Gluteal muscle metastasis with peritoneal dissemination from gastric cancer during postoperative adjuvant chemotherapy: a case report

Background

Skeletal muscle metastasis from gastric cancer is rare and has a poor prognosis. We reported a case of gluteal muscle metastasis with peritoneal dissemination from gastric cancer during postoperative adjuvant chemotherapy.

Case presentation

A 64-year-old man with gastric cancer underwent distal gastrectomy with D2 lymph node resection. The pathological diagnosis was poorly differentiated adenocarcinoma and signet cell carcinoma, T3N3bM0, Stage IIIC. Metastases were found in all regional lymph nodes, except 11p. The resection margin was negative. S-1 plus docetaxel therapy was administered as postoperative adjuvant chemotherapy. Six month post-operation, the patient presented with right gluteal muscle tenderness and abdominal distension. Computed tomography revealed a solid mass in the right gluteal muscle, a disseminated nodule on the abdominal wall, and massive ascites. Pathological examination of the gluteal muscle revealed signet cell carcinoma, similar to the resected gastric cancer. The tumor was diagnosed as gastric cancer metastases. Ascites cytology was class V. Thereafter, the patient underwent one course of capecitabine plus cisplatin combined with trastuzumab. Radiation therapy was also administered to relieve the pain of gluteal muscle metastasis. However, chemoradiotherapy was ineffective, and the patient died 2 months after the recurrence.

Conclusions

Skeletal muscle metastasis and peritoneal dissemination during adjuvant chemotherapy indicated a poor prognosis.

Successful Conversion Surgery Following Chylous Ascites After Nivolumab for Advanced Gastric Cancer

CASE REPORT

A 75-year-old man who underwent nivolumab as the third-line chemotherapy for advanced gastric cancer had chylous ascites (CA) after the primary tumor shrank remarkably. Total parenteral nutrition and subcutaneous octreotide were initiated, and CA disappeared. Nivolumab was continued for a total of 23 courses. Computed tomography showed lymph node swelling; however, staging laparoscopy showed that peritoneal metastasis had disappeared. Therefore, conversion surgery and distal gastrectomy with D1+ dissection were performed.

RESULTS

The pathological diagnosis was type IV, poorly differentiated adenocarcinoma (por2) with signet ring cells, ypT2 (muscularis propria), without lymphatic or venous invasion, and no involvement of the proximal and distal margins. After the operation, no recurrence was observed over 7 months with no adjuvant chemotherapy.

CONCLUSION

Nivolumab has the potential to lead to R0 resection for patients with peritoneal carcinomatosis gastric cancer. To our knowledge, this is the first report of successful conversion surgery after nivolumab-related chylous ascites.

Control of inferior vena cava injury during laparoscopic surgery using a double balloon-equipped central venous catheter: proof of concept in a live porcine model

BACKGROUND

Iatrogenic inferior vena cava (IVC) injury is a rare but potentially life-threatening complication during laparoscopic surgery. This experimental study aimed to assess the hemostatic ability of a new device, double balloon-equipped central venous (DB-CV) catheter, for IVC injury.

METHODS

The DB-CV catheter comprises a triple-lumen sphincterotome combined with two dilating balloons having a diameter of 25 mm. The experimental procedures were performed in five pigs. The DB-CV catheter was inserted via the right femoral vein. For the IVC occlusion test, correct placement of the balloons was confirmed by indocyanine green fluorescence imaging, and hemodynamic data were recorded. For the IVC injury test, a 3- to 4-mm circumferential incision was created in IVC, and hemostasis was initiated using balloon inflation 5 s after the injury.

RESULTS

Hemodynamic changes were minimal, with a 20 mmHg reduction in the mean arterial pressure because of IVC occlusion. All bleeding from IVC injuries was successfully temporarily stopped by direct balloon compression, with a mean time to hemostasis of 69 s and mean blood loss of 32 ml. Subsequently, the positioning of IVC injuries between two balloons made it possible to suture the injured IVC.

CONCLUSIONS

Balloon occlusion using the DB-CV catheter provides a rapid temporal hemostatic effect and can overcome the serious condition of massive hemorrhage from IVC injuries.

Downregulation of dual-specificity phosphatase 4 enhances cell proliferation and invasiveness in colorectal carcinomas

It is widely accepted that aberrant activation of the Wnt signaling pathway is responsible for the development of precursor lesions of colorectal cancer (CRC). However, the molecular mechanisms involved in the process of progression from these precursor lesions to invasive lesions of CRC are not fully understood. Recently, we reported that constitutive activation of MAPK accompanied by downregulation of dual‐specificity phosphatase 4 (DUSP4), a MAPK phosphatase, contributes to the progression of precursor lesions in the pancreas. In this study, we found that downregulation of DUSP4 was related to constitutive activation of ERKs in CRC cells. Restoration of DUSP4 resulted in inactivation of ERKs, leading to suppression of both proliferation and invasiveness, as shown by treatment with an MEK inhibitor. Furthermore, immunohistochemistry revealed that DUSP4 expression was upregulated in the superficial region of CRC tissue, whereas it was significantly downregulated in the deep region. In contrast, ERKs in the deep region were markedly hyperactivated compared to those in the superficial region. These results suggest that activation of the MAPK signaling pathway caused by downregulation of DUSP4 is responsible for progression of CRCs and would be a promising therapeutic target.

[A case report of pulmonary embolectomy for acute pulmonary thromboembolism without extra-corporeal circulation]

A 69-year-old man complaining of abrupt dyspnea was admitted by ambulance. Acute massive pulmonary thromboembolism was diagnosed by pulmonary arteriography but after PAG cardiac standstill developed. Infusing of heparin and tPA immediately, cardiopulmonary resuscitation was successful after 5 minutes. Repeated PAG showed that thrombus in the right intermediate pulmonary artery was not detected, but was still detected in the left main pulmonary artery. The emergency embolectomy of left main pulmonary artery was performed without extracorporeal circulation and massive thrombi were removed. Mechanical respiratory support was required and we suffered from the frequent bleeding of the air way for one night. The patient was discharged about one month without any complaints.

[A case of surgical treatment for thymic Hodgkin's disease with tracheo-bronchial stenosis]

An 18-year-old female was introduced our hospital for facial swelling and subcutaneous tumor of anterior neck. Chest X-ray and CT films showed mediastinal mass with tracheo-bronchial stenosis. Incisional biopsy specimens of neck tumor revealed that the tumor was suggestive of malignant lymphoma. Because of progressive dyspnea after CHOP regimens the operation was performed and histopathological examinations revealed thymic Hodgkin's disease. After operation dyspnea was improved but dysphagia and hoarseness occurred. These symptoms were getting improved. She received 6 cycles of ABVD regimens and discharged after 5 months.

[A case of malignant fibrous histiocytoma in the thymic carcinoid]

The clinical case is 68 year old woman. The patient experienced dyspnea and back pain. Chest X-ray and CT showed a large well-defined mass from the left thorax expanding to the right. The tumor, which was derived from the left lobe of thymus, was removed. Cut surface of the resected tumor showed multilobar patterns and a yellow-white portion like a wedge in a part of the tumor. Histological examinations revealed that the multilobar portion was thymic carcinoid and a yellow-white portion was malignant fibrous histiocytoma. As far as we examined, literature pertaining to such double cancers has never been reported.

[A case of invasive thymoma displaying endobronchial and endocaval polypoid growth]

The hens' egg-sized tumor connecting from anterior mediastinum to the hilus by chest radiography and chest CT was noted in a 63 year old female who complained of facial swelling and cough. The defect of the thumb tip-sized shadow was noted in the superior vena cava by superior vena cavography, and polyp covered with white coating obstructing the right apical bronchus was noted by fibrotic bronchoscopy, and malignant finding was obtained by biopsy of this polyp. After midsternotomy, a mass invaded to the superior vena cava and the right upper lobe was resected, and then superior vena cava was reconstructed by using supported polytetrafluoroethylene. The resected specimen revealed that the tumor extended not only to the pulmonary parenchyma with polypoid growth into the lumina of bronchi but also to the superior vena cava with polypoid growth. The patient was discharged at the postoperative radiotherapy with 40 Gy, and he is still alive free from the disease 3 years and 11 months after operation.

[Experience of surgical therapy of pyothorax in the pleural fistula of the bronchi and esophagus due to esophageal cancer]

The esophagectomy and total left pneumonectomy were carried out in a 53-year-old male who had developed pyothorax in the pleural fistula of the bronchi and esophagus due to esophageal cancer, and then reconstruction of the esophagus by route of the anterior thoracic wall was performed using stomach tube biphasically. The postoperative course was favorable, and oral intake was possible, and his physical condition recovered as the patient could repeat stopping out from hospital while he died by pneumonia after 7 months. The remote metastasis or metastasis to the mediastinal lymph-node were not noted by autopsy. It is considered that there are cases having indication for active resection among A3-esophageal cancers.

[A case of abdominal wall fistula due to cholangioma]

A 59-year-old woman was admitted to our hospital complaining of intractable abdominal wall fistula. Several examinations led to the suspicion of a fistula due to liver cell tumor. Histologically, the tumor was diagnosed as cholangioma. Chemotherapy was very effective after fistulectomy, and to date, she has been doing well for 34 months.

Identification of hemorrhagic site of the intestine by RI-angiography

A 36-year-old man was transferred to our department because of massive malena followed by shock. Gastroduodenal endoscopy revealed no bleeding source in the stomach or the duodenum. RI-angiogram performed immediately after admission revealed a bleeding area at the jejunum and laparotomy was done. The bleeding lesion was detected by exploratory jejunotomy and a jejunectomy was successfully performed over 15 cm, including the lesion. RI-angiogram is useful as selective angiography in the diagnosis of intestinal bleeding and is less invasive.

[Coexisting malignant lymphoma and early cancer of the stomach]

A 62-year-old man with malignant lymphoma and early gastric cancer as two independent growths in the stomach was reported. In the resected stomach, malignant lymphoma was observed as a protruding lesion measuring 5.5 X 3.0 X 1.2 cm with four giant folds at the anterior wall of the upper gastric body. There also was a poorly differentiated adenocarcinoma as an early gastric cancer of type IIc + III; it measured 0.9 X 0.7 cm and invaded the submucosal layer at the antral portion. There were no pathological findings, excepting intestinal metaplasia, in the mucosal layer between the two lesions. There was no metastasis from either the malignant lymphoma or the adenocarcinoma to perigastric lymph nodes.