A case of intestinal intussusception with unique hemorrhagic polyps due to AL amyloidosis and excessive anticoagulation

Most adult intussusceptions are secondary to various pathological conditions that serve as a lead point. Because of their serious nature, intussusceptions often require emergency surgery. We report a surgical case of amyloidosis associated with intussusception, probably due to polypoid protrusions and bleeding tendencies. An 80-year-old man with abdominal pain was suspected of having jejunal intussusception on computed tomography. He had been prescribed warfarin for atrial fibrillation, and excessive anticoagulation was observed with a prolonged prothrombin time/international normalized ratio of 5.44 at presentation. After the excessive anticoagulation was resolved, emergency surgery was performed. The intussuscepted jejunum was resected, and a 7 cm long dark-red pedunculated polyp was identified as the lead point, which was accompanied by multiple small pedunculated polyps. Histopathological examination showed that these were all hemorrhagic polyps. Amyloid depositions were observed in the muscularis mucosae, submucosa, and the walls of the blood vessels. Immunohistochemical analysis revealed immunoglobulin light chain amyloidosis. This case is informative to discuss the clinical sequelae of gastrointestinal amyloid deposition.

[A Case of Jejunal Cancer Treated by Laparoscopic Partial Jejunectomy]

The patient was a 30s male visited our hospital with the complaints of abdominal pain and melena. The internal medicine physician could not detect the cause of the melena by upper and lower gastrointestinal endoscopy. Although the patient resolved with a fast as conservative management so he left our hospital once, he relapsed nausea and abdominal pain. He visited our department. We performed surgery under a preoperative diagnosis of intestinal obstruction. The histopathological diagnosis was moderate differentiated jejunal adenocarcinoma(Stage ⅡA). At present, 1 year 7 months since surgery, the patient survives although with lymphnode recurrence.

Clinical Impact of Two-Week Placement of a Subcutaneous Suction Drain in Preventing Incisional Surgical Site Infection in Open Gastrointestinal Surgery with Class 4 Dirty Wound: A Retrospective Study

Background: Two recent randomized controlled trials demonstrated the beneficial effects of subcutaneous drainage in preventing incisional surgical site infection (SSI) in colorectal surgery. This study aimed to evaluate the efficacy of subcutaneous suction drains (SSDs) compared with primary skin closure (PC) in class 4 dirty wound surgery. Patients and Methods: Eighty-one patients undergoing open gastrointestinal surgery with class 4 dirty wounds were enrolled in this study, 30 of whom underwent SSD insertion, whereas the other 51 were treated with PC. Because several studies have reported that the median onset of the development of incisional SSI was eight to 13 days after surgery, we used a two-week placement of an SSD. Comparison of patients treated with SSD and PC and multivariable analysis were performed to test the ability of SSD in decreasing the SSI rate. Results: No differences were observed between the two groups in terms of gender, body mass index, American Society of Anesthesiology score, steroid use, presence of diabetes mellitus, peri-operative transfusion, and surgery type. Surgical site infection incidence was lower in the SSD group (6.6%; 2/30) than that in the PC group (23.5%; 12/51; p = 0.069). Multivariable analysis revealed that the presence of diabetes mellitus was an important independent risk factor for incisional SSI, and the placement of an SSD has substantial preventive effects on incisional SSI (p = 0.018 and p = 0.014, respectively). Conclusions: This study suggested the potential importance of a two-week placement of an SSD for preventing incisional SSI in class 4 dirty wound surgery.

Identification of lenvatinib prognostic index via recursive partitioning analysis in advanced hepatocellular carcinoma

BACKGROUND

After the advent of new treatment options for advanced hepatocellular carcinoma (HCC), the identification of prognostic factors is crucial for the selection of the most appropriate therapy for each patient.

PATIENTS AND METHODS

With the aim to fill this gap, we applied recursive partitioning analysis (RPA) to a cohort of 404 patients treated with lenvatinib.

RESULTS

The application of RPA resulted in a classification based on five variables that originated a new prognostic score, the lenvatinib prognostic index (LEP) index, identifying three groups: low risk [patients with prognostic nutritional index (PNI) >43.3 and previous trans-arterial chemoembolization (TACE)]; medium risk [patients with PNI >43.3 but without previous TACE and patients with PNI <43.3, albumin-bilirubin (ALBI) grade 1 and Barcelona Clinic Liver Cancer stage B (BCLC-B)]; high risk [patients with PNI <43.3 and ALBI grade 2 and patients with PNI <43.3, albumin-bilirubin (ALBI) grade 1 and Barcelona Clinic Liver Cancer stage C (BCLC-C)]. Median overall survival was 29.8 months [95% confidence interval (CI) 22.8-29.8 months] in low risk patients (n = 128), 17.0 months (95% CI 15.0-24.0 months) in medium risk (n = 162) and 8.9 months (95% CI 8.0-10.7 months) in high risk (n = 114); low risk hazard ratio (HR) 1 (reference group), medium risk HR 1.95 (95% CI 1.38-2.74), high risk HR 4.84 (95% CI 3.16-7.43); P < 0.0001. The LEP index was validated in a cohort of 127 Italian patients treated with lenvatinib. While the same classification did not show a prognostic value in a cohort of 311 patients treated with sorafenib, we also show a possible predictive role in favor of lenvatinib in the low risk group.

CONCLUSIONS

LEP index is a promising, easy-to-use tool that may be used to stratify patients undergoing systemic treatment of advanced HCC.

Continuous ghrelin infusion attenuates the postoperative inflammatory response in patients with esophageal cancer

PURPOSE

The aim of this study was to clarify whether ghrelin infusion is useful for suppressing inflammatory responses after esophagectomy.

METHODS

A phase I study of ghrelin administration after esophagectomy was performed in 20 patients with esophageal cancer. The anti-inflammatory effect of ghrelin was compared with 20 consecutive patients who did not receive ghrelin infusion. Additionally, 10 patients with intermittent infusion for 10 days were compared with 10 patients with continuous infusion for 5 days. The primary endpoint was the duration of systemic inflammatory response syndrome (SIRS). Secondary endpoints included postoperative complications, serum C-reactive protein (CRP), interleukin-6 (IL-6), and growth hormone (GH) levels.

RESULTS

No adverse events of ghrelin administration occurred. Patients with ghrelin infusion had higher plasma ghrelin levels on postoperative day (POD) 3 (p = 0.003) and shorter SIRS duration (p = 0.007) than patients without ghrelin infusion. Although SIRS duration was similar (p = 0.19), patients with continuous ghrelin infusion had significantly higher plasma ghrelin (p < 0.001) and GH levels (p = 0.002) on POD 3 than patients with intermittent ghrelin infusion. Serum CRP and IL-6 levels on POD 3 tended to be lower in the continuous infusion versus intermittent infusion group.

CONCLUSIONS

Ghrelin was safely administered after esophagectomy and may reduce excess postoperative inflammatory responses. Continuous infusion is better for this purpose than intermittent infusion.

[Two Cases of Hepatic Encephalopathy after Chemotherapy for Metastatic Colorectal Cancer]

We reported 2 cases of hepatic encephalopathy after chemotherapy for advanced colorectal cancer. Case 1: A 49-year-old male was diagnosed advanced sigmoid colon cancer with peritoneal dissemination, multiple liver metastasis and multiple osseous metastasis. After resection of primary lesion, we administered mFOLFOX6 plus bevacizumab combination therapy. He was in comatose(Japan coma scale 200)3 days after 2 courses of administration of this regimen. Case 2: A 57-year-old female was diagnosed advanced rectal cancer with multiple huge liver metastasis and multiple osseous metastasis. We administered mFOLFOX6 plus panitumumab combination therapy. She was in comatose(Japan coma scale 100)3 days after 10 courses of administration of this regimen. In both cases, radiographic imaging showed no abnormal sign and blood examination revealed a high level of serum ammonia. We diagnosed their disturbance of consciousness as a symptom of hepatic encephalopathy. Branched-chain amino acid infusion rapidly improved disturbance of consciousness. We must consider the symptom, hepatic encephalopathy in patients receiving chemotherapy for advanced colorectal cancer.

[A Case of Successful Management of Postoperative Chylous Ascites by Combination Therapy with Octreotide and Etilefrine]

We have report a case of an 81-year-old woman who underwent distal pancreatectomy for pancreatic body cancer. Chy- lous ascites with high triglyceride(TG)level, 201mg/dL, occurred on postoperative day 2. Continuous drainage and conservative management, such as low fat diet, fasting, total parental nutrition, and octreotide monotherapy, could not resolve the problem. Successful treatment was achieved using subcutaneous octreotide injection and intravenous etilefrine infusion without any adverse side-effect. These medications were able to cause smooth muscle contraction in the thoracic duct, and also to reduce chyle flow. The amount of drainage decreased and the TG level was restored to 66mg/dL. The drainage tube was removed on postoperative day 22, 5 days after the start of both octreotide and etilefrine. This combination therapy with octreotide and etilefrine would be one of effective and safety treatment for management of postoperative intractable chylous ascites.

Detection of copy number variations in epilepsy using exome data

Epilepsies are common neurological disorders and genetic factors contribute to their pathogenesis. Copy number variations (CNVs) are increasingly recognized as an important etiology of many human diseases including epilepsy. Whole-exome sequencing (WES) is becoming a standard tool for detecting pathogenic mutations and has recently been applied to detecting CNVs. Here, we analyzed 294 families with epilepsy using WES, and focused on 168 families with no causative single nucleotide variants in known epilepsy-associated genes to further validate CNVs using 2 different CNV detection tools using WES data. We confirmed 18 pathogenic CNVs, and 2 deletions and 2 duplications at chr15q11.2 of clinically unknown significance. Of note, we were able to identify small CNVs less than 10 kb in size, which might be difficult to detect by conventional microarray. We revealed 2 cases with pathogenic CNVs that one of the 2 CNV detection tools failed to find, suggesting that using different CNV tools is recommended to increase diagnostic yield. Considering a relatively high discovery rate of CNVs (18 out of 168 families, 10.7%) and successful detection of CNV with <10 kb in size, CNV detection by WES may be able to surrogate, or at least complement, conventional microarray analysis.

[A Patient Underwent Pancreaticoduodenectomy with Reconstruction of Replaced Right Hepatic Artery]

A 78 year-old man was diagnosed as a pancreatic cancer in department of gastroenterology in our hospital. Enhanced computed tomography demonstrated an aberrant right hepatic artery(ARHA)arising from superior mesenteric artery(SMA). We conducted sub-stomach preserving pancreaticoduodenectomy(SSPPD- II A-1). As the preoperative diagnosis, right hepatic artery(RHA)was arising from SMA and running through the tumor, and we resected the ARHA with the tumor and reconstructed RHA to gastroduodenal artery(GDA). Pathological diagnosis was non invasive tumor with neither lymph node metastasis nor invasion of the vasculature. We report a case of the patient underwent pancreaticoduodenectomy with reconstruction of aberrant right hepatic artery.

[A Colorectal Cancer with Invasive Micropapillary Carcinoma]

A 76-year-old woman with bloody stool visited a nearby hospital. Colonoscopy showed a type 1 tumor in the rectum, and the biopsy indicated moderately differentiated adenocarcinoma. She was referred to our hospital. Abdominal contrast-enhanced CT did not show swollen lymph nodes in the regional nodes or distant metastases. Laparoscopic lower anterior resection was performed. Histopathological examination indicated pT1b, pN3, ly3, and v1, fStage III b, which had a partial invasive micropapillary carcinoma(IMPC)component of papillary adenocarcinoma. Although she received postoperative adjuvant chemotherapy, she died of a thromboembolism with paraneoplastic syndrome 20 months after the operation. IMPC has a high incidence of lymphatic invasion and lymph node metastases. IMPC is rare in cases of colorectal cancer and it is important to accumulate and investigate colorectal cancer patients with IMPC.

[A Case of Unresectable Advanced Gastric Cancer Treated with Palliative Radiation Therapy for Massive Bleeding]

The patient was a 77-year-old man. He was diagnosed with Stage IV gastric cancer with pancreatic invasion and pyloric stenosis. After gastrojejunostomy, S-1 monotherapy was started. Melena and fatigue appeared 2 months after chemotherapy, and Grade 3 anemia was confirmed. Palliative radiotherapy of 30 Gy in 10 Fr was administered to control bleeding from the lesion. The progression of anemia stopped and outpatient chemotherapy became possible. Palliative radiotherapy for persistent bleeding from unresectable advanced gastric cancer is considered an effective treatment option to control bleeding.

[Anorectal Malignant Melanoma Is a Very Rare Disease and Has a Poor Prognosis]

We performed abdomino-perineal-resection(APR)on 2 cases of anorectal malignant melanoma. The first case was a 70- year-old woman suffering from bloody stool. Colonoscopy showed a black tumor in the rectum. Biopsy revealed a malignant melanoma. A CT scan showed multiple lung metastases and liver metastasis. She underwent surgery for the purpose of bleeding control, but died shortly thereafter because her liver and lung metastases had worsened. The second case was a 43- years-old man suffering from bloody stool. He had a black type 3 tumor in the rectum. A biopsy revealed malignant melanoma. A CT scan showed lateral lymph node swelling. He underwent APR with right side-lateral dissection. An established treatment for anorectal malignant melanoma has not been agreed upon and it is controversial. We experienced 2 cases that underwent surgery and we report them along with relevant information from the literature.

[Experiences of Colonic Stents in Patients with Colonic Stenosis Due to Peritoneal Dissemination of Gastric Cancer]

Stoma is a treatment option often adopted for large bowel obstruction accompanying peritoneal dissemination of gastric cancer, but the invasiveness of this intervention can be an issue for patients with limited prognosis and reduced quality of life. In our hospital, colonic stenting for bowel obstruction due to peritoneal dissemination from gastric cancer was performed for 7 consecutive patients. Oral ingestion became possible in 5 cases, and colonic stent was considered a useful treatment choice for appropriate cases.

A novel missense mutation affecting the same amino acid as the recurrent PACS1 mutation in Schuurs-Hoeijmakers syndrome

A novel causative variant (c.608G>A, p.Arg203Gln) in PACS1.

Novel biallelic SZT2 mutations in 3 cases of early-onset epileptic encephalopathy

The seizure threshold 2 (SZT2) gene encodes a large, highly conserved protein that is associated with epileptogenesis. In mice, Szt2 is abundantly expressed in the central nervous system. Recently, biallelic SZT2 mutations were found in 7 patients (from 5 families) presenting with epileptic encephalopathy with dysmorphic features and/or non-syndromic intellectual disabilities. In this study, we identified by whole-exome sequencing compound heterozygous SZT2 mutations in 3 patients with early-onset epileptic encephalopathies. Six novel SZT2 mutations were found, including 3 truncating, 1 splice site and 2 missense mutations. The splice-site mutation resulted in skipping of exon 20 and was associated with a premature stop codon. All individuals presented with seizures, severe developmental delay and intellectual disabilities with high variability. Brain MRIs revealed a characteristic thick and short corpus callosum or a persistent cavum septum pellucidum in each of the 2 cases. Interestingly, in the third case, born to consanguineous parents, had unexpected compound heterozygous missense mutations. She showed microcephaly despite the other case and previous ones presenting with macrocephaly, suggesting that SZT2 mutations might affect head size.

A case of atypical Kabuki syndrome arising from a novel missense variant in HNRNPK

A novel causative variant (c. 464T>C, p.Leu155Pro) in the heterogeneous nuclear ribonucleoprotein K (HNRNPK) gene.

Order by Quenched Disorder in the Model Triangular Antiferromagnet RbFe(MoO_{4})_{2}

We observe a disappearance of the 1/3 magnetization plateau and a striking change of the magnetic configuration under a moderate doping of the model triangular antiferromagnet RbFe(MoO_{4})_{2}. The reason is an effective lifting of degeneracy of mean-field ground states by a random potential of impurities, which compensates, in the low-temperature limit, the fluctuation contribution to free energy. These results provide a direct experimental confirmation of the fluctuation origin of the ground state in a real frustrated system. The change of the ground state to a least collinear configuration reveals an effective positive biquadratic exchange provided by the structural disorder. On heating, doped samples regain the structure of a pure compound, thus allowing for an investigation of the remarkable competition between thermal and structural disorder.

[Surgical Outcome of Palliative Surgery for Gastric Cancer Patients with Bowel Obstruction Due to Peritoneal Dissemination]

A retrospective cohort analysis was performed for 21 consecutive patients who underwent palliative surgery for bowel obstruction due to peritoneal metastasis from gastric cancer. Surgical site infection occurred in 5 of 21 patients, but there were no severe(Clavien-Dindo Grade III or higher)complications, and symptoms of bowel obstruction were improved in 20 of 21 patients. The median survival time was 6.6 months. The survival rate was significantly worse for patients in modified Glasgow prognostic score(mGPS)group D compared with those in mGPS group non-D(p=0.0001). Surgery for malignant bowel obstruction was feasible and effective for palliation.

[A Case of Metastatic Colorectal Cancer Refractory to Standard Chemotherapies Treated with TAS-102 with Bevacizumab]

A 51-year-oldwoman with lung, liver, andd istant lymph node metastases from sigmoidcolon cancer was treatedusing TAS-102 with bevacizumab as fourth-line chemotherapy. There was a 35%decrease in the size of target lesions after the first 4 cycles of therapy, and disease control has been maintained for 9 months. The only Grade 3 or worse adverse event experiencedwas neutropenia. In patients with refractory colorectal cancer, the combination of TAS-102 with bevacizumab might be an effective andsafe treatment.

[A Case of an Elderly Patient with Advanced Gastric Cancer Successfully Treated with Combination S-1 and Oxaliplatin Therapy]

The patient was an 80-year-old man. He had a chief complaint of epigastric pain. The upper gastrointestinal endoscopy showed a type 4 tumor of the stomach, and the CT scan showed multiple para-aortic lymph node metastases. The patient was diagnosed with cStage IV gastric cancer. At first, he could take only small amounts of liquid. After starting S-1 and oxaliplatin (SOX), he was able to resume a full diet and his general condition was improved. A CT scan after 4 courses of chemotherapy showed a significant reduction in the wall thickness of the stomach and the size of the lymph nodes. SOX chemotherapy could be a promising treatment option for elderly patients with advanced gastric cancer.

[A Case of Appendiceal Mucinous Cystadenoma Treated Using Laparoscopic Appendectomy]

A 73 year-old woman who was treated for breast cancer and visited our hospital regularly was suspected of having a mucinous cystadenoma of the appendix. Malignancy could not be determined using abdominal computed tomography, magnetic resonance imaging, or colonoscopy. Even if mucinous cystadenoma is benign, there is the possibility that the tumor will rupture, discharge its contents, and cause pseudomyxoma peritonei. We performed laparoscopic appendectomy. According to the histopathological results, the tumor was diagnosed as a low grade appendiceal mucinous neoplasm. We report a case of mucinous cystadenoma of the appendix treated using laparoscopy-assisted appendectomy and discuss the case with literature reviews.

Exome sequencing for bipolar disorder points to roles of de novo loss-of-function and protein-altering mutations

Although numerous genetic studies have been conducted for bipolar disorder (BD), its genetic architecture remains elusive. Here we perform, to the best of our knowledge, the first trio-based exome sequencing study for BD to investigate potential roles of de novo mutations in the disease etiology. We identified 71 de novo point mutations and one de novo copy-number mutation in 79 BD probands. Among the genes hit by de novo loss-of-function (LOF; nonsense, splice site or frameshift) or protein-altering (LOF, missense and inframe indel) mutations, we found significant enrichment of genes highly intolerant (first percentile of intolerant genes assessed by Residual Variation Intolerance Score) to protein-altering variants in general population, an observation that is also reported in autism and schizophrenia. When we performed a joint analysis using the data of schizoaffective disorder in published studies, we found global enrichment of de novo LOF and protein-altering mutations in the combined group of bipolar I and schizoaffective disorders. Considering relationship between de novo mutations and clinical phenotypes, we observed significantly earlier disease onset among the BD probands with de novo protein-altering mutations when compared with non-carriers. Gene ontology enrichment analysis of genes hit by de novo protein-altering mutations in bipolar I and schizoaffective disorders did not identify any significant enrichment. These results of exploratory analyses collectively point to the roles of de novo LOF and protein-altering mutations in the etiology of bipolar disorder and warrant further large-scale studies.

Secretory Ig a in Saliva and Academic Stress

Several reports have proposed that the concentration of secretory immunoglobulin A (S-IgA) in saliva is an indicator of psychological stress. With this in mind, we decided to examine it in 10 second year medical student volunteers at Kawasaki Medical School course between May 4 and July 13, 2000 and discussed the relationship between S-IgA and the stress from academic examinations. Saliva was collected three times (on rising, at forenoon, and at bedtime) every Thursday. During this period, sporadic academic examinations were held twice and term-end examinations occurred during the last two weeks. Results showed the concentration of S-IgA significantly higher at the on rising time-point than at the other two time-points. There was also a tendency for the S-IgA level in saliva to be higher on the day before academic examinations and during them and lower on the days between these examinations. In addition, daily variations in the S-IgA concentration sometimes seemed to be disturbed by other academic stress. Therefore, it may be possible to use this measurement to monitor psychological stress in students and workers.

Depression-like episodes in mice harboring mtDNA deletions in paraventricular thalamus

Depression is a common debilitating human disease whose etiology has defied decades of research. A critical bottleneck is the difficulty in modeling depressive episodes in animals. Here, we show that a transgenic mouse with chronic forebrain expression of a dominant negative mutant of Polg1, a mitochondrial DNA (mtDNA) polymerase, exhibits lethargic behavioral changes, which are associated with emotional, vegetative and psychomotor disturbances, and response to antidepression drug treatment. The results suggested a symptomatic similarity between the lethargic behavioral change that was recurrently and spontaneously experienced by the mutant mice and major depressive episode as defined by DSM-5. A comprehensive screen of mutant brain revealed a hotspot for mtDNA deletions and mitochondrial dysfunction in the paraventricular thalamic nucleus (PVT) with similar defects observed in postmortem brains of patients with mitochondrial disease with mood symptoms. Remarkably, the genetic inhibition of PVT synaptic output by Cre-loxP-dependent expression of tetanus toxin triggered de novo depression-like episodes. These findings identify a novel preclinical mouse model and brain area for major depressive episodes with mitochondrial dysfunction as its cellular mechanism.

Tubular adenoma of the common bile duct with uptake in 18F-FDG PET: A case report

A 64-year-old man presented with epigastric discomfort and nausea. Laboratory analyses revealed increased levels of total and direct bilirubin, and increased levels of aminotransferases. Computed tomography revealed the presence of a mass in the distal common bile duct. Endoscopic retrograde cholangiopancreatography and intraductal ultrasonography revealed a 25 mm filling defect in the distal common bile duct, and biopsy of the lesion disclosed the presence of tubular adenoma. Using fluorine-18 fluorodeoxyglucose positron emission tomography (¹⁸F-FDG PET) revealed an increased accumulation of the tracer in the lesion, with a maximum standard uptake value (SUV_max) of 3.3. The patient received a pylorus-preserving pancreatoduodenectomy. The histopathological examination revealed a tubular adenoma with low-grade atypia. The patient remains alive 15 months following the surgery, with no evidence of recurrence of the adenoma. ¹⁸F-FDG PET has been successfully applied in clinical practice to detect a wide variety of tumor types, including lymphoma, lung, colon and bile duct cancer. In the present study, a case of bile duct adenoma with low-grade atypia was reported, revealing the uptake of ¹⁸F-FDG. ¹⁸F-FDG PET may be able to detect premalignant tumors of the bile duct, although whether ¹⁸F-FDG PET is able to differentially discriminate between diagnoses of adenoma and carcinoma of the bile duct remains to be fully elucidated, and the assessment of further case studies is required.

[Long-Term Survival with Multidisciplinary Therapy for Rectal NET with Liver Metastases--A Case Report]

We report a case of a 71-year-old man with liver metastases from a rectal neuroendocrine tumor(NET). The patient's chief complaint was melena. He was diagnosed with rectal carcinoma with liver metastases during his initial visit. Therefore, we started UFT/LV as first-line chemotherapy. After 2 courses, the patient's disease had progressed, so the treatment was changed to S-1 as second-line chemotherapy. The patient showed a partial response. In February 2010, we performed an anterior resection, and in April 2010 we performed a posterior segment and S2/8 partial hepatectomy. Histopathological examination showed rectal NET with liver metastases. In December 2011, multiple liver metastases were found, and multimodal treatment including TACE, RFA and somatostatin analogues was selected to treat the recurrent tumor. The patient survived for 10 years after his first visit and for 3 years and 6 months after the recurrence. Multidisciplinary therapy was effective for treating rectal NET with liver metastases.

[A Case of Surgical Treatment for Mixed Adenoneuroendocrine Carcinoma of the Ampulla of Vater]

A 56-year-old woman was referred to our hospital because of epigastric discomfort and jaundice. Contrast-enhanced computed tomography and gastrointestinal endoscopy revealed an ampullary tumor. A biopsy specimen showed adenocarcinoma of the ampulla of Vater. The carbohydrate antigen (CA19-9) level was elevated, but insulin and glucagon levels were in the normal range. Based on a diagnosis of adenocarcinoma of the ampulla of Vater, we performed subtotal stomach-preserving pancreatoduodenectomy with regional lymph node dissection. Postoperative histopathological examinations indicated both neuroendocrine carcinoma (40%) and adenocarcinoma (60%) components in the ampulla of Vater and regional lymph node metastasis. According to the 2010 WHO Classification of Tumours of the Digestive System, the diagnosis of mixed adenoneuroendocrine carcinoma (MANEC) of the ampulla of Vater was confirmed. The patient was treated for 6 months with oral administration of TS-1 as adjuvant chemotherapy. Currently, the patient is alive without recurrence 8 months after surgery. MANEC of the ampulla of Vater is rare. It is a highly malignant tumor, and the standardization of its treatment, including surgery, chemotherapy, and radiotherapy requires further study.

[A Case of Intractable Bile Leakage after Surgery for Gallbladder Cancer Successfully Treated by Transcatheter Arterial Embolization]

An 83-year-old man underwent extended cholecystectomy for gallbladder cancer. On postoperative day 13, he developed fever and computed tomography (CT) revealed fluid collection at the cut surface of the liver. Ultrasound-guided fluid drainage was conducted, and he was diagnosed with biliary leakage. Radiological examination using a contrast agent revealed that the anterior branch of the bile duct (B5) was completely interrupted. Simple drainage and ethanol injections into the bile duct proved ineffective. Thus, we performed transcatheter arterial embolization (TAE) in the anterior segmental artery (A5) to stop the production of bile in the injured part of anterior segment. The treatment was effective, and he was discharged 15 days after TAE. TAE might be a useful method for treating intractable interrupted-type bile leakage.

[Effect of Post-Gastrectomy Adjuvant S-1 Chemotherapy on Muscle Volume in Gastric Cancer Patients]

OBJECTIVE

To examine the effect of S-1 adjuvant chemotherapy on muscle volume after curative gastrectomy in gastric cancer patients.

PATIENTS

Forty-eight gastric cancer patients (31 men and 17 women) who underwent curative gastrectomy (distal gastrectomy: n=37, and total gastrectomy: n=11) between April 2010 and July 2011 were enrolled in this study. Sixteen patients underwent S-1 adjuvant chemotherapy (S-1 group) for 1 year after the operation, and 32 patients did not (NT group).

METHODS

The psoas muscle areas were measured at the fourth lumbar vertebrae on CT images obtained before the operation, and at 6, 12, and 24 months after the operation. Muscle areas was statistically examined by comparing the preoperative and postoperative ratios.

RESULTS

The muscle areas 12 months after the operation decreased to 0.86 ± 0.11 in the S-1 group and to 0.96 ± 0.08 in the NT group (p<0.05), and the significant difference disappeared at 24 months (0.93 ± 0.10 vs. 0.93 ± 0.11, NS). In the patients who underwent distal gastrectomy, the muscle areas decreased to 0.90 ± 0.05 in the S-1 group and to 0.96 ± 0.09 in the NT group at 12 months (p<0.05). Meanwhile, in those who underwent total gastrectomy, the muscle areas decreased to 0.80 ± 0.15 and 0.93 ± 0.03, respectively (NS).

CONCLUSIONS

S-1 adjuvant chemotherapy affected muscle volume loss after gastrectomy in the gastric cancer patients, but the patients recovered from the adverse effect by 12 months after chemotherapy.

[A case report of advanced gastric cancer with bulky lymph node metastases successfully treated with induction chemotherapy followed by curative resection]

The patient was a 74-year-old woman with advanced gastric cancer in the greater curvature of the antrum and lesser curvature of the angle.Abdominal computed tomography revealed bulky lymph node metastases of No. 3, 8a, and 11p.She was diagnosed with clinical Stage IIIA gastric cancer (cT3N2M0) and underwent surgery.Laparotomy findings revealed invasion of bulky lymph nodes to the common hepatic artery and pancreas.Since radical resection was not feasible, exploratory laparotomy was performed.After the surgery, she received 1 course of S-1 monotherapy and 3 courses of S-1/cisplatin (CDDP) therapy.The therapeutic response, as assessed by imaging studies, was partial for the primary lesions and complete for the enlarged lymph nodes.Distal gastrectomy and D2 lymph node dissection were performed.Histopathological findings showed no evidence of lymph node involvement, allowing the patient to undergo radical surgery.The patient received postoperative adjuvant chemotherapy with S-1.She is alive 11 months after the surgery, with no evidence of recurrence.Induction chemotherapy appears to be a promising option for advanced gastric cancer with significant lymph node involvement.

[A case report of neuroendocrine carcinoma of the stomach with liver metastases curatively resected after neoadjuvant chemotherapy]

The patient was a 73-year-old male with advanced gastric cancer in the lesser curvature of the antrum.Abdominal computed tomography revealed multiple liver metastases(S5, S8).He was diagnosed with clinical Stage IV gastric cancer (cT3N0M1H1).He received 3 courses of combined neoadjuvant chemotherapy with capecitabine, cisplatin, and trastuzumab because immunostaining indicated the tumor was human epidermal growth factor receptor 2(HER2)-positive.The therapeutic response, as assessed by imaging studies, was partial for the primary lesions and stable for liver metastases.Distal gastrectomy, D2 lymph node dissection, and S5 extended subsegmentectomy of the liver were performed.Histopathological findings indicated that both the primary tumor and liver metastases were neuroendocrine carcinoma.The patient declined post-operative adjuvant chemotherapy and he is alive 6 months after the surgery with no evidence of recurrence.Surgery with neoadjuvant chemotherapy appears to be a promising option for advanced gastric cancer with liver metastases.

Expression of insulin-like growth factor-II mRNA-binding protein-3 as a marker for predicting clinical outcome in patients with esophageal squamous cell carcinoma

Insulin-like growth factor-II mRNA-binding protein-3 (IMP3) is an important factor in carcinogenesis, although its clinical significance in esophageal squamous cell carcinoma (ESCC) remains unknown. The present study investigated the associations between IMP3 expression and the clinicopathological parameters. IMP3 expression was assessed in 191 resected ESCC specimens, and the associations between IMP3 expression in ESCC, the clinicopathological parameters and patient prognosis were examined. Using immunohistochemistry, 113 (59.2%) tumors were identified as IMP3-positive. IMP3 positivity correlated significantly with high pathological (p)Stage, pT stage and pN stage. The IMP3-positive patients exhibited a poorer prognosis compared with the IMP3-negative patients. In univariate analyses, histology [hazard ratio (HR), 1.94; 95% confidence interval (CI), 1.18–3.49; P=0.0082], pT (HR, 2.34; 95% CI, 1.55–3.62; P<0.0001), pN (HR, 2.85; 95% CI, 1.81–4.69; P<0.0001), lymphatic invasion (HR, 2.08; 95% CI, 1.26–3.70; P=0.0036), venous invasion (HR, 1.79; 95% CI, 1.21–2.64; P=0.0039), neoadjuvant chemotherapy (NAC) (HR, 2.01; 95% CI, 1.35–3.00; P=0.0005) and IMP3 expression (HR, 2.12; 95% CI, 1.40–3.29; P=0.0003) were significantly associated with overall survival. Using multivariate analyses, histology (HR, 1.87; 95% CI, 1.13–3.29; P=0.014), pN (HR, 2.19; 95% CI, 1.36–3.66; P=0.0010), NAC (HR, 1.88; 95% CI, 1.24–2.86; P=0.0028) and IMP3 expression (HR, 1.84; 95% CI, 1.18–2.93; P=0.0064) were significant prognostic factors. IMP3 may therefore be a prognostic factor for patients with ESCC who have undergone a curative resection.

Clinicopathological and prognostic significance of FOXM1 expression in esophageal squamous cell carcinoma

BACKGROUND

Esophageal squamous cell carcinoma (ESCC) has a poor prognosis because invasion and metastasis are prevalent. To improve diagnosis, it is important to identify and characterize tumor-specific molecular markers in ESCC. FOXM1 is overexpressed and correlates with pathogenesis in a variety of human malignancies. We aimed to investigate the clinical significance of FOXM1 overexpression in ESCC.

PATIENTS AND METHODS

FOXM1 expression was assessed in ESCC specimens from 174 curatively-resected cases. The relationships between FOXM1 expression, clinicopathological parameters, and prognoses were examined.

RESULTS

Immunohistochemical analysis showed that 94 (54.0%) tumors were positive for FOXM1 expression. FOXM1 positivity did not correlate with any clinicopathological parameter. However, FOXM1-positive cases had poorer prognoses than FOXM1-negative ones (p=0.0037, log-rank test). In multivariate analysis, the following were independent prognostic factors: pT, pN, neoadjuvant chemotherapy, and FOXM1 expression (hazard ratio=1.69, 95% confidence interval=1.06-2.75, p=0.027).

CONCLUSION

FOXM1 may be a novel prognostic factor in patients with ESCC who undergo curative resection.

Clinical application of ghrelin administration for gastric cancer patients undergoing gastrectomy

Loss of body weight is a common (and the most serious) sequela after gastrectomy. It impairs quality of life, increases various diseases including infection, and may affect long-term survival. Ghrelin, an intrinsic ligand of the growth hormone secretagogue receptor, was discovered in the stomach in 1999. In addition to growth hormone secretion, ghrelin has pleiotropic functions including appetite stimulation, increasing bowel movement and absorption, and anti-inflammatory reactions. In consequence, ghrelin comprehensively leads positive energy balance and weight gain. The fundic gland of the stomach produces the majority of ghrelin, and plasma ghrelin declines to 10-30 % of the preoperative level after total gastrectomy and 50-70 % after distal gastrectomy. Although plasma ghrelin is never restored after total gastrectomy, it gradually recovers to the preoperative level within a few years after distal gastrectomy. Chronic gastritis due to Helicobacter pylori infection and vagotomy are additional factors that perturb the ghrelin secretion of gastric cancer patients after gastrectomy. A randomized clinical trial that revealed that recombinant ghrelin administration successfully increased both food intake and appetite, and ameliorated weight loss after total gastrectomy. Ghrelin administration could thus be a promising strategy to transiently improve the nutritional status of patients who who have undergone gastrectomy, but its effect in the long term remains unclear. Further studies are warranted to elucidate the mechanism of ghrelin and to create and evaluate the analogs that could be administered orally or subcutaneously.

Single-incision laparoscopic partial gastrectomy for gastric submucosal tumors without compromising transumbilical stapling

INTRODUCTION

Although SILS has become an increasingly popular type of surgery, its application for gastric submucosal tumors (SMT) has been only sporadically reported. We herein describe 12 recent cases with gastric SMT located in the greater curvature or anterior wall. The aim is to validate technical feasibility and safety of single-incision laparoscopic partial gastrectomy. Thus far, this is one of the largest series of patients with gastric SMT who underwent SILS.

METHODS

From July 2009 to April 2013, single-incision laparoscopic partial gastrectomy was attempted in 12 consecutive patients with gastric SMT. Three trocars were assembled in the umbilical incision, and the lesion was mobilized and staple-resected with endoscopic stapling devices.

RESULTS

SILS surgery was successfully completed without any additional trocars. The median operating time was 96.5 min, and median blood loss was 7.5 mL. The median tumor size was 30 mm, with histopathologic diagnosis of gastrointestinal stromal tumor (10) and schwannoma (2). There was no immediate postoperative morbidity. During a median follow-up of 12 months, all patients were on full regular diet without any gastrointestinal symptoms.

CONCLUSION

SILS with transumbilical gastric stapling is a safe and practical alternative to conventional multiport laparoscopy in patients with gastric SMT, except for cases originating in the lesser curvature and close to the cardia/ pylorus.

MicroRNAs and liver function

MicroRNAs (miRNAs) are small, noncoding RNA molecules that regulate gene expression post-transcriptionally through complementary base pairing with thousands of messenger RNAs. Although the target genes and precise biological functions of individual miRNAs remain largely unknown, miRNAs are speculated to play important roles in diverse biological processes in both normal and pathological states. The liver is a vital organ that plays major roles in a number of physiological functions. Recent advances in the study of liver miRNAs using gene-modified mice or in vivo nucleic acid delivery to overexpress specific miRNAs or inhibit miRNA functions have revealed the crucial biological roles of individual miRNAs in physiologically essential liver functions in vivo. Because miRNA-based strategies are being applied to clinical therapeutics, the importance of precise knowledge of miRNA functions cannot be underestimated, not only from a scientific point of view, but also from a clinical perspective to make the most of such drugs and avoid unexpected harmful effects. The aims of this review are to describe current knowledge regarding both known and as-yet-undiscovered molecular aspects of the biological roles of miRNAs in the liver, with a special emphasis on lipid, glucose, drug, and iron metabolism as vital functions of the liver as well as important therapeutic targets.

Clinical trial of ghrelin synthesis administration for upper GI surgery

Appetite and weight loss following gastrectomy or esophagectomy is one of the major problems that affect the postoperative QoL. Ghrelin, mainly secreted from the stomach, is related to appetite, weight gain, and positive energy balance. This hormone level had been shown to become low for a long time after upper GI surgery. The efficacy of ghrelin synthesis administration for postoperative weight loss was investigated from a clinical trial to develop a new strategy for weight gain. In addition to this treatment for appetite and weight loss, we focused on the anti-inflammatory role of ghrelin. For the purpose of controlling postoperative cytokine storm after esophagectomy, this hormone was introduced in the clinical trial. Finally, ghrelin replacement therapy during chemotherapy in patients with esophageal cancer is also presented. Our clinical trials and their results are presented in this chapter.

Transportation and fate of cationic surfactant in river water

The degradation, sorption, transportation and material balance of cationic surfactants discharged from domestic waste into river water was studied. Ion-pair solid-phase extraction behavior showed that the sorption of cationic surfactants as an ion-pair with anionic surfactant onto river sediment was so strong that little cationic surfactant was found in the bulk water. Cationic surfactant was found in river sediment at more than 500 times higher concentration than that in the bulk water. The degradation of the cationic surfactant was very slow in river water and much slower in the sediment. A material balance of cationic surfactant was estimated for a river running through Toyama City by measuring the flow rate and the concentration of cationic surfactant in the water at several points. It was found that more than 30% of cationic surfactant introduced to the river was lost during the river running through ca. 3 km in 3 h. This reduction probably comes from a quick transfer of the cationic surfactant from river water to sediment and water weed by means of adsorption or precipitation with suspending solids.

A novel WT1 gene mutation associated with wilms' tumor and congenital male genitourinary malformation

WT1 is located on the short arm of human chromosome 11 and consists of 10 coding exons. Mutations of this gene have been reported to be the cause of Wilms' tumor, congenital male genitourinary malformations, and/or renal disorders. We describe here a novel WT1 gene mutation, i.e. a point mutation at intron 7 (+2) in both the tumor and the germline cells of a patient with Wilms' tumor and congenital male genitourinary malformation, but without renal disorder. The position of the mutation is at a splice donor site of intron 7, which causes the splicing out of exon 7 and generates a truncated protein. This type of mutation in the WT1 zinc finger domain has not been reported before. The mutation is of paternal origin and is heterozygous in the germline cells. In the tumor cells, however, the maternal allele is largely lost, from 11p12 to 11p15, which results in maternal loss of heterozygosity. These results, together with the data from previous reports, suggest that WT1 may function in gonadogenesis, nephrogenesis, and Wilms' tumor tumorigenesis.

An operated case of lung cancer with pleural plaques: its asbestos bodies, fiber analysis and asbestos exposure

This case was a 79-year-old man with pleural plaques, which had been pointed out in the left lung field on chest X-ray six years ago. A new shadow in the right chest appeared in 1999 and was closely examined. Cytological class IV carcinoma was detected in his lung tissue obtained by broncho-fiberscope. Lobectomy of the right upper lobe was performed, and calcified pleural plaques were found on the chest wall. The clinical diagnosis was poorly differentiated squamous cell carcinoma, T1N0M0. In World War II when he was 26 years old, he had worked as a boiler man on a battle cruiser for one year. The amount of asbestos bodies (AB) was 3,348 per gram dry lung tissue. The cores of AB and asbestos fibers were examined and showed that amosite was the most prevalent and crocidolite, tremolite and chrysotile were present in that order. After leaving the navy, he had worked as a farmer throughout his life, suggesting that he had never contacted asbestos occupationally after being a boiler man. It is strongly suggested that he had been exposed to asbestos during his work as a boiler man and that produced pleural plaques and lung cancer 50 years' later.

Isolated diffuse mesangial sclerosis and Wilms tumor suppressor gene

Diffuse mesangial sclerosis is a rare renal disease, occurring either in isolation or as part of Denys-Drash syndrome. Denys-Drash syndrome originates from mutations of the Wilms tumor suppressor gene (WT1 ). We describe the presence of WT1 mutations in 7 Japanese children with isolated diffuse mesangial sclerosis.

[Wilms' tumors and malformation complexes]

Wilms' tumor is an embryonal tumor which is derived from metanephric metanephric blastema. The occurrence of both sporadic and hereditary forms, along with various congenital abnormalities of Wilms' tumor suggest that the tumors develop when a predisposing germ line mutation is accompanied by a second mutation. The existence of both gross chromosomal abnormalities has led to the genetic characterization of a number of loci involved in the development of Wilms' tumor. A tumor suppressor gene for Wilms' tumor, WT1, has been isolated from the 11p13 region. The product of this gene is a transcription factor with four zinc fingers. Because of expression of WT1 is limited to the developing glomeruli of the kidneys and the genital ridge, it is thought to have a functional role in renal and gonadal organogesis. Thus dysfunction of WT1 causes loss of normal regulation of proliferation and leads to tumor formation and occurrence of Wilms' tumor anomaly complexes. The role of the imprinting genes, H19 and IGF2 in oncogenesis of Wilms' tumors are also discussed.

Nephrotic syndrome and end-stage renal disease with WT1 mutation detected at 3 years

We report a boy who presented at 3 years with nephrotic syndrome and end-stage renal failure. Although histopathological findings showed end-stage kidney, isolated diffuse mesangial sclerosis (IDMS) was suspected because of his clinical course, and was confirmed by the presence of WT1 (Wilms tumor suppressor gene) mutation. He did not have ambiguous genitalia or Wilms tumor. The karyotype was 46:XY. A constitutional mutation in exon 7 (953G-->A, 312Arg-->Gin) was detected. A few cases of male IDMS, associated with WT1 mutations, have been reported. We believe that investigation for the WT1 mutation should be performed not only in Denys-Drash syndrome and IDMS, but also in end-stage renal disease with unexplained nephrotic syndrome of early onset. WT1 mutation-associated nephrotic syndrome has an increased risk of Wilms tumor. Careful ultrasound evaluations or bilateral nephrectomies are indicated.

[Long-term follow-up study on sequelae of carbon monoxide poisoning; serial investigation 33 years after poisoning]

1. We examined 156 patients 33 years after CO poisoning occurred at the Miike Mikawa Mine, Fukuoka, Japan. The subjects were classified according to age as follows: between 55 and 59 years (n = 14), 60 and 69 years (n = 62), 70 and 79 years (n = 60), and 80 and 87 years (n = 18). The mean age was 69.2 years old. Concerning the duration of coma that occurred soon after the accident, 64 remained comatose from 0 to 6 hours, 46 from 6 to 12 hours and 46 from 12 to 48 hours. 2. Subjective symptoms were observed in 96.8% of the patients. Among them, forgetfulness was noted in 89.7%, followed by irritability in 66.7%, headache in 59.6%, insomnia in 55.8%, limb pain in 46.8%, dull head feeling in 42.9% and dizziness in 36.5%. 3. Intellectual disturbances were observed in 68.6% of the patients, including impression disturbance in 58.3%, memory disturbance in 51.9%, calculation disturbance in 63.5%, thinking disturbance in 61.5% and disorientation in 14.1%. 4. Apathy and disorder of volition and interest which were found in 72.4% were included in personality change because all symptoms persisted for many years. Personality change was classified as follows: weakness of emotion and will (hypobulia) in 54.4%, infantilism in 35.2%, hyperactive, talkactive and lack of inhibition in 18.5%, lack of self-possession and unstable temper in 9.6%, depression in 15.3%, neurosis in 7.6% and schizophrenic state in 2.5%. Among these symptoms of personality change, weakness of emotion and will and infantilism were conspicuous among the patients who remained in a coma for more than 6 hours soon after the accident but showed no relationship with age. 5. Neurological symptoms that were found in 48.7% of the patients were classified as sensory disturbance in 25.6%, peripheral nerve symptoms in 16.0%, pyramidal symptoms in 14.1%, ataxia and cranial nerve symptoms in 7.1%, paroxysmal symptoms in 6.4% and focal symptoms in 4.5%, extrapyramidal symptoms in 21.8% (Parkinsonism in 4.5%, tremor in 10.9% and muscle rigidity in 16.0%) and vegetative symptoms in 37.2%. 6. At the time of investigation, 5 CO poisoning patients were classified as serious cases (3.2%), 20 as comparatively serious (12.8%) medium-degree cases, 28 as comparatively mild (17.9%) medium-degree cases, 37 as comparatively serious (23.7%) mild cases, 42 as comparatively mild (26.9%) mild cases, 24 (15.4%) as having symptoms which were not problematic, and 24 (15.4%) as having symptoms that markedly worsened due to complication. 7. A total of 138 (88.4%) cases had complications were classified as follows: 78 cases (50.0%) of hypertension, 62 cases (39.7%) of cerebral infarction, 24 cases (15.4%) of cardiac disturbance, 21 cases (13.5%) of diabetes mellitus, 14 cases (9.0%) of hepatic disturbance and six cases of silicosis (3.8%). 8. Cranial MRI was carried out for 129 cases (82.7%). Of the abnormal findings identified, cerebral atrophy accounted for 72.0% (93 cases), including moderate and severe cases in 47.2% (61 cases), pallidum lesion for 37.9% (49 cases), lacunar infarction (including cerebral infarction) for 52.7% (68 cases), and hippocampal atrophy for 18.6% (24 cases). Many cases of cerebral atrophy and hippocampal atrophy were observed in patients who remained in the initial coma for more than 12 hours and were 80 years of age or old. The cases of pallidum lesion were observed in patients who remained in the initial coma for more than 6 hours, and no relationship with age was found. The other findings, cerebral atrophy and lacunar infarction showed a slight relationship with age. 9. Among the moderate and serious cases of intellectual disturbance, cerebral atrophy constituted to 62.5%, lacunar infarction 68.7% and pallidum lesion 50.0%. Among the moderate and serious cases of personality change, cerebral atrophy constituted 78.5%, lacunar infarction 35.0% and pallidum lesion 50.0%. Moreover, among extrapyramidal symptoms, pallidum lesion constituted 58.6%, cerebral atrophy 55.1% and lacun