[Two Cases in Which Simultaneous Laparoscopic Surgery and Breast Cancer Surgery Using a Head-Mounted Monitor Were Useful].

Herein, we report on how we were able to reduce the operation time by simultaneously performing laparoscopic surgery and breast cancer surgery using a head-mounted monitor(HMS-3000MT, Sony corporation). Case 1: 60s, female. A 5.5 cm leiomyoma was found in the central thoracic esophagus, and a 1 cm breast cancer was found in the C region of the left mammary gland. Subtotal esophagectomy with right thoracotomy and laparoscopy and a left partial mastectomy were performed. For the abdominal surgery, HMS-3000MT was used under hand-assisted laparoscopy, and a left partial mastectomy was performed concurrently. Operation time was 367 minutes(simultaneous surgery for 56 minutes). Esophagus: leiomyoma, 50×45 mm; and mammary gland: 16×15 mm, pTis(DCIS), pN0(sn), cM0, and pStage 0. Case 2: 70s, female. A 3 cm sized GIST was found on the posterior wall of the middle gastric body, and a breast cancer of 1.3 cm was also found in the B region of the right mammary gland. Using HMS-3000MT, laparoscopic local resection of the stomach and right total glandectomy were performed concurrently. Operation time was 114 minutes(simultaneous surgery for 58 minutes). Stomach: GIST, 25×22 mm, and modified Flecher classification low risk; and mammary gland: invasive ductal carcinoma, 15×15 mm, pT1c, pN0(sn), cM0, and pStage Ⅰ. Conclusion: In 2 fields of surgery, simultaneous surgery using HMS-3000MT was considered to be a useful method to shorten the operation time.

[A Case of Ectopic Pheochromocytoma between the Abdominal Aorta and Inferior Vena Cava].

We report a case of ectopic pheochromocytoma which is relatively rare. A 50-year-old man was found to have an abdominal tumor on a medical examination, and contrast-enhanced computed tomography showed a retroperitoneal tumor between the abdominal aorta and the inferior vena cava. As a result of close examinations, an ectopic pheochromocytoma was suspected. He was asymptomatic and suspected infiltrating into great vessels, but possibility of a malignant neoplasm could not be ruled out for the tumor had a tendency to enlarge, the resection of the tumor was performed. During the operation, the invasion of the tumor into the great vessels was denied and the tumor was completely resected. Large fluctuation of the blood pressure was not observed during the operation. Histopathological evaluations of the resected specimen revealed the ectopic pheochromocytoma. A pheochromocytoma was newly defined as a tumor with malignant potential for metastasis in all cases by the WHO classification published in 2017. He was diagnosed as moderately malignant by GAPP score, therefore the careful follow-up was considered necessary in the future.

[A Case of Metastatic Breast Cancer with BRCA1 Mutation after Breast Reconstruction and Pregnancy].

We present the case of a 31-year-old woman with a chief complaint of a left breast mass. The patient visited our department for an evaluation of this left breast mass. Left breast cancer(cT1cN0M0, cStage Ⅰ, triple negative type)was diagnosed, and left partial mastectomy and sentinel node biopsy were performed. Although the pStage was the same prior to surgery, a BRCA1 mutation was identified on genetic testing. After administration of postoperative adjuvant chemotherapy (epirubicin, cyclophosphamide, and paclitaxel), consorted mastectomy, tissue expander insertion, and breast reconstruction with silicone implant were performed. Spontaneous pregnancy occurred 1 year and 10 months after the first operation. She had an uneventful delivery with a normal course of labor 2 years and 6 months after the surgery. Two years and 11 months after the first operation, she visited our institution with complaints of headache, dizziness, and difficulty eating. Upon assessment, brain, lung, liver, and bone metastases were identified on contrast-enhanced computed tomography. Concentrated glycerin and fructose, steroid administration, and whole-brain irradiation improved the symptoms due to cerebral edema. Thereafter, olaparib was started, and treatment was continued while maintaining partial response(PR).

[A Case of Laparoscopic Distal Gastrectomy for Gastric Cancer with an Adachi Type â ¥ Group 24 Vascular Anomaly].

We report a case of successful laparoscopic distal gastrectomy for gastric cancer with an Adachi type Ⅵ group 24 vascular anomaly. A male in his 60s exhibited a type 0-Ⅱa plus Ⅱc lesion at the lesser curvature of the gastric angle by esophagogastroduodenoscopy and was diagnosed with tub2. He was referred to us for surgical treatment. The clinical diagnosis was cT1bN0M0, and cStage Ⅰ. Preoperative multidetector-row computed tomography(MDCT)showed an Adachi type Ⅵ group 24 vascular anomaly. At laparoscopic surgery, we dissected No. 8a lymph nodes with exposure of the surface of the portal vein because the common hepatic artery was absent. The left gastric artery and splenic artery formed a common trunk. As there are various kinds of vascular anomalies of the celiac artery branch, we must understand the arterial running pattern prior to gastric surgery. This technique is more useful in laparoscopic surgeries where tactile sensation is limited. To prevent perioperative and postoperative complications, we must recognize the anomaly pattern prior to surgery using MDCT.

[A Case in Which Trastuzumab Combined Chemotherapy Was Effective for Recurrence of Post-Operative Gastric Cancer with Partial HER2 Overexpression].

We report a case in which recurrent partial HER2-positive gastric cancer showed complete clinical response to capecitabine (Cape)/oxaliplatin(L-OHP/OX)(CapeOX)plus trastuzumab(Tmab)combined chemotherapy for 32months. A 65-yearold man underwent distal gastrectomy, D2 lymph node dissection, and Roux-en-Y reconstruction for type 2 gastric cancer of the prepyloric anterior wall in December 2014. Pathological stage was as follows: L, ant, Type 2, 32×22 mm, tub1>tub2> por1, pT2(MP), int>med, INF c>a, Ly1a, V0, pN0, cM0, cH0, cP0, pCY0, pStage I B, pPM0(60mm), pDM0(75mm), pR0. Immunostaining of the tumor indicated overexpression of the HER2 gene in more than 10% of the well differentiated tubular adenocarcinoma(tub1). Nineteen months post-surgery, pancreatic head lymph node metastasis was diagnosed, and we started CapeOX plus Tmab combined chemotherapy. After 19 courses, the metastatic lymph node reduced its size until we could not detect it on CT. We continued treatment for 45 courses(about 32 months). During the courses, there were adverse events such as peripheral neuropathy(Grade 3, CTCAE v5.0), which required interruption of L-OHP, and oral mucosal ulcer (Grade 2).

[A Case of Laparoscopic Low Anterior Resection and Adrenalectomy for Rectal Cancer and Adrenal Tumor].

A 70-year-old woman had consulted a doctor at a former clinic because of bloody stool and colonoscopy revealed a type 2 tumor of the rectum. She was referred to our hospital for further examinations and treatment. Preoperative blood examination showed an elevated HbA1c level of 10.2%. Abdominal CT showed a 25mm tumor in the left adrenal gland. The patient was diagnosed with adrenal Cushing's syndrome based on low ACTH levels, disappearance of circadian variation in blood cortisol levels, lack of inhibition by dexamethasone loading, and high urinary cortisol levels. Laparoscopic adrenalectomy for left adrenal tumor and low anterior resection for rectal cancer were performed. The pathological findings were rectal cancer, pap, pT1b(SM), pN0, cM0, fStageⅠof rectal cancer, and adrenal cortical adenoma. The postoperative course was uneventful with steroid replacement therapy. The ileal stoma was closed 4 months after surgery. Surgery in hyperadrenalism requires perioperative steroid replacement therapy because of the risk of postoperative acute adrenal failure. In addition, when diabetes is poorly controlled, we should be careful about risk of leakage and susceptibility to infection.

[A Case of Appendiceal Mucinous Adenocarcinoma Detected with a Bladder Tumor].

A 74-year-oldwoman hadconsultedthe department of urology in our hospital because of microscopic hematuria. Cystoscopy revealeda urinary bladder tumor, suspectedas an adenocarcinoma basedon biopsy. MRI showeda cystic tumor of the appendix with vesical fistula; therefore, she underwent an operation with a diagnosis of appendiceal cancer invading the urinary bladder. During the operation, we found that the appendix sunk into the urinary bladder with right adnexa. Therefore, we performed ileocecal resection, partial resection of the urinary bladder, and right adnexectomy. Macroscopically, the bladder was filled with a large number of mucus lumps. A papillary tumor, 4 cm in size, growing in the lumen of the bladder was detectedat the invasion site. Microscopically, proliferating carcinoma cells in a papillary form were observedin the lumen of the appendix with mucus production, invading the wall of the urinary bladder at the fundus of the appendix. Thus, the patient was diagnosed with mucinous adenocarcinoma of the appendix(V, type 1, 45×30 mm, muc, pT4b[SI, urinary bladder], int, INF c, ly0, v0, pN0, cM0, pStage II ). Primary appendiceal cancer invading the urinary bladder is very rare; herein, we report a rare case of appendiceal mucinous adenocarcinoma detected with a bladder tumor and present a literature review.

[A Case of Primary Sclerosing Cholangitis Difficult to Distinguish from a Hilar Cholangiocarcinoma].

A 78-year-old man, who had presented with onset of ulcerative colitis at the age of 56 years and had been in remission for the past several years, attended our hospital with a diagnosis of obstructive jaundice. A hilar cholangiocarcinoma with right hepatic artery invasion was suspected on contrast enhanced CT. An endoscopic retrograde cholangiography indicated Bismuth type 2 stenosis. The stenotic bile duct brushings revealed no malignancy. Primary sclerosing cholangitis(PSC)and IgG4- related cholangitis were included in the differential diagnosis; however, a significant result could not be obtained in any other examinations. A hilar cholangiocarcinoma could not be ruled out, and rt. hepatic lobectomy and caudate lobectomy with resection of the extrahepatic bile duct were performed after obtaining informed consent. The histopathological findings revealed no atypical cells in the stenotic lesion, but fibrosis and inflammatory cell infiltration were observed around the bile duct. These findings were consistent with PSC. On the other hand, atypical cell proliferation with lymph duct infiltration was found in the mucosa of the gall bladder. It is difficult to preoperatively diagnose PSC localized to the hilar bile duct, and if possible, the existence of concomitant malignant lesions in the biliary tract should be considered.

[A Case of MALT Lymphoma of the Rectum Treated with Intersphincteric Resection (ISR)].

A 60-year-old woman visited a local hospital complaining of melena. On colonoscopy, she was found to have 2 tumors in the lower rectum, each of approximately 10 mm in diameter. A biopsy of the tumors indicated MALT lymphoma, and the patient was referred to our hospital. We performed intersphincteric resection (ISR) with lymph node dissection according to the guidelines for the treatment of rectal cancer for 2 reasons. One reason was that eradication therapy for Helicobacter pylori was not effective in this case, and we needed to obtain an accurate histopathological diagnosis as to whether the patient had diffuse large B cell lymphoma (DLBCL). The other reason was that it was localized disease in the rectum, and that curative resection could be performed. MALT lymphoma of the rectum occurs frequently in the lower rectum and has a relatively good prognosis. It is important to consider the quality of life when selecting an operative method. ISR is thought to be a good option.

[Preoperative Chemotherapy and Risk Factors for Colorectal Liver Metastases].

Between February 2007 and December 2013, 65 liver resections for colorectal metastases were performed in our institution. Preoperative chemotherapy was conducted in 47 patients, of whom 42 were treated with modified FOLFOX6 (mFOLFOX6)-based preoperative chemotherapy. For cases of solitary tumors smaller than 2 cm that are located in the liver surface area, we selected upfront surgery. In the patients who underwent preoperative chemotherapy and upfront surgery, the 3-year OS was 73.9% (Grade A: 81.8%, Grade B: 77.8%, and Grade C: 0%) and the 5-year OS was 62.5%. The 3-year OS in the preoperative chemotherapy group was 63.3%. OS did not differ significantly between the patients who were grouped according to the time of metastasis onset or the extent of metastasis according to the Japanese classification. In the multivariate analysis, no statistical differences were found between the risk factors for recurrence. However, further follow up is needed. Moreover, we believe that the relationships of morphological response to chemotherapy, pathological response, and clinical prognosis should be assessed in the future.

[A Case of Extranodal Nasal Type, NK／T Cell Lymphoma in the Ileum with Perforated Peritonitis during Chemotherapy].

A 65-year-old woman complaining of melena and a high fever was admitted to our hospital. Colonoscopy revealed a large tumor with a wide ulcer in the terminal ileum, and nasal type, extranodal NK/T cell lymphoma was suspected via biopsy. Owing to rapid progression of hepatocellular damage with hepatomegaly and splenomegaly, chemotherapy with CHOP was initiated immediately. Two days later, the patient developed panperitonitis, and emergency laparotomy was performed. The tumor in the terminal ileum widely adhered to the bladder, where a deep perforated ulcer was found, for which palliative ileocecal resection was performed. Enlargement of the residual tumor caused an abdominal abscess, intestinal obstruction, and hepatic failure, and the patient died 75 days after surgery. In summary, we initiated chemotherapy to control the deteriorating systemic condition of the patient. However, nasal type, extranodal NK/T cell lymphoma is a rapidly progressing lymphoma occasionally accompanied by perforation of the tumor. Surgery preceding chemotherapy should be considered an alternative treatment.

[A Case of Von Hippel-Lindau Disease with Nonfunctioning Pancreatic Neuroendocrine Tumors Treated by Duodenum-Preserving Resection of the Head of the Pancreas and Spleen-Preserving Resection of the Tail of the Pancreas].

A 26-year-old woman presented to our department with a diagnosis of multiple nonfunctioning pancreatic neuroendocrine tumors. She had a family history of pheochromocytoma and a medical history of bilateral adrenalectomy for pheochromocytoma at the age of 25 years. During follow-up treatment for adrenal insufficiency after the surgery, highly enhanced tumors in the pancreas were detected on contrast-enhanced CT. Other examinations found that the patient did not satisfy the clinical criteria for von Hippel-Lindau (VHL) disease. Considering her age and risk of developing multiple heterotopic and heterochronous tumors, we performed a duodenum-preserving resection of the head of the pancreas and spleen-preserving resection of the tail of the pancreas with informed consent. The histopathological findings revealed that all of the tumors were NET G1. She underwent genetic testing postoperatively and was diagnosed with VHL disease. This diagnosis meant that we were able to create an optimal treatment plan for the patient. If a tumor predisposition syndrome is suspected, VHL disease should be borne in mind and genetic testing after genetic counseling should be duly considered.

[A Case of Pseudo-Meigs Syndrome Associated with Metachronous Ovarian Metastasis from Ascending Colon Cancer].

We experienced a case of pseudo-Meigs syndrome associated with metachronous metastasis to the ovary from ascending colon cancer. A 65-year-old woman underwent curative surgery for ascending colon cancer at another hospital. A follow-up CT carried out 3 months after the surgery revealed a right ovarian tumor and a large amount of ascites. The patient was diagnosed with ovarian metastasis from ascending colon cancer with carcinomatous peritonitis. Palliative care was recommended, and she presented at our department for a second opinion. In spite of a large amount of ascites and pleural effusion, no disseminating tumor was detected on contrast-enhanced CT at our hospital, and we recommended that she undergo a diagnostic laparotomy. The laparotomy was negative for carcinomatous peritonitis and a right oophorectomy was performed. The histopathological findings indicated that the ovarian tumor was consistent with metastasis from ascending colon cancer. After the surgery, we initiated chemotherapy with mFOLFOX6+bevacizumab and the symptoms were well controlled. A follow-up CT carried out 11 months after the surgery revealed a left ovarian tumor and increased ascites, and the patient underwent a left oophorectomy. Then, chemotherapy with the same regimen was administered for 12 months, and she did not develop any signs of recurrence for 27 months after the surgery. Ovarian metastasis from colon cancer may occasionally cause pseudo-Meigs syndrome, and it is important to be aware of the usefulness of oophorectomy for the control of ascites and pleural effusion.

Abnormal tau deposition in neurons, but not in glial cells in the cerebral tissue surrounding arteriovenous malformation.

We report an autopsy case of arteriovenous malformation (AVM) of the right frontal lobe in a 50-year-old man, in whom post mortem examination revealed massive tau deposition in the affected cerebral cortex. The patient was diagnosed as having AVM at the age of 21 years, and died of unknown cause at the age of 50 years. Immunostaining with anti-phosphorylated tau antibody (AT8) revealed many NFTs and neuropil threads, but not glial tau accumulation, in the right frontal cortex surrounding the AVM. The NFTs and neuropil threads contained both 3-repeat and 4-repeat tau. Ultrastructurally, the NFTs consisted of paired helical filaments. In the other brain areas, a few NFTs were found in the parahippocampal gyrus. There was no amyloid deposition in the brain. A variety of disease conditions, including brain tumor, viral encephalitis, angioma and cervical spondylotic myelopathy, have been reported to show Alzheimer-type NFTs. The present findings indicate that abnormal tau deposition can occur in neurons, but not in glial cells, of the affected cerebral cortex surrounding AVM.

[A case of advanced rectal cancer treated effectively with intersphincteric resection and preoperative chemotherapy].

An approximately 50-year-old man with rectal cancer(RbP)[ cT3(cA), cN3, cM0, and cStage IIIb] who desired anus preservation was administered mFOLFOX6 therapy. This treatment decreased the size of both the tumor and the lymph node, and intersphincteric resection (ISR) was performed. Histopathology demonstrated tumor invasion beyond the muscularis propria, and the histological effectiveness was Grade 2. Because computed tomography showed an abscess in the dissection area, we performed postoperative drainage and the patient recovered. Therapy with mFOLFOX6 was repeated after the patient was discharged from hospital. Increased adoption of anus-preserving surgery is expected via successful control of local recurrence and distant metastasis by neoadjuvant chemotherapy.

CT-based deep learning enables early postoperative recurrence prediction for intrahepatic cholangiocarcinoma.

Preoperatively accurate evaluation of risk for early postoperative recurrence contributes to maximizing the therapeutic success for intrahepatic cholangiocarcinoma (iCCA) patients. This study aimed to investigate the potential of deep learning (DL) algorithms for predicting postoperative early recurrence through the use of preoperative images. We collected the dataset, including preoperative plain computed tomography (CT) images, from 41 patients undergoing curative surgery for iCCA at multiple institutions. We built a CT patch-based predictive model using a residual convolutional neural network and used fivefold cross-validation. The prediction accuracy of the model was analyzed. We defined early recurrence as recurrence within a year after surgical resection. Of the 41 patients, early recurrence was observed in 20 (48.8%). A total of 71,081 patches were extracted from the entire segmented tumor area of each patient. The average accuracy of the ResNet model for predicting early recurrence was 98.2% for the training dataset. In the validation dataset, the average sensitivity, specificity, and accuracy were 97.8%, 94.0%, and 96.5%, respectively. Furthermore, the area under the receiver operating characteristic curve was 0.994. Our CT-based DL model exhibited high predictive performance in projecting postoperative early recurrence, proposing a novel insight into iCCA management.

A bioartificial liver that combines plasma dialysis and whole liver perfusion.

BACKGROUND/AIMS: The development of a bioartificial liver with xenogeneic hepatocytes requires sufficient hepatocyte mass for metabolic support, decreased immunogenicity, and prevention of viral transmission. Therefore, the authors developed a plasma dialysis system using a selective plasma filter, and combined this dialysis system with whole liver plasma perfusion (PDWLP). In this system, the patient's plasma was dialyzed with normal plasma recycled through the pig liver. METHODOLOGY: Female inbred Large White pigs were used for the hepatic failure model and for liver donation. Fulminant hepatic failure (FHF) was induced by the intraportal administration of alpha-amanitin and lipopolysaccharide. Nine hours after this injection, the FHF pigs were connected to the dialysis system for 6 h (n = 5). Control FHF pigs were not connected to the dialysis system (n = 10). RESULTS: Animal survival was lengthened, and cardiovascular stability was demonstrated in the PDWLP treated pigs. This system suppressed the production of substances that promote encephalopathy. The liver necrosis and neutrophil infiltration were significantly less in the experimental pigs. CONCLUSIONS: The experimental treatment attenuated the progression of FHF. Extracorporeal liver, perfused with oxygenated plasma, functioned for 6 h without hyperacute rejection. This type of hybrid bioartificial liver may be useful for treating FHF patients.

Central and peripheral actions of somatostatin on the growth hormone-IGF-I axis.

Somatostatin (SRIF) analogs provide safe and effective therapy for acromegaly. In a proportion of patients, however, SRIF analogs may lead to discordant growth hormone (GH) and IGF-I suppression, which suggests a more complex mechanism than attributable to inhibition of GH release alone. To elucidate whether SRIF acts peripherally on the GH-IGF-I axis, we showed that rat hepatocytes express somatostatin receptor subtypes-2 and -3 and that IGF-I mRNA and protein levels were suppressed in a dose-dependent manner by administration of octreotide. The inhibitory effect of SRIF was not apparent without added GH and in the presence of GH was specific for IGF-I induction and did not inhibit GH-induced c-myc or extracellular signal regulated kinase (ERK) phosphorylation. Pertussis toxin treatment of hepatocytes incubated with GH and SRIF, or with GH and octreotide, abrogated the inhibitory effect on GH-induced IGF-I, which confirms the requirement for the inhibitory G-protein. Treatment with SRIF and GH increased protein tyrosine phosphatase (PTP) activity and inhibited signal transducer and activator of transcription-5b (STAT5b) phosphorylation and nuclear localization. Octreotide also inhibited GH-stimulated IGF-I protein content of ex vivo-perfused rat livers. The results demonstrate that SRIF acts both centrally and peripherally to control the GH-IGF-I axis, providing a mechanistic explanation for SRIF analog action in treating patients with GH-secreting pituitary adenomas.

A novel plasma filtration therapy for hepatic failure: preclinical studies.

There is a need to develop artificial means of liver replacement and/or assistance with the aim of either supporting patients with borderline functional liver cell mass until their liver regenerates, or until a donor liver becomes available for transplantation. Selective plasma filtration is a novel approach to blood purification therapy designed to reduce the level of circulating toxins of hepatic and renal failure, mediators of inflammation and inhibitors of hepatic regeneration. The results of preclinical studies indicate that treatment of pigs with experimentally-induced fulminant hepatic failure is safe and effective in extending survival time and arresting brain swelling. In addition, the amount of ammonia, aromatic amino acids, IL6, TNFalpha and C3a removed during the 6-h treatment in the present study was higher by 34% to 175% than the total plasma content of those substances at the start of therapy.

Preoperative Chemotherapy with Bevacizumab Extends Disease-free Survival After Resection of Liver Metastases from Colorectal Cancer.

BACKGROUND: The benefit of preoperative chemotherapy for patients with liver metastases from colorectal cancer remains unclear. We evaluated the efficacy of preoperative chemotherapy with bevacizumab in such patients, and attempted to identify clinical predictors of recurrence. PATIENTS AND METHODS: Between February 2007 and December 2013, a total of 65 liver resections for colorectal metastases were performed at our Institution; 47 patients underwent preoperative chemotherapy, which consisted of modified FOLFOX6 (mFOLFOX6) in 42 cases. The last clinical follow-up was in December 2014. Demographic and clinicopathological factors were reviewed for each patient, and potential predictors of recurrence after liver resection were evaluated. Disease-free survival (DFS) and overall survival (OS) were compared with respect to clinicopathological factors. RESULTS: The 3- and 5-year OS rates were 73.9% and 62.5%, respectively. The time at which metastases appeared, and the extent of metastasis according to the Japanese classification did not significantly affect OS or DFS. However, mFOLFOX6 plus bevacizumab significantly improved DFS compared to mFOLFOX6 alone. Patients did not experience worsening of hepatic dysfunction during preoperative chemotherapy, and tolerated surgical stress well. CONCLUSION: Preoperative chemotherapy with bevacizumab appears to be an effective treatment modality for liver metastases from colorectal cancer, and results in prolonged DFS.