Late recurrence of low-risk gastrointestinal stromal tumor of jejunum diagnosed 30 years after tumor resection: A case report and literature review.

Gastrointestinal stromal tumors (GISTs) have a significant risk of metastasis, although the degree varies in each case. The present report describes a case of late recurrence of GIST that was diagnosed 30 years after the primary tumor resection. An 80-year-old man was transported to Sanjo General Hospital (Sanjo, Japan) with hemorrhagic shock from gastrointestinal bleeding. Abdominal contrast-enhanced computed tomography revealed an 11.7-cm heterogenous tumor in the retroperitoneum adjacent to the third portion of the duodenum. The patient had a medical history of resection of 'leiomyoma' of the upper jejunum when he was 50 years old. Pathological examination using archival pathological samples revealed that the previously excised tumor was GIST because the tumor cells showed positive immunoreactivity for KIT and DOG1. Treatment was started with imatinib, a selective KIT tyrosine inhibitor, even though endoscopy failed to provide biopsy specimens. Positron emission tomography conducted on the 28th treatment day revealed that imatinib completely shut down 18F-fluorodeoxyglucose uptake in the tumor, confirming that the tumor was imatinib-sensitive. A literature review yielded 12 GIST cases wherein metastases were diagnosed >10 years after primary tumor resection. Of the 12, four were originally diagnosed as benign. Clinicians should keep in mind that GISTs were formerly confused with non-GIST tumors and that there is a risk of relapse 10 years or later after curative surgery.

Conversion surgery for stage IV gastric cancer: a multicenter retrospective study.

BACKGROUND: Recent improvements in systemic chemotherapy have provided an opportunity for patients with stage IV gastric cancer (GC) to undergo conversion surgery (CS). The aim of this study was to evaluate the long-term outcomes of patients who underwent CS and to elucidate the prognostic factors for CS in stage IV GC. METHODS: A total of 79 patients who underwent CS with the aim of R0 resection for stage IV GC at six institutions from January 2008 to July 2019 were enrolled. We retrospectively reviewed the clinicopathological data and prognosis. RESULTS: Of the 79 patients, 23 (31.1%) had initially resectable disease (IR) before chemotherapy, defined as positive for cancer on peritoneal cytology (CY1), resectable hepatic metastasis, or para-aortic lymph node No. 16a2/b1 metastasis. Of the 56 remaining patients with primary unresectable disease, 39 had peritoneal dissemination. R0 resection was accomplished in 63 patients (79.7%). The 3-year OS rates for patients with IR and unresectable disease were 78.3% and 44.5%, respectively. Multivariate analysis showed that IR (P = 0.014) and R0 (P = 0.014) were statistically significant independent prognostic factors for favorable OS. Among patients with peritoneal dissemination alone, OS was significantly better for patients with R0 resection than for patients with R1/2 resection, with the 3-year OS rates of 65.5% and 23.1%, respectively (P = 0.011). CONCLUSIONS: CS is a treatment option for selected patients with stage IV GC. Patients with IR and patients who achieve R0 resection may obtain a survival benefit from CS.

[A Case of Ascending Colon Cancer with Essential Thrombocythemia].

Essential thrombocythemia(ET)is a rare myeloproliferative disorder characterized by thrombocytosis and a risk of thrombotic and hemorrhagic events. ET rarely occurs simultaneously with colorectal cancer. Including our case, only 5 cases of c o l orectal cancer with ET have been reported in Japan. Herein, we report a case of colon cancer in an ET patient who underwent laparoscopic right hemicolectomy. Our perioperative management avoided complications such as thrombosis or bleeding. An 81-year-old woman developed bloody stools. She was previously diagnosed with ET 9 years ago. Aspirin, cilostazol, and hydroxyurea(HU)were prescribed. Colonoscopy revealed a tumor at the ascending colon. Histopathological examination showed a well-differentiated tubular adenocarcinoma. Since the patient had anemia, aspirin and cilostazol were discontinued after diagnosis. HU was discontinued from the day before surgery to 2 days after surgery. Enoxaparin was subcutaneously administered for 1 to 3 days after surgery. Aspirin and cilostazol were resumed on the fourth day post-surgery. The patient could be discharged when her condition stabilizes with no thrombosis and bleeding after 8 days.

Gastric adenosquamous carcinoma producing granulocyte-colony stimulating factor: a case of a rare malignancy.

BACKGROUND: A gastric adenosquamous carcinoma (ASC) that produces granulocyte-colony stimulating factor (G-CSF) is an uncommon malignancy with a poor prognosis. Due to the rarity of this lesion, a standard treatment for the disease has not been established. CASE PRESENTATION: We describe a case of a 66-year-old male with a G-CSF-producing gastric ASC who presented with severe anemia and leukocytosis. A radical resection was performed, followed by a course of adjuvant chemotherapy. Histopathologic examination revealed that the tumor consisted of areas of both squamous cell carcinoma and adenocarcinoma. Immunohistochemical staining with an anti-G-CSF antibody was also positive. He was started on adjuvant capecitabine and oxaliplatin (CapeOX) 6 weeks after surgery. The patient stopped treatment after 3 months due to his own preference. Eight months following surgery, the patient was found to have diffuse lymph node, liver, and peritoneal metastases. CONCLUSIONS: G-CSF-producing gastric ASC is a rare and aggressive tumor. Because patients are usually diagnosed at an advanced stage, multidisciplinary evaluation and innovative treatments are needed. The rarity of this disease, with its aggressive features, poses a significant challenge in its treatment. In this brief case report, we summarize the management and outcomes of G-CSF-producing gastric ASC.

Prognostic factors after imatinib secondary resistance: survival analysis in patients with unresectable and metastatic gastrointestinal stromal tumors.

BACKGROUND: Patients undergoing imatinib therapy for gastrointestinal stromal tumors (GISTs) show drug resistance during treatment in the late stages. The aims of this study were to determine survival after the appearance of imatinib secondary resistance (ISR) and to identify the prognostic factors. METHODS: Eligible were patients with unresectable and metastatic GISTs who were diagnosed with ISR and/or underwent treatment for ISR in our institution between 2001 and 2012. A total of 48 patients were enrolled and overall survival was retrospectively analyzed. The Cox proportional hazards model was used to identify the independent prognostic factors. Median follow-up time was 58 months. RESULTS: As of the cutoff date, 41 of the 48 patients with ISR had died, of which 39 died of GISTs. The overall 1-, 3-, and 5-year survival rates of the 48 patients were 64.6, 32.8, and 20.4 %, respectively, and median survival time was 22 months. The favorable independent prognostic factors identified were long progression-free survival in first-line imatinib therapy (P = 0.04), small diameter of progressive disease (PD) (P = 0.02), and surgical resection of PD (P = 0.01). CONCLUSION: Surgical resection of PD in selected cases could improve prognosis in ISR patients undergoing GIST treatment.

Potential drug interaction between warfarin and linezolid.

OBJECTIVE: Warfarin is known to interact with many drugs; however, there are currently no descriptions of an interaction with linezolid in the literature. It was recently brought to our attention, however, that several warfarin-medicated patients have experienced an increase in the prothrombin time international normalized ratio (PT-INR) following the administration of linezolid. We therefore performed a retrospective survey in order to investigate the possibility of an interaction between warfarin and linezolid. METHODS: The survey items included age, gender, underlying disease, type of surgery, type of infectious disease, duration of linezolid administration, laboratory values and the dose of warfarin. The PT-INR was observed over time before treatment and at days 4 or 5 and 10, completion and one week after the end of concomitant therapy. Patients The subjects included six patients who were recovering from recent heart-related surgery. RESULTS: The PT-INR increased from 1.62±0.32 before concomitant linezolid administration to 3.00±0.83 at day 4 or 5 after concomitant administration (p<0.01) and significantly decreased from 1.65±0.45 at the completion of the regimen to 1.26±0.1 one week later (p<0.05). With respect to the relationship between the dose of warfarin and the PT-INR in five cases, the PT-INR increased following concomitant linezolid treatment in all cases. CONCLUSION: Although it has been reported that linezolid does not influence the metabolism or protein binding of warfarin, our data showed potential drug interactions between warfarin and linezolid. Our data suggest that PT-INR monitoring after the completion of concomitant warfarin and linezolid therapy is important.

[Surgical Resection after Chemotherapy for Ampullary Carcinoma with Synchronous Liver Metastasis--Report of a Case].

A 63-year-old woman presented with abnormalities in liver enzyme levels on laboratory studies, which were detected during a routine medical check-up. She was diagnosed with carcinoma of the ampulla of Vater with a synchronous solitary liver metastasis (S7). She was treated with gemcitabine plus S-1. After 2 courses of the chemotherapy, computed tomography revealed that the primary and metastatic tumors had not changed in size, but new lesions had not appeared. A pylorus-preserving pancreaticoduodenectomy and partial resection of the liver (S7) were performed. She received gemcitabine monotherapy for 1 year and she remains alive and well with no evidence of disease 2 year 10 months after resection.

Telmisartan, a partial agonist of peroxisome proliferator-activated receptor gamma, improves impairment of spatial memory and hippocampal apoptosis in rats treated with repeated cerebral ischemia.

Telmisartan, an angiotensin type 1 receptor blocker (ARB), is used for hypertension to control blood pressure and has been shown to have a partial agonistic effect on peroxisome proliferator-activated receptor gamma (PPARgamma). Recently, the ligand of PPARgamma has been implicated in cerebroprotection due to its anti-inflammatory effect. In this study, we investigated whether telmisartan has a cerebroprotective effect on memory impairment and neuronal cell death induced by repeated cerebral ischemia. Repeated cerebral ischemia (RI: 10 min x 2) significantly induced impairment of spatial memory and hippocampal apoptosis in rats. Fourteen-day pre- and post-ischemic administration of telmisartan (0.3, 1, 3mg/kg/day, p.o.) increased the number of correct choices and reduced the number of errors made in the eight-arm radial maze task in a dose-dependent manner in RI treated rats. TUNEL-positive cells in the hippocampus CA1 areas were also reduced following 14-day administration of telmisartan (3mg/kg/day, p.o.). Seven-day post-ischemic administration of telmisartan improved spatial memory and reduced TUNEL-positive cells while 7-day pre-ischemic administration of telmisartan did not. These effects of telmisartan were inhibited by the PPARgamma antagonist, GW9662. On further experiment, 7-day post-ischemic administration of telmisartan reduced the expression of caspase-3 in the hippocampus, and this effect was also inhibited by GW9662. These results suggest that telmisartan improves memory impairment and reduces neuronal apoptosis via a PPARgamma-dependent caspase-3 inhibiting mechanism. Telmisartan, which has the unique character of having both ARB and PPARgamma agonistic effect, will be useful for preventing memory impairment after cerebrovascular disease.

Cerebroprotective action of telmisartan by inhibition of macrophages/microglia expressing HMGB1 via a peroxisome proliferator-activated receptor gamma-dependent mechanism.

Telmisartan is known to block angiotensin (Ang) II type-1 receptors (AT(1)R), and also activate peroxisome proliferator-activated receptor gamma (PPARgamma) signaling. Recently, PPARgamma has been implicated as a regulator of cellular proliferation and inflammatory responses. In the present study, we investigated the anti-inflammatory effects of telmisartan on middle cerebral artery (MCA) occlusion in mice. Telmisartan was administered orally to mice at 2h before and 2h after MCA occlusion. Infarct size was determined at 24h after MCA occlusion. In addition, cerebral blood flow (CBF) was measured during MCA occlusion. The effect of telmisartan on inflammatory markers, including Iba1 (macrophage/microglia marker) immunoreactivity and plasma high-mobility group box1 (HMGB1), was also investigated at 24h after MCA. Telmisartan significantly decreased the infarct area in dose-dependent manner without affecting CBF. Furthermore, the cerebroprotective effect of telmisartan was inhibited by GW9662, PPARgamma antagonist. Telmisartan significantly decreased the number of Iba1-positive cells expressing HMGB1 and decreased plasma HMGB1 levels. These effects were partially inhibited by GW9662. These data suggest that telmisartan may be a potential treatment for post-ischemic injury by partially inhibiting the inflammatory reaction after cerebral ischemia via a PPARgamma-dependent HMGB1 inhibiting mechanism.

Association of NKT cells and granulocytes with liver injury after reperfusion of the portal vein.

Reperfusion of the liver was conducted by clamping the portal vein for 30 min in mice, followed by unclamping. Unique variation in the number of lymphocytes was induced and liver injury occurred thereafter. The major expander cells in the liver were estimated to be natural killer T cells (i.e., NKT cells), whereas conventional T cells and NK cells increased only slightly or somewhat decreased in number and proportion at that time. Reflecting the expansion of NKT cells in the liver, a Th0-type of cytokine profile was detected in sera, and cytotoxic activity was enhanced in liver lymphocytes. In NKT cell-deficient mice including CD1d (-/-) mice and athymic nude mice, the magnitude of liver injury decreased up to 50% of that of control mice. It was also suspected that accumulating granulocytes which produce superoxides might be associated with liver injury after reperfusion. This might be due to stress-associated production of catecholamines. It is known that granulocytes bear surface adrenergic receptors and that they are activated by sympathetic nerve stimulation after stress. The present results therefore suggest that liver injury after reperfusion may be mainly caused by the activation of NKT cells and granulocytes, possibly by their cytotoxicity and superoxide production, respectively.