ABSTRACT
A woman in her late 80s visited a local physician complaining of nausea, loss of appetite, and constipation. She was referred to our hospital for detailed examination. Computed tomography (CT) revealed that the entire stomach, pancreas, spleen, transverse colon, and small intestine were prolapsed into the mediastinum and left thoracic cavity through the esophageal hiatus, which was dilated. Moreover, the small intestine was narrowed at the hiatus and dilated in the abdominal cavity, presenting ileus. After diagnosing type IV esophageal hiatal hernia with upside-down stomach and starting conservative treatment, the ileus improved and oral intake was resumed. Subsequent CT showed continued prolapse of the pancreas, spleen, transverse colon, small intestine, and entire stomach, but CT taken 5 years earlier had shown similar findings of prolapse. Thus, we decided not to perform surgery and instead opted for close follow-up after discharge. The patient is well without any symptoms of obstruction as of 1.5 years after discharge.
ABSTRACT
Although axillary lymph node dissection (ALND) is conventionally indicated for metastasis in the sentinel lymph node (SLN), the omission of ALND is being discussed more often in recent years. However, because of the lack of specific guidelines, it is unclear which cases should be treated without ALND. In this study, we performed one-step nucleic acid amplification of the SLN with metastasis to determine the total tumor load (TTL), that is, the number of cytokeratin (CK) 19 mRNA copies. After ultrasonography (US) of ALN, the ultrasonographic findings were combined with TTL to rate SLN metastasis. In the rating, a total score was obtained by assigning 1 point each for (a) TTL of ≥15000 copies/μL, (b) US findings of a long-to-short LN diameter ratio of ≤2, and (c) US findings of no echogenic hilus. We then investigated the association between the total score and metastasis in the non-SLN. Results showed that while 87.5% (5/6) of patients with positive non-SLN scored ≥2 points, only 3.1% (1/34) of patients with negative non-SLN did so, suggesting that a total copy number of CK19 mRNA, US findings of a long-to-short LN diameter ratio, and the presence/absence of echogenic hilus are important predictors for non-SLN metastasis. This novel scoring system is expected to help determine which patients need ALND or what postoperative therapy is necessary.
ABSTRACT
The patient is a women in her 60s. After medical examinations, she was told that the result of fecal occult blood reaction testing was positive. Moreover, colonoscopy found type 2 cancer in her sigmoid colon. The patient underwent sigmoidectomy. The 3D dissection of lymph node and colorectal side-to-end anastomosis were performed. Pathologically, the case was diagnosed as moderately differentiated adenocarcinoma (stage II). Adjuvant chemotherapy was not given. During follow-up observation, the tumor marker levels were elevated above normal. A work-up revealed a recurrence of the cancer on the abdominal wall. The lesion was surgically removed with a margin of about 2 cm from the tumor secured. Pathological diagnosis of this recurrent case was not inconsistent with the previous diagnosis of sigmoid colon cancer. As the relapse was thought to be due to the implantation of cancer cells in the abdominal wall, we need to follow the surgical procedure with scrupulous care and exercise the utmost precaution to protect incision wound on the abdominal wall.