A rare case of intrahepatic cholangiocarcinoma with tumor thrombus in the bile duct.

Intrahepatic cholangiocarcinoma (ICC) is a refractory liver malignancy; however, as its histological characteristics have been clarified, a good operative strategy for the subtypes of ICC can be expected. A 72-year-old woman was diagnosed with a large primary liver cancer with biliary tumor thrombus (BTT) and obstructive jaundice. An enhanced imaging modality showed hypervascular ICC or combined hepatocellular carcinoma (HCC). As her liver functional parameters permitted major hepatectomy, preoperative biliary drainage was performed, followed by a radical left hepatectomy accompanied by tumor thrombectomy with D2 lymphadenectomy. During the operation, the BTT was found to have widely spread into the right hepatic duct and the common bile duct and was histologically diagnosed as an adenocarcinoma. As ductal cancer invasion was not macroscopically observed, the planned operation was completed. The postoperative histological diagnosis was determined by discussion to be a rare mass-forming ICC with BTT. Her postoperative course was uneventful, and a 1-year survival without tumor relapse was observed with adjuvant chemotherapy. In the field of biliary surgery, although advanced ICC still has a poor prognosis, curable surgical intervention is possible for specific findings, such as BTT and HCC with BTT.

A case of spontaneous hemopneumothorax in which the condition worsened after chest drainage.

A 45-year-old woman was referred to our hospital with sudden chest pain. She came on foot with normal vital signs. Computed tomography (CT) revealed right mild pneumothorax with niveau level. We suspected spontaneous hemopneumothorax (SHP) and inserted a thoracic drain. After 800 ml of blood and air was evacuated immediately, the outflow from the drain stopped. However, despite the outflow of blood from the drainage tube having stopped, she developed hemorrhage shock 2 h after drainage. Contrast-enhanced CT revealed extra-vascular signs at the top of the right pleural cavity. Emergency video-assisted thoracic surgery (VATS) was performed. We identified the chest drain as being obstructed by blood clot. Continuous bleeding from a small aberrant vessel at the top of the thoracic cavity was identified, and we stanched it easily by clipping. The present experience suggests that routine enhanced CT and aggressive emergent VATS should be performed in cases of SHP.

[Aortic Root Reimplantation for Extra-cardiac Unruptured Sinus of Valsalva Aneurysm].

Aneurysms of the sinus of Valsalva are rare. We report a case of extra-cardiac unruptured aneurysm of the sinus of Valsalva with moderate aortic regurgitation (AR). A 57-year-old woman was referred to our institution because of AR. Echocardiography showed moderate AR and computed tomographic scanning demonstrated an extra-cardiac aneurysm of the unruptured sinus of Valsalva, which extended from the right sinus of Valsalva to the non-coronary sinus of Valsalva. She underwent aortic root reimplantation procedure with a Valsalva graft. Although mild AR was observed postoperatively, her postoperative course was uneventful.

Posterior mediastinal ganglioneuroma with peripheral replacement by white and brown adipocytes resulting in diagnostic fallacy from a false-positive 18F-2-fluoro-2-deoxyglucose-positron emission tomography finding: a case report.

INTRODUCTION: Ganglioneuroma is a rare tumor in the posterior mediastinum; fat-containing ganglioneuromas are rarely reported. The present case report documents a brown fat-containing, posterior mediastinal ganglioneuroma, which has not been reported previously. Radiological examination, in particular 18F-2-fluoro-2-deoxyglucose-positron emission tomography, suggested that the tumor had low-grade malignant potential. This led to uncertainty at preoperative diagnosis. CASE PRESENTATION: An asymptomatic 66-year-old Japanese woman with no significant past medical history was referred for the evaluation of a posterior mediastinal mass. Although its size had not changed in the past 5 years, a malignant lipomatous tumor could not be excluded due to the presence of intratumoral fat and increased 18F-2-fluoro-2-deoxyglucose uptake observed by positron emission tomography imaging. A computed tomography-guided core-needle biopsy revealed a mixture of mature adipocytes, spindle-shaped cells, and fibrotic stroma. Definite diagnosis was not possible, and surgical resection was performed. Three years after the surgery, she remains disease-free. CONCLUSIONS: Histological diagnosis of the surgically resected mass confirmed ganglioneuroma with substantial amounts of white and brown adipose tissues in peripheral areas. The existence of both ganglion cells and brown fat tissue intensified the accumulation of 18F-2-fluoro-2-deoxyglucose, resulting in a false-positive result by positron emission tomography. Considering this, ganglioneuroma should not be excluded either clinically or pathologically in fat-containing, posterior mediastinal tumors.

[A case of long-term survival after low-dose FP systemic chemotherapy for a tumor thrombus in the inferior caval vein and multiple lung metastases from recurrent hepatocellular carcinoma].

We report a case of long-term survival of a patient who received low-dose 5-fluorouracil and cisplatin (FP) systemic chemotherapy and underwent partial resection of the lung for a tumor thrombus in the inferior caval vein (IVC) and multiple lung metastases from recurrent hepatocellular carcinoma (HCC). The patient was a 66-year-old man who was admitted to our hospital for the treatment of a 13-cm liver tumor. He underwent an extended posterior sectionectomy of the liver. Pathological diagnosis revealed moderately differentiated hepatocellular carcinoma (vp1, vv1, sm[-, 1.5mm], ch, T3N0M0, stage III). At 3 months postoperatively, computed tomography (CT) revealed a tumor thrombus in the IVC and multiple (>20) lung tumors that were considered HCC recurrences. Low-dose FP systemic chemotherapy was initiated, and the tumors reduced in size. However, a new lesion in the left lung was detected at 13 months postoperatively. Thoracoscopyassisted resection of the tumor that was histologically diagnosed as an HCC metastasis was performed at 26 months postoperatively. The patient is cancer free at 46 months postoperatively. Therefore, low-dose FP systemic chemotherapy is one of the therapeutic options for the treatment of HCC recurrences of IVC tumor thrombi and multiple lung metastases. However, the occurrence of new lesions should be carefully monitored.

[Parasternal approach for anterior apical lung cancer with invasion of the first rib].

For complete resection of anterior apical invasive lung cancer, it is of clinical significance to select the appropriate surgical approaches based on the anatomic location of the tumor and extent of invasion of adjacent anatomic structures. However, patients with anterior apical lung cancer without vessel invasion are occasionally burdened with unnecessarily excessive surgical invasion. We present 2 cases of anterior apical lung cancer invading the 1st rib but not subclavian vein, who underwent complete resection through the parasternal approach. We also discuss the feasibility of this approach.

Preoperative neutrophil to lymphocyte ratio as a prognostic predictor after curative resection for non-small cell lung cancer.

BACKGROUND: The prognostic impact of neutrophil to lymphocyte ratio (NLR) in non-small cell lung cancer (NSCLC) was examined using patients with a follow-up period more than 5 years. PATIENTS AND METHODS: Two hundred and eighty four consecutive resected NSCLC patients were reviewed retrospectively. In this study, patients who were treated with a follow-up period less than 5 years were omitted, RESULTS: The mean value of NLR was 2.44±2.22 (range: 0.56-29.44). The 5-year survival of the patients with a high NLR (≥2.5) was significantly worse than that of the patients with a low NLR (47.06% vs. 67.84%, p<0.0001). Univariate analysis of the clinicopathological factors affecting survival revealed that age, gender, histology, pT status, pN status, high serum CEA level, positive findings of pleural lavage cytology and high NLR were significant risk factors for reduced survival. On multivariate analysis, a high NLR was an independent risk factor for reduced survival. CONCLUSION: A high preoperative NLR may be a convenient biomarker to identify patients with a poor prognosis after resection for NSCLC.

Bronchial flap closure of the lower membranous trachea.

A novel method for closure of the lower membranous trachea after right pneumonectomy using a flap derived from the cartilaginous portion of the right main bronchus is described in this study. This technique was used successfully in patients with tracheal stenosis due to a giant posterior mediastinal tumor known as schwannoma. Because of the severe tracheobronchial stenosis and destroyed right lung, tumor resection combined with resection of the lower membranous trachea and right pneumonectomy was carried out. We closed the defect in the membranous lower trachea with the flap derived from the right main bronchus. The clinical course was uneventful.

Postoperative serum C-reactive protein levels in non-small cell lung cancer patients.

PURPOSE: The significance of the postoperative serum C-reactive protein (CRP) level as a prognosis indicator was evaluated in patients with non-small cell lung cancer (NSCLC). PATIENTS AND METHODS: A total of 276 patients who had undergone a curative resection of NSCLC were retrospectively reviewed. RESULTS: The overall and disease-specific survival rates in the postoperative CRP/high group (≥ 0.5 mg/dL at 30 days postoperation: n = 130) were significantly lower than those in the postoperative CRP/low group (< 0.5 mg/dL at 30 days postoperation: n = 146). However, based on a multivariate analysis, the postoperative CRP level was not among the unfavorable indicators regarding survival. The patients were divided into two groups, namely, the preoperative CRP/low group (n = 231) and the CRP/high group (n = 45). The proportion of the postoperative CRP/low group (60.2%) in the preoperative CRP/low group was significantly lower than that in the preoperative CRP/low group (15.6%; p <0.0001). No significant difference was observed in the disease-specific survival rates in the postoperative CRP/high group and the postoperative CRP/low group in either the preoperative high/group or low/group. CONCLUSIONS: The overall and disease-specific survival rates in the postoperative CRP/high group were significantly lower than that in the postoperative CRP/low group. This difference may be associated with the relationship between the pre- and postoperative CRP levels.

Prognostic significance of tumour marker index based on preoperative CEA and CYFRA 21-1 in non-small cell lung cancer.

BACKGROUND: Prognostic impact of tumour marker index (TMI) based on preoperative serum carcinoembryonic antigen (CEA) and CYFRA 21-1 in non-small cell lung cancer (NSCLC) was examined using patients with a follow-up period more than 5 years. PATIENTS AND METHODS: Two hundred and ninety-three consecutive NSCLC patients were reviewed retrospectively, and any patients with follow-up periods less than 5 years were omitted. RESULTS: The 5-year survival of the patients with normal and high serum CEA levels was 71.52% and 48.41%, respectively (p<0.0001). The 5-year survival of the patients with a high serum CYFRA 21-1 level was 39.66%, which was significantly poorer compared with that of the patients with a normal serum CYFRA 21-1 level (66.95%, p<0.0001). There was a 5-year-survival rate of 72.28% in patients with a TMI less than or equal to 1.0 compared to only 37.08% in patients with a TMI greater than 1.0 (p<0.0001). Both univariate and multivariate analyses indicated the independent prognostic impact of TMI. CONCLUSIONS: TMI may be useful for predicting the prognosis of NSCLC patients.

[A case of advanced gastric cancer with liver metastases successfully treated by combination therapy of TS-1 and docetaxel].

The patient was a 70-year-old man who was diagnosed inoperable because of liver metastases of advanced gastric cancer and his respiratory dysfunction. He received docetaxel at the starting dose of 40 mg/m(2) by iv infusion over 1 hour on day 1 and TS-1 at the full dose of 80 mg/m(2) daily for two weeks every three weeks. After 6 cycles of this combination therapy, gastric cancer with liver metastases entirely disappeared. No re-growth of gastric cancer has been seen for three years with chemotherapy of TS-1. This chemotherapy shows a high degree of safety and efficacy in this patient.