Ischemia prediction score (IsPS) in patients with strangulated small bowel obstruction: a retrospective cohort study.

BACKGROUNDS: Intestinal ischemia of strangulated small bowel obstruction (SSBO) requires prompt identification and early intervention. This study aimed to evaluate the risk factors and develop a prediction model of intestinal ischemia requiring bowel resection in SSBO. METHODS: This was a single-center, retrospective cohort study of consecutive patients underwent emergency surgery for SSBO from April 2007 to December 2021. Univariate analysis was performed to identify the risk factors for bowel resection in these patients. Two clinical scores (with contrasted computed tomography [CT] and without contrasted CT) were developed to predict intestinal ischemia. The scores were validated in an independent cohort. RESULTS: A total of 127 patients were included, 100 in the development cohort (DC) and 27 in the validation cohort (VC). Univariate analysis showed that high white blood cell count (WBC), low base excess (BE), ascites and reduced bowel enhancement were significantly associated with bowel resection. The ischemia prediction score (IsPS) comprised 1 point each for WBC ≥ 10,000/L, BE ≤ -1.0 mmol/L, ascites, and 2 points for reduced bowel enhancement. The simple IsPS (s-IsPS, without contrasted CT) of 2 or more had a sensitivity of 69.4%, specificity of 65.4%. The modified IsPS (m-IsPS, with contrasted CT) of 3 or more had a sensitivity of 86.7%, specificity of 76.0%. AUC of s-IsPS was 0.716 in DC and 0.812 in VC, and AUC of m-IsPS was 0.838 and 0.814. CONCLUSION: IsPS predicted possibility of ischemic intestinal resection with high accuracy and can help in the early identification of intestinal ischemia in SSBO.

[A Case of Long-Term Survival with Tumor Resection and DOX plus DTIC Therapy for Desmoid Tumor after FAP Surgery].

The patient is a 22-year-old, female. She had a family history of familial adenomatous polyposis(FAP)and a prophylactic total colorectal resection was performed for FAP at age of 18. She presented with fever and abdominal distention and palpated a mass with tenderness in the right lower abdomen. Contrast-enhanced CT scan of the abdomen showed a heterogeneous contrast effect around the tumor margins. With the diagnosis of intra-abdominal desmoid tumor, a partial duodenal resection, small bowel mass resection, and right fallopian tube resection were performed along with the tumor, and an artificial anus was created with the jejunum. Contrast-enhanced CT scan of the abdomen 16 months after resection of desmoid tumor showed a 6.5 cm long desmoid tumor recurrence in the mesentery. She received 5 courses of doxorubicin (DOX)plus dacarbazine(DTIC)therapy followed by continued NSAIDs. Seven years after the operation, she has been able to maintain the shrinkage of the recurrent tumor and is still on medication. Long-term surveillance is necessary because of the possibility of the appearance of other associated lesions in the future.

[A Case of Right Hemicolectomy for Inflammatory Myofibroblastic Tumor Arising in the Right Transverse Colon].

The patient was a 21-year-old male. He presented with right lower abdominal pain and showed tenderness in the same area. An abdominal contrast-enhanced CT examination revealed a 45 mm tumor that continuously stained in the right transverse colon. The patient presented with tenderness and rebound tenderness. Due to a suspected submucosal tumor, laparotomy was performed and an elastic hard tumor of 5 cm in size was found on the serous membrane side of the right transverse colon. As malignancy could not be ruled out, a right hemicolectomy with lymph node dissection was performed. The pathological diagnosis was an inflammatory myofibroblastic tumor(IMT), characterized by the proliferation of spindle- shaped spindle-shaped fibroblast-like cells with inflammatory cell infiltration. As of 9 years post-surgery, there has been no recurrence. However, long-term surveillance is necessary.

[A Case of Surgery for Skin Metastasis of Papillary Thyroid Carcinoma in a Very Elderly Patient to Improve the Quality of Life].

The patient was a 100-year-old woman who underwent right lobe thyroidectomy for papillary thyroid cancer in another hospital around 1990. She developed local recurrence in 2010 and underwent anterior tracheal local recurrence resection in May 2017. Subsequently, metastases were confirmed in the lateral cervical lymph nodes, but the patient only received TSH suppression because of her advanced age. Multiple pulmonary metastases developed in November 2020 and supraclavicular lymph node metastases in July 2021, but the patient was under the care of a visiting physician on best supportive care. The patient was referred to our hospital in January 2022 due to the appearance of a cutaneous mass in the sternal incision area, which gradually increased in size. A well-mobile, well-defined, spherical mass was found in the sternotomy area. The maximum diameter was 19 mm. The cytological findings were consistent with cutaneous metastasis of papillary thyroid carcinoma. As the patient was elderly and had multiple pulmonary metastases, she was temporarily observed. However, by June 2022, the mass had increased from 19 mm to 33 mm with cutaneous discoloration. There was no tendency for multiple pulmonary metastases to grow during this period. The decision was made to operate in order to prevent a decline in quality of life due to self-destruction of the cutaneous metastasis. The tumor was removed under general anesthesia, including the cutaneous discoloration, and reconstructed with a rhomboid skin flap. Post-operatively, there was no local recurrence or significant increase in pulmonary metastases. It is suggested that resection of cutaneous metastasis of malignant tumors may be effective in preserving quality of life even in a 100-year-old elderly patient like the present case and should be considered as an indication.

[Long-Term Survival of a Patient with Advanced Antral Gastric Cancer Successfully Treated with Multidisciplinary Therapy].

We report the case of long-term survival of a patient with advanced antral gastric cancer with multiple paraaortic lymph nodes metastasis who was successfully treated with multidisciplinary therapy. A 70-year-old female was admitted to our hospital complaining of vomiting. Upper gastrointestinal endoscopy revealed a Type 3 tumor in the gastric antrum. Computed tomography(CT)showed a marked decrease in the size of the primary gastric tumor and lymph nodes after 9 courses of mFOLFOX6 therapy. Subsequently, 7 courses of paclitaxel plus ramucirumab(PTX plus Rmab)therapy and 10 courses of nivolumab therapy were administered. After nivolumab therapy, marked shrinkage of the lymph nodes was observed on CT. Distal gastrectomy with D2(+ #16a2+b1)lymph node dissection was performed. The pathological finding was ypT0N1M0 with a Grade 3 effect of the chemotherapy. After 6 months of adjuvant chemotherapy with S-1, CT revealed supraclavicular lymph node metastases. After 4 courses of nivolumab therapy, CT showed a marked increase in the size of the lymph node. Consequently, the regimen was changed to irinotecan. After 16 courses of irinotecan therapy, CT showed a marked shrinkage in the size of the lymph node. The patient is currently alive with no signs of recurrence for 5 years, ie, since the initiation of the multidisciplinary therapy.

[An Experience of Multidisciplinary Treatment for Advanced Esophageal Cancer with Tumor Perforation during Preoperative Chemotherapy].

Perforation of esophageal cancer is one of the fatal oncologic emergencies, and a prompt and accurate treatment strategy is required. Here, we report a case of advanced esophageal cancer that had perforated during preoperative chemotherapy and was successfully resected with multidisciplinary treatment. The prognosis of perforated esophageal cancer can be expected to improve by multidisciplinary treatment appropriately combining initial treatment for infection control and subsequent cancer treatment.

Robotic complete mesocolic excision of right-sided colon cancer with bulky lymph node metastases using the da Vinci® Si™ system: A case report.

Reports on robotic surgery in the treatment of right-sided colorectal cancer most commonly use the da Vinci® Xi™ system; however, with the increasing popularity of robotic surgery for the treatment of colon cancer, it is likely to be performed using the da Vinci Si™ and X™ systems. The present study reported the case of a 63-year-old woman who underwent complete mesocolic excision (CME) with the da Vinci Si system involving a rotation technique for ascending colon cancer with bulky lymph node metastasis to the anterior pancreas. Robot-assisted right hemicolectomy was planned for this patient with T4aN2bM0, stage IIIc cancer. A lap protector and EZ access (Hakko Co. Ltd.) were fixed in the umbilical incision, and the da Vinci camera port was placed just off-center at the EZ access to allow the camera port to be repositioned by rotating it. The medial approach was used. The bulky metastatic lymph nodes at the head of the pancreas were dissected after ligating the right colic artery and vein. During CME, rotation of the EZ access was used to avoid interference between the robotic arms. The right colon was released from the retroperitoneum and resected. A functional end-to-end anastomosis was created, and right colectomy was successfully completed. The total operation time was 271 min and the console time with the da Vinci Si system was 140 min. The patient was discharged on postoperative day 8 without complications. In conclusion, robotic right colectomy was successfully performed and rotation of the EZ access facilitated robotic surgery using the da Vinci Si system.

[A Case of Anal Canal Adenocarcinoma with Perianal Pagetoid Spread without a Macroscopic Finding].

We report a case of anal canal cancer with Pagetoid spread without a macroscopic skin lesion. A 54-year-old man was admitted to a hospital with complaints of bloody stools. Endoscopic examination revealed a polyp in the anal canal, and endoscopic mucosal resection was performed. Pathological examination revealed an adenocarcinoma accompanied by Pagetoid spread and the positive surgical margin. We additionally performed trans-anal resection twice, but the resected horizontal margin was positive. Mapping biopsy of rectal mucosa and perianal skin revealed adenocarcinoma in only rectal mucosa. Abdominoperineal resection was performed. Histopathological examination showed invasive adenocarcinoma with pagetoid spread and that the surgical margin was negative. Pagetoid spread of anal canal adenocarcinoma usually showed macroscopic abnormal findings, but in this case, there was no skin lesion. It suggests that preoperative mapping biopsy is helpful for determining the excision range. It is necessary to keep in mind that anal canal adenocarcinoma with no skin lesion may cause Pagetoid spread.

[A Case of Malignant Rectal B Cell Lymphoma That Was Difficult to Differentiate from Rectal Neuroendocrine Tumor].

A 74-year-old woman with a chief complaint of hematochezia was admitted to our hospital. Colonoscopy revealed a 2 cm submucosal tumor with an erosion in the Rb of the rectum. Biopsy showed various inflammatory cell clusters, but no malignant findings. Thoracoabdominal CT and abdominal MRI showed no abnormal findings other than that of rectal wall thickening. Somatostatin receptor scintigraphy performed on suspected rectal NET showed no abnormal accumulation. A total of 3 biopsies were performed, but a definitive diagnosis was not confirmed, and transanal rectal mucosal resection was performed for diagnostic purposes. Immunohistochemistry showed CD20(+)and bcl-2(+), and the lesion was diagnosed as malignant rectal B cell lymphoma. For 1 year postoperatively, the patient showed no recurrence. For this case, biopsy often failed to confirm a definitive diagnosis on rectal submucosal tumors. If the tumor is >1 cm in diameter in a rectal NET, a rectal resection with lymph node dissection is required, and anal function may be impaired. Local tumor excision for diagnosis and treatment may be worthwhile in rectal submucosal tumors if pre-resection diagnosis with biopsy is difficult.

[A Case of Nivolumab Responding to Multiple Lymph Node Metastases during Multidisciplinary Treatment for Esophageal Cancer].

In nivolumab therapy for unresectable advanced esophageal cancer, there are a few cases that show a complete response, and long-term survival can be expected in such cases. Here, we report a case in which nivolumab had a complete response to multiple lymph node metastases during multidisciplinary treatment for esophageal cancer and survived for a relatively long period despite being elderly. Examination of complete response cases provides us with significant insights in considering the unexplained biomarkers of immune checkpoint inhibitors and treatment discontinuation during complete response.

The Association of Thymidine Phosphorylase with Gastric Cancer Prognosis.

BACKGROUND: Thymidine phosphorylase(TP)plays an important role in angiogenesis and solid tumor invasion. This study aimed to investigate TP expression in gastric cancer(GC), its correlation with clinicopathological features, and its prognostic significance. METHODS: Clinical data and tumor specimens were retrospectively collected from patients with GC in Ikeda Municipal Hospital between January 2005 and December 2006. Tumor specimens were immunohistochemically analyzed for TP expression graded as 0, 1+, 2+, or 3+ and divided into low(0/1+)and high(2+/3+)TP expression groups. To determine its potential prognostic value, any correlation between TP expression and the clinicopathological features of the patients was statistically assessed. RESULTS: Among 111 patients with GC, 33 had high TP expression(29.7%)and 78 had low TP expression(70.3%). There were significant differences in tumor size, tumor depth, venous invasion, lymphatic invasion, and clinical stage between the two groups. Analysis of the Kaplan-Meier survival curves revealed that the high TP group had significantly shorter overall survival(OS; p<0.01)and progression-free survival(PFS; p<0.01)than the low TP group. Moreover, the high TP group had significantly shorter OS(p=0.040)and a trend toward a shorter PFS(p=0.064) than the low TP group in patients with stage Ⅱ, Ⅲ, and Ⅳ cancer. Multivariate analysis revealed that high TP expression was significantly associated with tumor size, tumor type, and lymphatic invasion in patients with GC. CONCLUSIONS: Our results suggest that high TP expression might predict poor prognosis in GC.

Comparison of 5-year postoperative outcomes after Billroth I and Roux-en-Y reconstruction following distal gastrectomy for gastric cancer: Results from a multi-institutional randomized controlled trial.

AIM: We previously reported in a randomized controlled trial that Billroth I and Roux-en-Y reconstructions were generally equivalent regarding body weight change and nutritional status 1 year after distal gastrectomy for gastric cancer. We describe the long-term follow-up data 5 years after distal gastrectomy. METHODS: We analyzed consecutive gastric cancer patients who were randomly assigned to undergo Billroth I or Roux-en-Y reconstruction after distal gastrectomy. We evaluated body weight change, nutritional status, late complications, quality of life (QOL) using the European Organization for Research and Treatment of Cancer Core QOL Questionnaire, and dysfunction using the Dysfunction After Upper Gastrointestinal Surgery for Cancer, 5 years after surgery. RESULTS: A total of 228 patients (Billroth I = 105; Roux-en-Y = 123) were eligible for efficacy analyses in this study. Body weight loss 5 years after surgery did not differ significantly between the Billroth I and Roux-en-Y groups (10.0% ± 7.9% and 9.6% ± 8.4%, respectively; P = .70). There were no significant differences in other aspects of nutritional status between the two groups. Reflux esophagitis occurred in 19.0% of the patients in the Billroth I group vs 4.9% in the Roux-en-Y group (P = .002). Regarding QOL, Billroth I was significantly inferior to Roux-en-Y on the diarrhea scale (Billroth I: 28.6, Roux-en-Y: 16.0; P = .047). Regarding dysfunction, no score differed significantly between the two groups. CONCLUSIONS: Billroth I and Roux-en-Y reconstructions were generally equivalent regarding body weight change, nutritional status, and QOL 5 years after distal gastrectomy, although Roux-en-Y more effectively prevented reflux esophagitis and diarrhea.

[A Case of Recurrent Hepatocellular Carcinoma Successfully Treated by Radiation Therapy].

We report a case of recurrent hepatocellular carcinoma(HCC)successfully treated by radiation therapy. A 79-year-old woman was diagnosed with HCC and underwent liver resection. Seven months after resection, CT and MRI detected a new HCC, and she had a surgery again. One year after the surgery, CT and MRI detected local recurrence, and she underwent the third operation. Three months after the operation, the third liver recurrence was treated by transcatheter arterial chemoembolization( TACE). Four months later, a new lesion was detected and treated by stereotactic body radiation therapy(SBRT) twice. She remains alive without recurrence 27 months after the last radiation therapy. Very few evidence is reported of radiation therapy for HCC, but this case suggests that radiation therapy provides a benefit for patients with HCC after other treatments.

[A Long-Term Survival Case of Neuroendocrine Carcinoma of Gallbladder-Report of a Case].

The patient is 77-year-old man. He received open cholecystectomy and choledocholithotomy when he was 74 years old. Because postoperative diagnosis was small cell neuroendocrine carcinoma(NEC), the resection of gallbladder bed and hilus lymph nodes were performed. During the follow up period, the liver metastases and portal vein tumor thrombosis appeared. Therefore, chemotherapy was performed according to small cell lung cancer. In addition to chemotherapy, radiation therapy was performed for the purpose of local control. He is still alive about 3 years after the first operation. This case suggested the efficacy of multidisciplinary treatment including operation, chemotherapy, and radiation therapy in NEC of gallbladder patient with liver metastasis.

[Pathological Complete Response in a Case of Advanced Gastric Cancer with Para-Aortic Lymph Nodes Metastasis Treated by Preoperative Chemotherapy with S-1 and Oxaliplatin(SOX Therapy)].

The patient was a 73-year-old man, diagnosed as advanced gastric cancer with para-aortic lymph nodes(PAN)metastasis. He was treated by 3 courses of neoadjuvant chemotherapy(NAC)with S-1 and oxaliplatin(SOX therapy). CT showed significant reduction of both primary tumor and metastatic lymph nodes. We performed distal gastrectomy with D2 plus PAN dissection. The histopathological findings showed no residual viable tumor cell. The pathological effect of chemotherapy was judged Grade 3(pCR)in both primary tumor and dissected lymph nodes. He is alive without recurrence 21 months after surgery.

[A Case of Fibrolamellar Hepatocellular Carcinoma in a 25-Year-Old Vietnamese Male].

We report a rare case of hepatic fibrolamellar hepatocellular carcinoma(FLC). A 25-year-old Vietnamese male experienced loss of appetite and abdominal pain. He was referred for further examination of a 20 cm tumor in the left lobe of the liver detected in mass screening ultrasonography. He tested negative for HBs-antigen and HCV-antibody. The serum PIVKA- Ⅱ level was elevated. Liver function test findings were normal. The arterial phase of contrast enhanced abdominal CT revealed a 20×30 cm tumor that was well-enhanced, except for a central scar in the left lobe of liver. Enhanced MRI showed a high intensity tumor. T2-weighted MRI showed an iso-intensity tumor with a low-intensity central fibrous scar. Upon diagnosing the patient with FLC, we performed left hepatic trisegmentectomy. Pathological findings of the surgical specimen showed eosinophilic large neoplastic cells surrounded by fibrous stroma arranged in a lamellar fashion. This confirmed the diagnosis. FLC, which occurs in noncirrhotic livers of young patients, is a distinct clinicopathological variant of hepatocellular carcinoma. Hepatectomy for FLC should be accompanied with regional lymphadenectomy because of its association with lymph node metastasis. We also reviewed cases reported in Japan.

[Laparoscopic Surgery for Synchronous Retroperitoneal Tumor and Ovarian Mature Teratoma-A Case Report].

A 72-year-old woman was transferred to our hospital after being diagnosed with retroperitoneal and ovarian tumors. Abdominal computed tomography revealed a well-defined mass lesion measuring 35 mm on the dorsal side of the descending part of the duodenum that was surrounded by the head of the pancreas and inferior vena cava. In addition, a cystic mass measuring 90 mm was found in the pelvis. Hence, the patient was diagnosed synchronous retroperitoneal tumor and teratoma. Laparoscopic retroperitoneal tumor resection and right adnexectomy were performed. The pathological findings indicated that the retroperitoneal tumor was a diffuse large B-cell lymphoma and the pelvic tumor was a mature cystic teratoma of the ovary. On the basis of the computed tomography findings, we judged that the tumor had a poor tendency to infiltrate and could be peeled off and resected using laparoscopic surgery. In this rare case, the retroperitoneal tumor and mature teratocarcinoma were simultaneously resected laparoscopically.

[A Case of Castleman's Disease with Lymphadenopathy during the Treatment of Gastric Cancer].

We report a patient who had Castleman's disease with lymphadenopathy during the treatment of gastric cancer. In May 2017, a 63-year-old man underwent gastrointestinal endoscopy, which revealed a tumor on the posterior wall of the lower part of the stomach. Based on a biopsy, he was diagnosed with suspected adenocarcinoma, Group 4. In June 2017, he visited our hospital, and endoscopic submucosal dissection(ESD)was performed. The pathological diagnosis of the resected specimens was L, Less, 20×10 mm, Type 0-Ⅱc, tub1, pT1a(M), UL(-), ly(-), v(-), pHM0, pVM0, pStage ⅠA. He was referred to our department for the treatment of abdominal lymphadenopathy. His lymphadenopathy was localized in the gastric lesser curvature as an enlarged lymph node 15mm in size, based on the findings of contrast-enhanced CT. On FDG- PET/CT, we found a slight accumulation of SUVmax 2.4 in the early phase in the same lymph node. We could not confirm a diagnosis, and we performed laparoscopic dissection of the lymph node for diagnosis and treatment. The size of the specimen was 14×14mm, surface was smooth, and lymph node was elastic and soft. We found lymphoid follicles with atrophic germinal center using HE staining. We also found increased hyperplastic blood vessels around the germinal center, and he was diagnosed with hypervascular Castleman's disease.

[Long-Term Survival of a Patient with Para-Aortic Lymph Node Recurrence Who Underwent Lymph Node Dissection and Received Chemotherapy Following Curative Gastrectomy].

A 66-year-old man underwent total gastrectomy for gastric cancer. S-1 was administered as adjuvant chemotherapy. Abdominal CT showed para-aortic lymph node recurrence 31 months after the surgery. There was no other recurrence according to PET-CT, and we performed para-aortic lymph nodes dissection 41 months after the surgery. Lymph node recurrence in the retrocrural space was observed 37 months after the 2nd surgery. We administered S-1 plus L-OHP chemotherapy. After 4 courses, CT revealed that he had achieved complete response, and he has remained disease-free for 79 months after lymph node dissection. Some patients with para-aortic lymph node recurrence after curative gastrectomy may benefit from treatment including chemotherapy and surgical dissection.

[Two Cases of Pancreatectomy for Pancreatic Metastasis from Renal Cell Carcinoma].

Metastasis of renal cell carcinoma to the pancreas is a relatively rare condition. We encountered 2 such cases. The first case was a 72-year-old man who underwent a left nephrectomy owing to left renal cancer in 2005. An abdominal dynamic CT scan 12 years after surgery revealed tumors in the pancreatic body and right kidney. A PET-CT scan revealed low intensity uptake of both tumors, and therefore, metastasis of the left renal cell carcinoma to the pancreas was suspected. We then performed partial resections of the pancreatic tail and right kidney. Pathologic findings confirmed that the pancreatic tumor and right renal tumor were metastases of the left renal cell carcinoma. The postoperative course was favorable, and the patient has been followed up in an outpatient setting for 10 months with no signs of recurrence. The second case was a 51- year-old woman with tumors in the left kidney and pancreatic head that were detected by abdominal contrast CT and MRI. We diagnosed the patient with left renal cell carcinoma with metastasis to the pancreas. We performed a radical nephrectomy of the left kidney and full pancreatectomy. Pathologic findings confirmed left renal cell carcinoma, pStage Ⅳ, with metastasis to the pancreas. The postoperative course was favorable without recurrence for 14 years. We report on two cases of metastasis of renal cell carcinoma to the pancreas in patients who underwent radical resections and had favorable postoperative courses, with some bibliographic consideration.