Laparoscopic sigmoidectomy for sigmoid colon cancer with left-sided inferior vena cava and persistent descending mesocolon.

Left-sided inferior vena cava (IVC) is a rare congenital malformation, as is persistent descending mesocolon, a developmental anomaly in which the colonic mesentery does not fuse with the dorsal abdominal wall. Although these anomalies are mostly asymptomatic, they should be identified preoperatively to avoid iatrogenic injury. We report a case of sigmoid colon cancer in a patient with both anomalies. The patient was an 80-year-old man whose preoperative computed tomography (CT) scan showed that the IVC ascended vertically along the left side of the abdominal aorta, and the descending colon was at the abdominal midline. Coronal CT was particularly useful for visualizing these anomalies. With this better understanding of the malpositioned anatomy, we successfully performed laparoscopic sigmoidectomy with lymph node dissection. Careful evaluation of preoperative CT imaging based on a clear understanding of such anatomical anomalies is particularly important for performing safe laparoscopic surgery.

[Two Cases of Lung Stage â ¢Squamous Cell Carcinoma Treated with Carboplatin (CBDCA)plus Nab-Paclitaxel(Nab-PTX)].

Case 1: 83 years old man. For left upper lobe lungs squamous cell carcinoma infiltrating left main pulmonary artery. After 2 courses went of carboplatin(CBDCA)(AUC: 6)+weekly nab-paclitaxel(nab-PTX)(AUC: 6)+, left upper lobectomy and ND2 lymph nodes dissection. Tumor disappeared in pathology and diagnosed of Ef. 3. Case 2: 81 years old man. Right upper lobe lungs squamous cell carcinoma in #4R lymph node metastasis with the superior vena cava invasion. After 2 courses went of CBDCA(AUC: 6)+weekly nab-PTX(100mg/m2), left upper lobectomy and ND2 lymph nodes dissection. Tumor disappeared in pathology and diagnosed of Ef. 3. Nab-PTX may be considered a preoperative chemotherapeutic agent of choice for squamous cell carcinoma.

Pulmonary edema after laparoscopic hepatectomy in a patient with Budd-Chiari syndrome-associated hepatocellular carcinoma.

An 84-year-old man diagnosed with Budd-Chiari syndrome (BCS) developed a 20-mm hepatocellular carcinoma. We performed laparoscopic hepatectomy without complications, but the patient's percutaneous oxygen saturation gradually worsened and pulmonary edema was detected 50 minutes after extubation. He was subsequently re-intubated and received diuretic therapy. He was discharged on postoperative day 32. Patients with severe BCS have been reported to have an expanded plasma volume. In addition, pneumoperitoneum during laparoscopic surgery has been reported to decrease the venous flow in the portal vein and/or renal vein, the collateral pathways in BCS. The cause of pulmonary edema in the present case may have involved increased venous return following decompression of pneumoperitoneum pressure under the state of an expanded plasma volume. This case suggests that clinicians should pay special attention to achieving volume control in patients with BCS, particularly during laparoscopic surgery and minimizing the duration of pneumoperitoneum.

An unusual case of thoracic impalement injury with severe pleural adhesion.

Thoracic impalement injury is an uncommon form of trauma. In the present report, we describe the case of a 78-year-old man who was injured by 2 metal rods. We decided to remove the rod on the right side by performing video-assisted thoracic surgery. However, during this procedure, total pleural adhesion was identified. Therefore, a mini-thoracotomy was performed and the rod was removed safely; the patient's postoperative course was uneventful. The rod on the left side did not pass through the thoracic cavity. There are only a few reports of thoracic impalement injury in literature, and cases with total pleural adhesion are very rare. Careful preoperative planning and a multidisciplinary approach are essential for managing this type of injury.

[Rectal cancer with local re-recurrence successfully treated by carbon ion radiotherapy].

A 61 year-old male with rectal cancer underwent anterior resection with D2 lymph node dissection in August 2007. Carcinoembryonic antigen (CEA) level was 5.6 before the operation. Pathological findings were Rs, tub2¼>tub1, type 3, pSE, ly1, v2, pN1 (1/23), H0, P0, M0 , pStage IIIA. Adjuvant chemotherapy with tegafur-uracil (UFT) 600 mg/Leucovorin (LV) 75 mg was administered for 1 year. A recurrence at a site of anastomosis developed and lower anterior resection was required in September 2010. CEA level was 5.4 before the operation. After 7 courses of capecitabine plus oxaliplatin (XELOX) treatment, the right #283 lymph node increased to 8 mm in October 2011 and the patient was diagnosed with a re-recurrence of the original tumor (CEA level, 4.6). Carbon ion radiotherapy (73.6 Gy/16 Fr/4 weeks) was performed between November 28 and December 22, 2011. Although the right #283 lymph node had shrunk by January 2012, a single node in the S3 domain of the right lung was observed and became progressively larger, indicating a lung metastasis (CEA level, 5.4). The patient received carbon ion radiotherapy (60.0 Gy/4 Fr) for the lung metastasis between July 30 and August 2, 2012. No additional recurrences have been seen through February 2014.

Assessment of SMAD4, p53, and Ki-67 alterations as a predictor of liver metastasis in human colorectal cancer.

PURPOSE: The liver is the most common site of metastasis in patients with colorectal cancer (CRC), and this is a determinant of the prognosis. However, no reliable molecular predictors of liver metastasis have yet been identified. METHODS: Sixty-two surgical specimens of colorectal cancer were studied. The first group included 25 patients who achieved a disease-free survival period of at least 6 years (CRC-M0), and the second group included 37 patients with synchronous (n = 22) or metachronous (n = 15) liver metastasis (CRC-M1). SMAD4, p53, and Ki-67 expression levels were assessed immunohistochemically. RESULTS: The loss of SMAD4 expression and elevated Ki-67 expression were found significantly more frequently in CRC-M1 patients than in CRC-M0 patients (P = 0.0047 and P = 0.013, respectively). Statistically significant differences were also observed between the CRC-M0 group and the metachronous metastasis group. No difference was seen in the overexpression of p53 between the groups. A combination analysis of SMAD4 and Ki-67 revealed no cases with maintained levels of SMAD4 and a low Ki-67 expression had or developed liver metastasis. CONCLUSION: The loss of SMAD4 expression and elevated Ki-67 expression was therefore found to significantly correlate with liver metastasis, regardless of the time of occurrence, thus indicating these factors to be predictive markers for liver metastasis in patients with CRC.

HPV infection in an HIV-positive patient with primary squamous cell carcinoma of rectum.

Primary squamous cell carcinoma (SCC) of the colorectum is a rare malignancy of unknown etiology and pathogenesis. We report a case of primary SCC of the rectum. A 55-year-old man with a rectal tumor and human immunodeficiency virus (HIV) infection was referred to our hospital. Histopathology of biopsy specimens showed characteristics of SCC. We diagnosed the patient as having primary moderately differentiated SCC of the rectum according to the criteria proposed by Cooper. Human papillomavirus (HPV) DNA was amplified by polymerase chain reaction analysis of unfixed tumor biopsy specimens. In addition, no p53 overexpression or nuclear staining of retinoblastoma protein (Rb) was observed in neoplastic cells by immunohistochemical staining. We suggest from our case that HPV infection following the inactivation of the cellular tumor suppressor Rb and the immune suppression induced by HIV infection play an etiologic role in the pathogenesis of rectal SCC, consistent with the well-established concept of HPV-associated anal carcinogenesis.

Proteasome affects the expression of aryl hydrocarbon receptor-regulated proteins.

The effect of proteasome inhibition with N-acetyl-leucyl-leucyl-norleucinal (ALLN) on the protein expression regulated by aryl hydrocarbon receptor (AhR) was studied in T47D breast tumor cells. The luciferase reporter gene assay using a construct which has the xenobiotic responsive element showed that the inducible expression of the reporter with AhR ligands was significantly reduced by co-treatment with ALLN. The same suppressive effect by ALLN was observed for ethoxyresorufin O-deethylase (EROD) activity induced by an AhR ligand, 3-methylcholanthrene (3MC). Despite the above effects, the induced expression of CYP1A1 and CYP1B1 mRNAs was unaffected by ALLN. While lactacystin, another proteasome inhibitor, exhibited the same effect as ALLN on EROD activity induced by 3MC, leupeptin, which is one of the cysteine protease inhibitors, had no such effect. Based on the evidence obtained, it appears that proteasome inhibition results in a reduction in the expression of AhR-regulated proteins.

[Gemcitabine concurrent with radiation for locally advanced pancreatic cancer].

Gemcitabine (GEM) concurrent with radiation is clinically not well defined. We herein report four cases of chemo-radiotherapy against locally advanced pancreatic cancer using low-dose GEM concurrent with extra-beam radiation. A total of eight cases entered the study. Three were resected and five were non-resected cases. Intraoperative radiation was carried out in every case using an 8 or 10 centimeter cone with a radiation dose of 25 Gy. Postoperative radiation was 2 Gy per day on weekdays for 5 weeks. Four cases were concurrent with low-dose GEM (40 mg/m2) twice a week, whereas the other four were radiation only. With the use of GEM concurrent with radiation, tumor markers decreased more than 80 percent regardless of the tumor resection. CT scan confirmed a necrotic change and the decrease of the tumor size. In conclusion, low dose GEM concurrent with radiation therapy may be a promising therapeutic choice for the local control of advanced pancreatic cancers.

Significance of HDAC6 regulation via estrogen signaling for cell motility and prognosis in estrogen receptor-positive breast cancer.

Histone deacetylase (HDAC) 6 is a subtype of the HDAC family; it deacetylates alpha-tubulin and increases cell motility. Here, we investigate the impact of an alteration of HDAC6 expression in estrogen receptor alpha (ER)-positive breast cancer MCF-7 cells, as we identified that HDAC6 is a novel estrogen-regulated gene. MCF-7 treated with estradiol showed increased expression of HDAC6 mRNA and protein and a four-fold increase in cell motility in a migration assay. Cell motility was increased to the same degree by stably transfecting the HDAC6 expression vector into MCF-7 cells. In both cases, the cells changed in appearance from their original round shape to an axon-extended shape, like a neuronal cell. This HDAC6 accumulation caused the deacetylation of alpha-tubulin. Either the selective estrogen receptor modulator tamoxifen (TAM) or the pure antiestrogen ICI 182,780 prevented estradiol-induced HDAC6 accumulation and deacetylation of alpha-tubulin, leading to reduced cell motility. Tubacin, an inhibitory molecule that binds to the tubulin deacetylation domain of HDAC6, also prevented estradiol-stimulated cell migration. Finally, we evaluated HDAC6 protein expression in 139 consecutively archived human breast cancer tissues by immunohistochemical staining. The prognostic analyses for these patients revealed no significant differences based on HDAC6 expression. However, subset analysis of ER-positive patients who received adjuvant treatment with TAM (n = 67) showed a statistically significant difference in relapse-free survival and overall survival in favor of the HDAC6-positive group (P < 0.02 and P < 0.05, respectively). HDAC6 expression was an independent prognostic indicator by multivariate analysis (odds ratio = 2.82, P = 0.047). These results indicate the biological significance of HDAC6 regulation via estrogen signaling.

Vascular endothelial growth factor C promotes lymph node metastasis in a rectal cancer orthotopic model.

PURPOSE: Vascular endothelial growth factor C (VEGF-C), a novel member of the vascular endothelial growth factor family, is a relatively specific lymphangiogenic growth factor. It has been suggested that increased expression of VEGF-C in primary tumors is correlated with lymph node metastasis. We conducted this study to determine whether VEGF-C directly affects lymphangiogenesis and lymph node metastasis in colorectal cancer. METHODS: For an accurate analysis and clear visualization of metastases, the rectal cancer cell line, DLD1, was engineered to stably express green fluorescent protein (GFP) (DLD1/GFP). We implanted DLD1/GFP cells overexpressing VEGF-C orthotopically into the rectal walls of nude mice. RESULTS: Lymph node metastasis was confirmed in all (100%) of the mice bearing DLD1/GFP-VEGF-C tumors, but in only 25% of the mice bearing control tumors. There were more lymph node metastases per mouse in the mice bearing DLD1/GFP-VEGF-C tumors than in the mice bearing control tumors. There were no differences in cell growth and motility in vitro or in the resulting tumor volume from the implanted cells between the two groups. Immunohistochemical staining revealed that VEGF-C induced the growth of lymphatic vessels, which were enlarged in the tumor periphery and contained tumor cell emboli. CONCLUSION: These results suggest that VEGF-C-induced lymphangiogenesis mediates tumor spread and the formation of lymph node metastasis.

[Controversies in endocrine therapy for breast cancer].

Major advances have been made in the treatment of postmenopausal women with hormone-sensitive breast cancer. Although tamoxifen has been the standard endocrine therapy for the past twenty years, the development of a third generation of aromatase inhibitors (Als), which effectively inhibit estrogen synthesis in extragonadal sites, gives us a wider range of choices in endocrine therapy. However, many questions remain with respect to the optimal use of Als. Differences between Als and tamoxifen as well as non-steroidal and steroidal Als in their long-term adverse effects on bone demineralization and lipid metabolism are only starting to emerge. The preferable orders for use of non-steroidal and steroidal Als, Als and pure anti-estrogen in patients with metastatic disease are emerging subjects to be examined, following several studies that showed non-cross reactivity between these types of drug. Neo-adjuvant endocrine therapy is now attempting to apply breast conserving surgery in larger numbers of elderly patients who are not suitable for neo-adjuvant chemotherapy. Moreover, many investigators are currently searching for surrogate markers in neo-adjuvant endocrine treatment that can predict the responsiveness and prognosis with adjuvant endocrine therapy. Further research concomitant with clinical trials may lead to a more reliable endocrine therapy modality in the treatment of breast cancer.

Quantification of vascular endothelial growth factor-C and its receptor-3 messenger RNA with real-time quantitative polymerase chain reaction as a predictor of lymph node metastasis in human colorectal cancer.

BACKGROUND: This study was undertaken to determine whether vascular endothelial growth factor-C (VEGF-C) and the expression of its receptor VEGF receptor-3 (VEGFR-3) are correlated with lymph node metastasis in human colorectal cancer and whether their expression levels might be used to predict lymph node metastasis. METHODS: Fifty-three surgical specimens of colorectal cancer with (n = 24) or without (n = 29) lymph node metastasis were studied. The messenger RNA (mRNA) expression of VEGF-C and VEGFR-3 was quantified with a new method for kinetic quantitative polymerase chain reaction (PCR), real-time quantitative (RTQ) reverse transcriptase-PCR. In addition, their protein expressions were assessed immunohistochemically. RESULTS: The VEGF-C mRNA level in primary tumors correlated with VEGF-C protein expression, lymph node metastasis, and lymphatic invasion. Sixteen of 24 patients with lymph node metastasis showed VEGF-C mRNA overexpression. Morphologically, VEGF-C protein expression in primary tumors showed a statistically significant relationship with lymph node metastasis and lymphatic invasion. CONCLUSION: Real-time quantitative reverse transcriptase-PCR is a sensitive method for detection and quantification of VEGF-C and VEGFR-3 mRNA expression. Furthermore, the expression levels of VEGF-C mRNA and protein in colorectal cancer are correlated with lymph node metastasis and lymphatic invasion.

Obstructive jaundice due to internal herniation: a case report and review of the literature.

A 45-year-old man was suffering from abdominal pain and vomiting. He was admitted to our hospital with a diagnosis of ileus and obstructive jaundice. He had undergone Roux-en-Y anastomosis for choledocholithiasis 14 years earlier. A computed tomography scan revealed a dilated afferent loop and dilated intrahepatic bile duct. Upper gastrointestinal examination with contrast medium and percutaneous transhepatic cholangiography showed a high intestinal obstruction around the jejunojejunal anastomosis. The patient underwent laparotomy based on a diagnosis of obstructive jaundice due to ileus. During the operation, he was found to have internal herniation of the small bowel through a rent in the mesentery around the Roux-en-Y anastomosis for choledochojejunostomy. The hernia was reduced, and bowel resection was performed due to stenosis of the afferent loop. Jejunojejunal anastomosis was re-performed and the defect in the mesocolon was closed. Internal herniation after Roux-en-Y anastomosis is a rare sequela, but it should be recognized that this complication can occur after Roux-en-Y anastomosis. For prevention of internal herniation around the Roux-en-Y limb, secure closing of the mesenteric defects is important.