A component of high-grade fetal lung adenocarcinoma diagnosed as the cause of lymph node metastasis

High-grade fetal lung adenocarcinoma (H-FLAC) is a rare type of tumor. There have been no reports demonstrating the degree of metastatic susceptibility of this tumor type. In this report, we describe a case in which 15% of the adenocarcinoma components were H-FLAC diagnosed as the cause of lymph node metastasis. A 75-year-old man presented with suspected primary lung cancer (clinical stage IIA, T2bN0M0) and underwent left upper lobectomy and superior mediastinal lymph node dissection. Postoperative histopathology revealed lung cancer with only lobar bronchial lymph node (#11) metastasis. Approximately 60% of the invasive adenocarcinoma showed a papillary morphology, 25% showed a lepidic morphology, and 15% showed a fetal morphology. The histomorphological and immunohistological features of #11 metastasis were similar to those of H-FLAC. Herein, we report a rare and important case of H-FLAC with proven lymph node metastasis, showing that even a small amount of H-FLAC tissue can cause metastasis.

The Roles and Regulatory Mechanisms of Tight Junction Protein Cingulin and Transcription Factor Forkhead Box Protein O1 in Human Lung Adenocarcinoma A549 Cells and Normal Lung Epithelial Cells

Tight junction (TJ) protein cingulin (CGN) and transcription factor forkhead box protein O1 (FOXO1) contribute to the development of various cancers. Histone deacetylase (HDAC) inhibitors have a potential therapeutic role for some cancers. HDAC inhibitors affect the expression of both CGN and FOXO1. However, the roles and regulatory mechanisms of CGN and FOXO1 are unknown in non-small cell lung cancer (NSCLC) and normal human lung epithelial (HLE) cells. In the present study, to investigate the effects of CGN and FOXO1 on the malignancy of NSCLC, we used A549 cells as human lung adenocarcinoma and primary human lung epithelial (HLE) cells as normal lung tissues and performed the knockdown of CGN and FOXO1 by siRNAs. Furthermore, to investigate the detailed mechanisms in the antitumor effects of HDAC inhibitors for NSCLC via CGN and FOXO1, A549 cells and HLE cells were treated with the HDAC inhibitors trichostatin A (TSA) and Quisinostat (JNJ-2648158). In A549 cells, the knockdown of CGN increased bicellular TJ protein claudin-2 (CLDN-2) via mitogen-activated protein kinase/adenosine monophosphate-activated protein kinase (MAPK/AMPK) pathways and induced cell migration, while the knockdown of FOXO1 increased claudin-4 (CLDN-4), decreased CGN, and induced cell proliferation. The knockdown of CGN and FOXO1 induced cell metabolism in A549 cells. TSA and Quisinostat increased CGN and tricellular TJ protein angulin-1/lipolysis-stimulated lipoprotein receptor (LSR) in A549. In normal HLE cells, the knockdown of CGN and FOXO1 increased CLDN-4, while HDAC inhibitors increased CGN and CLDN-4. In conclusion, the knockdown of CGN via FOXO1 contributes to the malignancy of NSCLC. Both HDAC inhibitors, TSA and Quisinostat, may have potential for use in therapy for lung adenocarcinoma via changes in the expression of CGN and FOXO1.

[Invasive Mucinous Adenocarcinoma that Invades the Wall of a Cystic Lesion:Report of a Case]

Invasive mucinous adenocarcinoma (IMA) is a rare and special type of lung adenocarcinoma. We report a case of IMA presenting as a cystic lesion in the S10 of the right lung, diagnosed by surgical biopsy and treated with right lower lobectomy. The patient was a 60-year-old man who was found to have a 10-mm-sized frosted ground-glass opacity with a 10-mm-sized air space in the S10 of the right lung while undergoing follow-up after renal cancer surgery in 2018. The air space gradually enlarged and, in 2022, began to show a 40-mm-sized cyst, with partial wall thickening and nodularity on the caudal side. A thoracoscopic partial pneumonectomy was performed to confirm the diagnosis of IMA, and a thoracoscopic radical resection of the right remaining lower lobe was performed. It is important to recognize that adenocarcinoma may occur in patients with thin-wall cavity, as in this case. Additionally, it is necessary to determine the treatment strategy based on the assumption that the tumor may extend to the entire cavity wall, even if it is thin-walled.

[Inflammatory Polyp due to Peanut Aspiration, Needed to Differentiate from Malignant Tumor: Report of a Case]

The patient was in his 70s. He was addmitted to our hospital because of obstructive pneumonia for 3 months. Chest computed tomography( CT) showed a nodule at the base of the right B8, obstructing the basal branch, with consolidation of the peripheral lung. Bronchoscopy revealed the right basal trunk obstruction by a tumorous lesion. FDG-PET showed heterogeneous FDG uptake at the right hilum and the lower lobe suggesting malignancy, and a thoracoscopic right lower lobectomy was performed. Pathology showed a granulation-like nodule and a brown oval foreign body incarcerated in the peripheral bronchus, which was later revealed to be a peanut, and no obvious malignant findings were observed.

Perceptual Translucency in 3D Printing Using Surface Texture

We propose a method of reproducing perceptual translucency in three-dimensional printing. In contrast to most conventional methods, which reproduce the physical properties of translucency, we focus on the perceptual aspects of translucency. Humans are known to rely on simple cues to perceive translucency, and we develop a method of reproducing these cues using the gradation of surface textures. Textures are designed to reproduce the intensity distribution of the shading and thus provide a cue for the perception of translucency. In creating textures, we adopt computer graphics to develop an image-based optimization method. We validate the effectiveness of the method through subjective evaluation experiments using three-dimensionally printed objects. The results of the validation suggest that the proposed method using texture may increase perceptual translucency under specific conditions. As a method for translucent 3D printing, our method has the limitation that it depends on the observation conditions; however, it provides knowledge to the field of perception that the human visual system can be cheated by only surface textures.

Downregulation of angulin-1/LSR induces malignancy via upregulation of EGF-dependent claudin-2 and TGF-β-dependent cell metabolism in human lung adenocarcinoma A549 cells

Abnormal expression of bicellular tight junction claudins, including claudin-2 are observed during carcinogenesis in human lung adenocarcinoma. However, little is known about the role of tricellular tight junction molecule angulin-1/lipolysis-stimulated lipoprotein receptor (LSR). In the lung adenocarcinoma tissues examined in the present study, expression of claudin-2 was higher than in normal lung tissues, while angulin-1/LSR was poorly or faintly expressed. We investigated how loss of angulin-1/LSR affects the malignancy of lung adenocarcinoma cell line A549 and normal human lung epithelial (HLE) cells. The EGF receptor tyrosine kinase inhibitor AG1478 prevented the increase of claudin-2 expression induced by EGF in A549 cells. Knockdown of LSR induced expression of claudin-2 at the protein and mRNA levels and AG1478 prevented the upregulation of claudin-2 in A549 cells. Knockdown of LSR induced cell proliferation, cell migration and cell metabolism in A549 cells. Knockdown of claudin-2 inhibited the cell proliferation but did not affect the cell migration or cell metabolism of A549 cells. The TGF-β type I receptor inhibitor EW-7197 prevented the decrease of LSR and claudin-2 induced by TGF-β1 in A549 cells and 2D culture of normal HLE cells. EW-7197 prevented the increase of cell migration and cell metabolism induced by TGF-β1 in A549 cells. EW-7197 prevented the increase of epithelial permeability of FITC-4kD dextran induced by TGF-β1 in 2.5D culture of normal HLE cells. In conclusion, downregulation of angulin-1/LSR induces malignancy via EGF-dependent claudin-2 and TGF-β-dependent cell metabolism in human lung adenocarcinoma.

Vaginal Microbiota and Pregnancy Outcomes of Patients with Conization Histories

Background: One of the major risks of preterm birth is a history of conization. However, the risk of infection due to this procedure is still not well known. Using next-generation sequencing, we aimed to reveal the influence of conization on vaginal microbiota in the following pregnancy, and their relationship between spontaneous preterm birth (sPTB). Methods: We conducted a prospective cohort study including 133 pregnant patients, of whom 25 had conization histories and 108 did not. Vaginal microbiome samples were collected using swabs by an obstetrician upon inclusion in the first trimester and during delivery. V1-V2 of the 16S rRNA gene were amplified and analyzed to identify the bacteria. Results: The conization group had a significantly lower delivery week (34 weeks vs. 36 weeks, p = 0.003) and higher sPTB rate (64% vs. 8.3%, p ≤ 0.001) than the control group. In the conization group, alpha (Chao 1, p = 0.02; phylogenetic diversity whole tree, p = 0.04) and beta diversity (permutational multivariate analysis of variance test, p = 0.04) of the vaginal microbiota was significantly higher during delivery in patients who delivered preterm than in those who delivered term. Community-state type IV in the first trimester was significantly associated with sPTB (overall odds ratio 3.80, 95% confidence interval 1.33-10.8, p = 0.01). Conclusions: Conization is a risk factor for sPTB. Increased risk of sPTB in patients after conization may belong to the vulnerable defense mechanism, due to the shortened cervix and decreased cervical mucus.

Endometrial and vaginal microbiomes influence assisted reproductive technology outcomes

OBJECTIVE

The role of Lactobacillus-dominant microbiota in the endometrium in reproductive function is unclear. We therefore aimed to explore the impact of the balance of Lactobacillus and pathological bacteria in the endometrial and vaginal microbiomes on the pregnancy outcomes of women treated with assisted reproductive technology (ART).

METHODS

This study included 35 women with infertility submitted to good-quality embryo transfers. The cutoff values for abundance of Lactobacillus species (spp.) and pathological bacteria in the endometrium and vagina were calculated. Women with Lactobacillus spp. and pathological bacteria abundance above the cutoff values were categorized in the high-abundance group, whereas those with abundance below cutoff values were categorized in the low abundance group. We divided the patients into four groups based on the combination of high/low abundance of Lactobacillus spp. and pathological bacteria.

RESULTS

The 35 cases of good-quality embryo transfer resulted in 21 pregnancies. Pregnant women were present in significantly higher proportions in the high Lactobacillus spp. abundance and low pathological bacteria abundance group, whereas the opposite combination (i.e., low Lactobacillus spp. abundance and high pathological bacteria abundance) saw a significantly higher proportion of nonpregnant women (p=0.022).

CONCLUSIONS

The balance between Lactobacillus and pathological bacterial abundance in the endometrial and vaginal microbiomes is associated with pregnancy from ART.

Clinical effect of soft coagulation for air leak treatment during pulmonary lobectomy

Background

Soft coagulation using the VIO soft coagulation system is used to treat minor lung air leaks during pulmonary resection in Japan. We previously reported that it has a similar effect as the air leak treatment with fibrin glue. We evaluated the efficacy of soft coagulation using the VIO soft coagulation system for lung air leakage during pulmonary resection.

Methods

Intraoperative air leaks from the interlobar lung parenchyma were observed in 42 of the 283 patients who underwent video-assisted thoracoscopic surgery lobectomy between 2016 and 2018. We retrospectively reviewed these 42 patients who were treated using the VIO soft coagulation system for air leaks. We classified the air leaks in to grades using the Macchiarini scale score and evaluated the surgical outcomes of air leak treatment.

Results

Air leaks from the interlobar lung parenchyma having Macchiarini scale scores 1, 2, and 3 occurred in 8, 17, and 17 patients, respectively. In all the 8 patients with score 1 air leaks (100%), the air leaks could be controlled using the VIO soft coagulation system alone, and none had delayed pneumothorax requiring intervention. Of the score 2 and 3 air leaks, 52.9% and 35.3% were controlled using the VIO soft coagulation system alone, respectively.

Conclusions

Macchiarini scale score 1 air leaks from the interlobar lung parenchyma could be well controlled using the VIO soft coagulation system. Therefore, soft coagulation with this system may be an alternative method for treating minor air leaks during pulmonary resection surgery.

Number of lymph nodes dissected and upstaging rate of the N factor in robot-assisted thoracic surgery versus video-assisted thoracic surgery for patients with cN0 primary lung cancer

PURPOSE

The accuracy of lymph node (LN) dissection in robotic surgery for lung cancer remains controversial. We compared the accuracy of LN dissection in robot-assisted thoracic surgery (RATS) vs. video-assisted thoracic surgery (VATS).

METHODS

The subjects of this retrospective analysis were 226 patients with cN0 primary lung cancer who underwent robot-assisted or video-assisted thoracic lobectomy with LN dissection, in our department, between April, 2016 and February, 2021. We compared the numbers of all LNs and mediastinal LNs dissected, the time required for LN dissection, complications, and upstaging rates of the N factor between the groups. Furthermore, we performed an inverse probability of treatment weighting-adjusted analysis to reduce potential bias between the groups.

RESULTS

The number of dissected LNs was higher in the RATS group in both the unweighted and weighted analyses. The time required for lymph node dissection was also longer in RATS. There was no significant difference in complications or in the upstaging rate of the N factor between the groups.

CONCLUSION

More LNs were dissected with RATS. Thus, the usefulness of robot-assisted surgery for LN dissection needs to be investigated further.

O-256 Effect of an endometrial microbiota on pregnancy outcome of frozen embryo transfer (FET) cycles

Study question

Is specific microbiota in the endometrial fluid (EF) associated with pregnancy outcome in a frozen embryo transfer (FET) cycles?

Summary answer

Lactobacillus had high abundance in the microbiota of endometrial fluid of patients with successful pregnancy after FET treatment.

What is known already

Recently, the relationship between endometrial microbiota and repeated implantation failure (RIF) has been reported. While Lactobacillus-dominated microbiota (LDM, defined as > = 90 % Lactobacillus species) in the EF of the receptive phase was reported to be associated with favorable reproductive outcome, non-LDM (< 90 % Lactobacillus species) was found to decrease implantation, clinical pregnancy, ongoing pregnancy, and live birth rates. However, it is still unclear the effect of the microbiota on pregnancy outcome of the patients with the assisted reproductive technology, especially a frozen embryo transfer (FET) treatment.

Study design, size, duration

We included 802 cycles with clinical results of pregnancy outcome after FET treatment at our clinic from December 2018 to January 2021. Endometrium fluid was collected before FET and microbiota was examined. We examined the relationship between endometrial microbiota and pregnancy outcome in 463 cycles in which the endometrial microbiome test results were available, pregnancy outcome was known, CD138 negative, and less than 38years (229 cycles were positive pregnancy and 234 cycles were negative pregnancy).

Participants/materials, setting, methods

Sampling was performed carefully avoiding contamination before FET treatment. Extracted genomic DNA was sequenced for the region of 16S ribosomal RNA using next-generation sequencer (Endometrial microbiome test, Varinos, Japan). The sequencing data was assigned to bacterial taxonomy and the background-contaminated bacteria were excluded from the microbiome profile. Lactobacillus abundance was calculated. After concordance of patient background, Lactobacillus abundance between successful and unsuccessful pregnancy group was compared.

Main results and the role of chance

We investigated the effect of microbiota in EF, especially Lactobacillus, for the infertile female with frozen embryo transfer (FET) as an assisted reproductive treatment with large amount of cycles (802 cycles). First, all of cycles were divided into a successful pregnancy group (305/802) and an unsuccessful pregnant group (497/802), and then the abundance of Lactobacillus was analyzed (the pregnancy ratio was 38.0%). The mean abundance of Lactobacillus in EF was significantly higher in the successful pregnant group than in the unsuccessful pregnant group (70.2% 40.5 versus 63.5% 43.1, p = 0.007). To further refine the conditions of each cycle, patient backgrounds of each cycle were compared. There was a significant difference in age and CD138 results between the successful pregnant group and unsuccessful pregnant group, so the analysis was performed with the limited cycles with CD138-negative and under 38 years (229/463 versus 234/463, respectively). However, even under this strict condition, the mean abundance of Lactobacillus was significantly higher in the pregnant group than in the unsuccessful pregnant group (72.1% 39.7 versus 61.1% 44.4, p = 0.003). These results suggest that the endometrial environment with high Lactobacillus abundance is more conducive to pregnancy in FET treatment.

Limitations, reasons for caution

The limitation of this study is that the design is not a randomized controlled one, although it is prospective.

Wider implications of the findings

The results of this study suggest that the endometrial microbiota at the time of embryo implantation, especially Lactobacillus genus, is highly relevant to pregnancy outcome, implying that disruption of the intrauterine microbiota may cause infertility. We need further studies to improve the endometrial microbiota of infertile women.

Trial registration number

not applicable

Robot-assisted vs. video-assisted thoracoscopic surgery in lung cancer

Background

The major advantages of robot-assisted surgery are the fine field of view provided by the high-precision three-dimensional (3D) images and the good operability provided by the robotic arms that enables precise movements. A growing number of retrospective studies have compared robotic-assisted thoracoscopic surgery (RATS) with video-assisted thoracoscopic surgery (VATS), but the number of cases is limited and the results are contradictory.

Methods

We studied the medical records of primary lung cancer patients who underwent lobectomy with lymph node dissection between 2017 and 2020. Four hundred and eleven patients fulfilled the inclusion criteria in this study (RATS: 103; VATS: 308). We compared the perioperative factors and postoperative results of the VATS and RATS groups. Further, we adjusted background factors using propensity score matching (PSM) then compared the results of 200 patients (100 patients in each group). In this study, we matched interlobar fissure completeness, which affects operative difficulty and operative time; however, this has been superficially compared in previous studies.

Results

After PSM, a significant difference was observed in the intraoperative blood loss (RATS: 53.3 mL, VATS: 120.3 mL, P=0.04). The rates of surgical complications were comparable between the groups (10.0% vs. 13.0%, P=0.66) with similar mean operation times (RATS: 215.0 min, VATS: 210.1 min, P=0.57). The mean postoperative stay in the RATS group was shorter than that in the VATS group (10.0 vs. 11.5 days, P=0.04).

Conclusions

Initial experience of RATS had no obvious drawbacks when compared with that of VATS on propensity-matched analysis.

Fabrication of a Human Skin Mockup with a Multilayered Concentration Map of Pigment Components Using a UV Printer

In this paper, we propose a pipeline that reproduces human skin mockups using a UV printer by obtaining the spatial concentration map of pigments from an RGB image of human skin. The pigment concentration distributions were obtained by a separating method of skin pigment components with independent component analysis from the skin image. This method can extract the concentration of melanin and hemoglobin components, which are the main pigments that make up skin tone. Based on this concentration, we developed a procedure to reproduce a skin mockup with a multi-layered structure that is determined by mapping the absorbance of melanin and hemoglobin to CMYK (Cyan, Magenta, Yellow, Black) subtractive color mixing. In our proposed method, the multi-layered structure with different pigments in each layer contributes greatly to the accurate reproduction of skin tones. We use a UV printer because the printer is capable of layered fabrication by using UV-curable inks. As the result, subjective evaluation showed that the artificial skin reproduced by our method has a more skin-like appearance than that produced using conventional printing.

Microbiome analysis in women with endometriosis: Does a microbiome exist in peritoneal fluid and ovarian cystic fluid?

Purpose

To investigate the relationship between the microbiome of the female genital tract and endometriosis.

Methods

This prospective cohort study included 36 women who underwent laparoscopic surgery for ovarian tumor from July 2019 to April 2020. Of them, 18 had endometriosis, and 18 did not have endometriosis. Vaginal secretions, endometrial fluid, peritoneal fluid, and ovarian cystic fluid were collected during surgery. Next‐generation sequencing of bacterial 16S rRNA was performed to characterize the microbiome.

Results

Specific microbiomes were not detected in either peritoneal fluid or ovarian cystic fluid regardless of the presence or absence of endometriosis and the type of cyst. When the cutoff value of infectious bacterial abundance in the vagina was set as 64.3%, there were many cases more than a cutoff value in the endometriosis group significantly (p = 0.01). When the cutoff value of infectious bacterial abundance in the endometrium was set as 18.6%, there were many cases more than a cutoff level in the endometriosis cases significantly (p = 0.02).

Conclusion

Peritoneal fluid and ovarian cystic fluid are almost sterile, although dysbiosis may occur in the vaginal and endometrial microbiome in women with endometriosis.

[Congenital Pericardial Defect Incidentally Found at Thoracoscopic Left Upper Lobe Resection:Report of a Case]

We report a rare case of a congenital pericardial defect that was incidentally found at thoracoscopic left upper lobe resection in a patient with lung cancer. A 75-year-old man with a left upper lobe lung cancer was referred to our hospital. We performed thoracoscopic left upper lobectomy and incidentally found a pericardial defect intraoperatively. Careful lymph node dissection was necessary to avoid injury of phrenic nerve and pulmonary artery. Surgery for lung cancer was completed without pericardial repair. After surgery, no complications associated with the pericardial defect has not been encountered.

Dysfunction of epithelial permeability barrier induced by HMGB1 in 2.5D cultures of human epithelial cells

Airway and intestinal epithelial permeability barriers are crucial in epithelial homeostasis. High mobility group box 1 (HMGB1), increased by various stimuli, is involved in the induction of airway inflammation, as well as the pathogenesis of inflammatory bowel disease. HMGB1 enhances epithelial hyperpermeability. Two-and-a-half dimensional (2.5D) culture assays are experimentally convenient and induce cells to form a more physiological tissue architecture than 2D culture assays for molecular transfer mechanism analysis. In 2.5D culture, treatment with HMGB1 induced permeability of FITC-dextran into the lumen formed by human lung, nasal and intestinal epithelial cells. The tricellular tight junction molecule angulin-1/LSR is responsible for the epithelial permeability barrier at tricellular contacts and contributes to various human airway and intestinal inflammatory diseases. In this review, we indicate the mechanisms including angulin-1/LSR and multiple signaling in dysfunction of the epithelial permeability barrier induced by HMGB1 in 2.5D culture of human airway and intestinal epithelial cells.

[Spinal Cord Infarction after Right Upper Lobectomy Combined with Chest Wall Resection]

A 42-year-old man presented with a one-month history of back pain. Chest computed tomography revealed a mass (7.6×5.7 cm) in the right upper lobe, suspicious of chest wall invasion. We performed right upper lobectomy combined with chest wall resection. Partial dissections of the second to sixth ribs and the third and fourth vertebral bodies were conducted. Postoperatively, motor paralysis of the right lower extremity was observed and a diagnosis of spinal infarction was made. After cerebrospinal fluid drainage and administration of edaravone with early rehabilitation, he was able to walk with a brace and was discharged from the hospital.

Next-generation sequencing of 16S rRNA for identification of invasive bacterial pathogens in a formalin-fixed paraffin-embedded placental specimen: a case report of perinatal fulminant Streptococcus pyogenes infection

Intrauterine infection is one of the most important causes of maternal death. In perinatal emergency, we often miss an opportunity to obtain culture specimens. In this study, we tried to examine whether we investigated whether bacteria causing infection can be detected from a formalin-fixed paraffin-embedded (FFPE) placental specimen. We examined the placenta from a maternal invasive infection that resulted in infectious abortion at 18 weeks of gestation. The case was diagnosed by acute fever and abdominal pain, and the patient was cured after 3 weeks of intensive antimicrobial treatment. Four Streptococcus pyogenes strains were isolated from vaginal fluid and blood cultures of the patient. All of the strain types were emm1/ST28. We amplified the V1-V2 region of 16S rRNA from an FFPE placental specimen and sequencing was performed using a next-generation sequencer (NGS). Taxonomic analysis was then performed for sequenced data. We succeeded in detecting causative pathogens from the FFPE placenta: 69.1% of the predominantly identified bacteria were S. pyogenes and other small populations of bacteria were detected. Our results revealed the utility of NGS for 16S rRNA analysis of an FFPE placenta. This method may reveal previous perinatal invasive infections of unknown origin retrospectively.

Vessel sealing system for video-assisted lung resection for cancer reduces chylothorax and bleeding

Background

The objective of this study was to analyze the efficacy of the LigaSure^TM vessel sealing system for lung cancer resection with node dissection, as this has not been sufficiently evaluated.

Methods

From 2004 to 2018, 948 patients underwent anatomical pulmonary resection with node dissection for non-small cell lung carcinoma (NSCLC) via the video-assisted thoracoscopic surgery (VATS) approach. Medical records of these patients were reviewed retrospectively. Univariate and multivariate analyses were conducted to determine the risk factors for chylothorax and blood loss.

Results

Of the 948 patients, 318 (33.5%) who underwent anatomical lung resection with node dissection by conventional methods without vessel sealing system and 630 (66.5%) who underwent lung resection with node dissection with the vessel sealing system were included. The median intraoperative blood loss was 100 mL. Postoperative chylothorax occurred in 9 (2.8%) patients in the conventional method group with 2 (0.3%) patients in the vessel sealing system group (P=0.001). Patients in the vessel sealing group who developed chylothorax were cured by conservative treatment. Univariate and multivariate analyses identified male sex [odds ratio (OR) 2.053; 95% confidence interval (CI): 1.494–2.820; P<0.001] and the use of vessel sealing system (OR 0.342; 95% CI: 0.256–0.457; P<0.001) as independent predictors of intraoperative blood loss. The univariate and multivariate analyses identified the use of the vessel sealing system (OR 0.108; 95% CI: 0.023–0.504; P=0.005) as an independent predictor of chylothorax incidence.

Conclusions

Vessel sealing system for lung cancer resection could decrease chest tube duration, amount of intraoperative bleeding, and incidence of chylothorax in patients who undergo lung resection with node dissection.

[Probable Immunoglobulin G4 (IgG4)-related Periaortitis Requiring Differentiation from Mediastinal Tumor]

A 42-year-old man with a history of suspected of Behcet's disease underwent oral steroid treatment. During follow-up, chest X-ray revealed an abnormal shadow of the mediastinum. Chest computed tomography(CT) showed a circumferential tumor around the descending thoracic aorta. Enhanced CT showed a lowly and uniformly enhanced tumor at delay phase. A mediastinal tumor was suspected, which prompted a biopsy of the periaortic tumor by video-assisted thoracic surgery (VATS). Histopathological diagnosis showed numerous immunogloblin G4 (IgG4)-positive plasma cells suggesting the possibility of IgG4-related periaortitis. However, based on the diagnostic criteria, the case was comprehensively diagnosed as probable IgG4-related periaortitis, steroid treatment may have affected blood IgG4-positive cells and tissues.

The left main bronchus transected incorrectly during video-assisted thoracoscopic lobectomy: a case report

Background

Several severe intraoperative complications of lung cancer surgery have been reported, but the incorrect transection of the main bronchus is a very rare and serious complication. We report a surgical case of a patient with left lower lobe lung cancer invading the inferior segment of the lingula, with fused interlobar fissure and dense pleural adhesion, in which the left main bronchus was mistaken for the left lower lobe bronchus and was transected.

Case presentation

A 64-year-old woman with lung adenocarcinoma was referred to our hospital for surgical treatment. Chest computed tomography (CT) scan showed a 30-mm nodule with a clear border and irregular margins in the center of the anterior (S8) segment of the lower lobe of the left lung and another similar 30-mm nodule in the lateral (S9) segment of the same lobe. Metastasis within the same lobe was suspected. A thoracoscopic left lower lobectomy was scheduled for the patient. As the patient had a moderately, fused fissure, dense pleural adhesion, and suspicious tumor invasion from the left S8 segment to the left S5 segment, and the interlobar node tightly adhered to the main PA at the site of basilar artery origin of the LLL, we performed left lower lobectomy and a left S5 segmentectomy using the fissureless fissure-last technique. During surgery, the left main bronchus was mistaken for the left lower lobe bronchus and was transected. After transecting the left main bronchus, we performed a sleeve bronchoplasty to prevent pneumonectomy.

Conclusions

We experienced the rare and serious intraoperative complication of the incorrect transection of the main bronchus. There are few reports of this intraoperative complication, and it should not be overlooked by surgeons.

[Successful Robotic Resection of Left Upper Mediastinal Tumor]

A man was diagnosed with a left upper mediastinal mass. The mass was located near the left subclavian vein, phrenic nerve, vagus nerve, left subclavian artery, and left brachiocephalic vein. He underwent a robotic surgery without additional approaches such as cervical approach on transmanubrial approach. Robotic surgery enabled to remove the tumor safely due to the highly flexible robot forceps under a 3-dimensional visual field. Robotic surgery may be effective for tumors in the upper mediastinum, where important blood vessels and nerves are closely present.

HMGB1 enhances epithelial permeability via p63/TGF-β signaling in lung and terminal bronchial epithelial cells

High mobility group box 1 (HMGB1) is involved in the induction of airway inflammation and injury in patients with chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis (IPF). HMGB1 increased by transforming growth factor-β1 (TGF-β1), impairs airway epithelial barrier function in the lung. In the present study, to investigate how HMGB1 affects the barrier of normal human lung epithelial (HLE) cells, monolayer cells (2D culture) and bronchial-like spheroid cells (2.5 D Matrigel culture), which have lumen formation, were pretreated with TGF-β type I receptor kinase inhibitor EW-7197 before treatment with HMGB1. In 2D culture, treatment with HMGB1 decreased expression of angulin-1/LSR, TRIC and CLDN-1, -4, -7 and increased that of CLDN-2. Pretreatment with EW-7197 prevented the changes of all tight junction molecules induced by HMGB1. In 2.5D Matrigel culture, treatment with HMGB1 induced permeability of FITC-dextran (FD-4) into the lumen, whereas pretreatment with EW-7197 prevented the hyperpermeability of FD-4 into the lumen caused by HMGB1. In 2.5D Matrigel culture, knockdown of transcription factor p63 prevented the hyperpermeability induced by HMGB1 as well as pretreatment with EW-7197. In the 2D culture of HLE cells with HMGB1, knockdown of p63 increased the level of angulin-1/LSR and CLDN-4, while pretreatment with EW-7197 enhanced the increase of CLDN-4 induced by knockdown of p63. Immunohistochemical analysis of IPF, CLDN-2, HMGB1 and p63 revealed that their levels were higher in the regenerative epithelium of the terminal bronchial region than in normal epithelium. HMGB1 induces epithelial permeability of HLE cells via p63/TGF-β signaling in normal lung and IPF.

[Left Upper Lobectomy Followed by Left Lower Pulmonary Vein Reconstruction after Miscutting the Common Trunk of the Left Pulmonary Veins]

A 65-year-old woman was diagnosed with lung cancer on the left upper lobe. During thoracoscopic left upper lobectomy, the common trunk of pulmonary vein was mistaken for the left upper pulmonary vein and divided incorrectly. Instead of left pneumonectomy, we successfully performed pulmonary vein reconstruction. As a result of anticoagulant therapy for 1 month, postoperative course was uneventful.

Effects of fatty acids on inducing endoplasmic reticulum stress in bovine mammary epithelial cells

Fatty acids play important roles in the regulation of endoplasmic reticulum (ER) stress-induced apoptosis in different cells. Currently, the effects of fatty acids on bovine mammary epithelial cells (MEC) remain unknown. Our study examined bovine MEC viability and measured unfolded protein response (UPR)-related gene and protein expressions following fatty acid treatments. To evaluate the role of fatty acids, we treated MAC-T cells (a line of MEC) with 100 to 400 μM of saturated (palmitic and stearic acid) and unsaturated (palmitoleic, oleic, linoleic, and linolenic acid) fatty acids and 1 to 5 mM of short- and medium-chain fatty acids (acetic, propionic, butyric, and octanoic acid). Thereafter, we determined UPR-related gene expression using quantitative real-time PCR. Palmitic acid stimulated expression of XBP1s, ATF4, ATF6A, and C/EBP homologous protein (CHOP). Stearic acid increased expression of XBP1s and CHOP and decreased expression of ATF4 and ATF6A. Results of Western blot analysis and 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay revealed that palmitic and stearic acid reduced MAC-T cell viability and induced extreme ER stress by increasing the protein expression of ER stress markers, such as phospho-PKR-like endoplasmic reticulum kinase, phospho-eIF2α, cleaved CASP-3, and CHOP. Among unsaturated long-chain fatty acids, palmitoleic acid increased expression of ATF4 and ATF6A. Oleic acid increased expression of XBP1s, ATF4, and ATF6A. Linoleic and linolenic acids increased expression of XBP1s, ATF4, and ATF6A but decreased expression of XBP1s and ATF6A at the highest dose. Although palmitoleic, oleic, and linoleic acid decreased CHOP expression, only palmitoleic acid increased MAC-T cell viability. Therefore, unsaturated long-chain fatty acids did not induce severe ER stress. Acetic, propionic, and butyric acids decreased expression of ATF4, ATF6A, and CHOP and increased XBP1s expression. Although only octanoic acid increased ATF4 and ATF6A expressions, it lowered expression of XBP1s and CHOP. Although fatty acid treatment did not increase the levels of ER stress proteins, butyric and octanoic acids reduced cell viability, possibly because of early differentiation. These results suggest that saturated fatty acids play important roles in MEC viability by inducing severe ER stress compared with unsaturated fatty acids. In addition, acetic and propionic acids (short- and medium-chain fatty acids) reduced ER stress. Therefore, the present study reflects the new insight that serum fatty acid concentration plays an important role in maintaining the lactation physiology of dairy cows.

Pulmonary vessels and bronchial anatomy of the left lower lobe

PURPOSE

To identify and clarify the comprehensive anatomic patterns in the left lower lobe (LLL).

METHODS

Using computed tomography (CT) imaging data, including that obtained using three-dimensional CT, we reviewed the anatomic patterns of the pulmonary vessels and bronchi in the left lungs of 539 patients, focusing on the LLL.

RESULTS

The two-stem type in A⁶ was observed in 131 (24.7%) patients and the three-stem type in A⁶ was observed in 11 (2.1%) patients. The independent two-stem type in B⁶ was observed in four (0.75%) patients. The B⁷ with independent branching from the basal bronchi was observed in 42 (7.9%) patients. B* was observed in 129 (24.0%) patients and B* was accompanied by A* in all patients. An extrapericardial common trunk of the left pulmonary veins was identified in five patients (0.93%).

CONCLUSION

We identified various bronchovascular patterns in the LLL of a large number of patients. Our results provide useful information for anatomic pulmonary resection, especially segmentectomy.

IRE1-XBP1 Pathway of the Unfolded Protein Response Is Required during Early Differentiation of C2C12 Myoblasts

In skeletal muscle, myoblast differentiation results in the formation of multinucleated myofibers. Although recent studies have shown that unfolded protein responses (UPRs) play an important role in intracellular remodeling and contribute to skeletal muscle differentiation, the involvement of IRE1-XBP1 signaling, a major UPR signaling pathway, remains unclear. This study aimed to investigate the effect of the IRE1-XBP1 pathway on skeletal muscle differentiation. In C2C12 cells, knockdown of IRE1 and XBP1 in cells remarkably suppressed differentiation. In addition, apoptosis and autophagy were dramatically enhanced in the XBP1-knockdown cells, highlighting the participation of IRE1-XBP1 in cell survival maintenance with differentiation stimuli during skeletal muscle differentiation. In myogenic cells, we demonstrated that the expression of CDK5 (cyclin-dependent kinase 5) is regulated by XBP1s, and we propose that XBP1 regulates the expression of MyoD family genes via the induction of CDK5. In conclusion, this study revealed that IRE1-XBP1 signaling plays critical roles in cell viability and the expression of differentiation-related genes in predifferentiated myoblasts and during the early differentiation phase.

[Paraffinoma with Spinal Paralysis 40 Years After Pleural Plombage for Tuberculosis]

Paraffin had been used for pleural plombage in the treatment of tuberculosis. However, paraffin use has been reported to cause late postoperative complications. A 79-year-old man was presented with an extramedullary tumor and spinal paralysis. Forty-seven years ago, he had undergone pleural plombage using paraffin for the treatment of pulmonary tuberculosis. Since the extramedullary tumor was found to be paraffinoma, paraffin in the vertebral canal and thoracic cavity was removed surgically. All the paraffin in the vertebral canal and thoracic cavity was removed. After surgery, the patient remains well, without spinal paralysis.

An aluminum shield enables the amphipod Hirondellea gigas to inhabit deep-sea environments

The amphipod Hirondellea gigas inhabits the deepest regions of the oceans in extreme high-pressure conditions. However, the mechanisms by which this amphipod adapts to its high-pressure environment remain unknown. In this study, we investigated the elemental content of the exoskeleton of H. gigas specimens captured from the deepest points of the Mariana Trench. The H. gigas exoskeleton contained aluminum, as well as a major amount of calcium carbonate. Unlike other (accumulated) metals, aluminum was distributed on the surface of the exoskeleton. To investigate how H. gigas obtains aluminum, we conducted a metabolome analysis and found that gluconic acid/gluconolactone was capable of extracting metals from the sediment under the habitat conditions of H. gigas. The extracted aluminum ions are transformed into the gel state of aluminum hydroxide in alkaline seawater, and this gel covers the body to protect the amphipod. This aluminum gel is a good material for adaptation to such high-pressure environments.

[Surgical Treatment for Pneumopyothorax Secondary to Pancreatic Fistula]

A 46-year-old woman with cervical cancer with multiorgan metastasis visited our hospital. She underwent a total gastrectomy, splenectomy, distal pancreatectomy, left adrenalectomy, and left partial diaphragmatic resection. Postoperatively, she developed pleural effusion with high level of amylase secondary to a pancreatic fistula, consequently causing left-sided empyema. She developed acute respiratory distress syndrome. Urgent surgical treatment was scheduled, and left lower lobectomy, with diaphragmatic partial resection were performed under the venovenous extracorporeal membrane oxygenation. After surgery, intensive care for 45 days was necessary and she was discharged home 6 months post operatively.

MAPLE 2.3.0: an improved system for evaluating the functionomes of genomes and metagenomes

MAPLE is an automated system for inferring the potential comprehensive functions harbored by genomes and metagenomes. To reduce runtime in MAPLE analyzing the massive amino acid datasets of over 1 million sequences, we improved it by adapting the KEGG automatic annotation server to use GHOSTX and verified no substantial difference in the MAPLE results between the original and new implementations.

Complete genome sequence and expression profile of the commercial lytic enzyme producer Lysobacter enzymogenes M497-1

Lysobacter enzymogenes M497-1 is a producer of commercialized achromopeptidase and is expected to harbour genes encoding various other antimicrobial enzymes. Here, we present the complete sequence of the genome of M497-1 and the expression profiles of the genes for various antimicrobial enzymes. Of the 117 peptidase-encoding genes found in the 6.1-Mb genome of M497-1, 15 genes (aside from the gene encoding the achromopeptidase) were expressed at a level higher than that of the average ribosomal protein genes in the 24-h culture. Thus, the strain was found more valuable than hitherto considered. In addition, M497-1 harbours 98 genes involved in the biosynthesis of various natural products, 16 of which are M497-1-specific across 4 Lysobacter species. A gene cluster starting at LEN_2603 through LEN_2673 among the 98 genes closely resembled the lysobactin biosynthesis gene cluster of Lysobacter sp. ATCC 53042. It is likely that M497-1 may produce lysobactin or related antibacterial compounds. Furthermore, comparative genomic analysis of M497-1 and four other Lysobacter species revealed that their core genome structure comprises 3,737 orthologous groups. Our findings are expected to advance further biotechnological application of Lysobacter spp. as a promising source of natural bioactive compounds.

Polysaccharide hydrolase of the hadal zone amphipods Hirondellea gigas

Hirondellea species are common inhabitants in the hadal region deeper than 7,000 m. We found that Hirondellea gigas thrived in the Challenger Deep possessed polysaccharide hydrolases as digestive enzymes. To obtain various enzymes of other H. gigas, we captured amphipods from the Japan Trench, and Izu-Ogasawara (Bonin) Trench. A phylogenetic analysis based on the cytochrome oxidase I gene showed close relationships among amphipods, despite the geographic distance between the localities. However, several differences in enzymatic properties were observed in these H. gigas specimens. We also carried out RNA sequencing of H. gigas from the Izu-Ogasawara Trench. The cellulase gene of H. gigas was highly homologous to cellobiohydrolase of Glucosyl Hydrolase family 7 (GH7). On the other hand, enzymatic properties of H. gigas's cellulase were different from those of typical GH7 cellobiohydrolase. Thus, these results indicate that hadal-zone amphipod can be good candidates as the new enzyme resource.

An automated system for evaluation of the potential functionome: MAPLE version 2.1.0

Metabolic and physiological potential evaluator (MAPLE) is an automatic system that can perform a series of steps used in the evaluation of potential comprehensive functions (functionome) harboured in the genome and metagenome. MAPLE first assigns KEGG Orthology (KO) to the query gene, maps the KO-assigned genes to the Kyoto Encyclopedia of Genes and Genomes (KEGG) functional modules, and then calculates the module completion ratio (MCR) of each functional module to characterize the potential functionome in the user’s own genomic and metagenomic data. In this study, we added two more useful functions to calculate module abundance and Q-value, which indicate the functional abundance and statistical significance of the MCR results, respectively, to the new version of MAPLE for more detailed comparative genomic and metagenomic analyses. Consequently, MAPLE version 2.1.0 reported significant differences in the potential functionome, functional abundance, and diversity of contributors to each function among four metagenomic datasets generated by the global ocean sampling expedition, one of the most popular environmental samples to use with this system. MAPLE version 2.1.0 is now available through the web interface (http://www.genome.jp/tools/maple/) 17 June 2016, date last accessed.

Functional Classification of Uncultured "Candidatus Caldiarchaeum subterraneum" Using the Maple System

In this study, the metabolic and physiological potential evaluator system based on Kyoto Encyclopedia of Genes and Genomes (KEGG) functional modules was employed to establish a functional classification of archaeal species and to determine the comprehensive functions (functionome) of the previously uncultivated thermophile “Candidatus Caldiarchaeum subterraneum” (Ca. C. subterraneum). A phylogenetic analysis based on the concatenated sequences of proteins common among 142 archaea and 2 bacteria, and among 137 archaea and 13 unicellular eukaryotes suggested that Ca. C. subterraneum is closely related to thaumarchaeotic species. Consistent with the results of the phylogenetic analysis, clustering and principal component analyses based on the completion ratio patterns for all KEGG modules in 79 archaeal species suggested that the overall metabolic and physiological potential of Ca. C. subterraneum is similar to that of thaumarchaeotic species. However, Ca. C. subterraneum possessed almost no genes in the modules required for nitrification and the hydroxypropionate–hydroxybutyrate cycle for carbon fixation, unlike thaumarchaeotic species. However, it possessed all genes in the modules required for central carbohydrate metabolism, such as glycolysis, pyruvate oxidation, the tricarboxylic acid (TCA) cycle, and the glyoxylate cycle, as well as multiple sets of sugar and branched chain amino acid ABC transporters. These metabolic and physiological features appear to support the predominantly aerobic character of Ca. C. subterraneum, which lives in a subsurface thermophilic microbial mat community with a heterotrophic lifestyle.

High frequency of phylogenetically diverse reductive dehalogenase-homologous genes in deep subseafloor sedimentary metagenomes

Marine subsurface sediments on the Pacific margin harbor diverse microbial communities even at depths of several hundreds meters below the seafloor (mbsf) or more. Previous PCR-based molecular analysis showed the presence of diverse reductive dehalogenase gene (rdhA) homologs in marine subsurface sediment, suggesting that anaerobic respiration of organohalides is one of the possible energy-yielding pathways in the organic-rich sedimentary habitat. However, primer-independent molecular characterization of rdhA has remained to be demonstrated. Here, we studied the diversity and frequency of rdhA homologs by metagenomic analysis of five different depth horizons (0.8, 5.1, 18.6, 48.5, and 107.0 mbsf) at Site C9001 off the Shimokita Peninsula of Japan. From all metagenomic pools, remarkably diverse rdhA-homologous sequences, some of which are affiliated with novel clusters, were observed with high frequency. As a comparison, we also examined frequency of dissimilatory sulfite reductase genes (dsrAB), key functional genes for microbial sulfate reduction. The dsrAB were also widely observed in the metagenomic pools whereas the frequency of dsrAB genes was generally smaller than that of rdhA-homologous genes. The phylogenetic composition of rdhA-homologous genes was similar among the five depth horizons. Our metagenomic data revealed that subseafloor rdhA homologs are more diverse than previously identified from PCR-based molecular studies. Spatial distribution of similar rdhA homologs across wide depositional ages indicates that the heterotrophic metabolic processes mediated by the genes can be ecologically important, functioning in the organic-rich subseafloor sedimentary biosphere.

A deeply branching thermophilic bacterium with an ancient acetyl-CoA pathway dominates a subsurface ecosystem

A nearly complete genome sequence of Candidatus 'Acetothermum autotrophicum', a presently uncultivated bacterium in candidate division OP1, was revealed by metagenomic analysis of a subsurface thermophilic microbial mat community. Phylogenetic analysis based on the concatenated sequences of proteins common among 367 prokaryotes suggests that Ca. 'A. autotrophicum' is one of the earliest diverging bacterial lineages. It possesses a folate-dependent Wood-Ljungdahl (acetyl-CoA) pathway of CO(2) fixation, is predicted to have an acetogenic lifestyle, and possesses the newly discovered archaeal-autotrophic type of bifunctional fructose 1,6-bisphosphate aldolase/phosphatase. A phylogenetic analysis of the core gene cluster of the acethyl-CoA pathway, shared by acetogens, methanogens, some sulfur- and iron-reducers and dechlorinators, supports the hypothesis that the core gene cluster of Ca. 'A. autotrophicum' is a particularly ancient bacterial pathway. The habitat, physiology and phylogenetic position of Ca. 'A. autotrophicum' support the view that the first bacterial and archaeal lineages were H(2)-dependent acetogens and methanogenes living in hydrothermal environments.

Alternate-day treatment with S-1 in patients with gastric cancer: a retrospective study of strategies for reducing toxicity

BACKGROUND

In patients with adverse events of S-1, the dose is generally reduced or the treatment cycle is shortened. Whether the therapeutic effectiveness of modified regimens is similar to that of the standard dosage remains unclear.

METHODS

We retrospectively studied patients with gastric cancer who received S-1 on alternate days.

RESULTS

A total of 266 patients received S-1 on alternate days. In 116 patients, S-1 was initially given at the standard dosage but was switched to alternate-day treatment because of toxicity within 28 days on average. The other 150 patients initially received alternate-day treatment because of poor general condition. In the adjuvant chemotherapy group (n = 96), the 3-year survival rate was 88% in patients with stage II, 73% in stage IIIA, and 67% in stage IIIB who underwent D2 lymph-node dissection. In the palliative surgery group (n = 96), the response rate was 13%, with a median survival time (MST) of 624 days. In patients with unresectable/recurrent disease (n = 74), the response rate was 25%, with an MST of 338 days. Among the 116 patients who initially received treatment on consecutive days, 100% had grade 1, 53% had grade 2, and 5.2% had grade 3 adverse events. When S-1 was switched to alternate-day treatment, toxicity decreased in all patients. In the 266 patients who received alternate-day treatment, 8% had grade 1, 6% had grade 2, and 0% had grade 3 adverse events.

CONCLUSION

Alternate-day treatment with S-1 may have milder adverse events without compromising therapeutic effectiveness.

Comparison of alternate-day versus consecutive-day treatment with S-1: assessment of tumor growth inhibition and toxicity reduction in gastric cancer cell lines in vitro and in vivo

BACKGROUND

The toxic effects of S-1 can lead to discontinuation of treatment. Strategies for reducing toxicity without compromising therapeutic effectiveness are required.

METHODS

We used the human gastric cancer cell lines MKN28 and MKN45 to examine such strategies in vitro. The cell lines were treated with three different regimens, given on alternate days (alternate-day) or on consecutive days (consecutive-day). On consecutive days, treatment A provided the same total dose as the alternate-day treatment, and treatment B was given for the same number of days as the alternate-day treatment. A fourth group served as control. In vitro, the relative inhibition (RI) of tumor growth by 5-fluorouracil was calculated using the 2-(2-methyl-4-nitrophenyl)-3-(4-nitrophyl)-5-2, 4-disulfophenyl)-2H-tetrazolium (WST-8) method. We also carried out an in vivo experiment in which tumor-bearing nude mice (BALBc/nu-nu) were used to examine the antitumor activity of S-1. Leukocyte counts and gastrointestinal mucosal injury were compared in mice that received alternate-day and consecutive-day treatments.

RESULTS

In vitro, for MKN28, the RI was 22.9% for alternate-day, 34.1% for consecutive-day A, and 37.7% for consecutive-day B treatments. For MKN45, the RI was 51.1% for alternate-day, 52.2% for consecutive-day A, and 50.5% for consecutive-day B treatments. In vivo, for MKN28, the treated groups showed higher inhibition than the control, and inhibition of tumor growth was higher with alternate-day than with consecutive-day treatment. The RI was significantly higher with alternate-day (49.3%) than with consecutive-day treatment (16.2%; P < 0.05). For MKN45, the RI was greater than 50% in both treated groups. With consecutive-day treatment, 5 of the 14 mice used died during treatment. Leukocyte counts were lower in the mice with consecutive-day than with alternate-day treatment, or control. Atrophic changes and inflammatory cell infiltration of the small intestinal mucosa were severe after consecutive-day, but minimal after alternate-day treatment.

CONCLUSION

Experimentally, alternate-day treatment with S-1 is equivalent to consecutive-day treatment in terms of RI of tumor growth, with lower toxicity.

Gasless laparoscopy-assisted distal gastrectomy is feasible and useful for non-obese patients with early gastric cancer

BACKGROUND/AIMS

To evaluate the feasibility and usefulness of gasless laparoscopy-assisted distal gastrectomy except when treating obese patients compared with open distal gastrectomy for early cancer.

METHODOLOGY

We treated 92 patients with distal gastrectomy for early gastric cancer consecutively. Patients with massive submucosal invasion and/or LN swelling were allocated for the open method, and patients with slightly invasive submucosal cancer were allocated for gasless laparoscopy-assisted surgery. As exceptions we employed open surgery for overweight patients and gasless laparoscopy for elderly and/or feeble patients.

RESULTS

We attempted to perform open and laparoscopy-assisted surgery on 52 and 40 patients, respectively. Three cases in the laparoscopy-assisted group were converted to open surgery because of obesity. The age was older and BMI was lower in the laparoscopy-assisted group. In terms of operative time and blood loss as well as postoperative recovery, the results for the laparoscopy-assisted group were superior to those of the open surgery group. There were no cases of cardiopulmonary complications for the laparoscopy-assisted group.

CONCLUSIONS

Gasless laparoscopy-assisted distal gastrectomy is feasible and useful for early gastric cancer except when treating obese patients.

Doxifluridine combined with weekly paclitaxel for second-line treatment in patients with gastric cancer resistant to TS-1

BACKGROUND

Many patients with gastric cancer respond to TS-1, but some fail to respond or have recurrence. Second-line therapy is needed.

METHODS

We performed a pilot study in patients with advanced gastric cancer who did not respond to TS-1 or who had disease recurrence. The patients received oral doxifluridine (600 mg/day) on days 1 to 21 and an intravenous infusion of paclitaxel (70 mg/m(2)) on days 7, 14, and 21 of a 28-day cycle. The treatment was repeated until disease progression or prohibitive toxicity. Response rate, duration of response, median survival time (MST), effects on pleural effusion, ascites, and other signs, and toxicity were evaluated.

RESULTS

The study group comprised 52 patients. The response rate was 28%. The duration of response was 103 days. The MST after the start of second-line treatment was 175 days (95% confidence interval, 135 to 224 days). Pleural effusion or ascites resolved or decreased in 73% of the patients. Hair loss occurred in 32 patients (62%), and leukopenia developed in 28 (54%, grade 3 in 1 patient and grade 2 or lower in the others). The MST after the start of treatment with TS-1 was about 16 months.

CONCLUSION

A combination of doxifluridine and weekly paclitaxel is expected to be an effective second-line treatment for gastric cancer not responding to TS-1, especially in patients with malignant ascites or pleural effusion. However, it remains unclear whether paclitaxel plus doxifluridine results in a better response and survival benefit than paclitaxel alone in this subgroup of patients. Further studies are therefore necessary.

Minimum leakage rate (0.5%) of stapled esophagojejunostomy with sacrifice of a small part of the jejunum after total gastrectomy in 390 consecutive patients

BACKGROUND

The development of new surgical instruments and devices has facilitated the performance of esophagojejunostomy after total gastrectomy. However, total prevention of dehiscence of anastomoses remains difficult. We introduced a new procedure for esophagojejunostomy using a circular stapler, requiring sacrifice of only a small part of the jejunum.

METHODS

The study group comprised 390 consecutive patients who underwent reconstruction by Roux-en-Y esophagojejunostomy, performed with a circular stapler, sacrificing a small part of the jejunum after total gastrectomy. We assessed anastomotic leakage and anastomotic stenosis after surgery.

RESULTS

Only 2 patients (0.5%) had leakage and 4 (1.0%) had anastomotic stenosis after reconstruction. All the patients were cured by conservative therapy.

CONCLUSIONS

Esophagojejunostomy performed with a circular stapler after total gastrectomy, with sacrifice of only a small part of the jejunum, is a useful and easy procedure, with a leakage rate of 0.5%.

Aggressive G-CSF-producing gastric cancer complicated by lung and brain abscesses, mimicking metastases

A 57-year-old Japanese man had type II c gastric cancer with marked lymph node metastases associated with leukocytosis and elevated granulocyte colony-stimulating factor (G-CSF). Total gastrectomy and distal pancreatectomy with lymph node dissection were performed. Although the primary lesion was negative for G-CSF by histopathological immunostaining, a highly increased G-CSF m-RNA level, measured using reverse transcriptase-polymerase chain reaction in frozen sections, led to a diagnosis of G-CSF-producing gastric cancer. The leukocytes and G-CSF decreased immediately after surgery. He then had an intraabdominal recurrence, and was diagnosed with multiple tumors in his lung and brain, with abnormally elevated leukocytes and greatly increased G-CSF; he died 4 months after the surgery. Autopsy showed intraabdominal recurrence of cancer, with no metastases to the lung or brain, but with multiple brain and lung abscesses. We speculate that the excessively increased neutrophils induced by G-CSF infiltrated the lung and brain and formed abscesses, mimicking metastases.

Alternate-day oral therapy with TS-1 for advanced gastric cancer

BACKGROUND

TS-1 (1M tegafur-0.4M 5-chloro-2,4-dihydroxypyrimidine-1M potassium oxonate) has a high single-agent response rate, of more than 40%, for gastric cancer; however, the recommended regimen of 4 weeks of administration interrupted by 2 weeks of drug withdrawal frequently causes adverse effects. The alternate-day dosage of pyrimidine fluoride anticancer drugs could reduce their adverse effects without compromising their effects. We attempted an alternate-day therapy with TS-1 aiming at the avoidance of adverse effects and significantly longer duration of administration.

METHODS

We observed patients for clinical effects and adverse effects under alternate-day dosage of TS-1, and determined blood 5-fluorouracil (FU) levels. The judgment of clinical effects was based on the New Guidelines to Evaluate the Response to Treatment in Solid Tumors (RECIST), whereas the evaluation of adverse effects was based on the National Cancer Institute NCI-common toxicity criteria (CTC).

RESULTS

In 72 (78%) of 92 patients, the TS-1 regimen was converted to the alternate-day dosage because of adverse effects. Twenty patients were treated with the alternate-day dosage regimen from the start because of the fear of adverse effects. The alternate-day dosage was clinically effective, as 28 of 34 patients after relatively curative resection remained alive and free from recurrence. The median survival time of 58 patients after noncurative resection or with unresectable or recurrent cancer was 332 days. Fifty-three percent of these 58 patients achieved partial response and stable disease of more than 12 weeks' duration. We followed time-dependent changes in blood 5-FU levels in 36 of the patients on alternate-day therapy, in whom TS-1 had been administered daily before being administered every other day. The trough level was significantly lower when TS-1 was administered on alternate days, and blood 5-FU reached a peak at sufficiently effective levels at 2 h even after administration on the alternate-day basis.

CONCLUSION

. This study demonstrated that, compared with daily administration, alternate-day administration of TS-1 reduces adverse effects, and simultaneously ensures effective blood levels and provides sufficient clinical effects.TS-1 (1 M tegafur-0.4 M 5-chloro-2,4-dihydroxypyrimidine-1 M potassium oxonate) has a high single-agent response rate, of more than 40%, for gastric cancer; however, the recommended regimen of 4 weeks of administration interrupted by 2 weeks of drug withdrawal frequently causes adverse effects. The alternate-day dosage of pyrimidine fluoride anticancer drugs could reduce their adverse effects without compromising their effects. We attempted an alternate-day therapy with TS-1 aiming at the avoidance of adverse effects and significantly longer duration of administration.

Tracheoesophageal fistula secondary to chemotherapy for malignant B-cell lymphoma of the thyroid: successful surgical treatment with jejunal interposition and mesenteric patch

We report a case of tracheoesophageal fistula (TEF) secondary to chemotherapy for primary thyroid lymphoma. A 65-year-old man with a short history of a rapidly enlarging neck mass was diagnosed as having thyroid lymphoma of diffuse, large B-cell type. The TEF occurred during the first course of chemotherapy including cyclophosphamide, doxorubicin, vincristine and prednisolone. After placing a feeding gastrostomy without oral intake, eight cycles of chemotherapy were completed and complete remission was achieved. Although the cervical mass disappeared, TEF and esophageal stenosis persisted. Total thyroidectomy and resection of the stenotic cervical esophagus were carried out followed by interposition of the revascularized jejunum and its mesenteric patch to cover the TEF. This seems to be the first report of a TEF caused by chemotherapy for primary thyroid B-cell lymphoma. A variety of treatments for TEF including simple closure, tracheal resection, colonic bypass and muscle flap have been reported with low success rates. Our procedure using a jejunal mesenteric patch seems to be unique and may be a new treatment strategy for TEF.

[A case of type 4 gastric cancer with peritoneal dissemination successfully treated over 2 years by alternate-day administration of TS-1]

We report a patient with unresectable advanced gastric cancer who has been being treated by TS-1 administration on alternate days for 2 years. The patient was a 50-year-old female with type 4 gastric cancer accompanied by Schnitzler metastasis and pleural effusion. TS-1 administration was initiated at a daily dose of 100 mg with a schedule of 4-week administration and 2-week suspension. However, grade 2 hepatic dysfunction and leukocytopenia developed. When the daily TS-1 administration was changed to alternate-day administration at the same dose, no side effects were observed, allowing the continuation of treatment. She has maintained a minor response (MR)-no change (NC) for 1 year and 5 months, and is still symptom-free and being treated on an outpatient basis at present, 2 years after treatment. TS-1 is an anti-cancer drug that plays a central role in chemotherapy for gastric cancer. However, in some patients, side effects sometimes develop using the routine administration method, making continuation of administration difficult. Alternate-day TS-1 administration has great potential as a protocol that produces long-term anti-tumor effects while reducing side effects.

Gasless laparoscopy-assisted distal gastrectomy for early cancer via mini-laparotomy using an abdominal wall lift

BACKGROUND/AIMS

To investigate the technical ease and results of gasless laparoscopy-assisted distal gastrectomy with lymph node dissection via mini-laparotomy using abdominal wall lift for early gastric cancer.

METHODOLOGY

We submitted 20 patients to laparoscopy-assisted distal gastrectomy for early gastric cancer located in the middle or lower stomach. The initial 10 cases underwent perigastric lymph node dissection (D1), and the subsequent 10 cases received further dissection around the left gastric and common hepatic arteries (D1 + a). Mini-laparotomy was placed at the beginning of the procedure. We lifted up the laparotomy and the subcutaneous tissue around the umbilicus by retractors. We accomplished the dissection, resection and reconstruction mainly via the mini-laparotomy using a direct view and a laparoscopic image.

RESULTS

Two cases were converted to open. The operative time was significantly longer in D1 + a (225 +/- 49 min) than in D1 (172 +/- 38 min). Blood loss was significantly more in D1 + a (247 +/- 155 mL) than in D1 (109 +/- 60 mL). There was no difference between the two groups in terms of days to first flatus, first oral intake or discharge from the hospital. Postoperative complications included 2 wound infections each in D1 and D1 + a group, and 1 anastomotic stenosis in D1 + a group.

CONCLUSIONS

Gasless laparoscopy-assisted distal gastrectomy with D1 + a via mini-laparotomy using abdominal wall lift seems to be feasible and useful for early gastric cancer.

Memory of chirality generated by spontaneous crystallization and asymmetric synthesis using the frozen chirality

Asymmetric synthesis using frozen chirality generated by spontaneous crystallization was performed. Achiral asymmetrically substituted imide with a tetrahydronaphthyl group on the nitrogen atom crystallized in a chiral fashion, with space group P2(1)2(1)2(1). The molecular chirality generated by spontaneous crystallization was retained in cold THF. The half-life determined on the basis of decreasing optical activity followed by CD spectrometer was 7.8, 33.1, and 150.0 min at -20, -30, -40 degrees C, respectively. The energy barrier (DeltaG()) of racemization was calculated with the temperature dependence of the kinetic constant to be 18.24-18.36 kcal mol(-)(1) at 233-253 K. The memorized frozen chirality was transferred to permanent optically active alcohols by nucleophilic addition with n-buthyllithium.