Microanatomical organization of hepatic venous lymphatic system in humans.

Lymphatic fluid drains from the liver via the periportal lymphatic, hepatic venous lymphatic, and superficial lymphatic systems. We performed a postmortem study to clarify the three-dimensional structure and flow dynamics of the human hepatic venous lymphatic system, as it still remains unclear. Livers were excised whole from three human cadavers, injected with India ink, and sliced into 1-cm sections from which veins were harvested. The distribution of lymphatic vessels was observed in 5 µm sections immunostained for lymphatic and vascular markers (podoplanin and CD31, respectively) using light microscopy. Continuity and density of lymphatic vessel distribution were assessed in en-face whole-mount preparations of veins using stereomicroscopy. The structure of the external hepatic vein wall was assessed with scanning electron microscopy (SEM). The lymphatic dynamics study suggested that lymphatic fluid flows through an extravascular pathway around the central and sublobular veins. A lymphatic vessel network originates in the wall of sublobular veins, with a diameter greater than 110 µm, and the peripheral portions of hepatic veins and continues to the inferior vena cava. The density distribution of lymphatic vessels is smallest in the peripheral portion of the hepatic vein (0.03%) and increases to the proximal portion (0.22%, p = 0.012) and the main trunk (1.01%, p < 0.001), correlating positively with increasing hepatic vein diameter (Rs = 0.67, p < 0.001). We revealed the three-dimensional structure of the human hepatic venous lymphatic system. The results could improve the understanding of lymphatic physiology and liver pathology.

[A Case of Descending Colon and Rectal Cancer with Acute Myeloid Leukemia Performed Robot‒Assisted Hartmann's Procedure].

The case is a 68‒year‒old male, who had been diagnosed with acute myeloid leukemia(AML)prior to rectal cancer surgery, was referred to our hospital for treatment in July 2019. We planned to treat the AML first, and then the colorectal cancer. After completion of 1 course of CAG therapy(cytarabine, aclarubicin, G‒CSF), his white blood cell count increased sufficiently, so he underwent a robot‒assisted Hartmann operation in October. A second course of CAG therapy was started 15 days postoperatively. However, he was then diagnosed with exacerbation of the AML; remission induction therapy (daunorubicin, cytarabine)was started in November. In December, he developed a fever and abdominal pain, and on CT scan, it was discovered that an abscess had formed around the rectal resection site. Myelosuppression from AML led to prolonged sepsis; and by January 2020, the sepsis was systemic. His actual cause of death was given as circulatory failure. We report this, because only a few cases on the treatment of overlapping AML and colorectal cancers can be found in the literature.

[A Case of Stage â £ Gastric Cancer with Para-Aortic Lymph Node Metastasis, and Multiple Liver, Lung, and Bone Metastases Leading to Conversion Therapy].

We report a case of unresectable gastric cancer with para-aortic lymph node metastasis, and multiple liver, lung, and bone metastases leading to conversion therapy. A 70s-year-old man visited previous doctor with epigastralgia. He was diagnosed as stage Ⅳ gastric cancer with para-aortic lymph node metastasis, and multiple liver, lung, and bone metastases by upper gastrointestinal endoscopy, contrast enhanced computer tomography(CT), and positron emission tomography(PET). After a regimen consisting of 6 courses of capecitabine plus cisplatin plus trastuzumab, para-aortic lymph node metastasis and liver, lung, and bone metastases were absent in CT and PET images. So, he visited our department for surgery treatment. We judged curative resection could be achieved for gastric cancer. Total gastrectomy, D2 and paraaortic lymphadenectomy, and cholecystectomy were performed. The histopathological examination of the resected specimen revealed the efficacy of chemotherapy was Grade 2b. The patient was discharge 14 days after the operation, and capecitabine plus trastuzumab was started as adjuvant chemotherapy, and the patient remains alive without recurrence 11 months after surgical treatment.

Effective dissection for rectal cancer with lateral lymph node metastasis based on prognostic factors and recurrence type.

PURPOSE: There are no reports showing the significance and effective range of dissection for patients with lateral lymph node metastasis (LLNM). This study aimed to investigate the indications for lateral lymph node dissection (LLND) in patients with LLNM based on prognostic factors and recurrence types. METHODS: We reviewed 379 patients with advanced rectal cancer who were treated with total mesorectal excision plus LLND. We analyzed background factors and survival times of patients who had LLNM to determine prognostic factors and recurrence types. RESULTS: Pathological LLNM occurred in 44 (11.6%). Among patients with LLNM, the predictors of poor prognoses, according to univariate analysis, were > 3 node metastases, the presence of node metastasis on both sides, and spreading beyond the internal iliac lymph nodes. Moreover, LLNM beyond the internal iliac region was found to be an independent prognostic risk factor. Twenty-eight of the 44 patients with lateral lymph node metastasis (64%) relapsed, 22 of whom had distant metastases and 11 of whom experienced local recurrences. Among the latter group, nine (20%) and two (5%) had recurrences in the central and lateral pelvis, respectively. CONCLUSION: The therapeutic benefit of resection was high, especially in patients with ≤ 3 positive lateral lymph nodes, one-sided bilateral lymph node areas, and positive nodes localized near the internal iliac artery.

Widespread anorectal lymphovascular networks and tissue drainage: analyses from submucosal India ink injection and indocyanine green fluorescence imaging.

AIM: Abdominoperineal resection is associated with poor prognosis in patients with advanced lower rectal cancer. This study aimed to analyse the functional lymphovascular network and tissue drainage in the anorectal region. METHODS: In this descriptive study, we performed microanatomical evaluations and intra-operative imaging analysis in a cadaver and patients with rectal cancer. Specimens with India ink injection were collected from a cadaver and from six patients who underwent abdominoperineal resection. Intra-operative indocyanine green fluorescence imaging was performed on four patients who underwent surgery for lower rectal cancer. India ink was injected into the submucosa at the dentate line of specimens. Tissue sections were examined by immunohistochemistry for D2-40 and CD31. Intra-operative indocyanine green was injected into the submucosa at the dentate line. Lymph flow was traced using a near-infrared camera system. RESULTS: Fascia branching from the rectal longitudinal muscle layer extended to the posterior hiatal ligament and lateral endopelvic fascia connective tissue lamina on the surface of the levator ani muscle. The fascia contained veins labelled with ink in their lumina and initial lymphatics. Intra-operative indocyanine green fluorescence imaging revealed extensive lymph flow from the muscle layer of the anal canal to the hiatal ligament and endopelvic fascia along the longitudinal muscle layer fibres. CONCLUSIONS: The anorectal region contained widespread venous and lymphatic networks in proportion to its specific connective tissue framework around the longitudinal-muscle-layer-extending muscle bundles, which provides extensive networks for tissue fluid and cells.

A detailed pathway and termination of thoracic duct in a Japanese female cadaver with situs inversus totalis.

Although the thoracic duct (TD) requires special attention during thoracic surgery, to our knowledge, its detailed course in the situs inversus totalis (SIT) case has not been reported. We encountered an 86-year-old Japanese female cadaver with SIT during a student anatomical practice and examine the TD. The TD originated from the cisterna chyli at the level of the 2nd lumbar vertebra, ascended along with the left side of aorta and then passed behind the aortic arch on the right side of the esophagus. The TD turned right at the first thoracic vertebra and finally emptied into the basal portion of the right external jugular vein without branching. The present running pathway of the TD was approximately in the inverted position of the normal, but its connection site to the vein and manner was very rare and has not been reported to date. Therefore, this junctional anomaly may occur during the developmental period in SIT. Further anatomical and embryological studies are required, but this report provides useful morphogenetic information of the TD and lymphovenous junction in SIT.

Dual energy CT is useful for the prediction of mesenteric and lateral pelvic lymph node metastasis in rectal cancer.

The aim of the present retrospective study was to investigate the predictability of dual-energy computed tomography (DECT) for pararectal lymph node (PRLN) metastasis and lateral pelvic lymph node (LPLN) metastasis in rectal cancer (RC). The present study involved 44 patients with RC who were examined by DECT and then underwent surgery between May 2015 and September 2017. LPLN dissection was performed in 24 patients. The normalized iodine concentration (nIC), the ratio of iodine concentration in the lymph node (LN) to that in the common iliac artery on DECT, of the largest PRLN and LPLN was calculated, and the association between LN metastasis and nIC was analyzed. The median nIC value for PRLNs was significantly lower in PRLN metastasis-positive cases compared with PRLN metastasis-negative cases in the arterial phase [0.18 vs. 0.25; P=0.01; cut-off, 0.24; area under the curve (AUC), 0.733] and portal phase (0.47 vs. 0.61; P=0.03; cut-off, 0.59; AUC, 0.701). A significant difference was not identified between the median maximum short axis diameter of PRLNs in PRLN metastasis-positive and metastasis-negative cases (7.6 vs. 6.4 mm; P=0.33). The nIC for LPLNs was not significantly different between LPLN metastasis-positive and metastasis-negative cases in the arterial phase (0.15 vs. 0.21; P=0.19); but was significantly lower in LPLN metastasis-positive cases compared with LPLN metastasis-negative cases in the portal phase (0.29 vs. 0.56; P=0.04; cut-off, 0.29; AUC, 0.877). The maximum short axis diameter of LPLNs was significantly larger in metastasis-positive cases compared with LPLN metastasis-negative cases (9.1 vs. 4.8 mm; P=0.03; cut-off, 7.0 mm; AUC, 0.912). In conclusion, the nIC was identified to be significantly lower in metastasis-positive cases, which may be useful for the prediction of PRLN and LPLN metastases. A combination of size-based diagnosis and DECT may increase the accuracy of preoperative diagnosis.

[A Case of Myocardial Metastasis of Esophageal Squamous Cell Carcinoma].

Myocardial metastasis for esophageal squamous cell carcinoma(ESCC)is relatively rare and it is diagnosed as a part of widespread metastasis in the terminal stage. We experienced a case of myocardial metastasis of ESCC treated effectively with chemoradiotherapy. A 56-year-old man was diagnosed ESCC(clinical T3N2M0, Stage III). He received neoadjuvant chemotherapy of 5-fluorouracil plus cisplatin followed by subtotal esophagectomy with dissection of the 3 regional lymph nodes. The pathological diagnosis was moderate differentiated squamous cell carcinoma, CT-pT3(T3), pN1, sM0, fStage III. Four months after surgery, he had no clinical symptom, however myocardial metastasis located in the apex was detected on the follow up positron emission tomography(PET). Chemoradiotherapy was performed for the myocardial metastasis. Myocardial metastasis treated effectively with chemoradiotherapy almost disappeared on the PET and computed tomography taken 3 months after chemoradiotherapy. He died, however, of multiple liver and bone metastases 15 months after the initial surgery.

[A Case of Advanced Gastric Cancer with Peritoneal Dissemination after Gastrectomy Effectively Treated with Combination Chemotherapy of Ramucirumab and Paclitaxel].

The REGARD and RAINBOW trials revealed the effectiveness of ramucirumab(RAM)for advanced gastric cancer patients who had been previously treated with chemotherapy. In the latest Japanese gastric cancer treatment guidelines, PAM plus paclitaxel(PTX)was positioned as a second-line chemotherapy for advanced gastric cancer. We report a case of advanced gastric cancer with peritoneal dissemination after gastrectomy effectively treated with RAM plus PTX. A 66-year-old woman underwent total gastrectomy with D2 lymph node dissection, splenectomy, and distal pancreatectomy. The pathological diagnosis was poorly differentiated adenocarcinoma, pT4b(pancreas), N3b, P1, CY1, Stage Ⅳ. She was treated with postoperative chemotherapy of S-1 plus cisplatin. However, 5 months after surgery, computed tomography(CT)showed ascites and recurrence of peritoneal dissemination. Cytological examination showed adenocarcinoma cells in the ascites. She was treated with combination chemotherapy of RAM and PTX as second line chemotherapy. After 1 course of this therapy, CT revealed complete disappearance of ascites and significant reduction in the size of the peritoneal dissemination. The patient survived without progression for 8 months after the recurrence was detected.

[A Case of Complete Pathological Response of Unresectable Synchronous Colorectal Hepatic Metastasis with Icterus after FOLFOX plus Panitumumab Therapy].

A 35-year-old man was diagnosed with initially unresectable synchronous liver metastases from sigmoid colon cancer. We started FOLFOX plus panitumumab therapy. After 3courses of chemotherapy, the liver metastases became resectable. Sigmoidectomy, extended left lobectomy, and partial hepatectomy were performed. On the final histopathological analysis, all hepatic lesions were fibrotic without viable cancer cells. Nineteen months after the surgery, CT revealed isolated residual liver recurrence in segment 5. After partial hepatectomy, the patient is alive without recurrence. We report a case of pathological complete response with FOLFOX plus panitumumab therapy for initially unresectable colorectal liver metastases with icterus.

[The Impact of Neutrophil-Lymphocyte Ratio on the Prognosis in Patients Who Underwent Esophagectomy for Esophageal Cancer].

BACKGROUND: Thene utrophil-lymphocyteratio (NLR)reflects a patient's systemic inflammatory response. Several studies have revealed that the NLR is associated with a poor prognosis in several types of malignant tumors such as colorectal and lung cancer. The aim of this study was to evaluate the impact of preoperative NLR on the prognosis of patients with esophageal cancer. METHODS: The NLR was calculated for 93 consecutive patients with clinical Stage II or III esophageal cancer, who underwent curative esophagectomy following neoadjuvant chemotherapy between 2011 and 2013. The impact of preoperativeNLR on overall survival(OS)after esophagectomy was evaluated. The NLR cut off value was set to 2. RESULTS: The 3-year OS of patients with NLR≥2 was significantly shorter than patients with NLR<2(40.5% vs 67.9%, p=0.005). In a multivariateCox model, NLR≥2(HR: 2.342, 95%CI: 1.095-5.007, p=0.028), pathological depth of tumor(HR: 3.207, 95%CI: 1.114- 9.233, p=0.031), and an ageove r 60(HR: 2.342, 95%CI: 1.117-6.501, p=0.027)were identified as independent prognostic factors for OS after esophagectomy. CONCLUSIONS: The preoperative NLR was significantly associated with a poor prognosis in esophageal cancer patients who underwent curative esophagectomy following neoadjuvant chemotherapy.