Prognostic Nutritional Index Considering Resection Range Is Useful for Predicting Postoperative Morbidity of Hepatectomy.

BACKGROUND: Poor preoperative nutritional and immunological status are major risk factors for postoperative complications in patients with various malignancies. Lower preoperative prognostic nutrition index (PNI) is associated with higher rates of postoperative complications and poorer prognosis in those patients. The aim of this study was to analyze the predictive value of the PNI for post-hepatectomy complications in patients with hepatocellular carcinoma (HCC), and evaluate its utility in the surgical procedure. METHODS: This retrospective study included 510 patients who underwent open hepatectomies for HCC. The predictive value of the preoperative nutritional and immunological status for postoperative complications was assessed using the PNI. Postoperative complications were defined as grade II or higher per the Clavien-Dindo classification. Postoperative complication rates were compared according to surgical procedure (major hepatectomy vs minor hepatectomy). RESULTS: Patients with postoperative complications had significantly lower PNIs than those without (43.1 ± 5.5 vs 47.0 ± 5.7, P < 0.001). In the multivariate analysis, low preoperative PNI (< 45) was an independent risk factor for postoperative complications after hepatectomy (hazard ratio, 3.85). When patients were classified per their PNI (high vs low) and extent of surgical procedures (major vs minor), there were more complications among patients with low PNI than those with high PNI, regardless of the extent of surgical procedures. Specifically, the group of patients with low PNI who underwent major hepatectomy had significantly higher rates of postoperative complications than the other groups. CONCLUSIONS: Adding the resection range to the PNI is useful for predicting the postoperative morbidities of hepatectomy patients.

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

CASE REPORT: A 75-year-old man who underwent nivolumab as the third-line chemotherapy for advanced gastric cancer had chylous ascites (CA) after the primary tumor shrank remarkably. Total parenteral nutrition and subcutaneous octreotide were initiated, and CA disappeared. Nivolumab was continued for a total of 23 courses. Computed tomography showed lymph node swelling; however, staging laparoscopy showed that peritoneal metastasis had disappeared. Therefore, conversion surgery and distal gastrectomy with D1+ dissection were performed. RESULTS: The pathological diagnosis was type IV, poorly differentiated adenocarcinoma (por2) with signet ring cells, ypT2 (muscularis propria), without lymphatic or venous invasion, and no involvement of the proximal and distal margins. After the operation, no recurrence was observed over 7 months with no adjuvant chemotherapy. CONCLUSION: Nivolumab has the potential to lead to R0 resection for patients with peritoneal carcinomatosis gastric cancer. To our knowledge, this is the first report of successful conversion surgery after nivolumab-related chylous ascites.

Mesenteric venous thrombosis as a rare complication of decompression sickness.

BACKGROUND: Decompression sickness (DCS) induced by extravascular and intravascular gas bubbles during decompression can present with varying manifestations, such as joint pain, numbness, cutaneous symptoms, and cardiopulmonary dysfunction. However, mesenteric venous thrombosis (MVT) is a rare complication of DCS. To the best of our knowledge, only a few cases have been reported, and surgical cases of MVT secondary to DCS have not yet been reported. CASE PRESENTATION: A 59-year-old man who was a fisherman and recreational diver dived to a depth of 100 feet. After diving, he noted abdominal and postcervical pain and visited a community hospital. Computed tomography (CT) revealed a large amount of intravenous gas, so he was diagnosed with DCS. He was then transferred to a previous hospital, where hyperbaric oxygen therapy (HBOT) was performed. HBOT reduced the amount of venous gas, but his abdominal pain worsened, so he was transferred to our hospital. CT showed pneumatosis cystoides intestinalis. Because of the possibility of intestinal necrosis, a laparoscopic examination was performed, which revealed necrosis of the transverse colon. We therefore performed a transverse colon resection. He was discharged 36 days after the surgery and followed an uneventful postoperative course. CONCLUSIONS: DCS is likely to cause MVT. If intestinal necrosis is suspected, a laparoscopic examination may be useful for determining the diagnosis and treatment. MVT should be included as a differential diagnosis of abdominal pain that persists after HBOT.

A phase II randomized trial of adjuvant chemotherapy with S-1 versus S-1 plus cisplatin for completely resected pathological stage II/IIIA non-small cell lung cancer.

OBJECTIVES: Platinum-based combination chemotherapy is the standard postoperative adjuvant treatment for pathological stage II/III non-small cell lung cancer (NSCLC). Oral S-1 therapy has good efficacy and relatively low toxicity for the treatment of advanced NSCLC. We investigated whether long-term S-1 monotherapy is also useful as an adjuvant therapy after surgery in patients with NSCLC. PATIENTS AND METHODS: We conducted a phase II randomized open-label multi-institutional study in patients with pathological stage II/IIIA NSCLC (7th TNM classification) who underwent complete resection from 2009 to 2013. The primary endpoint, the 2-year disease-free survival (DFS) rate, was evaluated using the Bayesian method. Eligible patients were randomly assigned to two arms: oral S-1 monotherapy (S-1 arm) and S-1 plus cisplatin combination therapy followed by S-1 (S-1 plus cisplatin arm) both for a total of 1 year. RESULTS: A total of 70 and 71 patients were enrolled in S-1 arm and S-1 plus cisplatin arm, respectively. The 2-year DFS rates were 52% (95% confidence interval [CI], 0.40-0.63) and 61% (95% CI, 0.48-0.70) for S-1 arm and S-1 plus cisplatin arm, respectively. Both arms met the primary endpoint. Neither DFS nor OS was significantly different between the arms (log-rank test: P = 0.1695 and P = 0.8684, respectively). The main G3/4 adverse events were loss of appetite and anemia (S-1 vs. S-1 plus cisplatin: 4.3% vs. 11.6% and 0% vs. 5.8%, respectively). The treatment completion rate did not differ between the two arms (S-1 vs. S-1 plus cisplatin: 45.7%, 95% CI, 41.9-66.3% vs. 43.5% 95% CI, 44.0-68.4%). CONCLUSIONS: Long-term adjuvant chemotherapy with S-1 was a feasible and promising treatment for patients with completely resected NSCLC, regardless of cisplatin addition. S-1 monotherapy should be investigated further, based on its low toxicity and practical convenience.

A case report of successful diagnosis of a pulmonary nodule by a survey of oncogenic mutations; primary lung carcinoma or pulmonary metastasis?

INTRODUCTION: The number of patients diagnosed with solid carcinomas is increasing, and the most common site of metastasis is the lungs. It is often difficult to make a differential diagnosis between primary lung carcinoma and metastatic lung tumor in using histological examination and by determining their immunohistological status. PRESENTATION: A 64-years-old man presented with dyspnea with chest computed tomography (CT) findings of a pulmonary tumor, and afterwards suffered from a sudden bowel hemorrhaged due to colorectal carcinoma. The histological diagnosis of a pulmonary tumor was poorly differentiated adenocarcinoma. Both Thyroid transcription factor-1 (TTF-1) and Cytokeratin20 (CK20) were immunohistologically negative. Of the some oncogenic mutations investigated, a neuroblastoma RAS viral oncogen homolog (NRAS) codon13 G13D mutation was detected in both the colorectal carcinoma and the pulmonary tumor tissue samples. Based on the result, the pulmonary tumor was diagnosed as a metastasis derived from colorectal carcinoma. DISCUSSION: Recently, examination of the oncogenes of solid carcinomas has been clinically investigated in primary lung caricnoma and in colorectal carcinomas. The clinical advantage of the oncogenic mutation survey is to identify the site, and the type, of amino acid change in detail. This case is a rare successful case of a survey of the oncogenes for giving a differential diagnosis. CONCLUSION: A survey of the oncogenic genes is very useful to make a differential diagnosis between primary lung carcinoma and metastatic lung tumor.

Complete resection of unicentric Castleman disease in the superior mediastinum: A case report.

INTRODUCTION: Castleman disease (CD) is a rare benign lymphoproliferative disorder characterized by benign lymph node hyperplasia in a single site (unicentric CD [UCD]) or in multiple sites (multicentric CD [MCD]). Patients with UCD are usually asymptomatic; however, those with MCD usually develop fever, weight loss, and peripheral lymphadenopathy. CASE PRESENTATION: We describe a case of surgically resected UCD in the superior mediastinum in which the involved lymph node was surrounded by important vessels and trachea, necessitating a median sternotomy for complete resection of the tumor. DISCUSSION: Preoperative diagnosis of UCD in the thorax is very difficult, and surgical resection or excision is necessary. Complete resection is recommended for UCD because it is curative and has a 5-year survival rate of 100%. CONCLUDION: UCD should be included in the differential diagnosis of asymptomatic mediastinal tumors. Surgical resection or excision is preferred to ensure an accurate diagnosis and appropriate treatment if malignant disease cannot otherwise be ruled out.

Laparoscopy-assisted distal gastrectomy for early gastric cancer with versus without prophylactic drainage.

PURPOSE: Little has been reported on routine prophylactic abdominal drainage after gastrectomy, especially after laparoscopy-assisted distal gastrectomy (LADG). We conducted this retrospective study on patients undergoing LADG to evaluate the benefit of routine drainage in LADG procedures. METHODS: The subjects were 21 patients who underwent surgery for early gastric cancer (EGC) between January 2004 and March 2008. They comprised 10 who underwent LADG with drainage before January 2006 and 11 who underwent LADG without drainage after February 2006. We compared patient and tumor characteristics, operative results, and postoperative outcomes between the groups. RESULTS: The no-drain group of patients were able to eat their first meal significantly sooner than the drain group patients (P < 0.01); however, the time to start ambulating, passing flatus, and drinking was similar in the two groups. There were no significant differences between the groups in the postoperative complication rate or the postoperative hospital stay. The drain did not seem to add benefit, and no complications due to the lack of drain placement were noted in the no-drain group. CONCLUSION: Routine prophylactic abdominal drainage after LADG for EGC may not be necessary.

Laparoscopic cholecystectomy with and without abdominal prophylactic drainage.

AIM: As techniques in laparoscopic cholecystectomy (LC) have improved, the role of routine prophylactic abdominal drainage may be limited. A retrospective review was carried out of patients undergoing elective LC to evaluate the benefit of routine drainage in simple uncomplicated procedures. METHODS: This study of 295 patients with cholecystolithiasis or gallbladder polyp included 145 patients who underwent LC with drainage and 150 patients who underwent LC without drainage between 2003 and 2007. Allocation to drain or not to drain was non-randomized and based on surgeon preference according to intraoperative findings. Patient characteristics, operative results, and postoperative outcomes were compared between the two groups with univariate analysis. RESULTS: Time to first flatus and length of postoperative hospital stay in the LC without drainage group were shorter than in the LC with drainage group. There was no significant difference between the two groups with respect to postoperative complication rate. No complications were noted due to the lack of drain placement. CONCLUSION: The use of drain after simple elective uncomplicated LC could safely be limited to appropriate patients as judged by the operating surgeon.

Performance evaluation of 4 measuring methods of ground-glass opacities for predicting the 5-year relapse-free survival of patients with peripheral nonsmall cell lung cancer: a multicenter study.

OBJECTIVE: To evaluate the performance of 4 methods of measuring the extent of ground-glass opacities as a means of predicting the 5-year relapse-free survival of patients with peripheral nonsmall cell lung cancer (NSLC). METHODS: Ground-glass opacities on thin-section computed tomographic images of 120 peripheral NSLCs were measured at 7 medical institutions by the length, area, modified length, and vanishing ratio (VR) methods. The performance (Az) of each method in predicting the 5-year relapse-free survival was evaluated using receiver operating characteristic analysis. RESULTS: The mean Az value obtained by the length, area, modified length, and VR methods in the receiver operating characteristic analyses was 0.683, 0.702, 0.728, and 0.784, respectively. The differences between the mean Az value obtained by the VR method and by the other 3 methods were significant. CONCLUSIONS: Vanishing ratio method was the most accurate predictor of the 5-year relapse-free survival of patients with peripheral NSLC.

The use of a water seal to manage air leaks after a pulmonary lobectomy: a retrospective study.

BACKGROUND: The methods for managing chest drainage tubes during the postoperative period differ among thoracic surgeons and, as a result, the optimal method remains controversial. PATIENTS AND METHODS: We reviewed 170 consecutive patients undergoing a pulmonary lobectomy for either primary lung cancer or metastatic lung cancer from January 1998 to December 2002. After the operation, the chest drainage tube was placed on a suction pump with a negative pressure of -10 cmH(2)O in 120 patients before 2001, while such drainage tubes were kept on water seal in 47 cases mainly since 2001. RESULTS: Regarding the preoperative and postoperative variables, postoperative air leak as well as the video-assisted thoracic surgery (VATS) procedure were more frequently observed in the water seal group than in the suction group (p=0.01580, p<0.001, respectively). In comparing these different populations, each Kaplan-Meier curve, which presented the duration of the postoperative air leak seemed to be similar between the two methods. CONCLUSION: These observations suggest that applying chest tubes on water seal seems to be an effective method for preventing postoperative air leak in clinical practice. However, a prospective randomized trial using a larger series of patients is warranted for this subject.

Multimodal treatment for resectable epithelial type malignant pleural mesothelioma.

BACKGROUND: Malignant pleural mesothelioma is a rare malignancy. The outcome remains poor despite complete surgical resection. PATIENTS AND METHODS: Eleven patients with histologicaly proven epithelial type malignant pleural mesothelioma undergoing extrapleural pneumonectomy with systemic chemotherapy and/or radiotherapy before and after surgical resection were retrospectively reviewed. RESULTS: Ten out of 11 patients underwent complete surgical resection, of these 7 patients had stage I disease. Of these 7 patients, 5 are alive without any recurrence, a 2-year survival rate of 80% was observed in this group. There was no operative mortality or morbidity. CONCLUSION: Extrapleural pneumonectomy with perioperative adjuvant treatment is safe and effective procedure for epithelial type malignant pleural mesothelioma.

Induction chemoradiotherapy and surgical resection for selected stage IIIB non-small-cell lung cancer.

BACKGROUND: Combination chemotherapy using an oral combination of uracil and tegafur (UFT) plus cisplatin and concurrent thoracic radiotherapy is reported to have a high response rate and less toxicity for locally advanced non-small-cell lung cancer (NSCLC) patients. We performed a phase II trial using this chemoradiotherapy as an induction treatment. METHODS: Patients with marginally resectable stage IIIB NSCLC, an age younger than 70 years, a performance status of 0 or 1, and good organ function were eligible. The UFT (400 mg/m(2)) was administered orally on days 1 through 14 and 22 through 35 and cisplatin (80 mg/m(2)) was injected intravenously on days 8 and 29. Radiotherapy with a total dose of 40 Gy was delivered in 20 fractions from day 1. A surgical resection was performed from 3 to 6 weeks after completing the induction treatment. RESULTS: Twenty-seven patients, 18 male and 9 female with a median age of 56 years and ranging from 36 to 69 years, were entered into the phase II trial. Clinical T4 and N3 cancers were observed in 22 and 7 patients, respectively. Twenty-five (93%) achieved a partial response. The most frequently observed adverse event was grade 3 leukopenia in 26%. Of 25 patients who underwent a thoracotomy, 22 had a tumor resection. In all 22 patients a complex resection including a resection of the superior vena cava, carina, and vertebrae was required. Operative morbidity and mortality rates were 36% and 4% respectively. The calculated 1-year and 3-year survival rates of all 27 patients were 73% and 56% respectively. CONCLUSIONS: Chemotherapy using UFT plus cisplatin and concurrent radiotherapy as induction treatment and a surgical resection for patients with marginally resectable stage IIIB NSCLC is feasible and promising. However it is difficult to conduct multi-institutional trials even for selected stage IIIB disease as a complex resection in almost all patients is necessary.

Smoke exposure, histologic type and geography-related differences in the methylation profiles of non-small cell lung cancer.

Aberrant methylation of several known or putative tumor suppressor genes occurs frequently during the pathogenesis of lung cancers. There are major smoke exposure, histology, geography and gender-related changes in non-small cell lung cancer (NSCLC). We investigated smoking-related, histologic, geographic and gender differences in the methylation profiles of resected NSCLCs. We examined 514 cases of NSCLC and 84 corresponding nonmalignant lung tissues from 4 countries (USA, Australia, Japan and Taiwan) for the methylation status of 7 genes known to be frequently methylated in lung cancers [p16, RASSF1A (RAS association domain family 1), APC, RARbeta, CDH13, MGMT and GSTP1]. Multivariate analyses were used for data analysis. Adenocarcinoma was the major histologic type in women and never smokers; analyses that involved smoke exposure and gender were limited to this histology. Our major findings are a) methylation status of any single gene was largely independent of methylation status of other genes; b) the rates of methylation of p16 and APC and the mean Methylation Index (MI), a reflection of the overall methylation status, were significantly higher in ever smokers than in never smokers; c) the mean MI of tumors arising in former smokers was significantly lower than the mean of current smokers; d) the methylation rates of APC, CDH13 and RARbeta were significantly higher in adenocarcinomas than in squamous cell carcinomas; e) methylation rates of MGMT and GSTP1 were significantly higher in the USA and Australian cases than in those from Japan and Taiwan; and (f) no significant gender-related differences in methylation patterns were noted. Our findings demonstrate important smoke exposure, histologic type and geography-related differences in the methylation profiles of NSCLC tumors.

[A case of preoperative concurrent chemoradiotherapy and curative resection for locally advanced non-small-cell lung cancer].

We report the case of a 58-year-old man who underwent complete resection for locally advanced non-small-cell lung cancer (cT4N2M0). The patient received UFT (400 mg/m2 orally on days 1-14 and 22-35) and cisplatin (80 mg/m2 intravenously on days 8, 29) with a total 40 Gy, delivered in 20 fractions on days 1-26. The tumor reduction rate was 76%, and no remarkable toxicities were observed. The patient underwent complete resection and a pathologic complete response was observed. This induction concurrent chemoradiotherapy (followed by surgery) is considered to be effective and safe.

Differential expression of FEZ1/LZTS1 gene in lung cancers and their cell cultures.

PURPOSE: The FEZ1/LZTS1 (FEZ1) gene, located on chromosome 8p22 (8p22), was identified recently as a candidate tumor suppressor gene. Because loss of heterozygosity at 8p21-22 is a frequent event in lung cancers, we studied FEZ1 alteration in short-term cultures of resected lung cancer tumors and cell lines. EXPERIMENTAL DESIGN: We examined FEZ1 expression in 17 non-small cell lung cancer (NSCLC), 19 small cell lung cancer (SCLC) cell lines, and 6 pairs of short-term cultures of resected NSCLCs and accompanying nonmalignant bronchial cells (NBECs) by reverse transcription-PCR and Western blotting. To investigate the mechanism for silencing, cells were cultured with 5-aza-2'-deoxycytidine or trichostatin A. We screened for genomic mutations by PCR-single-strand conformational polymorphism. RESULTS: Thirteen of 17 NSCLC (76%) and 3 of 19 SCLC (16%) of cell lines showed absent expression (P = 0.001). Of the paired NSCLC-NBEC cultures, 3 of 6 showed loss of expression in tumor cell cultures. In the cell lines retaining expression, the amplicon products in SCLCs were more intense than those of NSCLCs and NBECs. Expression of FEZ1 was not restored by 5-aza-2'-deoxycytidine and trichostatin A. Although FEZ1 expression was moderately correlated with loss of heterozygosity of specific microsatellite makers at 8p21-22 in NSCLC cell lines, it was strongly correlated to D8S261 and LPL loci in SCLC cell lines. No mutation was found within cording region of FEZ1 by PCR-single-strand conformational polymorphism. CONCLUSIONS: We found differential FEZ1 expression in NSCLC and SCLC cell lines, and the absent expression in 3 of 6 short-term cultures of NSCLC tumors. FEZ1 may be related to tumorigenesis of lung cancer.

Bronchial leiomyoma with atelectasis in the left lower lobe.

Bronchial leiomyoma with atelectasis in the left lower lobe occurred in a 44-year-old woman. The leiomyoma was diagnosed by bronchofiberscopy, and left lower sleeve lobectomy was performed. The histopathology of the tumor revealed a leiomyoma with no evidence of malignancy. An early accurate diagnosis is thought to be important for a more conservative treatment.