[A Case of Effective Whole-Brain Irradiation and Lapatinib/Capecitabine Combination Therapy for HER2-Positive Breast Cancer with Multiple Brain Metastases].

We report the case of a 48-year-old female patient with HER2-positive and hormone receptor-negative breast cancer with multiple liver metastases. She underwent 6 cycles of FEC followed by docetaxel plus trastuzumab (TZB), resulting in a clinical complete response. After 15 cycles of a TZB-containing regimen, she complained of dizziness and nausea, and imaging examinations revealed multiple brain metastases. Whole-brain irradiation(33.6 Gy) was performed, and the chemotherapy regimen was changed to lapatinib (LAP: orally at 1,250 mg/day, every day) and capecitabine (CAP: orally at 2,000 mg/m2, every day for 2 weeks, followed by a 1-week rest interval, as 1 cycle). After 6 weeks of the new treatment, magnetic resonance imaging revealed marked shrinkage of brain metastases. A clinical complete response was maintained for 19 months. While brain metastasis is an important problem with treatment with TZB, LAP is drawing attention because of its ability to pass the blood-brain barrier because of its small molecular weight. LAP/CAP combination therapy may be an effective treatment option for brain metastases of HER2-positive breast cancer in which TZB essentially has no effect.

Techniques of Fluorescence Cholangiography During Laparoscopic Cholecystectomy for Better Delineation of the Bile Duct Anatomy.

To evaluate the clinical and technical factors affecting the ability of fluorescence cholangiography (FC) using indocyanine green (ICG) to delineate the bile duct anatomy during laparoscopic cholecystectomy (LC).Application of FC during LC began after laparoscopic fluorescence imaging systems became commercially available.In 108 patients undergoing LC, FC was performed by preoperative intravenous injection of ICG (2.5  mg) during dissection of Calot's triangle, and clinical factors affecting the ability of FC to delineate the extrahepatic bile ducts were evaluated. Equipment-related factors associated with bile duct detectability were also assessed among 5 laparoscopic systems and 1 open fluorescence imaging system in ex vivo studies.FC delineated the confluence between the cystic duct and common hepatic duct (CyD-CHD) before and after dissection of Calot's triangle in 80 patients (74%) and 99 patients (92%), respectively. The interval between ICG injection and FC before dissection of Calot's triangle was significantly longer in the 80 patients in whom the CyD-CHD confluence was detected by fluorescence imaging before dissection (median, 90  min; range, 15-165  min) than in the remaining 28 patients in whom the confluence was undetectable (median, 47  min; range, 21-205  min; P < 0.01). The signal contrast on the fluorescence images of the bile duct samples was significantly different among the laparoscopic imaging systems and tended to decrease more steeply than those of the open imaging system as the target-laparoscope distance increased and porcine tissues covering the samples became thicker.FC is a simple navigation tool for obtaining a biliary roadmap to reach the "critical view of safety" during LC. Key factors for better bile duct identification by FC are administration of ICG as far in advance as possible before surgery, sufficient extension of connective tissues around the bile ducts, and placement of the tip of laparoscope close and vertically to Calot's triangle.

Resection of a methicillin-resistant Staphylococcus aureus liver abscess in a patient with Crohn's disease under infliximab treatment: a case report.

INTRODUCTION: A liver abscess in Crohn's disease is a rare but important entity that is associated with a poor prognosis and high mortality when treatment is delayed. We report a case of successful liver segmentectomy for a methicillin-resistant Staphylococcus aureus liver abscess in a patient with Crohn's disease under infliximab treatment. CASE PRESENTATION: A 31-year-old Japanese man, who had been treated with infliximab infusions for Crohn's disease, was referred to our hospital presenting with an abrupt onset of high fever and an elevated white blood cell count and serum C-reactive protein level. Computed tomography revealed a liver abscess occupying segment 8. The limited effect of percutaneous transhepatic abscess drainage and antibiotics led us to perform radical resection of the abscess. The patient recovered quickly after surgery and the postoperative course was uneventful. CONCLUSION: The present case suggests that surgical removal of an abscess should be considered for patients under immunosuppression or refractory to conventional treatment.

A rapidly progressive and fatal case of nonalcoholic steatohepatitis following pancreaticoduodenectomy.

Nonalcoholic fatty liver disease (NAFLD)/nonalcoholic steatohepatitis (NASH) usually occurs in patients with metabolic syndrome. However, it can develop in relation with pancreaticoduodenectomy (PD) independent of insulin resistance. NAFLD/NASH potentially progresses to liver cirrhosis and subsequent end-stage liver disease, but in general the disease progression is very slow. We here report the case of a 57-year-old Japanese woman who underwent PD for pancreatic head cancer, subsequent to which she developed rapidly progressive NASH without prior liver diseases, resulting in death due to hepatic failure 5 months after PD. Marked body weight loss was a distinguishing clinical feature. Severe malnutrition induced by pancreatic exocrine insufficiency, postoperative eating disorder and exacerbation of diabetes mellitus were thought to be etiologically associated with the rapid progression of her disease. This case suggests the necessity of close hepatic surveillance as well as nutritional evaluation followed by prophylactic pancreatic enzyme replacement and nutritional supply after PD.

Lifestyle modification and prevention of type 2 diabetes in overweight Japanese with impaired fasting glucose levels: a randomized controlled trial.

BACKGROUND: Previous studies demonstrated that intensive lifestyle modification can prevent type 2 diabetes mellitus among those with impaired glucose tolerance, but similar beneficial results have not been proved among those with impaired fasting glucose levels. We investigated the efficacy of lifestyle modification on type 2 diabetes incidence among those with impaired fasting glucose levels. METHODS: The present study was an unmasked, multicenter, randomized, controlled trial. A total of 641 overweight Japanese (aged 30-60 years) with impaired fasting glucose levels were recruited nationwide in Japan and randomly assigned to a frequent intervention group (n = 311) or a control group (n = 330). For 36 months after randomization, the frequent intervention group received individual instructions and follow-up support for lifestyle modification from the medical staff 9 times. The control group received similar individual instructions 4 times at 12-month intervals during the same period. The primary outcome was type 2 diabetes incidence in annual 75-g oral glucose tolerance tests, diagnosed according to World Health Organization criteria. RESULTS: There were no significant differences between the allocation groups in baseline characteristics and dropout rates. Estimated cumulative incidences of type 2 diabetes were 12.2% in the frequent intervention group and 16.6% in the control group. Overall, the adjusted hazard ratio in the frequent intervention group was 0.56 (95% confidence interval, 0.36-0.87). In the post hoc subgroup analyses, the hazard ratio reduced to 0.41 (95% confidence interval, 0.24-0.69) among participants with impaired glucose tolerance at baseline, and to 0.24 (0.12-0.48) among those with baseline hemoglobin A(1c) levels of 5.6% or more (the Japan Diabetes Society method). Such risk reduction was not observed among those with isolated impaired fasting glucose findings or baseline hemoglobin A(1c) levels of less than 5.6%. CONCLUSIONS: Lifestyle modifications can prevent type 2 diabetes among overweight Japanese with impaired fasting glucose levels. In addition, identifying individuals with more deteriorated glycemic status by using 75-g oral glucose tolerance test findings or, especially, measurement of hemoglobin A(1c) levels, could enhance the efficacy of lifestyle modifications. TRIAL REGISTRATION: umin.ac.jp/ctr Identifier: UMIN000001959.

Application of fluorescent cholangiography to single-incision laparoscopic cholecystectomy.

BACKGROUND: Although the use of single-incision laparoscopic cholecystectomy (SILC) is spreading rapidly, this technique has disadvantages. It does not allow for sufficient surgical views to be obtained or for intraoperative radiographic cholangiography to be performed. Fluorescent cholangiography using a preoperative intravenous injection of indocyanine green (ICG) may be useful for identifying the biliary tract during both SILC and conventional laparoscopic cholecystectomy. METHODS: For seven patients undergoing SILC, 1 ml of ICG (2.5 mg) was administered by intravenous injection before the surgery. The prototype fluorescent imaging system consisted of a xenon light source and a 30° laparoscope (diameter, 10 mm) equipped with a charge-coupled device camera capable of filtering out light with wavelengths shorter than 810 nm. The laparoscope was introduced through an umbilical trocar. Fluorescent cholangiography then was performed by changing the color images to fluorescent images using a foot switch during dissection of the triangle of Calot. RESULTS: Fluorescent cholangiography identified the confluence between the cystic duct and the common hepatic duct in all seven patients before and throughout the dissection of the triangle of Calot. The interval from the injection of ICG to the first obtained fluorescent cholangiography before dissection of the triangle of Calot ranged from 35 to 75 min. CONCLUSIONS: Fluorescent cholangiography enabled real-time identification of the extrahepatic bile ducts during SILC without necessitating catheterization of the bile duct. Such properties of fluorescent cholangiography are expected to be helpful for ensuring the safety of SILC and expanding the indications for the procedure.

Peripheral T-cell lymphoma that developed during the follow-up of IgG4-related disease.

IgG4-related disease is a recently recognized fibroinflammatory disorder characterized by extensive IgG4-positive plasma cell and lymphocyte infiltration of various organs. The pancreatic manifestation of IgG4-related disease is called autoimmune pancreatitis (AIP), in which autoimmune mechanisms are likely involved. On the other hand, some autoimmune and chronic inflammatory disorders, such as Sjögren's syndrome and rheumatoid arthritis, are associated with increased risks of non-Hodgkin lymphoma (NHL). There have been a few reports of cases with IgG4-related disease that had subsequently developed NHL, however, all of them suffered from B-cell lymphoma. We describe the first case of NHL, compatible with a subtype of peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS), which arose in IgG4-related sclerosing cholangitis. As patients with IgG4-related disease may be at an increased risk of developing NHL, such presentation during the follow-up of IgG4-related disease should be carefully scrutinized to exclude NHL.

Pancreaticoduodenectomy for bile duct carcinoma of a patient undergoing hemodialysis.

A 69-year-old Japanese man underwent pancreaticoduodenectomy for the resection of carcinoma at lower part of the common bile duct. Hemodialysis had already begun to treat chronic renal failure. He had been admitted for obstructive jaundice due to the carcinoma four months earlier. The serum total bilirubin was then 38.5 mg/dL, and the serum creatinine was 7 mg/dL. Hemodialysis was performed the day before the operation, and on the 1st, 3rd, 5th, 7th postoperative day. A rapidly degrading synthetic protease inhibitor was used as an anti-coagulant in the dialyzer to prevent systemic bleeding during the first postoperative week. Heparin was used from the second week. The maximum discharge from the drains was 2,300mL on the 3rd postoperative day. The drip intravenous infusion was changed from 1,900mL to 3,300mL during the first week to maintain the same body weight as the preoperative weight. Fresh frozen plasma and partial plasma fraction were used to maintain the colloidal pressure in the vessels so body weight reflects the fluid volume in the vessels. The postoperative course was uneventful. We present herein a successful case of pancreaticoduodenectomy for a patient undergoing hemodialysis to maintain the same body weight.

Pancreatic pseudocyst extending into the liver via the hepatoduodenal ligament: a case report.

A case of pancreatic pseudocyst extending into the liver via the hepatoduodenal ligament is reported. This is the first report clearly demonstrating that the hepatoduodenal ligament is another route of hepatic extension of pancreatic pseudocysts as well as the hepatogastric ligament, which is the most common. The importance of the topological anatomy of the peritoneum is emphasized in understanding the extrapancreatic extension of pancreatic pseudocysts.

Influence of perioperative blood transfusion on the prognosis of patients with gastric cancer receiving anticancer chemotherapy.

BACKGROUND: The deleterious effect of blood transfusions on survival has been reported in patients with cancers of various organs. However, it remains unclear whether there is any adverse effect of blood transfusion when the patients are administered anticancer drugs after surgery for gastric cancers.METHODS: Data from patients with gastric resection for advanced gastric cancer were retrospectively analyzed to determine the influence of perioperative blood transfusion on the survival rate. All patients were administered anticancer drugs (mitomycin C [MMC] and tegafur-uracil [UFT]). Sixty-nine (33%) of 208 patients received blood transfusion perioperatively, while 139 patients (67%) did not receive transfusion. Multivariate analysis of clinicopathologic prognostic factors, including blood transfusion, was performed. Lymphocyte subsets were measured to investigate the immunosuppressive effect of blood transfusion.RESULTS: The 5-year survival rate was 48.8% in the 69 transfused patients and 66.9% in the 139 non-transfused patients ( P < 0.01). Cox's multiple regression analysis showed that, when patients received anticancer drugs, perioperative blood transfusion was not a significant factor affecting survival after the gastric cancer surgery. However, the CD4/CD8 ratio at 3 months after the surgery was significantly lower in the transfused group than in the non-transfused group.CONCLUSION: Blood transfusion did not affect the survival of operated patients who received postoperative adjuvant chemotherapy. However, the finding that the ratio of CD4/CD8 after surgery was significantly higher in the non-transfused group than in the transfused group supports the notion that transfusion causes broad-spectrum immunosuppression.