Progressive atrophy in a deformed liver as a contributor to sigmoid volvulus.

The effect of a prior defect on secondary liver atrophy is unknown. We describe a case of sigmoid volvulus that was facilitated by progressive atrophy in a deformed liver. A 75-year-old man with abdominal pain and fullness was referred to our hospital. Computed tomography (CT) revealed reduced left hepatic lobe volume and a whirl sign, characteristic of sigmoid volvulus. The sigmoid volvulus was successfully detorted with endoscopy. Retrospective evaluation of liver morphology on CT and magnetic resonance imaging showed that the portal vein at the liver hilum was denuded due to a parenchymal defect of the medial segment, with compression by the crossing artery. As pulse Doppler ultrasonography demonstrated reduced portal blood flow in the region where liver atrophy developed, compression of the denuded portal vein presumably facilitated secondary atrophy and contributed to sigmoid volvulus. The present case shows that a deformed liver itself can be a cause of secondary atrophy. Therefore, continued monitoring of liver morphology and evaluation of portal blood flow to predict liver atrophy may be required, when an individual with a partial liver defect is encountered.

Chemoprevention of esophageal adenocarcinoma in a rat model by ursodeoxycholic acid.

Reflux of bile acid into the esophagus induces esophagitis, inflammation-stimulated hyperplasia, metaplasia such as Barrett's esophagus (BE), and esophageal adenocarcinoma (EAC). Caudal-type homeobox 2 (Cdx2) via nuclear factor (NF)-κB induced by bile acid is an important factor in the development of BE and EAC. In colorectal cancer, experimental data suggest a chemopreventive effect of ursodeoxycholic acid (UDCA). We hypothesized that UDCA may protect against the esophageal inflammation-metaplasia-carcinoma sequence by decreasing the overall proportion of the toxic bile acids. Wistar male rats that underwent a duodenoesophageal reflux procedure were divided into two groups. One group was given commercial chow (control group), and the other was given experimental chow containing UDCA (UDCA group). The animals were killed at 40 weeks after surgery, and their bile and esophagus were examined. In the UDCA group, the esophagitis was milder and the incidence of BE was significantly lower (p < 0.05) than in the control group, and EAC was not observed (p < 0.05). In analysis of the compartment of bile acid, UDCA was markedly increased in the UDCA group compared with the control group (32.7 ± 11.4 vs. 0.82 ± 0.33 mmol/L, p < 0.05) and cholic acid was decreased (32.7 ± 4.05 vs. 60.9 ± 8.26 mmol/L, p < 0.05). Expression intensity of Cdx2 and NF-κB was greater in the control group than in the UDCA group (p < 0.05). UDCA may be a chemopreventive agent against EAC by varying the bile acid composition.

[A case of advanced colon cancer successfully treated with combination therapy of cetuximab and oxaliplatin, leucovorin, and 5-fluorouracil].

A 65-year-old woman was referred to our hospital for examination of anemia. Colonoscopy showed a type 1 tumor in the ascending colon with nearly complete stenosis that was diagnosed as a tubular adenocarcinoma. Computed tomography (CT) revealed swelling of the regional, periaortic, and celiac lymph nodes and lymphangitis carcinomatosa. The patient was diagnosed as having Stage IV ascending colon cancer, and neoadjuvant chemotherapy was administered to avoid non-curative resection. The patient was treated with cetuximab and oxaliplatin, Leucovorin, and 5-fluorouracil( mFOLFOX6) combination chemotherapy. After 6 courses of chemotherapy, the primary lesion and multiple lymph node swellings greatly reduced in size and lymphangitis carcinomatosa improved. Accordingly, right colectomy with D3 nodal dissection was performed. The patient was recurrence free at her 8-month follow-up examination. Neoadjuvant chemotherapy with molecular targeted drugs is useful in the treatment of patients with unresectable primary cancer.

[A case of locally advanced rectal cancer successfully treated by laparoscopic intersphincteric resection and effective neoadjuvant chemoradiation therapy].

A 74-year-old woman was diagnosed as having lower rectal cancer. Colonoscopy revealed a type 2 circular tumor over 15 cm from the port side close to the dentate line. The patient was diagnosed as having a moderately differentiated adenocarcinoma by biopsy. Computed tomography (CT) and fluorodeoxyglucose (FDG)-positron emission tomography (PET) revealed thickening of the wall from near the anus to the rectosigmoid junction and an increase in the concentration of the surrounding adipose tissue as well as swelling of the left internal iliac lymph nodes with FDG accumulation. The patient was diagnosed as having cSE, cN3, cM0, cStage IIIb rectal cancer. Because the tumor was very close to the anus with advanced extramural invasion and because the patient desired anal sphincter preservation, we performed preoperative chemoradiation therapy( CRT) combined with capecitabine plus oxaliplatin( XELOX) and bevacizumab( BV). Radiation therapy was performed with a linear accelerator( LINAC) for stereotactic radiation therapy( Novalis®). Partial response (PR) was achieved by this therapy. Five weeks after CRT, the patient underwent laparoscopic-assisted intersphincteric resection( total ISR). Pathological examination revealed minimal residual cancer cells( Grade 2, pPR, pA, N0, M0, pPM0, pDM0, pRM0, pStage II). Increased implementation of anus-preserving surgery can be expected owing to the successful control of regional and distant metastases by neoadjuvant CRT. Based on these encouraging findings, we should consider the challenges posed by neoadjuvant CRT for the treatment of lower rectal cancer.

[A case of unresectable HER2-positive advanced gastric cancer successfully treated by combination therapy with trastuzumab and paclitaxel].

A 54-year-old man was referred to our hospital for close examination and treatment of an advanced gastric cancer. Gastrointestinal endoscopic examination showed a type 3 tumor, which was diagnosed as well-differentiated adenocarcinoma, and computed tomography showed multiple enlarged liver metastases in both the lobes. He underwent gastrojejunostomy and was treated with S-1 and cisplatin combination chemotherapy. However, after 4 courses of chemotherapy, progression of disease occurred. Because the human epidermal growth factor receptor type 2(HER2) test was positive, we started trastuzumab and paclitaxel combination chemotherapy as a second-line treatment. After administration of 7 courses of trastuzumab and 5 courses of paclitaxel, the primary lesion and multiple liver metastases were greatly reduced. Trastuzumab and paclitaxel combination chemotherapy appears to be an effective treatment for HER2-positive advanced gastric cancer.

PTD classification: proposal for a new classification of gastric cancer location based on physiological lymphatic flow.

BACKGROUND: We propose a new classification for the location of gastric cancer - the PTD classification (i.e., zones P, T, and D; see below), with the zones classified according to the physiological lymphatic flow. METHODS: Three hundred and thirty-six patients with T1 or small T2 gastric cancer who underwent sentinel node mapping at our hospital were enrolled. The relationship between the location of the gastric cancer and the physiological lymphatic flow derived from sentinel node mapping was investigated. Lymphatic basins were defined as lymphatic zones divided by the stream of stained lymphatic canals. RESULTS: One hundred and forty-six patients underwent standard gastrectomy with more than D2 dissection and the other 190 patients underwent function-preserving gastrectomy with the omission of lymph node dissection outside the lymphatic basin. In the former group, the progression pattern of lymph node metastasis was observed; nodal metastasis occurred in sentinel nodes first, and rarely extended outside the lymphatic basin. In the latter group, none of the patients have had a recurrence. The PTD classification we propose is as follows: the dividing line between the proximal region (zone P) and the transitional region (zone T) is the line that links the point of the watershed between the left gastroepiploic artery and right gastroepiploic artery, to the point that is the inflow point of the first descending branch of the left gastric artery; and the dividing line between zone T and the distal region (zone D) is an arc at a radius of 8 cm from the pylorus. There were no lymphatic basins within the right gastric artery area for tumors located in zone T. CONCLUSION: The advantage of the PTD classification is that if the PTD classification were to be used as a guide for gastric resection procedures, preservation of the pylorus would become possible without diminishing the prognosis in patients with cT1N0 cancer located in zone T.