[A Case of Advanced Gastric Cancer Treated with Curative Resection after Preoperative Secondary Chemotherapy with Irinotecan after Primary Chemotherapy with Docetaxel, Cisplatin, and S-1].

A 70-year-old man was diagnosed with advanced gastric cancer based on esophagogastroduodenoscopy(EGD). Abdominal computed tomography(CT)showed swelling of the lymph nodes and invasion to the liver and pancreas. The patient was treated using combined docetaxel, cisplatin, and S-1(DCS)chemotherapy. After 2 courses of treatment, the primary tumor and lymph node metastases continued to grow. The patient was treated using secondary chemotherapy with irinotecan (CPT-11). After 1 course of treatment, the primary tumor and regional lymph nodes reduced in size. We performed curative total gastrectomy with D2 lymph node dissection. There has been no recurrence for 15 months after adjuvant chemotherapy with capecitabine and oxaliplatin(CapeOX). Therefore, CPT-11 therapy is a possible option for the management of advanced gastric cancer after DCS therapy.

Low-Grade Neuroendocrine Carcinoma of the Skin (Primary Cutaneous Carcinoid Tumor) as a Distinctive Entity of Cutaneous Neuroendocrine Tumors: A Clinicopathologic Study of 3 Cases With Literature Review.

There is scarcity of information on primary cutaneous low-grade neoplasms commonly known as carcinoid tumors, owing to their rarity. The authors present 3 cases that were named "low-grade neuroendocrine carcinoma of the skin" (LGNECS). These occurred in the dermis and subcutis of the anterior chest or the inguinal region in the elderly. Histologically, the tumors showed infiltrating proliferation of nests of various sizes, with low-grade neuroendocrine cytologic features but without mucin production. All cases exhibited varying degrees of intraductal tumor components. On immunohistochemical examination, these tumors expressed estrogen receptor alpha, progesterone receptor, androgen receptor, gross cystic disease fluid protein 15, mammaglobin, and GATA3 as well as neuroendocrine markers. Although a literature review revealed 8 additional possible cases with no evidence of other diseases, it was difficult to determine if these were true cases of LGNECS, because of the limited information available. Based on its characteristic histologic features and immunoprofile, it can be proposed designating LGNECS as a distinct entity among cutaneous neuroendocrine tumors. Otherwise, such tumors could be misdiagnosed as mammary carcinomas (particularly when involving the skin of the breast) or as metastatic visceral neuroendocrine tumors of the skin.

Surgical treatment for rectal cancer with abnormally expanded inferior mesenteric vein resulting from pancreatic arteriovenous malformations.

A 52-year-old Japanese man presented for evaluation and treatment of rectal cancer. Screening computed tomography revealed pancreatic arteriovenous malformations (P-AVMs) and abnormally expanded inferior mesenteric vein (IMV) that resulted from P-AVMs. One-stage surgery for rectal cancer was dangerous so we first performed distal pancreatectomy to cure P-AVM and thus normalize the abnormally expanded IMV. After the operation, the IMV was occluded by the thrombi, and then the IMV became normal. We could perform safely radical laparoscopic surgery for rectal cancer. This is the first case report of P-AVMs combined with rectal cancer.

[Effective chemotherapy with bevacizumab/FOLFOX4 for neuroendocrine carcinoma of the ascending colon - a case study].

A 63-year-old woman underwent surgery for Stage IV cancer of the ascending colon with multiple lymph node metastases. The pathological diagnosis was neuroendocrine carcinoma. Following first-line chemotherapy, the patient presented clinically with progressive disease (PD). Second-line chemotherapy with bevacizumab/Leucovorin and 5-fluorouracil with oxaliplatin (FOLFOX4) was effective and a partial response (PR) was achieved after 7 courses of therapy, as determined by computed tomography (CT) examination. Neuroendocrine carcinoma is known to be extremely malignant; however, this case suggests that chemotherapy with bevacizumab may improve the prognosis of this disease.

Patterns of lymph node metastases in papillary thyroid carcinoma: results from consecutive bilateral cervical lymph node dissection.

BACKGROUND: In patients with papillary thyroid carcinoma (PTC), the appropriate extent of lymph node dissection has not yet been established due to lack of accurate patterns of lymph node metastases (LNM). The aim of this study was to clarify the LNM pattern in PTC patients based on our institution's experience with a consistent technique of bilateral neck dissection, and to consider the rational extent of lymph node dissection. METHODS: Between 1990 and 1999, 152 consecutive patients with PTC who underwent curative total thyroidectomy and bilateral neck dissection as initial treatment were analyzed. The patterns of LNM according to clinicopathological classification were analyzed using the lymph node ratio (LNR; number of metastatic lymph nodes/number of dissected nodes) and frequency (FLNM; number of patients with LNM/number of dissected patients) in cervical compartments. RESULTS: Regardless of clinicopathological classification, LNR in the central compartment was consistently higher than in other compartments, and FLNM in the ipsilateral lateral compartment was consistently higher than in other compartments except for multifocal tumors. The LNR and FLNM in the contralateral lateral compartment were significantly higher in advanced (≥T3) cases than in cases with smaller tumors (T1) and were comparable to those in the ipsilateral lateral compartment in advanced (≥T3) cases. CONCLUSIONS: The pattern of LNR provided a better reflection of the patterns of LNM. In terms of the LNR, central neck dissection is the basic extent of lymph node dissection for all clinically apparent PTC. In advanced patients, it is also advisable to include bilateral lateral neck dissection.

Nodular fasciitis of the breast.

We report a case of nodular fasciitis of the breast, which is a rare histological type of breast tumor. A 41-year-old woman had noticed a mass in her right breast. The mass was elastic-hard, 15 mm x 15 mm in size, and located mainly in the upper outer quadrant of the right breast. Mammography demonstrated an oval dense mass with spiculation. Ultrasonography revealed a hypoechoic lesion, 8 mm x 10 mm in size. Fine needle aspiration cytology and core needle biopsy showed no evidence of malignancy. Excisional biopsy was performed. The tumor was characterized by a proliferation of fibroblastic cells. Histologically, the excised tumor was consistent with nodular fasciitis of the breast. Nodular fasciitis should be considered in the differential diagnosis of a mass suspicious for breast cancer.

Adrenal incidentaloma: review of 197 patients and report of a drug-related false-positive urinary normetanephrine result.

PURPOSE: To determine the incidence and importance of functioning tumors among incidentally discovered adrenal masses in the era of laparoscopic surgery. METHODS: We defined adrenal incidentaloma as a tumor detected during abdominal imaging for adrenal-unrelated reasons, and we reviewed 197 consecutive patients with adrenal incidentaloma diagnosed since we started laparoscopic adrenalectomy. RESULTS: Incidentaloma was discovered initially in 91 (46%) patients and pheochromocytoma was detected as an incidentaloma in 21 (39%) of 54 patients. One patient, a 21-year-old woman taking mesalamine for ulcerative colitis, had a remarkably elevated urinary normetanephrine level, which resulted in the initial misdiagnosis of a 10-cm right adrenal incidentaloma as a pheochromocytoma. Laparoscopic right adrenalectomy resulted in a pathological diagnosis of ganglioneuroma. A series of urinary normetanephrine measurements were taken in parallel with the mesalamine doses. We found that other patients medicated with mesalamine, without adrenal tumors, had elevated urinary normetanephrine levels, confirming that mesalamine metabolites interfere with urinary normetanephrine measurements. CONCLUSIONS: It is essential to diagnose the functional potential of adrenal incidentaloma preoperatively, and not to perform laparoscopic adrenalectomy for adrenal incidentaloma without careful evaluation first.

Prevalence and profile of methamphetamine users in adolescents at a juvenile classification home.

The objective of the present study was to investigate the prevalence and risk factors of methamphetamine use in adolescents at a juvenile classification home. The present subjects were 1362 adolescents (1172 male and 190 female) who had been admitted to the Nagoya Juvenile Classification Home. The participants were divided into two groups, a methamphetamine user group and a control group, based on history of methamphetamine use. The presence of methamphetamine use was analyzed in terms of gender, age, number of admissions, violence (types of crime), history of psychiatric treatment, family history (crime, drug misuse and/or alcohol-related disorder), and experience of being abused by their parents or by the persons who were responsible for raising them. The prevalence of methamphetamine use was 6.8% (93/1362). Multivariate logistic regression analyses indicated that gender (female; odds ratio [OR]: 8.1; 95% confidence interval [CI]: 4.6-14.3), age (OR: 1.8, 95%CI: 1.5-2.1), number of admissions (>2, OR: 2.9, 95%CI: 1.8-4.8), violence (OR: 0.4, 95%CI: 0.2-0.7), history of psychiatric treatment (OR: 8.7, 95%CI: 4.0-19.0), and family history of drug misuse (OR: 4.0, 95%CI: 1.6-9.6) were all significantly associated with methamphetamine use. Approximately 7% of participants used methamphetamine. Female gender was a risk factor. Higher age and multiple admissions suggest the persistency and repetition of delinquency. Methamphetamine users were less violent than control subjects. Psychosocial environment (family history of drug misuse) and psychiatric problems (history of psychiatric treatment) were also related to methamphetamine use.

Influence of history of head trauma and epilepsy on delinquents in a juvenile classification home.

Juvenile delinquents often show poor impulse control and cognitive abnormalities, which may be related to disturbances in brain development due to head trauma and/or epilepsy. The aim of the present study was to examine the influence of head trauma and/or epilepsy on delinquent behavior. We examined 1,336 juvenile delinquents (1,151 males and 185 females) who had been admitted to the Nagoya Juvenile Classification Home, Aichi, Japan. Among them, 52 subjects with a history of epilepsy, convulsion or loss of consciousness, head injury requiring neurological assessment and/or treatment, or neurosurgical operation (head trauma/epilepsy group), were examined by electroencephalography and compared to subjects without these histories (control group) with respect to types of crime, history of amphetamine use, psychiatric treatment, child abuse, and family history. Among the 52 subjects, 43 (82.7%) showed abnormal findings. The head trauma/epilepsy group had significantly higher rates of psychiatric treatment (P<0.0001, OR=16.852, 95% CI=8.068-35.199) and family history of drug abuse (P<0.05, OR=2.303, 95% CI=1.003-5.290). Furthermore, the percentage of members who were sent to juvenile training school by the family court was significantly higher in the head trauma/epilepsy group (72.5%) than in the control group (38.9%, P<0.0001). The juvenile delinquents who had a history of head trauma and/or epilepsy showed a high prevalence of electroencephalograph abnormality, and higher rates of psychiatric treatment and family history of drug abuse, and were more likely to be sent to juvenile training school by the family court.

Intracaval endovascular ultrasonography for large adrenal and retroperitoneal tumors.

BACKGROUND: An accurate diagnosis of inferior vena cava (IVC) invasion is important in deciding the surgical strategy for a large adrenal tumor. We investigated the diagnostic value of intracaval endovascular ultrasonography (ICEUS) for invasion of the IVC by a large adrenal tumor. METHODS: Nine of 163 patients with adrenal and retroperitoneal tumors underwent ICEUS between 1993 and 2002. Intravascular ultrasonography was performed through the right femoral vein with the use of an 8Fr, 20-MHz transducer. The diagnostic criterion for detecting IVC invasion with ICEUS was identification of destruction of a single echogenic layer of the IVC wall or identification of an intracaval tumor mass. The ICEUS finding was confirmed by pathologic examination. RESULTS: The mean diameter of the tumors in 9 patients undergoing ICEUS and resection was 12.6 cm (range, 8.6-16 cm). Pathologic diagnosis varied: adrenocortical carcinoma, 4; malignant pheochromocytoma, 1; leiomyosarcoma, 1; metastatic lung cancer, 1; paraganglioma, 1; and neurilemmoma, 1. Vascular invasion was identified in 2 patients by ICEUS and confirmed by examination of resected specimens. The sensitivity, specificity, and positive predictive values of ICEUS for the diagnosis of the IVC invasion were 100%, 100%, and 100%, respectively. However, these values for computed tomography were 100%, 14%, and 25%, respectively; and for cavography, 100%, 57%, and 40%, respectively. CONCLUSIONS: ICEUS provides confirmatory information regarding tumor invasion of the IVC. This modality also can assist in formulating an operative strategy for large adrenal or retroperitoneal tumors.

Mild persistent hypercalcitoninemia after total thyroidectomy in patients with papillary thyroid carcinoma.

Total thyroidectomy was performed in 455 patients with differentiated thyroid carcinoma between 1978 and 1999. Serum calcitonin (CT) was determined preoperatively in all patients using polyclonal antibodies. Among the subjects, 25 patients showed elevated serum calcitonin levels preoperatively. Pathological diagnoses of 18 patients were confirmed as medullary thyroid carcinoma (MTC) postoperatively. Eight patients were diagnosed as papillary thyroid carcinoma (PTC) in the final pathological diagnosis without evidence of minimal foci of MTC or C cell hyperplasia, and they showed elevated CT levels preoperatively. Hypercalcitoninemia in 8 patients with PTC continued through out the 24 follow-up months with normal CEA levels. Extrathyroidal CT-producing diseases were all neglected, and precise pathological examination showed negative evidence of minute MTC or C cell hyperplasia in these 8 patients. Serum CT levels were simultaneously determined by a different CT assay kit using the same blood samples in 7 of 8 patients. Serum CT levels were all within normal values in another CT kit applying a different polyclonal antibody, although elevated CT values continued in the routine CT kit. The recognition of polymeric or fragmented CT by polyclonal antibody was thought to be the causative factor for the hypercalcitoninemia after total thyroidectomy in the patients with PTC. Knowledge of the false positive CT determination makes it important to employ different CT assay kits, especially the new generation of two-site immunoassays using two monoclonal antibodies against distinct epitopes of human CT, although the new generation kits are not clinically available in Japan.

Laparoscopic adrenalectomy for incidentaloma and bilateral adrenal disease.

Adrenalectomy is ideally suited to minimally invasive surgery based on the characteristics of adrenal tumours, which are usually small and benign. The aim of this study was to verify that laparoscopic adrenalectomy is minimally invasive and to assess the indication of laparoscopic adrenalectomy for incidentaloma. From October 1995 through August 2002, 133 patients underwent adrenal surgery at the Department of Surgery II, Nagoya University School of Medicine. Of these, 111 underwent laparoscopic adrenalectomy. All laparoscopic adrenalectomies were performed using the transabdominal lateral approach. In 50 of 133 patients, the adrenal tumours were incidentally discovered. There were 27 non-functioning adrenal tumours and six of seven preclinical Cushing's test syndrome cases incidentally discovered. Six of 27 non-functioning adrenal tumour patients underwent open adrenalectomy because of large tumour size or malignancy. Based on the present criteria for laparoscopic adrenalectomy, 15 of 133 patients were retrospectively considered to have required open adrenalectomy. The average size of a non-functioning adrenal tumour was 5.8 cm in diameter, which was equal to the average size of a phaeochromocytoma. A simultaneous bilateral laparoscopic adrenalectomy was performed in a patient in poor condition with advanced Cushing's syndrome due to adrenocorticotrophic hormone-independent macronodular adrenocortical hyperplasia (AIMAH). The adrenal glands were successfully removed without fragmentation in this patient, and the postoperative course was uneventful, thanks to the minimally invasive surgery. The laparoscopic technique assures less morbidity and faster recovery, and appears to be equally effective in eradicating functioning and non-functioning adrenal masses. The benefits of the laparoscopic approach to adrenalectomy should not result in a more aggressive attitude toward the excision of clinically silent, benign-appearing adrenal incidentalomas.

Inhibition of NF-kappaB activity decreases the VEGF mRNA expression in MDA-MB-231 breast cancer cells.

VEGF (vascular endothelial growth factor) secreted from tumor cells including breast cancer serves as a potent angiogenic factor which favors tumor growth and metastasis. Indeed, a higher concentration of serum VEGF has been shown to associate with a poorer prognosis in patients with breast cancer. On the other hand, constitutive expression of a transcription factor, NF-kappaB was correlated with progression and metastasis in a number of human breast cancers, suggesting a possible regulation of VEGF expression by NF-kappaB. We thus investigated the relationship between the expression of VEGF and constitutive NF-kappaB activity in three breast cancer cell lines, MCF-7, T47D, and MDA-MB-231. The basal levels of VEGF mRNA expression correlated with those of nuclear NF-kappaB activity in these cell lines. The highest NF-KB activity in MDA-MB-231 cells was associated with the highest expression of VEGF mRNA, while the activity and the mRNA levels were moderate in MCF cells and the lowest in T47D cells. In MDA-MB-231 cells, inhibition of NF-KB by adenovirus-mediated expression of a dominant negative NF-kappaB or by a proteasome inhibitor, MG132, decreased the VEGF mRNA. These results suggest that NF-kappaB is involved in the upregulation of VEGF mRNA and inhibition of the activity could be a new approach for the treatment of breast cancer by preventing angiogenesis.