Portal vein wedge resection and patch venoplasty with autologous vein grafts for hepatobiliary-pancreatic cancer

BACKGROUND

Advanced hepatobiliary-pancreatic cancer often invades critical blood vessels, including the portal vein (PV) and hepatic artery. Resection with tumor-free resection margins is crucial to achieving a favorable prognosis in these patients. Herein, we present our cases and surgical techniques for PV wedge resection with patch venoplasty using autologous vein grafts during surgery for pancreatic ductal adenocarcinoma (PDAC) and perihilar cholangiocarcinoma (PhCC).

CASE PRESENTATION

Case 1: 73-year-old female patient with PDAC; underwent subtotal stomach-preserving pancreatoduodenectomy, with superior mesenteric vein wedge resection and venoplasty with the right gonadal vein. Case 2: 67-year-old male patient with PDAC; underwent distal pancreatectomy and celiac axis resection, with PV wedge resection and venoplasty with the middle colic vein. Case 3: 51-year-old female patient with type IV PhCC; underwent left hepatectomy with caudate lobectomy and bile duct resection, with hilar PV wedge resection and venoplasty with the inferior mesenteric vein (IMV). Case 4: 69-year-old male patient with type IIIA PhCC; underwent right hepatopancreatoduodenectomy, with hilar PV resection and patch venoplasty with the IMV. All patients survived for over 12 months after the surgery, without local recurrence.

CONCLUSIONS

PV wedge resection and patch venoplasty is a useful technique for obtaining tumor-free margins in surgeries for hepatobiliary-pancreatic cancer.

Correlation between the Closure Time of Patent Ductus Arteriosus in Preterm Infants and Long-Term Neurodevelopmental Outcome

In patent ductus arteriosus (PDA) in preterm infants, the relationship between treatment timing and long-term developmental prognosis remains unclear. The purpose of this study was to clarify the relationship between the age in days when ductus arteriosus closure occurred and long-term development. Preterm infants with a birth weight of less than 1500 g who were admitted to our NICU over a period of 9 years (2011-2019) and were diagnosed with PDA were included. A new version of the K-type developmental test for corrected ages of 1.5 and 3 years was used as an index of development. The relationship between the duration of PDA and the developmental index was evaluated using Pearson's correlation coefficient, and multiple regression analysis was performed. Development quotient (DQ) at the ages of 1.5 and 3 years showed a correlation with the PDA closure date and the standard deviation (SD) value of the term birth weight. Multiple regression analysis showed a positive correlation of the DQ at 1.5 and 3 years with the SD value of the term birth weight and a negative correlation with the PDA closure date. In addition, a stronger correlation was found in the "posture/motor" sub-item at 3 years. On the other hand, the analysis including preterm infants without PDA showed that preterm infants with PDA closure on the 6th day or later after birth had a significantly lower 3-year-old DQ than preterm infants with a PDA exposure within 5 days. In conclusion, it is suggested that the decrease in cerebral blood flow due to PDA in preterm infants has an adverse effect on long-term neurodevelopment. Appropriate interventions, including surgical treatment for PDA in preterm infants without delay, ideally within 5 days of birth, may be effective in improving the developmental prognosis.

Factors associated with the development of epilepsy in very low birth weight infants

BACKGROUND

The survival rate of very low birth weight (VLBW) infants has recently improved. However, the occurrence of and factors associated with epilepsy in VLBW infants remain unknown. This study aimed to clarify the incidence, characteristics, and factors associated with epilepsy development in VLBW infants.

METHODS

All VLBW infants admitted to our hospital between 2012 and 2017 were included in this study. VLBW infants with a follow-up period of <1 year were excluded. Chromosomal abnormalities, brain anomalies, severe intraventricular hemorrhage (IVH), cystic periventricular leukomalacia (PVL), and hypoxic ischemic encephalopathy (HIE) were considered to be risk factors.

RESULTS

Epilepsy occurred in 21/526 (4.0%) VLBW infants. Chromosomal abnormalities, brain anomalies, severe IVH, cystic PVL, HIE, neonatal seizures, advanced maternal age, maternal diabetes mellitus, no administration of antenatal corticosteroids, and low Apgar scores at 1 and 5 min were associated with a risk of epilepsy. The median time to epilepsy onset was 8 months (range: 0-59 months), and the onset occurred within 2 years in 15/21 patients (71.4%) and within 4 years in 18/21 patients (85.7%). VLBW infants with risk factors developed epilepsy earlier and at a significantly higher rate than those without risk factors. Among infants who had risk factors and who developed epilepsy, 86.7% did so within 2 years of age, compared to 33.3% of those who developed epilepsy but did not have risk factors.

CONCLUSION

These findings regarding factors associated with a risk of development of epilepsy and temporal feature of epilepsy may contribute to the development of monitoring and treatment protocols for epilepsy in VLBW infants.

Crohn's disease-related anal fistula cancer diagnosed by examination under anesthesia: a case report

BACKGROUND

As the number of patients with inflammatory bowel disease (IBD) increases, the incidence of IBD-related colorectal cancer (CRC) is also on the rise. Crohn's disease (CD)-related CRC has been reported to have a poorer prognosis than sporadic CRC, and the early detection of CD-related CRC is difficult. Japanese patients with CD are reported to have a higher frequency of anorectal cancer than the Western population; however, methods for early diagnosis have not yet been established because of perianal pain during the examination.

CASE PRESENTATION

We report a case of CD-related anal fistula cancer that was detected early by surveillance examination under anesthesia (EUA). The patient was a 37-year-old man, diagnosed with CD at the age of 15 years and started medical treatment. However, due to poor disease control, the intestinal tract remained highly inflamed and the patient continued to have over 10 bowel movements per day. He was referred to our hospital for surgical treatment after a colonoscopy (CS), which revealed multiple active ulcers and stenoses. Since three perianal seton drainage tubes had been placed around his anus since the age of 33 years, we decided to perform an EUA to rule out cancer coexistence in the anorectal region. After a random biopsy of the rectum by CS under general anesthesia, we resected and curetted multiple perianal fistulas as much as possible and reinserted the seton drainage tubes. Pathological examination of the fistula tract revealed adenocarcinoma in one tract, indicating the coexistence of anal fistula cancer. Based on the diagnosis of multiple intestinal stenoses and anal fistula cancer due to CD, we performed hand-assisted laparoscopic total colectomy, rectal amputation, extensive perineal resection, and reconstruction using a left rectus abdominis flap.

CONCLUSION

In a long-term CD patient with anorectal lesions, we performed an EUA to diagnose the coexistence of anal fistula cancer at an early stage, and surgical resection was achieved. EUA is effective for the early detection and treatment of CD-related CRC and may contribute to an improved prognosis.

[A Case Report-A Successful Case of Distal Pancreatectomy with En Bloc Celiac Axis Resection for Locally Advanced Pancreatic Cancer with an Aberrant Right Hepatic Artery]

In cases of pancreatic cancer with anatomical variations of the hepatic artery, it is important to evaluate the hemodynamics of each case for surgical indication. We report the case of a 68-year-old man with locally advanced pancreatic cancer and an aberrant right hepatic artery who underwent distal pancreatectomy with celiac axis resection(DP-CAR). He was admitted to our institute due to abdominal discomfort. A CT scan showed pancreatic cancer invading the common hepatic artery. He underwent chemoradiotherapy with a diagnosis of locally advanced pancreatic cancer. After the tumor downstaging, we performed DP-CAR, which included a gastroduodenal artery and a proper hepatic artery resection. Even though delayed gastric emptying was observed after the operation, he was discharged on postoperative day 36.

Clinical development and evaluation of plasma angiogenesis factors from phase II study of FOLFIRI plus ramucirumab with recurrent colorectal cancer refractory to adjuvant chemotherapy with oxaliplatin/fluoropyrimidine (RAINCLOUD): RAINCLOUD-TR

173

Background: Higher levels of vascular endothelial growth factor-D (VEGF-D) is a potential predictive biomarker for ramucirumab (Ram) efficacy on overall survival and progression-free survival (PFS) in Ram+FOLFIRI vs Placebo+FOLFIRI for bevacizumab (Bev) refractory metastatic colorectal cancer (mCRC). However, it is not clear whether VEGF-D acts as a predictive biomarker in pts who pretreated without Bev. RAINCLOUD showed the clinical benefit of FOLFIRI+ plus Ram for pts with recurrent CRC refractory to adjuvant chemotherapy (median PFS was 6.2 months (M); ESMO-GI 2022). RAINCLOUD-TR was designed as a prospective biomarker study estimating the association of biomarkers with Ram efficacy. Methods: Plasma sample collections were done at time points of pre-/ post-treatments in pts receiving FOLFIRI+Ram. Measurements of 17 factors (including VEGF-A, VEGF-D and PlGF) were performed by multiplex assay with Luminex technology. The high/ low groups were defined bases on the median plasma level at the baseline. Results: From September 2017 to September 2021, 81 plasma samples were collected from 48 pts and 32 pts in both pre/ and post treatment. Level of VEGF-A, VEGF-D, PlGF and TSP-2 were all significantly higher in post vs pre-treatment [Table]. The ORR analyses were as follows; VEGF-A, VEGF-D and PlGF in low vs high were 50.0%/33.3% (p=0.35, HR 1.97), 55.0% /33.3% (p=0.22, HR 2.39), and 60.0%/28.6% (p=0.35, HR 1.95). The PFS analyses were as follows; VEGF-A, VEGF-D, and PlGF in low vs high were 6.1M/6.0M (p=0.815, HR 0.92), 7.6M /5.6M (p=0.095, HR 0.56), and 8.0M/4.2M (p=0.014, HR 0.40). In other factors, low TSP-2 were better ORR (low vs high: 66.7%/20.0% (p=0.004, HR 7.54) and PFS 7.5M/4.3M (p=0.022, HR 0.45). Conclusions: In this exploratory study, PFS was numerically greater for pts with low vs high VEGF-D for Ram in pts with mCRC pretreated without Bev. VEGF-D may not be predictive biomarker, but TSP-2 may be a potential prognostic biomarker, further studies in larger cohorts are needed to confirm our results. Clinical trial information: UMIN000028678 . [Table: see text]

[FOLFIRI plus RAM Therapy in Later Line of Unresectable Colorectal Cancer]

FOLFIRI plus ramucirumab(RAM)therapy has been reported to be effective and safe in the RAISE trial as second-line treatment for unresectable colorectal cancer. It is hypothesized that RAM may be effective in patients with PD treated with FOLFIRI plus bevacizumab(Bev)due to different mechanism of action from that of Bev, which is also an angiogenesis inhibitor. From January 2017 to December 2021, we conducted a retrospective study of 6 patients who had PD with 5-FU, oxaliplatin, irinotecan, or Bev as first or second-line treatment at our institution and who received FOLFIRI plus RAM in later line treatment. The 6 cases consisted of 3 patients in the third-line treatment, 1 patient in the fourth-line treatment, and 2 patients in the sixth-line treatment. The anti-tumor effect was PD in all cases in the third-line and fourth-line treatment, but the 2 patients of sixth-line treatment were controlled diseases.

Comparison of clinical outcomes of single-incision versus multi-port laparoscopic surgery for descending colon cancer: a propensity score-matched analysis

BACKGROUND

The clinical impact of single-incision laparoscopic surgery (SILS) for descending colon cancer (DCC) is unclear. The aim of this study was to evaluate the clinical outcomes of SILS for DCC compared with multi-port laparoscopic surgery (MPLS).

METHODS

We retrospectively analyzed 137 consecutive patients with stage I-III DCC who underwent SILS or MPLS at two high-volume multidisciplinary tertiary hospitals between April 2008 and December 2018, using propensity score-matched analysis.

RESULTS

After propensity score-matching, we enrolled 88 patients (n = 44 in each group). SILS was successful in 97.7% of the matched cohort. Compared with the MPLS group, the SILS group showed significantly less blood loss and a greater number of harvested lymph nodes. Morbidity rates were similar between groups. Recurrence pattern did not differ between groups. No significant differences were found between groups in terms of 3-year disease-free and overall survivals.

CONCLUSION

SILS appears safe and feasible and can provide satisfactory oncological outcomes for patients with DCC.

TRESBIEN (OGSG 2101): encorafenib, binimetinib and cetuximab for early recurrent stage II/III BRAF V600E-mutated colorectal cancer

The BRAF V600E mutation accounts for approximately 5% of colorectal cancer (CRC) cases and is an extremely poor prognostic factor. However, there are no clear recommendations regarding first-line therapy for patients with early recurrent BRAF V600E-mutated CRC, during or after adjuvant chemotherapy. Recently, a novel combination of encorafenib, binimetinib and cetuximab, showed a higher response rate than standard chemotherapy in patients with BRAF V600E-mutated CRC. Here we describe our plan for the TRESBIEN study (OGSG 2101), which is an open-label, multicenter, single-arm, phase II study designed to evaluate whether encorafenib, binimetinib and cetuximab are effective for patients with early recurrent BRAF V600E-mutated colorectal cancer, during or after adjuvant chemotherapy. The planned number of subjects is 25.

Evaluation of nephrotoxicity and ototoxicity following amikacin administration once daily or every 48 hours in neonates

The purpose of this study was to evaluate the effects of once daily (OD) or every 48 hours (every-48-h) administration of amikacin (AMK) on renal function and ototoxicity in neonates. We investigated the frequency of nephrotoxicity and ototoxicity in neonates who received AMK OD or every-48-h from April 2015 to March 2021 and underwent dose evaluation by therapeutic drug monitoring (TDM). In addition, the relationships among birth weight, gestational age, AMK peak and trough values, total duration of AMK administration, and total AMK dose were examined separately for nephrotoxicity and ototoxicity. AMK was administered OD in 38 patients and every-48-h in 62 patients. Nephrotoxicity was observed in 8 patients on OD versus 36 patients on every-48-h administration (P < .001), and ototoxicity was observed in 2 patients on OD versus 12 patients on every-48-h administration (P = .192). For nephrotoxicity, only the trough value was relevant (P = .007). In terms of ototoxicity, there were no influencing factors. The risk of nephrotoxicity was higher with every-48-h AMK administration than with OD AMK administration, with nephrotoxicity depending on the trough value. However, compared with OD, the every-48-h group had lower body weight and possibly poorer original renal function. In addition, ototoxicity did not differ by administration method. Based on these results, every-48-h administration of AMK can be used as safely as OD by performing TDM and preventing high concentrations.

Clinical outcomes of single incision laparoscopic surgery for colorectal cancer: A propensity score-matched analysis between well-experienced and novice surgeons

Background

Single incision laparoscopic surgery (SILS) is a recent advancement in minimally invasive techniques for colorectal cancer (CRC). However, SILS is a technically challenging procedure for novice surgeons. The aim of this study was to evaluate clinical outcomes of SILS for CRC performed by novice surgeons compared with those performed by well-experienced surgeons.

Methods

We retrospectively analyzed 1004 consecutive patients with stage I-IV CRC who underwent SILS between May 2009 and December 2018, using propensity score-matched analysis.

Results

After propensity score-matching, we enrolled 344 patients (n = 172 in each group). Before matching, significant group-dependent differences were observed in terms of age (P = 0.034) and tumor location (P < 0.001). After matching, preoperative clinical factors were similar between groups, but operative time was longer in the Novice group (213 vs 171 min, P < 0.001). Other operative factors and morbidity rates did not differ significantly between groups. The number of harvested lymph nodes was smaller in the Novice group (23 vs 25, P = 0.040), and the number of patients with lymph node metastases was smaller in the Novice group (57 vs 86, P = 0.002). The 3-year disease-free survival rate was 85.8% in the Novice group and 89.9% in the Experienced group (P = 0.512). Three-year overall survival rate was 92.2% in the Novice group and 90.0% in the Experienced group (P = 0.899).

Conclusion

SILS for CRC was safely performed by novice surgeons under the guidance of well-experienced surgeons, and could provide satisfactory oncological outcomes.

Comparison of clinical outcomes of single-incision versus multi-port laparoscopic surgery for rectosigmoid or upper rectal cancer

BACKGROUND

Single-incision laparoscopic surgery (SILS) for rectal cancer is technically challenging, and its clinical impact is unclear. The aim of this study was to evaluate clinical outcomes of SILS for rectal cancer compared with multi-port laparoscopic surgery (MPLS).

PATIENTS AND METHODS

We retrospectively analyzed 357 consecutive patients with stage I-III rectal cancer located in the rectosigmoid or upper rectum who underwent SILS or MPLS between January 2012 and December 2016, using propensity score-matched analysis.

RESULTS

After propensity score-matching, we enrolled 204 patients (n = 102 per group). Before matching, significant group-dependent differences were observed in tumor location (p < 0.001). After matching, preoperative clinical factors were similar between groups. SILS was successful in 73.5% of cases, an additional port was required in 23.5%, and 2.9% were converted to open surgery. Compared to the MPLS group, the SILS group showed shorter operative time (192 vs. 211 min, p = 0.015) and shorter postoperative hospital stay (9 vs. 11 days, p = 0.038). Other operative factors and morbidity rates did not differ significantly between groups. The number of harvested lymph nodes was smaller in the SILS group (24) than in the MPLS group (27, p = 0.008). Postoperative recurrence did not differ between groups, either before or after matching. No significant differences in 3-year disease-free, 3-year local recurrence-free, or 5-year overall survival were found between groups.

CONCLUSIONS

SILS is safe, is feasible, and offers satisfactory oncological outcomes in selected patients with rectosigmoid or upper rectal cancer.

Single-Incision Laparoscopic Cholecystectomy: a Single-Centre Experience of 1469 Cases

BACKGROUND

Despite having once been extensively used for cosmetics or pain reduction, the use of single-incision laparoscopic cholecystectomy (SILC) has declined in recent years due to technical difficulties and a reported increase in complications. Since the introduction of SILC in 2009, our hospital has been actively involved with this technique. Our experience suggests that SILC is not a difficult procedure and can be safe and useful, with particularly excellent cosmetic outcomes. This study retrospectively details the outcomes of SILC at our hospital.

METHOD

Data on 1469 cases of SILC performed on a waitlist basis at Osaka Police Hospital from May 2009 to December 2020 were collected and retrospectively analysed.

RESULTS

The median operative time and blood loss were 96 min and 0 mL, respectively. A total of 46 patients (3.1%) required conversion surgery, including 36 needing additional ports and 10 requiring laparotomy. Intraoperative complications included common bile duct injury in 1 patient (0.07%) and right hepatic artery injury in 1 patient (0.07%), with no other organ injury. Postoperative Clavien-Dindo 3 or higher complications were observed in 18 patients (1.2%). Incisional hernias occurred in 15 patients (1.0%). The median postoperative hospital stay was 3 days.

CONCLUSION

This study showed that SILC can be performed safely without any increase in complications, as reported previously. Granted that it is performed safely, SILC may be a useful technique due to its superior cosmetic outcomes or pain reduction.

Laparoscopic mesh removal for mesh infection related to pararectal incision of previous appendectomy after laparoscopic total extraperitoneal inguinal hernia repair: A case report

A 67-year-old man with a history of appendectomy 40 years ago underwent single-incision laparoscopic surgery for total extraperitoneal inguinal hernia repair. Postoperatively, the pararectal incisional scar obtained from the appendectomy was infected; thus, antibiotic therapy and drainage were performed. However, the infection persisted. After 5 postoperative months, the mesh was laparoscopically removed at a sufficient distance from the infected site. No enterocutaneous fistula was observed. After 1 year and 10 months, no recurrence of hernia or infection was observed. Thus, laparoscopic mesh removal is feasible. Infection of a 40-year-old incision rarely results in mesh infection. Therefore, in pararectal incision, the extent of mesh coverage should be considered; if the overlap is large, changing the technique by not covering the incision may be necessary.

Index for the appropriate vancomycin dosing in premature neonates and infants

BACKGROUND

In neonates, vancomycin (VCM) is used to treat Gram-positive bacterial infections. However, VCM blood concentrations are affected by gestational age, bodyweight (BW), and renal function. The initial VCM dose adjustment can therefore be difficult, and few reports have evaluated this issue. In this study, we investigated the factors determining the appropriate VCM dosing schedule in neonates, especially premature infants.

METHODS

The VCM dosage and trough concentrations were retrospectively investigated from the initial treatment to maintenance therapy in neonatal intensive care unit patients who underwent therapeutic drug monitoring. We examined the average single-administration VCM dosage during maintenance therapy. We then compared the actual VCM dose with that calculated using an index comprising six items that influence the VCM daily dose (postnatal age, gestational age, BW, serum creatinine level, urine output, and lactate level).

RESULTS

Twenty premature infants were included. The average BW of patients at the initial VCM administration was 975 g. During maintenance therapy, the average VCM dose was 8.4 mg/kg, and the median trough concentration was 12.4 μg/mL. When we applied the six-item index, 18 of 20 patients (90%) had concordant results between the actual VCM dosing schedule and the VCM calculated using the index.

CONCLUSIONS

The average VCM dose and six-item index can facilitate the transition from the initial VCM dose to an appropriate dose in many cases and contribute to early treatment in low-birthweight infants with more variable BW, distribution volumes, and renal function. In conclusion, our six-item index may help standardize VCM administration in premature infants.

Synergic Effects of Surfactant and Chelating Agent on Stubborn Keratin Grime for Easy Cleaning

We report on the synergic effect of surfactants and chelating agents on the mechanism to remove stubborn keratin grime (keratin-Ca), which is bound with calcium ions and one of the most difficult grimes to remove, in order to make it easier to clean bathtubs in less time and with less scrubbing. Our approach was to focus on keratin swelling, which we achieved by applying aqueous solutions with chelating agents and anionic surfactants, the combination of which greatly improved the swelling ratio, resulting in quick, easy removal of keratin-Ca with water rinsing and little scrubbing. For the swelling process, we added chelating agents and anionic surfactants to swell the keratin-Ca by both capturing calcium ions and improving solution permeation. Furthermore, we measured the structural change of the keratin-Ca during swelling by TD-NMR and confirmed that a certain combination of chelating agent and anionic surfactant improved swelling by affecting not only the amorphous part such as the keratin matrix, but also the crystalline part such as the intermediate filaments (IFs).

[A Case of Carcinomatous Meningitis from Gastric Cancer with Improvement of QOL by Ventriculoperitoneal Shunt]

In cases where carcinomatous meningitis leads to hydrocephalus and increases intracranial pressure, patients present with exacerbated pain and several neurological symptoms. It is reported that multidisciplinary therapy, including radiation therapy, drug therapy, and surgery, is performed for patients with carcinomatous meningitis; however, it is rarely successful. Ventriculoperitoneal shunting(V-P shunt)is a surgical intervention that might relieve the pain temporarily and improve the quality of life. VPS should be taken into consideration in line with patients' and their families' intentions since the overall survival is fairly short.

[Effect of Endoscopic Resection on Prognosis in T1b Colorectal Cancer]

With the advancement of endoscopic resection(ER)of colorectal cancer, surgical resection after ER has been increasing. This study evaluated the effects of initial ER on short- and long-term outcomes in T1b colorectal cancer. This retrospective cohort study enrolled patients with pathological T1b colorectal cancer who underwent colorectal surgical resection between 2008 and 2018. A total of 239 eligible patients were divided into 2 groups: patients initially treated using surgical resection with lymph node dissection(LND)(surgery alone, n=142)and patients treated using initial ER and additional surgical resection with LND(surgery after ER, n=97). No significant differences were observed in short-term outcomes(ie, operative time, blood loss, or postoperative complications)or the long-term outcomes(ie, recurrence rate, overall survival rate, or recurrence free survival rate)between groups.

[A Long-Survival Case of Lower Rectal Cancer with Unresectable Liver Metastases Treated with FOLFOXIRI plus Bevacizumab(BEV)]

A woman in her 30s visited our hospital complaining primarily of melena. Colonoscopy revealed the presence of a type 1 tumor in 2 cm from anal verge. Contrast-enhanced CT showed an unresectable massive liver metastasis in the left lobe of the liver and another metastasis in the right lobe. The patient received front-line chemotherapy with Leucovorin, fluorouracil, oxaliplatin, and irinotecan(FOLFOXIRI)plus bevacizumab(BEV). A year later, a marked reduction of liver metastases and primary lesions was confirmed by CT scan imaging. A multidisciplinary team recommended resection of the liver metastases followed by laparoscopic intersphincteric resection for primary lesions. However, after 1 year, a recurrence was diagnosed in the liver; hence, FOLFOXIRI plus BEV was reintroduced for volume reduction. The patient underwent a repeat hepatectomy since enough volume reduction was confirmed. One year later, she experienced a re-relapse of the metastasis in the liver. Currently, she is still undergoing chemotherapy following 7 years since the first visit. Long-term survival can be expected following surgical treatment during chemotherapy.

Short- and Long-Term Outcomes of Single-Incision Laparoscopic Surgery for Right-Side Colon Cancer

INTRODUCTION

There are little data concerning the long-term outcome of single-incision laparoscopic surgery (SILS) for colon cancer. Therefore, we investigated not only the short-term outcomes but also the long-term outcomes of SILS for right-side colon cancer.

METHODS

We retrospectively compared short- and long-term outcomes of SILS and conventional laparoscopic surgery (CLS) for right-sided colon cancer in our institution. Intergroup differences of short-term outcomes were evaluated using χ2 or Fisher exact tests and 2-sample Student t tests. The disease-free survival rates (long-term outcome) of stage II and III patients were estimated using the Kaplan-Meier method and compared using log-rank tests.

RESULTS

There were 290 operations conducted for right-side (cecum and ascending) colorectal cancers from April 2011 to July 2018. Open surgery was performed in 12 cases from start to the operation. SILS was performed in 196 cases and CLS in 55 cases. One patient underwent intraoperative conversion from SILS to laparotomy for bleeding control. In addition, 1 port was added to SILS in 3 cases. These 4 cases were included in the analysis as the SILS group according to the principle of intent to treat.

BACKGROUND

Factors including age, gender, body mass index, performance status, and tumor stage were not statistically different between the SILS and CLS groups. In short-term outcomes, the number of harvested lymph nodes was not statistically different. SILS required less operating time (p < 0.001) and resulted in a reduced bleeding volume (p < 0.001). There was no statistical difference in the frequency of overall complications (p = 0.06). The disease-free survival of stage II and III patients was not statistically different between the 2 groups.

CONCLUSIONS

With the proper adaptation of SILS by an experienced surgeon, the short- and long-term outcomes of SILS were not inferior to those of CLS. Therefore, SILS could be a treatment option for right-sided colon cancer.

Circulating MicroRNAs in Gastrointestinal Cancer

Simple Summary

The screening methods and therapeutic strategies for gastrointestinal cancer (GIC) have improved, but mortality in GIC patients remains high. Early detection and precise evaluation of GIC are required to further improve treatment outcomes in GIC patients. MicroRNAs (miRNAs), which do not encode proteins, have attracted attention as biomarkers of various diseases. Since the first report revealing the strong correlation between miRNAs and cancer in 2002, numerous studies have illustrated the changes in the expression and the biological and oncological effects of miRNAs in GIC. Furthermore, miRNAs circulating in the blood are reported to be associated with GIC status. These miRNAs are thought to be useful as noninvasive biomarkers because of their stability in blood. Herein, we discuss the potential of miRNAs as noninvasive biomarkers for each type of GIC on the basis of previous reports and describe perspectives for their future application.

Abstract

Gastrointestinal cancer (GIC) is a common disease and is considered to be the leading cause of cancer-related death worldwide; thus, new diagnostic and therapeutic strategies for GIC are urgently required. Noncoding RNAs (ncRNAs) are functional RNAs that are transcribed from the genome but do not encode proteins. MicroRNAs (miRNAs) are short ncRNAs that are reported to function as both oncogenes and tumor suppressors. Moreover, several miRNA-based drugs are currently proceeding to clinical trials for various diseases, including cancer. In recent years, the stability of circulating miRNAs in blood has been demonstrated. This is of interest because these miRNAs could be potential noninvasive biomarkers of cancer. In this review, we focus on circulating miRNAs associated with GIC and discuss their potential as novel biomarkers.

Risk Factors for Lymph Node Metastasis in Pathological T1b Colorectal Cancer

BACKGROUND/AIM

The rate of lymph node metastasis (LNM) of colorectal carcinoma (CRC) with a submucosal (SM) invasion depth of 1000 µm or more can reach 12.5%, which is the most common reason for additional resection in daily practice. Other studies have reported that the rate of LNM is less than 2%, regardless of the depth of invasion, if the lesions show good histology, lymphovascular infiltration is negative, and tumor budding is limited. The purpose of this study was to investigate new risk factors for LNM in T1b colorectal cancer.

PATIENTS AND METHODS

The 239 patients who were diagnosed with pathological T1b CRC after colorectal surgical resection at the Osaka Police Hospital in Japan between January 2008 and December 2018 were retrospectively reviewed in this study.

RESULTS

The LNM rate was 11.3% (27/239). The variables identified as being significant factors using multivariate analysis were: i) lymphatic invasion (Ly)-positive [odds ratio (OR)=5.97; 95% confidence interval (CI)=2.27-15.74], ii) female gender (OR=3.49; 95%CI=1.38-8.85), and iii) left-sided colorectal involvement (OR=4.98; 95%CI=1.22-20.39). If none of these risk factors were present with T1b, the LNM rate was 0% (0/28).

CONCLUSIONS

Ly-positive, female gender, and left-sided colorectal involvement could be risk factors for LNM in T1b CRC.

Giant Pulmonary Bulla Underlying Bronchopulmonary Dysplasia in a Very Low-birth-weight Infant: a Case Report.. [DOI: 10.21203/rs.3.rs-378547/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background: Acquired cystic lung disease is a serious respiratory complication of bronchopulmonary dysplasia in premature infants. Most cases of acquired cystic lung disease underlying bronchopulmonary dysplasia involve pulmonary interstitial emphysema. Although this is a reversible condition, there are a few instances where surgery might be necessary. An accurate diagnosis is important to decide the therapeutic strategy for acquired cystic lung disease. Here, we report a rare case of a giant pulmonary bulla in an infant treated with bullectomy. Case presentation: A male infant born at 23 weeks of gestation with a birth weight of 524 g was initially diagnosed with respiratory distress syndrome. During mechanical ventilatory support, he presented with recurrent pneumothorax and a gradually expanding pulmonary cyst in the right lung. Chest CT at 5 months of age revealed a large cyst located in the subpleural area adjacent to the multiple cystic air spaces. These findings are consistent with the diagnosis of giant pulmonary bulla with pulmonary interstitial emphysema underlying bronchopulmonary dysplasia . At 9 months of age, the giant pulmonary bulla expanded further due to acute bronchitis for which he developed respiratory failure and obstructive shock. This warranted a bullectomy for the giant pulmonary bulla. After the operation, the unresected pulmonary interstitial emphysema lesion did not expand further. He is currently three years old and has no respiratory problems. Conclusions: This case demonstrated that chest CT is useful for providing valuable anatomical information necessary in deciding the treatment strategy for acquired cystic lung disease in infants.

Factors affecting psychosocial development of very low birth weight infants at 18 and 36 months of age

AIM

To identify relationships between neonatal factors including conditions and treatments, nurturing environment, and psychosocial development of children born at very low birth weight (VLBW).

METHODS

In this longitudinal study, the medical records of 113 VLBW infants were examined, and the children were then followed up at 18 and 36 months of age. Their developmental quotient (DQ) was assessed using the Kyoto Scale of Psychological Development (KSPD), and their parents were asked about their own health, financial situation, education, and family support. Pearson's correlation and stepwise multiple regression analyses were used to explore relationships between DQ, potentially significant predictors on the KSPD, and nurturing environment.

RESULTS

DQ at 18 months was associated with the following neonatal factors: mechanical ventilation days (β = -.241, p = .020), Apgar score at 5 min (β = .278, p = .005), periventricular leukomalacia (β = -.218, p = .006), and treatment for retinopathy of prematurity (β = -.171, p = .048) (adjusted R2 = .32). DQ at 36 months was associated with the following neonatal and parenting factors: mechanical ventilation days (β = -.354, p < .001), periventricular leukomalacia (β = -.207, p = .009), sex (β = -.199, p = .011), mother's educational background (β = -.304, p < .001), mother's health status (β = -.159, p = .042) (adjusted R2 = .35).

CONCLUSIONS

These findings suggest that in addition to neonatal clinical parameters including conditions and treatments, the nurturing environment after discharge from the neonatal intensive care unit influences the psychosocial development of VLBW infants.

Long-term outcomes of single-incision versus multiport laparoscopic colectomy for colon cancer: results of a propensity score-based analysis

BACKGROUND

Long-term outcomes of single-incision laparoscopic colectomy (SILC) for colon cancer (CC), as practiced in real-world settings, especially in relation to disease stage, have not been established. We examined, retrospectively, both short- and long-term outcomes of SILC versus those of multiport laparoscopic colectomy (MPLC) performed for CC in a propensity-score-matched cohort.

METHODS

The study involved 263 patient pairs matched 1:1 from among 691 patients who, between January 2008 and May 2014, underwent either SILC or MPLC for a primary solitary CC at our hospital. Short-term and long-term operative outcomes were compared between the two groups.

RESULTS

Operation time was the only surgical outcome that varied significantly between the two groups (p = 0.0004). Overall 5-year cancer-specific survival (CSS) in the SILC group was 93.7 (95% CI 89.6-96.2)%, and CSS per pathological stage (I, II and III) was 98.5 (90.0-99.8)%, 96.0 (88.2-98.7)%, and 88.3 (79.6-93.6)%, respectively, whereas overall 5-year CSS in the MPLC group was 93.3 (89.4-95.9)%, and CSS per pathological stage was 100%, 95.4 (88.3-98.3)%, and 84.1 (74.1-90.8)% (p = 0.5278, 0.2679, 0.7666, and 0.9073), respectively. Overall 3-year disease-free survival (DFS) in the SILC group was 94.0 (90.2-96.4)%, and 3-year DFS per pathological stage was 98.6 (90.4-99.8)%, 90.1 (81.4-95.0)%, and 79.0 (69.4-86.2)%, respectively, whereas overall 3-year DFS in the MPLC group was 93.2 (89.4-95.7)%, and 3-year DFS per pathological disease stage was 100%, 94.5 (87.4-97.7)% and 75.5 (64.7-83.8)% (p = 0.2829, 0.7401, 0.4335 and 0.8518), respectively. Thus, oncological outcomes did not differ significantly between groups. Incisional hernia occurred in 21 (8.0%) SILC group patients and 17 (6.5%) MPLC group patients, without a significant between-group difference (p = 0.6139).

CONCLUSION

Our data indicate that perioperative and oncological outcomes of SILC performed for CC are comparable to those of MPLC performed for CC.

[Case Series of the TAS-102 plus Bevacizumab(Bev)Combination Therapy in Unresectable Advanced Colorectal Cancer]

A phase-Ⅱtrial of TAS-102 plus bevacizumab(Bev)combination therapy showed a progression-free survival(PFS)of 3.7-4.6 months. Here, we report 12 cases of unresectable advanced recurrent colorectal cancer treated with TAS-102 plus Bev therapy at our hospital between June 2017 and February 2020. The median PFS was 6 months(2-12). Adverse events greater than Grade 3 were neutropenia(33.3%), febrile neutropenia(8.3%), thrombocytopenia(8.3%), and vomiting (8.3%). The frequency of non-hematotoxicity was low. In conclusion, the TAS-102 plus Bev therapy may be a useful option for the late-line treatment of unresectable advanced recurrent colorectal cancer.

[Nodular Lymphocyte-Predominant Hodgkin Lymphoma(NLPHL)Which Originate from the Mesentery-A Series of Two Cases]

Nodular lymphocyte-predominant Hodgkin lymphoma(NLPHL)is a subtype of Hodgkin lymphoma. It is uncommon in Japan, and only a few cases of NLPHL originating from the mesentery have been reported. Most patients with NLPHL present in the early stage, but some patients have malignancy at initial presentation. We should perform staging laparotomy for the diagnosis and treatment of cases in which a lymph node biopsy is difficult.

[Launching Robot-Assisted Laparoscopic Surgery for Rectal Cancer in Our Hospital-Short-Term Results]

Robot-assisted laparoscopic surgery(RALS)for rectal cancer has been covered by National Health Insurance in Japan since April 2018. We launched RALS in our hospital in October 2019 and now report the short-term results(up to January 2020). Altogether, 15 consecutive patients(12 men, 3 women: median age 70 years)with rectal cancer underwent RALS during that period. For the first 2 cases, we performed RALS under the instruction of an experienced proctor from another institution. Among the 15 patients, 6 underwent high anterior resection and 9 low anterior resection. Median operating time was 358 min, median intraoperative blood loss was 0 mL, and there were no apparent intraoperative complications. Median postoperative length of hospital stay was 13 days, and only 1 patient developed a high-grade complication(Clavien-Dindo Grade Ⅲb)postoperatively. Hence, RALS for rectal cancer was launched successfully in our institution.

[A Case of Slow-Growing Intrahepatic Cholangiocarcinoma after Resection of Gastric Cancer]

An 83-year-old woman was given a diagnosis of gastric cancer and received distal gastrectomy 9 years ago. Three years later, CT revealed a tumor measuring 13 mm in diameter in hepatic segment 7. She was followed for 5 years, and the size of the tumor did not change. Eight years later after gastrectomy, the tumor size slightly enlarged to 17 mm, and biopsy revealed adenocarcinoma. The patient underwent liver resection of segment 7. The pathological diagnosis was well differentiated intrahepatic cholangiocarcinoma(ICC). No sign of recurrence has been found during a 1-year. This case, in which the patient was followed for 5 years before curative surgical treatment, is significant, because it demonstrates the slow-growing nature of ICC.

Neutropenia is an indicator of outcomes in metastatic colorectal cancer patients treated with FTD/TPI plus bevacizumab: a retrospective study

PURPOSE

Trifluridine/tipiracil (FTD/TPI) improves the overall survival (OS) of metastatic colorectal cancer (mCRC) patients. Additionally, FTD/TPI plus bevacizumab (BEV) has demonstrated promising efficacy for mCRC patients who are refractory to standard chemotherapy. Chemotherapy-induced neutropenia (CIN) has been reported to be an indicator of efficacy for FTD/TPI. This study investigated whether CIN was an indicator of efficacy for FTD/TPI plus BEV.

METHODS

We reviewed chemo-refractory mCRC patients who were treated with FTD/TPI alone (monotherapy) or FTD/TPI plus BEV (combination) at our institution and compared the safety and efficacy of the two. Progression-free survival (PFS) and OS were analyzed using Kaplan-Meier curves. We also investigated correlations between CIN and outcomes.

RESULTS

In total, 56 patients received FTD/TPI, among whom 24 and 32 were treated with monotherapy and combination therapy, respectively. The median PFS was 1.8 and 4.7 months for the monotherapy and combination arms, respectively (hazard ratio [HR]: 0.28; 95% confidence interval [CI]: 0.15-0.51; P < 0.001). The median OS was 6.3 and 11.7 months for the monotherapy and combination arms, respectively (HR 0.25; 95% CI 0.13-0.48; P < 0.001). CIN (Grade 3 or worse) developed in five (20.8%) and 17 (53.1%) patients from the monotherapy and combination arms, respectively (P = 0.030). Patients with CIN in the combination arm had improved PFS and OS compared with non-CIN patients (P = 0.033 and P = 0.045, respectively).

CONCLUSIONS

FTD/TPI plus BEV prolonged PFS and OS and had tolerable toxicity compared with FTD/TPI alone. CIN is an indicator of patients who will benefit from FTD/TPI plus BEV.

[Long-Term Survival in a Patient with Stage Ⅳ Gastric Cancer Successfully Treated with Multidisplinary Treatment]

A man in his 60s who had epigastric pain was referred to our hospital and diagnosed with advanced type 3 gastric cancer with multiple liver metastases, cT4acN2cN1(H1), cStage Ⅳ(HER2 3+). He underwent chemotherapy using capecitabine, cisplatin(CDDP), and trastuzumab(T-mab)(XPT). After 7 courses of XPT and 23 courses of XT, liver metastases disappeared, and we decided to perform open distal gastrectomy, D2+ #18 lymphadenectomy, and Billroth Ⅰ reconstruction as a conversion surgery. Despite adjuvant chemotherapy with S-1 plus T-mab, multiple lymph nodes recurrence occurred 3 months after the surgery. He was found to be in complete remission as assessed by CT after 5 courses of second-line CPT-11 treatment, which was discontinued after 17 courses. The patient is alive without recurrence at 57 months after the initial treatment and 22 months after the last treatment.

[A Case of Solitary Fibrous Tumor of the Liver]

Most solitary fibrous tumors(SFT)occur in the thoracic cavity and reports on liver SFT are very rare. We encountered a case of SFT of the liver, and thus, decided to report it with a review of literature. A 70-year-old man was informed of a liver tumor by his previous doctor and referred to us for further examination and treatment. Contrast-enhanced CT revealed a 3.5 cm cyst in the S2/3 of the liver and a 3.2 cm tumor with an early staining within the cyst. Laparoscopic lateral segmentectomy was performed and a diagnosis of hepatic cystic adenocarcinoma was made. Macroscopically, the tumor was white and welldefined. Histopathological examination revealed round chromatin-enriched tumor cells proliferated with round fibrillar cells or intercalated structures consisting of round or short spindle-shaped cells. Immunohistochemistry yielded negative results for CAM5.2, HepPar1, CD31, CD99, SMA, and HMB45 but positive results for CD34, Factor Ⅷ, Bcl-2, and STAT6; therefore, the patient was further diagnosed with liver SFT. Although liver SFT is rare, it was considered a differential diagnosis when multiple bloody liver tumors were detected. In addition, since there were reports of recurrence, careful follow-up in future, was deemed necessary.

[A Case of Robot-Assisted Abdominoperineal Resection for Local Control for Lower Rectal Cancer with Synchronous Liver and Lung Metastases]

The patient was a 70s woman who was referred to our hospital with a complaint of bloody stool. Colonoscopy revealed type 2 tumor at a distance of 1 cm from the dentate line, without obstruction. The pathological diagnosis was adenocarcinoma. Enhanced CT revealed a tumor at the rectum below peritoneal reflection as well as swelling of the mesorectal lymph nodes. Multiple liver and lung metastases were also observed. The diagnosis was lower rectal cancer cT4aN2M1b(H2, PUL2), cStage Ⅳ. Chemotherapy was performed for disease control because of unresectable metastases. She received 7 courses of mFOLFOX plus bevacizumab. Further, as the metastatic lesion was inhibited, the primary lesion was excised for the purpose of symptom control. We judged that sphincter preservation was impossible because it was 1 cm away from the dentate line. She underwent robot-assisted abdominoperineal resection with D3 lymphadenectomy and sigmoid colostomy.

Surgical Resection of Colorectal Cancer With Distant Metastases to Other than Liver or Lung

BACKGROUND/AIM

If both distant metastases and the primary tumour of colorectal cancer (CRC) are resectable, resection of the distant metastases is considered. The aim of this retrospective study was to determine the efficacy of curative resection of both primary and metastatic lesions in organs other than liver or lung in CRC patients.

PATIENTS AND METHODS

The medical records of 23 CRC patients who received R0 resection for primary and metastatic regions between 2009 and 2018 were retrospectively analyzed.

RESULTS

The 3-year overall survival (OS) in all 23 cases was 80.0%. There was no clinicopathological factor associated with OS on univariate analysis.

CONCLUSION

Curative surgical resection appears to be useful for distant CRC metastases to organs other than liver or lung.

[A Resected Case of Hepatocellular Carcinoma Recurrence with Bile Duct Tumor Thrombus after RFA]

Hepatocellular carcinoma with bile duct invasion is rare, with a reported incidence of 3.4%. A 71-year-old man with hepatocellular carcinoma underwent radiofrequency ablation(RFA)(S6, S7, S8)and required readmission 22 months after the RFA for hepatocellular carcinoma recurrence detected by gadoxetic acid-enhanced magnetic resonance imaging. Enhanced abdominal computed tomography and magnetic resonance cholangiopancreatography revealed a tumor thrombus in a biliary branch and left adrenal gland metastases. We performed a right lobectomy and left adrenalectomy. The biliary thrombus was easily removed. Postoperative histopathological examination of the resected specimen showed a moderately differentiated hepatocellular carcinoma invading the biliary tract and the absence of viable cells in the liver tumor. The patient has shown no recurrence 6 months after the hepatectomy.

[A Case of Complete Pathological Response in a Patient with Advanced Ascending Colon Cancer That Invaded the Liver and Duodenum after FOLFOXIRI plus Bevacizumab Chemotherapy]

A 71-year-old woman with advanced ascending colon cancer was admitted to our hospital. Abdominal computed tomography( CT)revealed locally advanced sigmoid colon cancer with suspected invasion of the liver and duodenum. The clinical stage of the disease was cT4bN3M1a, cStage Ⅳa, with wild-type RAS and UGT1A1 expression. An ileostomy was performed because of bowel obstruction. The patient received 6 courses of FOLFOXIRI plus bevacizumab(Bev). The only adverse event was Grade 3 neutropenia. Laparoscopic right hemicolectomy with lymph node dissection was performed. The pathological diagnosis was the absence of viable, Grade 3 carcinoma cells. This result suggested that preoperative FOLFOXIRI plus Bev chemotherapy is useful for the treatment of locally advanced colon cancer.

[A Case of Pathological CR in Local Advanced Rectal Cancer Treated with Laparoscopic ISR after XELOXIRI Chemotherapy]

A 67-year-old man without a history of surgery presented with bloody stool and anal pain. Colonoscopy and abdominal CT revealed locally advanced rectal cancer with right lateral lymph node metastasis. We administered 6courses of neoadjuvant therapy with capecitabine, oxaliplatin, and irinotecan(XELOXIRI)to the patient. After neoadjuvant chemotherapy, remarkable tumor shrinkage was observed. The patient underwent safety intrasphincteric resection(ISR)and lateral lymph node dissection with anal preservation. The postoperative course was uneventful, and he was discharged 17 days postoperatively. Pathologically, no residual cancer cells were observed in the rectum and lymph nodes(pathological CR). This case of locally advanced rectal cancer was successfully treated with laparoscopic ISR after XELOXIRI chemotherapy, and showed pathological CR. ISR after neoadjuvant XELOXIRI chemotherapy was safely performed and might be a good option for locally advanced rectal cancer.

[A Case of Peritoneal Recurrence of HCC Who Achieved Long-Term Survival after a Multidisciplinary Treatment]

The treatment for peritoneal dissemination of hepatocellular carcinoma(HCC)remains to be established. Therefore, peritoneal recurrence ofHCC has a poor prognosis. Here, we report a case ofperitoneal recurrence ofHCC after a liver resection. The patient underwent surgery for peritoneal recurrence 5 times already and had taken sorafenib for 3 years. No recurrence occurred for 55 months during the last follow-up. Therefore, multidisciplinary treatment for peritoneal recurrence of HCC, including surgical resection, may improve prognosis.

[Experience of Using Aflibercept Beta and FOLFIRI Chemotherapy for Metastatic Colorectal Cancer]

BACKGROUND

Aflibercept beta and FOLFIRI combination therapy were approved for metastatic colorectal cancer as secondline treatment in 2017. Aflibercept beta is a recombinant fusion protein that traps vascular endothelial growth factor(VEGF)- A, VEGF-B, and placental growth factor(PlGF).

METHODS

We retrospectively evaluated the efficacy and safety of aflibercept beta and FOLFIRI in metastatic colorectal cancer patients(pts)between June 2017 and April 2018 at our institution. Afliber- cept beta(4mg/kg)was administered with FOLFIRI every 2weeks.

RESULTS

Twenty pts received aflibercept beta and FOLFIRI. There were 11 males and 9 females, with a median age of 69.5(53-81)years. Performance status(PS)was 0 in 12 pts and 1 in the remaining 8 pts. Aflibercept beta and FOLFIRI were prescribed as second-line treatment in 8 pts and the others in 12 pts. The median number of aflibercept beta and FOLFIRI cycles was 5(1-11)cycles. Progression -free survival and overall survival have not yet been estimated. In terms of adverse events, serious adverse events of Grade 3 or higher, including Grade 5 neutropenia, were seen among all pts.

CONCLUSIONS

Aflibercept beta and FOLFIRI demonstrated acceptable toxicity in heavily pretreated metastatic colorectal cancer patients.

[Experience of Treatment with Lenvatinib in Patients with Advanced HCC-A in a Single Institution]

The efficacy of lenvatinib was evaluated in 7 patients with advanced hepatocellular carcinoma(HCC), between March 2018 and February 2019. Their mean age was 74.3 years, and 6 of them were men. All patients had an Eastern Cooperative Oncology Group(ECOG)performance status(PS)of 0. The median number of treatment days was 185. The relative dose intensity was 87.5%. The major Grade was 3, and the overall toxicity events were AST elevation(14.3%)and hypertension (14.3%). The 6-month progression-free and overall survival rates were 71.4% and 100%, respectively. The overall response rate was 57.1%, and the disease control rate was 71.4%. Lenvatinib can be used as a standard treatment for patients with advanced HCC.

Assessment of Upper Limb Physiological Features in Patients with Lymphedema After Breast Surgery Using Multiple Instruments

Background: Objective assessment of upper limb physiological features may allow for early detection and proper intervention for lymphedema after breast surgery. However, the development of diagnostic instruments and standard measurement procedures are required. Methods and Results: Four instruments (Venustron, Softmeasure, Myoton Pro, and iBDent), tape measurement, and water volumetry were investigated in this study. Inter-limb differences in physiological data were obtained from 40 patients with lymphedema after breast surgery and 38 control subjects. Four instruments and tape measurements were performed at four points. Inter-limb differences between patients with lymphedema and control subjects were determined. All measurements took <20 minutes with minimal pain reported. Inter-limb differences in water volumetry and tape measurements, especially when measured at 5 cm distal to the cubital fossa, were increased in International Society of Lymphology (ISL) stage II cases. All four instruments showed high reproducibility in standard silicon sample measurement. On the other hand, data from human samples were varied, and the utility for assessment of lymphedema was not determined. Conclusion: Water volumetry and tape measurement at 5 cm distal to the cubital fossa were useful to assess lymphedema in ISL stage II cases. Four instruments used in this study were feasible in clinical practice. In addition, inconsistent data from human tissue were not due to sensor limitations, rather, acquisition of accurate data from human tissue seemed to be difficult due to anatomical factors. In addition to high-quality sensor, development of system that produce accurate and reproducible results from human tissue is required.

Metachronous rectal metastasis from pulmonary adenocarcinoma after 11 years of chemo-, immuno-, and radiotherapy for recurrent lesions: a case report

Background

Rectal metastasis from pulmonary adenocarcinoma is rare, and it has been regarded as an end-stage phenomenon. Recently, however, advances in lung cancer treatment have improved the chance of long-term survival of patients with unresectable distant metastases. We describe the occurrence and management of metastatic spread of a pulmonary carcinoma to the rectum.

Case presentation

The patient was a 79-year-old woman who had undergone thoracoscopic left lobectomy for pulmonary adenocarcinoma and then, over the next 11 years, various drugs (carboplatin + paclitaxel (as adjuvant therapy), gefitinib, gemcitabine + vinorelbine, S1 (an oral 5-fluorouracil-based drug), carboplatin + pemetrexed + bevacizumab, erlotinib, nivolumab, afatinib, and carboplatin+ S1) were administered, especially for hilar and mediastinal lymph node recurrences. During the eleventh postoperative year, left and right iliac bone metastases were detected, and radiation therapy was undertaken for local control of these lesions. When ¹⁸F-fluorodeoxyglucose positron emission tomography was performed for evaluation of the disease, tracer accumulation in the upper rectum was seen. Colonoscopic examination of the rectum revealed an intramural mass with central ulceration, and the mass was diagnosed histologically as an adenocarcinoma. The bone metastases appeared to be controlled, and the patient’s performance status was good, but she had suffered constipation for about a year and desired treatment. Thus, laparoscopic low anterior resection was performed. Histopathologic analysis revealed a moderately differentiated adenocarcinoma existing mainly between the submucosa and serosa, and immunohistochemical analysis showed the tumor to be positive for cytokeratin (CK) 7, negative for CK20, positive for thyroid transcription factor-1, and negative for special AT-rich sequence-binding protein 2 and caudal type homeobox 2, confirming the diagnosis of rectal metastasis from the primary pulmonary adenocarcinoma. The patient recovered well without any change in her functional status. Systemic chemotherapy was resumed, and she continues to do well, now 6 months after surgery.

Conclusions

Surgery may be a good option for the management of an isolated rectal metastasis from pulmonary cancer in patients whose functional status is good.

Clozapine-induced antineutrophil cytoplasmic antibody-associated vasculitis: a case report

Clozapine is the most effective antipsychotic medication for refractory schizophrenia, but it has many possible serious side effects, including antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). However, the rare case reports available have not presented sufficient characteristic features of drug-induced AAV. Herein, we report a case of a 48-year-old Japanese woman with schizophrenia who presented with fever, arthralgia, myalgia and skin rash after 2 years of clozapine treatment. Her C-reactive protein (CRP) level increased, myeloperoxidase ANCA was positive and skin biopsy revealed leukocytoclastic vasculitis. Initially, steroid administration achieved remission, but her symptoms and high CRP levels relapsed every time the steroid dosage was tapered down. Upon discontinuation of clozapine, her symptoms and elevated CRP level immediately improved and the steroid was successfully tapered and discontinued. This outcome suggested that clozapine was the main cause of AAV.

Giant umbilical cord and hypoglycemia in an infant with Proteus syndrome

Proteus syndrome (PS) is characterized by the progressive, segmental, or patchy overgrowth of the skin, and other tissues. This is the first case report of recurrent severe insulin-independent hypoglycemia in an infant with PS. Somatic p.E17K of AKT1 mutation was confirmed. The patient also had a giant umbilical cord, which has not yet been reported in PS.

[A Middle-Term Survival Case of Pancreas Tail Cancer with Colonic Obstruction]

A 63-year-old man had abdominal pain and sequential constipation and diarrhea. He complained of abdominal pain and vomiting, and was admitted to the hospital with a diagnosis of ileus. CT demonstrated a colonic obstruction at the splenic flexure, which was suspected to be colon cancer. Ileostomy was performed in March 2015, and he underwent radical resection in May 2015. Cancer of the pancreas tail had invaded the spleen, colon, stomach, and left renal capsule. Distal pancreatectomy was performed, along with extended right hemicolectomy, left nephrectomy, partial gastrectomy, and stoma closure. He received adjuvant chemotherapy for 6 months after the operation. He is alive without recurrence of pancreatic cancer for over 3 years.