage chemotherapy. Performance statuses of all patients were 1 or 2, and all patients were managed by ambulatory treatment. CPT-11 was administered at a dose of 80-100mg/m2 weekly on day 1 for 3 consecutive weeks, followed by a 2-week rest period. One patient had a partial response and CPT-11 was administered for 68 weeks. Two patients had grade 3 neutropenia. Grade 3 diarrhea was not observed. CPT-11 is a very useful choice as salvage chemotherapy for breast cancer patients with recurrence or local progression.

Clinical significance of axillary microresiduals after neoadjuvant chemotherapy in breast cancer patients with cytologically proven metastases.

BACKGROUND: Neoadjuvant chemotherapy (NAC) has been widely accepted for advanced breast cancer patients, and pathological complete remission (pCR) was revealed to be an important prognostic factor. The pCR status of cytologically proven axillary metastases (ALN-pCR) offers a more powerful prognostic predictor than pCR of the main tumor. This study evaluated the clinical significance of residual micrometastases and discusses screening methods after NAC in patients with cytologically proven axillary metastases. METHODS: Eighty patients with a diagnosis of cytologically proven axillary metastases received NAC. All dissected lymph nodes were evaluated using multislice sectioning and cytokeratin immunohistochemistry, and categorized into four groups: no metastases (ALN-pCR), and with metastases 0.2 mm but 2 mm (ALN-mac). Disease-free survival (DFS) and overall survival (OS) were calculated by Kaplan-Meier method based on the status of residual metastases. RESULTS: DFS in patients with ALN-pCR and ALN-itc was significantly longer than that with ALN-mic (P = 0.007, P = 0.045, respectively). OS with ALN-pCR was significantly longer than that with ALN-mic (P = 0.004). There was no significant difference in DFS or OS between ALN-mac and ALN-mic. These data showed the clinical significance of microresidual metastases >0.2 mm after NAC in patients with cytologically proven axillary metastases. CONCLUSIONS: Using multislice sectioning, screening for ALN-mic after NAC was clinically important, and that for ALN-itc was not clinically essential.

Identification of vitronectin as a novel serum marker for early breast cancer detection using a new proteomic approach.

PURPOSE: Breast cancer is the most frequent malignancy in women. However, no useful serum markers with high sensitivity and specificity for the detection of early breast cancer have been identified. The search for biological markers of early breast cancer is of continual interest in experimental and clinical breast cancer research. We recently described a simple and highly reproducible three-step proteome analysis for identifying potential disease-marker candidates among the low-abundance serum proteins. METHODS: Serum samples from breast ductal carcinoma in situ (DCIS) patients and normal controls were subjected to a three-step serum proteome analysis. The steps were the following: first, immunodepletion of most abundant proteins; second, fractionation using reverse-phase high-performance liquid chromatography; and third, separation using two-dimensional electrophoresis (2-DE). Differences revealed by protein staining were further confirmed by Western blotting, immunohistochemical staining, and enzyme-linked immunosorbent assays (ELISA). RESULTS: Twenty-two upregulated and 26 downregulated spots were detected on the 2-DE gels, and a total of 33 proteins were identified by liquid chromatography and tandem mass spectrometry. Western blotting confirmed that the level of vitronectin was significantly increased in DCIS patients compared with that of normal controls. Immunohistochemical staining of vitronectin in breast cancer tissue revealed high expression in small vessel walls surrounding cancer cells and the extracellular matrix of stroma. Moreover, vitronectin serum concentrations, as measured by ELISA, were significantly increased in patients with DCIS or more advanced breast cancer compared with those of normal controls. CONCLUSIONS: Vitronectin could serve as a promising serum marker for the detection of primary breast cancer.