Frequency and prognostic impact of cachexia during drug treatment for unresectable advanced gastric cancer patients.

PURPOSE: Patients with unresectable advanced metastatic gastric cancer have a poor prognosis. This study examined the incidence and prognostic impact of cachexia during systemic drug treatment in such patients. METHODS: We enrolled patients with unresectable advanced gastric cancer who were treated with chemotherapy at Kochi Medical School from 2007 to 2020. Cancer cachexia was defined as > 5% weight loss or > 2% weight loss with a body mass index of < 20 kg/m2 within the past 6 months. Associations between clinicopathological parameters, cancer cachexia, and the overall survival were analyzed. RESULTS: Cancer cachexia occurred in 55.2% of 134 enrolled patients 6 months after chemotherapy. The incidence of cancer cachexia in initial unresectable gastric cancer was significantly higher than that in patients with recurrent cancer after curative resection. The median overall survival was significantly lower in the patients with cancer cachexia than in those without cancer cachexia at 6 months after starting systemic chemotherapy (13.7 months vs. 21.6 months, P = 0.032). Cancer cachexia at 6 months of starting treatment and CRP > 0.14 were identified as significantly associated with poor outcomes in a multivariate analysis (hazard ratio [HR] 1.339, 95% confidence interval [CI] 1.160-2.085, P = 0.019; HR 1.885, 95% CI 1.124-3.161, P = 0.016); respectively). CONCLUSIONS: Cancer cachexia was frequently observed in unresectable advanced gastric cancer patients who received chemotherapy and was useful as a prognostic factor for the overall survival.

Successful Conversion Surgery for Advanced Gastric Cancer With Multiple Liver Metastases Following Ramucirumab Plus Paclitaxel Combination Treatment.

AIM: To present the case of a patient with unresectable gastric cancer showing a remarkable effect by second-line drug treatment with ramucirumab plus paclitaxel and conversion surgery. CASE REPORT: A 68-year-old woman who was diagnosed with gastric cancer was referred to us. Esophagogastroduodenoscopy showed an ulcerated lesion with an irregular nodulated border in the lower third of the stomach, and histology of biopsied specimens indicated a poorly differentiated adenocarcinoma. Enhanced computed tomography revealed extensive invasion of the liver, and the patients was treated using S-1 plus oxaliplatin as first-line chemotherapy. Because she developed liver metastases, the treatment regimen was changed to ramucirumab plus paclitaxel as the second-line treatment. After four cycles of weekly paclitaxel with ramucirumab treatment, the liver metastases had completely disappeared. Because no other metastatic lesions in other organs were detected, we performed total gastrectomy with D2 lymphadenectomy. The macroscopic findings of the surgically resected specimen revealed an ulcerated lesion with an irregularly modulated lesion measuring 9.5×4.5 cm. Pathological analysis demonstrated a poorly differentiated adenocarcinoma in the stomach, with invasion to the liver through the serosal layer, and seven lymph node metastases. The postoperative course was unremarkable, and she received ramucirumab in combination with paclitaxel treatment. However, liver metastasis appeared at 4 months after the operation, for which she was treated with irinotecan. Although the patient continued to receive irinotecan chemotherapy for 10 months, her general condition gradually deteriorated, and she was started on best supportive care 13 months after conversion surgery. CONCLUSION: Conversion surgery may prolong survival not only through first-line but also second-line treatments in selected patients with unresectable advanced gastric cancer; however, assessments of additional cases and further studies are required to establish this treatment strategy.

Infectious complications after tracheoplasty for congenital tracheal stenosis: a retrospective comparative study.

PURPOSE: The factors related to infectious complications after tracheoplasty for congenital tracheal stenosis (CTS) remain unclear; we, therefore, assessed these factors in this study. METHODS: We divided 47 patients who underwent slide tracheostomy and tracheal resection for CTS between May 2016 and December 2020 into an infected group and a non-infected group. Their characteristics were compared between groups. Results are presented as the median (range) or incidence. RESULTS: Infectious complications were observed in 12 patients (25.5%). Empyema and mediastinitis were seen in 5 cases (10.6%). There was a significant difference in the following factors in the infected and non-infected groups, respectively: weight, 5457 (2868-20,750) g and 6554 (2275-20,800) g (p = 0.025); surgical time, 575.5 (313-646) min and 349 (270-651) min (p < 0.001); extracorporeal circulation time, 303.5 (186-610) min and 216 (117-478) min (p = 0.001); and postoperative intubation time, 13 (7-28) days, and 6 (5-22) days (p < 0.001). Age, malnutrition, cardiovascular comorbidities, and preoperative methicillin-resistant Staphylococcus aureus detection were not significantly different between the two groups. CONCLUSION: There were a few serious infectious complications and no perioperative deaths. Attention should be paid to low body weight, long surgical and extracorporeal circulation time, and intubation time in relation to infectious complications.

Histological features of complete tracheal rings in congenital tracheal stenosis.

PURPOSE: Congenital tracheal stenosis is a disease in which complete tracheal cartilage rings (CTCR) cause airway narrowing. Although tracheal cartilage malformation has been suggested as a cause of CTCR, no histological studies have been performed. Here, we report a comparison of the tissues from CTCR and normal tracheal cartilage. METHODS: Thirty-one infants who underwent slide tracheoplasty at our institution from May 2016 to August 2019 were included. Tissues from ten autopsy cases without tracheal lesions were used as controls. The survey items were tracheal cartilage cell density, cartilage thickness, and chondrocyte findings. RESULTS: The median cartilage cell density from cases was 23/125 × 125 µm2 and from controls was 23.5/125 × 125 µm2 (p = 0.90). The median cartilage thickness from cases was 689 µm and from controls was 840 µm (p = 0.11). Comparing the ventral and dorsal sides of the CTCR tissues, the cell density was significantly different (median ventral 23/125 × 125 µm2; median dorsal 19.5/125 × 125 µm2; p = 0.034). There were no significant findings in the chondrocytes of the CTCR tissues. CONCLUSION: CTCR tissues did not differ in cartilage density and thickness from normal tracheal cartilage.

Laparoscopic cholecystectomy for gallbladder torsion in a 3-year-old child.

BACKGROUND: Gallbladder torsion is a congenital abnormality of the gallbladder and is a rare cause of acute abdomen. Although gallbladder torsion is a life-threatening condition requiring emergency surgery, laparoscopic cholecystectomy for gallbladder torsion in pediatric patients has seldom been reported. CASE PRESENTATION: A 3-year-old boy with abdominal pain and vomiting was admitted to our hospital. He was diagnosed with acute cholecystitis through abdominal ultrasound and computed tomography, and he received antibiotics. Two days after admission, a repeat abdominal ultrasound revealed exacerbation of gallbladder wall thickness and lack of intramural blood flow, which led to a diagnosis of gallbladder torsion. Emergency laparoscopic cholecystectomy was performed, and the gallbladder was twisted counterclockwise at 270°. After an uneventful course of intraoperative and postoperative treatment, the patient was discharged on postoperative day 6. CONCLUSION: Laparoscopic cholecystectomy for gallbladder torsion was safely performed in a pediatric patient.

AFP-L3 as a Prognostic Predictor of Recurrence in Hepatoblastoma: A Pilot Study.

The α-fetoprotein (AFP) level is a sensitive biomarker of active hepatoblastoma (HB). This study aimed to clarify whether the Lens culinaris agglutinin A-reactive fraction of AFP (AFP-L3) after complete resection is a prognostic predictor of HB recurrence. Fourteen HB patients who underwent complete resection of HB were divided into the recurrence group (RG, n=4) and the non-recurrence group (NRG, n=10). The AFP level and AFP-L3 before and after radical surgery were compared between the 2 groups. There was no significant difference in AFP levels in the early postoperative period between the 2 groups (P=0.54), and AFP was not an early prognostic factor for HB recurrence. At 2 months after surgery, the AFP-L3 fell below the detection limit only in the NRG (7/10 cases) (NRG=70.0% vs. RG=0%, P=0.03). In addition, there were some cases of recurrence in those whose AFP level decreased to the normal range, but none in those whose AFP-L3 fell below the detection limit. In conclusion, the AFP-L3 decreased earlier than did the AFP level; thus, the AFP-L3 after complete resection may be a predictor for HB recurrence.

Correction to: Two infant cases of intraperitoneal arterial hemorrhage due to a duplication cyst: a case report.

An amendment to this paper has been published and can be accessed via the original article.

Two infant cases of intraperitoneal arterial hemorrhage due to a duplication cyst: a case report.

BACKGROUND: Intraperitoneal arterial hemorrhage without trauma is extremely rare. We report two infant cases of intraperitoneal arterial hemorrhage due to intestinal duplication. CASE PRESENTATION: In case 1, a 2-month-old girl experienced sudden intraperitoneal hemorrhage from the middle colic artery with no apparent trauma. Hemostasis was achieved with suturing of the hemorrhage point, but the cause of hemorrhage was still unknown. Computed tomography after the first operation revealed a duodenal duplication cyst and a pseudopancreatic cyst. Percutaneous drainage of the pseudopancreatic cyst was performed, and the contents had high pancreatic amylase. As the size of the duodenal duplication cyst also decreased with this drainage, we suspected that the duodenal duplication cyst was connected to the pseudopancreatic cyst and the arterial hemorrhage. We hypothesized that the pancreatic juice inside the duplication cyst leaked into the intraperitoneal cavity and caused rupture of the arterial wall. Therefore, marsupialization of the duodenal duplication was performed to evacuate the pancreatic juice contained in the cyst toward the native duodenum. The postoperative course was uneventful. In case 2, a 6-month-old boy experienced sudden intraperitoneal hemorrhage without trauma. The hemorrhage site was identified as the ileocecal artery, and hemostasis was achieved with sutures. Tissue near the hemorrhage point was biopsied, because the cause of arterial wall rupture was still unknown. The biopsied tissue was found to be intestinal mucosa. The patient had recurrent abdominal pain after the first operation, and computed tomography showed a duplication cyst located near the hemorrhage point. Therefore, we resected the intestinal duplication. Pathology results showed that the intestinal duplication contained intestinal mucosa, ectopic gastric mucosa, and pancreatic tissue. The postoperative course was uneventful. CONCLUSION: Intraperitoneal arterial hemorrhage without trauma is an extremely rare condition, and identifying its cause is difficult. To our knowledge, this is the first report of intraperitoneal arterial hemorrhage due to intestinal duplication. In cases of unexplained intraperitoneal arterial hemorrhage in infants, intestinal duplication near the hemorrhage point should be suspected.

Lymph node retrieval after colorectal cancer surgery: a comparative study of the efficacy between the conventional manual method and a new fat dissolution method.

PURPOSE: This study compared the efficacy of two different methods for lymph node (LN) searching after colorectal cancer surgery: the fat dissolution and the conventional manual method. METHODS: For the fat dissolution method, we used a commercially available solution of collagenase and lipase (FD group). The primary endpoint was the number of identified LNs in the FD group compared to an historical control (control group) after adjusting by propensity score matching. RESULTS: Using 37 matched patients from each group, we identified 20.6 ± 7.2 LNs using the fat dissolution method compared to 13.5 ± 5.9 using the conventional method (t test, P < 0.01). Three patients in the FD group received an inappropriate LN examination in terms of number, while the number of the retrieved LNs was < 12 in 12 patients in the control group. The mean diameter of LNs without metastasis was 3.2 ± 1.9 mm in the FD group, and 40% of metastasis cases were found in LNs < 5 mm in diameter. A pathological examination confirmed that using the fat resolution method did not change the morphological or immunochemical staining findings. CONCLUSION: We demonstrated that fat dissolution had a positive impact on the number of retrieved LNs after colorectal cancer surgery without disturbing the microscopic observation.

Lymph node retrieval after dissolution of surrounding adipose tissue for pathological examination of colorectal cancer.

Examination of >12 lymph nodes (LNs) is important for the diagnostic accuracy of nodal status following resection of colorectal cancer. In the present study, the efficacy of a fat dissolution technique for LN retrieval was evaluated using resected colon and rectum mesentery. First, the resected mesentery was searched for LNs by inspection and palpation immediately after surgery. Subsequently, fat dissolution liquid was applied to the remnant fat and the LN search was repeated. The primary endpoint was whether the second assessment would increase the number of evaluated LNs. Recruitment of 20 patients was planned. The study was conducted after institutional review board approval and written informed consent was obtained. Among 20 participants, 1 patient was excluded because LN dissection was not performed. The median number of LNs identified at the first and second assessments was 13 and 6, respectively, producing a significant increase in total LNs evaluated (13 vs. 20, respectively; P<0.01; paired t-test). One positive node was identified among the additionally identified LNs (0.9%, 1/107). The second assessment increased the number of LNs assessed to >12 in 4 patients, and although staging was not changed, the treatment was potentially altered in 2 stage II patients. The maximum diameter of the additionally obtained LNs was significantly smaller compared with those from the first assessment (4 vs. 7.7 mm, respectively; P<0.01; Wilcoxon signed-rank test). After the fat dissolution technique, the tumor cells were satisfactorily stained by carcinoembryonic antigen and cytokeratin-20. In conclusion, applying fat dissolution liquid to the remnant adipose tissue of the mesentery of the colon and rectum identified additional LNs. This method should be considered when insufficient LNs are identified after conventional LN retrieval.

Factors influencing the number of retrieved lymph nodes after colorectal resection: a retrospective study from a single institute.

Accurate diagnosis of lymph node (LN) metastasis is important to determine the staging and consequent treatment of resected colorectal cancer. Therefore, factors influencing the number of retrieved LNs were explored. This study included 400 patients that underwent surgical resection for Stage 0-III colorectal cancer from 2009 to 2014 in Kochi Medical School. In all cases, surgeons retrieved the LNs within the resected mesentery immediately after the operation without fixation. Age, gender, body mass index (BMI), American Association Anesthesiologist (ASA) scores, tumor locations, maximum tumor diameters, nodal status, and pathological tumor types were extracted as patient and tumor factors. The extent of LN dissection and surgical approaches (laparoscopic or laparotomy) were extracted as operative factors. Multivariate regression analysis was performed to identify independent predictive factors for LN number retrieved, after potential influential factors were explored by univariate analysis. As results, we found that the median number of retrieved LNs was 13, ranging from 1 to 50. Approximately 60% of the patients thus received an adequate examination (LN number of 12 or more). Multivariate analysis using the remaining factors of univariate analysis identified BMI, tumor diameter, nodal status, and extent of dissection as independent predictive factors for the number of retrieved LNs (P < 0.05). If any or all these factors are present, a vigorous search for LNs using additional measures, such as visual enhancement and fat dissolution method, should be considered.

[A Case of Advanced Gastric Cancer with Liver Metastasis Treated by Curative Surgery after Chemotherapy Using S-1 plus Oxaliplatin].

A 76-year-old man was referred to our hospital with gastric cancer.Esophagogastroduodenoscopy (EGD)revealed an irregular, nodulated lesion with ulcers in the lower part of the stomach, for which biopsy specimens indicated poorly differentiated adenocarcinoma.Abdominal computed tomography(CT)showed a well-defined mass lesion measuring 5.3 cm in the posterior segment of the liver.Under the clinical diagnosis of advanced gastric cancer with liver metastasis, the patient received chemotherapy using S-1 and oxaliplatin.After 8 courses of chemotherapy, abdominal CT and EGD revealed that the size of liver metastasis was reduced to 2.3 cm. He underwent distal gastrectomy with D2 lymphadenectomy and resection of the liver metastases because there was no evidence of further metastatic lesions in any other organs after 10 courses of chemotherapy.The gross appearance of the surgically resected specimen showed a shrunk gastric tumor measuring 3.5×3.0 cm and a well-circumscribed, solid liver mass.Pathological examination confirmed the diagnosis of solid-type, poorly differentiated adenocarcinoma in the stomach that had invaded the submucosal layer with no lymph node metastasis, and necrotic change of the liver mass.The postoperative course was uneventful, and the patient has been well, receiving maintenance chemotherapy using S-1, without evidence of recurrence for 9 months following the operation.Conversion surgery following chemotherapy might be a proposed treatment for patients with advanced gastric cancer; however, further studies and assessments are needed to establish this treatment strategy.

Neurofibroma of the Gallbladder Not Associated with Neurofibromatosis.

An 82-year-old woman had visited her local clinic with a history of abdominal discomfort and dyspepsia related to meals over a period of several months. Esophagogastroduodenoscopy revealed a superficial spreading tumor that, on biopsy, was proven to be an adenocarcinoma, and colonoscopy revealed an ascending mass that was found to be an adenocarcinoma on biopsy, so the patient was referred to our hospital. Abdominal computed tomography revealed a mass in the ascending colon with regional lymph node swelling and a gallbladder stone measuring 1.5 cm in diameter. The patient underwent laparoscopy-assisted distal gastrectomy with cholecystectomy and right colectomy with regional lymph node dissection, resulting in a diagnosis of poorly differentiated adenocarcinoma invading the gastric submucosal layer and moderately differentiated tubular adenocarcinoma invading the colonic serosa with lymph node metastasis. Macroscopic examination of the gallbladder revealed a well-circumscribed, solid tumor measuring 0.3 x 0.3 cm with a firm consistency in the neck portion associated with lithiasis. Microscopic examination of the gallbladder tumor revealed infiltration of spindle-shaped neoplastic cells that were arranged in a fasciculated and woven pattern in abundant intersecting bundles. Immunohistochemical analyses were positive for S-100 protein and neurofilament. Although neurofibromas commonly occur in the superficial skin or subcutaneous region, isolated neurofibroma of the gallbladder is quite rare. To the best of our knowledge, this is only the 11th case of a neurofibroma of the gallbladder to be reported in English literature. In the present case, as in most previously reported cases, the tumor was found incidentally in the resected gallbladder following cholecystectomy for cholecystolithiasis.