Malignant gastrointestinal neuroectodermal tumor presenting with small intestinal obstruction: A case report.

Malignant gastrointestinal neuroectodermal tumors (GNETs) are rare malignant mesenchymal neoplasms. To our knowledge, only 99 cases have been reported worldwide. The tumor has an aggressive malignancy, with a rapid progression. The histological features of GNET overlap with those of clear cell sarcoma, which contain Ewing sarcoma breakpoint region 1 mutation. GNETs lack melanocyte-specific markers, while clear cell sarcoma exhibits melanocytic differentiation. Various symptoms have been reported previously, and the most reported lesion is in the small bowel. The patient was a 69-year-old man who presented with abdominal pain and vomiting. Computed tomography revealed a nodule in the small bowel, which induced small intestinal obstruction. Enteroscopic images revealed a submucosal tumor. Surgery was performed, and the patient was diagnosed with GNET. Only two patients whose primary lesions were in the small intestine, including the patient in this report, have undergone enteroscopy before surgery. This is a rare case of GNET in which a patient underwent enteroscopy before surgical treatment.

Residual Carcinoma In Situ at the Ductal Stump has a Negative Survival Effect: An Analysis of Early-stage Cholangiocarcinomas.

OBJECTIVE: The aim of the study was to evaluate whether carcinoma in situ (CIS) residue at the ductal stump affects the survival of patients undergoing resection for extrahepatic cholangiocarcinoma. BACKGROUND: Positive ductal margin with CIS has been treated as a tumor-free margin from a prognostic viewpoint because several studies have reported that residual CIS foci at the ductal stump do not affect survival after resection. METHODS: Patients who underwent resection for extrahepatic cholangiocarcinoma were retrospectively reviewed. The surgical margin status was histologically divided into negative (R0), positive with CIS (R1cis), and positive with invasive cancer (R1inv). The survival and incidence of local recurrence were compared among the groups. RESULTS: Of 684 consecutive resected patients, 172 patients with early-stage (pTis-2N0M0) cholangiocarcinoma (perihilar, n = 144; distal, n = 28) were analyzed. The cumulative incidence of local recurrence in R1cis patients was higher than R0 patients (32.8% vs 4.4% at 5 years, P < 0.001) and lower than R1inv patients (50.0% at 2 years, P = 0.012). The disease-specific survival for R1cis patients was worse than for R0 patients (35.1% vs 78.7% at 5 years, P = 0.005) and better than for R1inv patients (40.0% at 2 years, P = 0.002). The uni- and multivariate analyses identified the surgical margin status as an independent prognostic factor (R1cis vs R0, relative risk 2.39, P = 0.026; R1inv vs R0, RR 10.28, P < 0.001). CONCLUSION: R1cis increases the incidence of local recurrence and shortens postoperative survival in patients with early-stage cholangiocarcinoma, although this prognostic effect was less severe compared with R1inv. R1cis should be avoided as much as possible in surgery for early-stage cancer, although it may be allowed in advanced tumors.

Cholangiocarcinoma with intraductal tubular growth pattern versus intraductal papillary growth pattern.

Intraductal neoplasms of the bile duct are macroscopically characterized by exophytic or polypoid growth patterns and have a favorable prognosis. Although some tumors with a predominantly tubular microscopic pattern have been reported, they have not been well characterized clinicopathologically. The purpose of the present study was to compare the newly recognized cholangiocarcinoma with an intraductal tubular growth pattern and cholangiocarcinoma with an intraductal papillary growth pattern and to investigate the pathological and prognostic significance of the former. This study analyzed 161 patients with tumors with exophytic or polypoid growth patterns from a large series of 733 cholangiocarcinoma cases surgically resected from January 1998 to May 2013. The study patients were divided into two groups: those whose tumors showed a predominantly tubular growth pattern (n=52) and those whose tumors exhibited a predominantly papillary growth pattern (n=109). Tubular growth pattern was associated with combined vascular resection and the absence of macroscopic mucin. Several histological indexes were significantly higher for the tubular growth pattern than the papillary one, including tubular adenocarcinoma, depth of invasion, microscopic lymphatic invasion, venous invasion, perineural invasion, and necrosis. Although the survival curves overlapped (P=0.693), the rate of liver metastasis was significantly higher for the tubular growth pattern than for the papillary one (P=0.012). Genomic DNA analysis focusing on somatic mutations in codons 12 and 13 of KRAS and codon 600 of BRAF revealed only one (4%) KRAS and no BRAF mutation among the 25 tubular cases examined. In conclusion, the tubular growth pattern exhibited differences in some histologic indexes, in addition to a higher hepatic metastasis rate and a lower KRAS mutation frequency, compared with the papillary growth pattern, but no difference in prognosis was observed. The distinctiveness of this tubular neoplasm should be further examined in the future.

Simultaneous laparoscopic colorectal resection and pulmonary resection by minithoracotomy: report of four cases.

The aim of the present study was to determine the feasibility of simultaneous resection of colorectal cancer by laparoscopy and a pulmonary lesion through minithoracotomy. Four patients underwent laparoscopic resection of colorectal cancer followed by pulmonary resection. The mean operative duration was 390 min and the mean blood loss was 133 mL. The postoperative course was uneventful. The indication for simultaneous resection of colorectal cancer by the laparoscopic approach and a pulmonary lesion is controversial. This method is safe and feasible in selected patients, but whether colorectal resection or pulmonary surgery is performed first should be determined on a case-by-case basis.

Mandatory palliative care education for surgical residents: initial focus on teaching pain management.

BACKGROUND: Knowledge concerning palliative care and the associated skills, including effective pain control, is essential for surgeons who treat cancer patients in daily practice. This study focuses on a palliative care training course that has been mandatorily conducted for all surgical residents of our hospital since 2009. METHODS: We evaluated the effectiveness of our mandatory palliative care training course by conducting a retrospective study of the patients' medical records and participants' questionnaire results and discussed the importance of palliative care education for surgical residents. RESULTS: All 12 surgical residents who participated in the course in 2009 had graduated 4-9 years back. They were assigned to look after a total of 92 cases (average, 7.66 cases per resident) during the course. The purpose of care in most cases (92.3%) was to mitigate pain. Introducing analgesic adjuvants such as gabapentin or amitriptyline accounted for the largest part of initial interventions (23.9%) aimed at controlling cancer pain, followed by changes in route of administration or doses of prior opioid analgesics (21.7%). Interventions with opioid analgesics were conducted most frequently (47.7%). The overall pain improvement rate was 89.1%. We used a questionnaire after the course to evaluate its effectiveness. CONCLUSIONS: The surgical residents stated that it was a meaningful course through which they gained practical knowledge on palliative care and that the experience would change their approach to home care.

An indication for correlation between the serum ADA level and gastric cancer risk.

BACKGROUND: Gastric atrophy caused by Helicobacter pylori (H. pylori) infection is a risk factor for gastric cancer. We aimed to evaluate the relationship between gastric cancer risk and tumor markers in the general population. MATERIALS AND METHODS: A total of 688 volunteers were examined to test their serum pepsinogen (PG) levels and anti-H. pylori antibodies, in addition to a total of 22 serum tumor markers. The participants were classified into four groups according to their anti-H. pylori antibody and serum PG serological status. Accordingly, groups A and D were negative, whereas groups B and C were positive for anti-H. pylori antibodies; and groups A and B were normal, whereas groups C and D were abnormal for serum PG levels. All the blood examination results were statistically evaluated using Student's t-test among these groups. RESULTS: There were 424, 202, 50, and 12 individuals in groups A, B, C, and D, respectively. Because of the small number of participants in groups C and D, we combined these two groups. Compared to the normal group (A), a statistically significant higher in adenosine deaminase level was found in group C+D (p=0.01). CONCLUSION: This result supports a previous study indicating that adenosine deaminase is involved in the regulatory system of chronic atrophic gastritis and gastric cancer risk.

Serum levels of CA15-3, KL-6 and BCA225 are positively correlated with each other in the general population.

BACKGROUND: Carbohydrate antigen 15-3 (CA15-3), Kerbs von den Lungen (KL-6) and breast cancer antigen 225 (BCA225) are widely used tumor markers for breast and lung cancer respectively. PATIENTS AND METHODS: We analyzed 460 Japanese volunteers for 99 items on blood examination including 27 serum tumor markers. Correlations between 27 tumor markers and the other items were statistically analyzed. RESULTS: Positive correlations were identified between CA15-3 vs. KL-6, CA15-3 vs. BCA225, and KL-6 vs. BCA225, with correlation coefficients of 0.84, 0.86, and 0.79, respectively. CONCLUSION: This is the first report to show a positive correlation among these markers in the general population. All of these are recognized as belonging to the mucin family, and this might be the reason for the positive correlation.