Preoperative controlling nutritional status score predicts systemic disease recurrence in patients with resectable biliary tract cancer.

INTRODUCTION: This study aimed to evaluate the association between the preoperative Controlling Nutritional Status (CONUT) score, survival outcomes, and recurrence pattern in patients with resectable biliary tract cancer (BTC). METHODS: A total of 224 BTC patients (gallbladder, n = 69; intrahepatic bile ducts, n = 26; perihilar bile ducts, n = 72; distal bile duct, n = 57) who underwent surgery with curative intent were enrolled. The best cutoff point of the preoperative CONUT score in discriminating survival was determined using χ2 scores. The sites of recurrence were subclassified as locoregional or distant. RESULTS: Patients were subdivided into the CONUT-low (score ≤ 3, n = 156) and the CONUT-high (score > 3; n = 68) groups. In-hospital mortality occurred more frequently in the CONUT-high group than in the CONUT-low group (7.4% vs. 1.3%; p = 0.028). A high preoperative CONUT score was independently associated with worse overall survival (hazard ratio [HR] 1.906, p = 0.001), worse disease-specific survival (HR 1.840, p = 0.006), and worse recurrence-free survival (HR 1.680, p = 0.005). Recurrence developed in 110 (49.1%) patients. A high preoperative CONUT score was independently associated with a higher risk of distant recurrence (HR 2.245, p = 0.001), but not locoregional recurrence. The incidences of distant recurrence at 5 years were 55.4% and 34.2% in the CONUT-high and CONUT-low groups, respectively (p = 0.001). CONCLUSIONS: The preoperative CONUT score independently predicts survival outcomes and may serve as a surrogate marker of aggressive systemic disease recurrence in patients with resectable BTC.

[Total Remnant Pancreatectomy for Remnant Pancreatic Carcinoma after Pancreaticoduodenectomy-A Report of Two Cases].

We report 2 cases of total remnant pancreatectomy for remnant pancreatic carcinoma after pancreaticoduodenectomy (PD). Case 1 pertained to a 51-year-old man who underwent PD for pancreatic carcinoma(pT3N0, R0). Twenty-seven months later, he developed a remnant pancreatic cancer. Total remnant pancreatectomy was performed, but he died due to liver and lung metastases 27 months after the second surgery. Case 2 pertained to a 58-year-old women who underwent PD for papilla of Vater cancer(pT1N0, R0). Eight-four months later, she developed remnant pancreatic cancer, for which total remnant pancreatectomy was performed. She died due to liver metastasis 8 months after the second surgery. Pathological findings revealed recurrent carcinoma in both cases and carcinoma in situ with extensive intraductal growth to the branch in case 2. Both cases had no complications after total remnant pancreatectomy and achieved good quality of life(QOL). Longterm follow up after pancreatectomy is necessary for early diagnosis of remnant pancreatic carcinoma.

[A Case of Cavitary Lung Metastasis of Rectal Cancer].

We report a rare case of cavitary lung metastasis of rectal cancer, diagnosed initially as septic pulmonary embolism. A 55- year-old woman underwent emergency Hartmann's operation for perforation of the rectal cancer with multiple liver metastases. A 2 cm-sized thin-walled cavitary lesion was seen in the left upperlobe of the lung by CT, and septic pulmonary embolism was suspected. She recoverd from sepsis after intensive care treatment. Pathological diagnosis is adenocarcinoma (tub2), T3N1M1, Stage Ⅳ, she underwent chemotherapy. Serum CEA level was high preoperatively but gradually decreased to normal 4 months after the operation. Multiple liver metastases showed calcification, and the lung lesions remained unchanged on CT. She continued chemotherapy while changing the anticancer drug due to side effects. One year and 5 months after operation, lung CT showed thickened wall and spicula around the cavitary lesion. Serum CEA level was normal, SLX and NSE slightly increased and serum aspergillus antigen was positive. Bronchial lavage cytology was Class Ⅰ and scrape cytology was Class Ⅲ in bronchoscopy. Lung metastasis, primary lung cancer or aspergilloma were suspected and we performed partial lung resection. The pathological diagnosis was rectal cancer lung metastasis.

[A Case of Peritoneal Lymphomatosis Diagnosed by Laparoscopic Biopsy].

Peritoneal lymphomatosis is an extremely rare presentation of lymphoma. We report a case of peritoneal lymphomatosis diagnosed by laparoscopic biopsy. A 56-year-old female presented to our hospital with a 2-week history of increasing abdominal distension associated with anorexia and generalized weakness. Abdominal CT findings demonstrated extensive disseminated peritoneal disease with marked thickening of the peritoneal surfaces and a large omental cake with large volume ascites. The examination of blood data and cytology of ascites indicated to the diagnosis of malignant lymphoma. She was proceeded to an urgent laparoscopic biopsy for diagnosis and observed the thickening of the peritoneal surfaces and large volume ascites. Pathological and immunohistochemical examination of the omentum revealed that it was diffuse large B-cell lymphoma presented by peritoneal lymphomatosis. The patient started an immediate course of combination chemotherapy consisting of rituximab, cyclophosphamide, doxorubicin vincristine and prednisolone(R-CHOP)and no recurrence has been noted for 5 years and 10 months from first visit. The differential diagnosis for disseminated peritoneal disease is vast. Laparoscopic biopsy was minimally invasive, and useful for an urgent and accurate the diagnosis and the treatment strategy of disseminated peritoneal disease.

[Implantation Cyst at Anastomosis after Anterior Resection of the Rectum-A Report of Five Cases].

We report 5 cases of implantation cysts at anastomosis after rectal surgery. All patients underwent resection of the rectum usingthe double staplingtechnique (DST). Implantation cysts were recognized within a period of 3 months to 6 years after surgery. Abdominal CT showed cystic masses with calcification in all cases. Colonoscopy revealed submucosal tumor-like lesions in 3 cases, and serum CEA level was increased in 2 cases. In one patient with anal pain, transanal aspiration was performed; the other 4 patients are free from symptoms and are beingobserved without treatment.

[A Case of Ascending Colon Cancer with Synchronous Liver Metastases and Peritoneal Dissemination].

The patient was a 73-year-old man with ascending colon cancer and synchronous liver metastases. A right hemicolectomy with a lymph node dissection was performed for the primary lesion. The resected specimen revealed a KRAS codon 12 mutation. After 6 courses of chemotherapy with capecitabine, oxaliplatin, and bevacizumab(Bv), we performed a partial hepatectomy and resection of the peritoneal dissemination. A computed tomography(CT)scan 5 months later revealed the recurrence of the liver metastases. After 8 courses of chemotherapy with 5-fluorouracil, Leucovorin, irinotecan, and Bv, we performed a partial hepatectomy. CT scan after 13 months revealed a recurrence in the peritoneal dissemination in the Douglas pouch and the right subphrenic space; therefore, we performed a low anterior resection and resection of the peritoneal dissemination with curative intent. CT scan after 19 months revealed a recurrence in the right subphrenic dissemination, a lung metastasis, and pleural dissemination. Chemotherapy with 5-fluorouracil, Leucovorin, and Bv was administered for 2 years and 5 months. After 5 years and 9 months of the primary operation, the patient is alive. Recently, we have focused on the mechanism of multidrug resistance through NAD(P)H: quinone oxidoreductase-1(NQO1)overexpression, which can be used to determine the role of an enzyme in sensitivity to toxicity and carcinogenesis. In this case, the pathological examination of the resected specimen revealed NQO1 negative expression. In conclusion, NQO1 may play a significant role in chemotherapy resistance in colorectal cancer patients.

[A rare case report of incarceration of Lambl's excrescence of aortic valve resulting in myocardial infarction].

We report a rare autopsy case of Lambl's excrescence of the aortic valve resulting in myocardial infarction. A 50-year-old female patient was referred to our hospital, but she died 4 hours after admission due to myocardial infarction. Autopsy disclosed Lambl's excrescence of the aortic valve, which obstructed the main branch of the left coronary artery. Histologically, fibrin thrombus and bacterial flora were found on surface of Lambl's excrescence. Differential diagnosis of infected Lambl's excrescence, so called endocarditis with infected vegetation, and papillary fibroelastomais discussed with a literature review.