Very early recurrence following pancreaticoduodenectomy in patients with ampullary cancer.

We aimed to identify the factors for very early recurrence (within 6 months) of ampullary cancer following curative resection and to compare the immunohistochemical expression rate of various antibodies between the 2 main histologic subtypes of ampullary adenocarcinoma.In this retrospective study, the postoperative outcomes and clinicopathologic factors for very early recurrence that occurred in 14 of 93 patients who underwent pancreaticoduodenectomy (PD) for ampullary adenocarcinoma between January 2002 and August 2014 were analyzed. Thereafter, we identified the factors associated with very early recurrence following surgery. Additionally, we compared the expression rates of CK7, CK20, MUC1, MUC2, MUC5AC, MUC6, S100P, and CDX2 between the 2 main histologic subtypes of ampullary adenocarcinoma (NCC2019-0138).The patients who underwent PD for ampullary cancer were divided into 2 groups: very early recurrence and others. Compared with the other patients, the 14 patients (32.6%) who developed very early recurrence had shorter median disease-free survival (4.2 vs 49.7 months, P = .001) and overall survival (18.2 vs 113.7 months, P < .001). Large tumor, lymph node metastasis, and pancreatobiliary type were independently associated with very early recurrence of ampullary cancer following PD.Large tumor, lymph node metastasis, and pancreatobiliary type were the independent risk factors for very early recurrence of ampullary cancer following curative resection. Therefore, ampullary cancer patients with these factors should be considered to receive aggressive adjuvant treatment and frequent post-operative follow-up.

[Ischemic Necrosis Caused by Retroanastomotic Hernia after Subtotal Gastrectomy].

After gastrojejunostomy, a small space can occur between the jejunum at the anastomosis site, the transverse mesocolon, and retroperitoneum, which may cause an intestinal hernia. This report presents a rare case of intestinal ischemic necrosis caused by retroanastomotic hernia after subtotal gastrectomy. A 56-year-old male was admitted to Kangwon National University Hospital with melena, abdominal pain, and nausea. His only relevant medical history was gastrectomy due to stomach cancer. Endoscopic findings revealed subtotal gastrectomy with Billroth-II reconstruction and a bluish edematous mucosal change with necrotic tissue in afferent and efferent loops including the anastomosis site. Abdominopelvic CT showed strangulation of proximal small bowel loops due to mesenteric torsion and thickening of the wall of the gastric remnant. Emergency laparotomy was performed. Surgical findings revealed the internal hernia through the defect behind the anastomosis site with strangulation of the jejunum between 20 cm below the Treitz ligament and the proximal ileum. Roux-en-Y anastomosis was performed, and he was discharged without complication. Retroanastomotic hernia, also called Petersen's space hernia, is a rare complication after gastric surgery, cannot be easily recognized, and leads to strangulation.

Horseshoe appendix identified during laparoscopic appendectomy: A case report and literature review.

RATIONALE: The horseshoe anomaly of the vermiform appendix is extremely rare. Preoperative confirmation of this anomaly is difficult; therefore, routine procedures, such as appendectomy, may become unexpectedly challenging when such anomalies are encountered during the surgical process. PATIENT CONCERNS: A 33-year-old man presented with abdominal pain in the right lower abdomen owing to acute appendicitis confirmed via computed tomography. Immediate laparoscopic appendectomy was decided as the method for treatment. DIAGNOSIS: Horseshoe anomaly was diagnosed as a gross finding during surgery. INTERVENTION: First, the appendiceal base was resected and appendectomy was performed via the retrograde method because the appendiceal tip was curled behind the cecum. However, it was discovered that the appendiceal tip was connected to the lateral part of the ascending colon and showed a horseshoe-shaped anomaly. The second appendiceal base arising from the ascending colon was also ligated, and the appendectomy was completed without any further complications. OUTCOMES: After successful completion of appendectomy, the patient was discharged without any complications 2 days later. LESSONS: An appendiceal anomaly is rarely seen during appendectomy or other forms of abdominal surgery; however, the ability of surgeons to both recognize and categorize an appendiceal anomaly is crucial if detected during surgery. After successfully recognizing the horseshoe anomaly of the appendix, it is important to know that 2 appendiceal base ligations will be required to complete the surgery successfully.

Solitary colonic metastasis from primary lung adenocarcinoma first presenting as intestinal obstruction: A case report.

RATIONALE: The brain, liver, adrenal glands, and bone are the most common sites of metastatic disease in patients with lung cancer. Symptomatic gastrointestinal metastases are rare. In the present report, we describe a rare case of a patient with intestinal obstruction due to solitary colonic metastasis from primary lung adenocarcinoma, wherein the intestinal obstruction was the first symptom of lung cancer. PATIENT CONCERNS: A 74-year-old man was admitted to the emergency room with abdominal pain and vomiting, and abdominal computed tomography (CT) indicated obstruction of the ascending colon due to a huge mass. DIAGNOSIS: The ascending colon cancer was found to be a metastatic adenocarcinoma based on the results of the pathology report. Chest CT and positron emission tomography-CT were performed to identify the cancer origin site. Moreover, immunohistochemical staining of the tissue specimen for thyroid transcription factor 1, cytokeratin 7 (CK7), and CK20 and CT-guided gun biopsy of the lung mass confirmed the presence of an adenocarcinoma that originated from the lung. INTERVENTION: Right hemicolectomy was performed as the primary treatment. OUTCOMES: The patient recovered without any problems due to the surgery itself. However, malignant pleural effusion deteriorated, and no additional palliative chemotherapy was performed. LESSONS: Patients with malignant bowel obstruction along with lung infiltration should be suspected of not only colon cancer with lung metastasis, but also lung cancer with colon metastasis.

A case of recurrent malignant fibrous histiocytoma of the mesentery.

Primary malignant fibrous histiocytoma (MFH) mainly occurs in the extremities, trunk and retroperitoneum. However, MFH of the mesentery is very rare, and locally recurred MFH is even rarer. MFH is severely malignant and invasive regionally. The neoplasm can spread quickly. This report is about a case of a recurred MFH in the mesentery, which locally recurred within 3 years from the original operation. The patient (female, age 71) underwent a resection of the small bowl and mesentery of the recurrent MFH with negative resection margins. In the 24 months that followed, there has not been any evidence of recurrence or other metastasis in the patient. Although the prognosis of recurred MFH in mesentery was poor, a clear resection might provide a good opportunity for long-term survival, suggesting that surgery might be an effective treatment. This is the first report on the surgical treatment of recurrent MFH of the mesentery.

Light-chain amyloidosis presenting with rapidly progressive submucosal hemorrhage of the stomach.

The gastrointestinal tract is frequently in involved light-chain (AL) amyloidosis, but significant hemorrhagic complications are rare. A 71-year-old man presented to our hospital with dyspepsia and heartburn for 1 month. Gastroscopy revealed a large submucosal hematoma at the gastric fundus. Two days later, a follow-up gastroscopy indicated extensive expansion of the hematoma throughout the upper half of the stomach. The hematoma displayed ongoing expansion during the endoscopic examination, suggesting that rupture was imminent. Emergency total gastrectomy was performed, and amyloidosis was confirmed after examining the surgical specimen. Bone marrow examination revealed multiple myeloma, and serum immunoglobulin assay confirmed the diagnosis of myeloma-associated AL amyloidosis. At manuscript submission, the patient was doing well and was undergoing chemotherapy.

CD44 expression in patients with combined hepatocellular cholangiocarcinoma.

PURPOSE: Combined hepatocellular cholangiocarcinoma (ChC) is a rare type of primary liver cancer, which is thought to have a poorer prognosis than hepatocellular carcinoma (HCC). Cancer stem cells are associated with tumorigenesis, tumor progression, recurrence, metastasis, and poor prognosis in several malignancies including HCC. The aim of this study was to investigate the expression pattern of cancer stem cell markers in ChC and HCC, and to evaluate whether this pattern correlated to patient prognosis. METHODS: Thirteen patients who underwent curative hepatic resection for ChC and 13 patients who underwent curative hepatic resection for HCC (matched control cases) were included. Immunohistochemical staining for cancer stem cell markers (cytokeratin [CK]7, CK19, C-kit, cluster of differentiation [CD] 44, CD133, and epithelial cell adhesion molecule) was performed and clinical outcomes were analyzed retrospectively. RESULTS: There was no significant difference in cancer stem cell marker expression between ChC and HCC. In ChC, the group that expressed CD44 showed earlier recurrence than the group that did not express CD44 (P = 0.040). CONCLUSION: The expression of cancer stem cell markers in ChC did not show a different pattern compared to that found in HCC. The expression of cancer stem cell marker CD44 was associated with poor prognosis in patients with ChC.

Primary large cell neuroendocrine carcinoma in the common bile duct: first Asian case report.

Large cell neuroendocrine carcinoma (LCNEC) in the biliary system is a poorly differentiated, high-grade neuroendocrine tumor. These tumors exhibit aggressive behavior and an increased tendency for early nodal and distant metastases. Herein, we report an unusual case of a pure primary LCNEC of the common bile duct (CBD). A 75-year-old female presented with nausea and jaundice. The patient underwent a CBD excision with lymph node dissection. Upon histological and immunohistochemical examination, the tumor exhibited pure large cell-type neuroendocrine features. Metastases were noted in two of the eight lymph nodes. The patient was administered adjuvant chemotherapy. The patient's cancer recurred 7 mo after surgery, and the patient died from liver failure 5 mo after recurrence. The prognosis of LCNEC of CBD remains poor despite curative resection and adjuvant chemotherapy. The role of additional therapies, such as multimodal treatment including radiation therapy, must be further studied to improve the prognoses of patients.

Primary carcinosarcoma of the gallbladder.

Carcinosarcoma of gallbladder (CSGB) is a rare malignancy characterized by malignant epithelial and mesenchymal components. Its pathogenesis is unknown and most CSGBs are associated with poor survival because the disease normally presents at an advanced stage, and as a result, curative resection is uncommon. This report describes a case that underwent curative resection. A 77-year-old woman presented with right upper quadrant pain. The preoperative diagnosis was gallbladder (GB) cancer, and thus, curative radical cholecystectomy was performed. However, pathologic examination of the surgical specimen revealed that the tumor was composed of two histologic components of squamous cell carcinoma and spindle cell sarcoma, which was consistent with a diagnosis of carcinosarcoma. The tumor was found to extend to the perimuscular connective tissue and to have metastasized to one lymph node (LN). The prognosis of CSGB remains poor despite curative resection, and thus, the authors recommend that effort be made to improve surgical outcomes.

Expression levels of cyclin G2, but not cyclin E, correlate with gastric cancer progression.

PURPOSE: Cyclin G2 and cyclin E are important cell-cycle regulators in various cancer tissues. However, little is known about cyclin G2 expression in human gastric cancer tissues, and the role of cyclin E is quite controversial. This study evaluated their clinical significance in gastric cancer tissues. MATERIALS AND METHODS: Immunohistochemical staining using the tissue array method was performed on 166 human gastric carcinomas. The clinicopathological features and prognostic significance were analyzed. RESULTS: Cyclin G2 and cyclin E expressions were positive in 110 (66.3%) and 77 (46.4%) human gastric cancer tissues, respectively. The incidence of cyclin G2 positivity was lower in females and in cancers with the undifferentiated type of histology. Moreover, cyclin G2 expression was inversely correlated with the more advanced stages (P < 0.05), the presence of lymph-node metastasis (P < 0.05), and the presence of perineural invasion (P < 0.05). However, no significant correlation was observed between the expression of cyclin E and all of the clinicopathological factors examined. Cyclin G2 expression was associated with a better overall survival (OS; 5-y OS, 50.6% for cyclin G2-positive versus 35.0% for cyclin G2-negative; P < 0.05). However, multivariate analysis revealed lymph-node metastasis, distant metastasis, and lymphatic invasion to be independent prognostic factors but not cyclin G2 expression. CONCLUSION: Our study could not demonstrate any significant relationship between cyclin E expression and the clinicopathological variables. However, cyclin G2 appears to be a negative cell-cycle regulator in gastric cancer, and its expression seems to be inversely related to gastric cancer progression.

Overexpression of phospholipase D suppresses taxotere-induced cell death in stomach cancer cells.

Phospholipase D (PLD) catalyzes the hydrolysis of phosphatidylcholine to generate phosphatidic acid (PA) and choline. There are at least two PLD isozymes, PLD1 and PLD2. Genetic and pharmacological approaches implicate both PLD isozymes in a diverse range of cellular processes, including receptor signaling, membrane transport control, and actin cytoskeleton reorganization. Several recent studies reported that PLD has a role in signaling pathways that oppose apoptosis and promote cell survival in cancer. In this study, we examined the role of PLD in taxotere-induced apoptosis in stomach cell lines; normal stomach (NSC) and stomach cancer cells (SNU 484). Taxotere treatment resulted in increase of PLD activity. To confirm the role of PLD in taxotere-induced apoptosis, PLDs were transfected into SNU 484 cells. Overexpression of PLD isozymes resulted in inhibition of taxotere-induced apoptotic cell death, evidenced by decreased degradation of chromosomal DNA, and increased cell viability. Concurrently, Bcl-2 expression was upregulated, and taxotere-induced activation of procaspase 3 was inhibited after PLD's transfection. However, when PLD was selectively inhibited by specific siRNA-PLD1 or -PLD2, taxotere-induced apoptosis was exacerbated in SNU 484 cells. On top of this, PA -- the product of PLDs, also resulted in upregulation of Bcl-2 in SNU 484. Although PA-induced Bcl-2 expression was blocked by mepacrine, an inhibitor of phospholipase A(2) (PLA(2)), increased Bcl-2 expression by PA was not abrogated by propranolol, an inhibitor of PA phospholyhydrolase (PAP). Taken together, PLD1 and PLD2 are closely related with Bcl-2 expression together with PLA(2), but not with PAP, during taxotere-induced apoptosis in SNU 484 cells.

Self-reported experience and outcomes of care among stomach cancer patients at a median follow-up time of 27 months from diagnosis.

GOALS OF WORK: We aimed to identify clinical experiences associated with outcomes of care among stomach cancer patients. MATERIALS AND METHODS: Four hundred thirty-two patients who had a diagnosis of stage I-III stomach cancer from 2001 through 2002 from two hospitals in South Korea responded to a survey questionnaire including sociodemographic and clinical data, information about care experiences, satisfaction with care, and quality of life (QOL). MAIN RESULTS: Involvement in decision making [adjusted odds ratio (aOR) = 1.81; 95% confidence interval (CI), 1.13 to 2.89] and reflection of patients' opinions in treatment decisions (aOR = 2.54; 95% CI, 1.65 to 3.93) were associated with decision satisfaction. The factors associated with willingness to choose the same treatment over again were involvement in decision making (aOR = 2.37; 95% CI, 1.53 to 3.68) and no treatment toxicity (aOR = 0.50; 95% CI, 0.29 to 0.87). Involvement in decision making, reflection of patients' opinions in treatment decisions, and treatment toxicity were associated with some functioning subscales of QOL (p < 0.05). Regular follow-up, however, was associated with poor social functioning. CONCLUSIONS: Quality improvement efforts for stomach cancer patients should focus not only on the quality of primary tumor therapy but also on how patients experience their care, such as patient-centered decision making, experience of treatment toxicity, and regular follow-up.

Health-related quality of life among disease-free stomach cancer survivors in Korea.

Previous studies about the quality of life (QOL) in stomach cancer survivors focused on selected clinical parameters and did not consider the broader implications for overall health and QOL. We evaluated the impact of demographic and treatment-related factors on the QOL of stomach cancer survivors. We asked 391 stage I-III stomach cancer survivors who had been disease-free for at least 1 year after surgery to complete a demographic questionnaire, the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire, and its stomach module, QLQ-STO22.Survivors undergoing total gastrectomy reported greater eating restrictions than those undergoing subtotal gastrectomy. Receiving chemotherapy or radiotherapy did not significantly affect any QLQ-C30 or QLQ-STO22 scores. Role and emotional functioning improved with increasing age, and stomach-specific symptoms (pain, eating restrictions, and anxiety) lessened. Compared with female survivors, male survivors had better physical and role functioning. Smoking status was also a significant negative predictor of physical functioning and anxiety. Comorbidities and selected demographic characteristics had a greater effect than type of treatment on the QOL of post-operative stomach cancer patients.