Dai Kitagawa

Postoperative management using intensive patient-controlled epidural analgesia and early rehabilitation after an esophagectomy.

PurposePatient-controlled epidural analgesia (PCEA) was developed for use after surgery for thoracic esophageal cancer to relieve wound pain, introduce early rehabilitation, and provide an uneventful postoperative recovery.MethodsThis retrospective study investigated 22 patients who underwent esophageal surgery to determine the efficacy of postoperative management with PCEA. In the PCEA group (n = 12), patients had two epidural catheters inserted to cover both the thoracic and abdominal incision with a patient-controlled bolus capability.ResultsPostoperative mechanical ventilation was administered in all cases in the control group (n = 10). On the other hand, this was only necessary in two patients in the PCEA group. The amount of time the patients stayed in the intensive care unit and the hospital was significantly shorter in the PCEA group than in the control group (P < 0.001 and P < 0.01, respectively). Respiratory complications occurred in four patients in the control group, and none in the PCEA group. The mean number of supplemental analgesics administered for breakthrough pain until the 7th postoperative day was 5.5 in the control group, and 1.3 in the PCEA group (P < 0.001).ConclusionsEarly rehabilitation is facilitated with intensive PCEA, while it also improves postoperative management and reduces hospitalization after esophageal surgery.

Reduced expression of focal adhesion kinase in intrahepatic cholangiocarcinoma is associated with poor tumor differentiation.

Objective: Focal adhesion kinase (FAK) expression has been linked to tumor cell invasion and metastasis, but its role in intrahepatic cholangiocarcinoma (ICC) has not been addressed. The goal of this study was to investigate FAK expression in ICC and to assess whether its expression is correlated with clinicopathological factors or prognosis in patients with ICC. Methods: FAK expression was examined using immunohistochemistry with sections from 56 resected ICC specimens. The correlations between FAK expression and clinical outcome were assessed. Results: The patients were divided into two groups according to the degree of FAK expression: high FAK group (n = 16) and low FAK group (n = 40). A lower expression of FAK was correlated with tumor size, poor differentiation, lymph node metastasis, vascular invasion, and intrahepatic metastasis. In the low FAK expression group, multiple recurrence and distant metastases were more prevalent than in the high FAK expression group. The overall and disease-free survival analysis indicated worse outcomes of the low FAK expression group (p < 0.01). Conclusions: A low expression of FAK in ICC is associated with a poor outcome after a surgical resection.

Extraskeletal osteosarcoma of the pleura: a case report

We herein present an exceedingly rare case of pleural osteosarcoma that was surgically resected in an elderly patient. A 74-year-old man, complaining of a dry cough and breathlessness on effort, was found to have massive pleural effusion on a chest X-ray. The chest CT and MRI scans indicated a massive effusion and a pleural tumor encasing the left lower lung. The resected tumor was histologically an osteosarcoma, measuring 11.3 × 9.0 × 6.0 cm. Because there was no evidence of any other primary tumor, the diagnosis of extraskeletal osteosarcoma was appropriate.

Clinicopathological analysis of ten patients with metaplastic squamous cell carcinoma of the breast

PurposePrimary squamous cell carcinoma (SCC) and metaplastic squamous cell carcinoma (MSCC) are rare types of breast cancer with specific histological features. They are characterized by rapid progression, a tendency toward cyst formation, and negativity for hormone receptors. Many studies have concluded that SCC of the breast carries a poor prognosis, based on the fact that conventional chemotherapy for ductal carcinoma of the breast is ineffective against SCC. This is a retrospective study of patients in a single center with SCC or MSCC.MethodsWe searched the records of the Tokyo Metropolitan Komagome Hospital for patients diagnosed with breast SCC or MSCC between 1979 and 2006. Squamous cell carcinoma was diagnosed when 100% of the malignant cells showed a squamous component (pure SCC) and MSCC was diagnosed when more than 50% of the malignant cells showed a squamous component. We analyzed the clinicopathological features, treatment methods, and outcomes of these patients.ResultsWe identified 10 (0.28%) patients with SCC or MSCC from among 3565 patients with malignant breast tumors treated at our hospital during this period. Nine patients had adenocarcinoma with squamous metaplasia, and one had pure SCC. Ultrasound showed a central cystic-necrotic component in seven tumors, and all of the tumors were negative for hormone receptors and HER2. Recurrence developed in two patients with lymph node metastasis, but not in the other eight patients. The 5-year survival rate and median survival time were 85.7% and 97 months, respectively.ConclusionsSquamous cell carcinoma or MSCC of the breast with features of the triple-negative subtype seems to be associated with a poor prognosis; however, nodenegative patients are likely to have a favorable prognosis.

The role of heat shock protein 27 expression in hepatocellular carcinoma in Japan: Special reference to the difference between hepatitis B and C

Abstract: 
Background: A recent report showed that heat shock protein (HSP)‐27 expression was related to histological grade and survival of patients with hepatocellular carcinoma (HCC).

Liver metastasis with intraductal invasion originating from rectal cancer: Report of a case

We report a case of liver metastasis with intraductal invasion from colorectal cancer. The patient underwent abdominoperineal resection of the rectum for rectal cancer, and a computed tomography (CT) scan, done 4 years later, revealed a low-density lobular mass in the left lobe of the liver, with a tumor embolus in the second branch of the left bile duct (B2). Because the preoperative imaging findings showed an intraductal growth pattern, we performed a left lobectomy of the liver for intrahepatic cholangiocarcinoma (IHCC). Immunohistochemically, the carcinoma cells, including the intraductal growth, were focally positive for Cytokeratin (CK) 20, but negative for CK 7. This CK staining pattern suggested that the liver tumor was a metastasis from the previously resected rectal cancer. Thus, metastases from colorectal cancer can involve intraductal growth.

Expression of Platelet-Activating Factor Receptor: A Novel Prognosticator in Patients with Hepatocellular Carcinoma following Hepatectomy

Backgrounds and Aims: Platelet-activating factor (PAF, 1-O-alkyl-2-acetyl-sn-glycero-3-phosphocholine) is a phospholipid mediator and acts by binding to a specific G-protein-coupled receptor. Though various functions of PAF have been associated with tumor activities, the mechanism of PAF-PAF receptor signaling in the development of hepatocellular carcinoma (HCC) remains to be elucidated. Methods: In this study, PAF receptor (PAFR) expression was examined in hepatoma cell lines (Huh7, PLC/PRF/5 and HepG2) and clinical samples of HCC (n = 60) using immunohistochemical staining. The relationships between the expression of PAFR and clinicopathological parameters were also investigated. Results: An immunohistochemical study showed that 24 HCC cases (40%) showed a lower PAFR expression than non-cancerous hepatocytes. The patients were divided into two groups according to the degree of PAFR expression: the high (n = 36) and low PAFR groups (n = 24). Lower expression of PAFR was correlated with poor differentiation, portal vein invasion, high levels of serum α-fetoprotein and poor prognosis after surgery. In the low PAFR group, multiple recurrences and distant metastases were more often observed than in the high PAFR group. Multivariate analysis revealed that lower PAFR expression in addition to portal vein invasion is significantly related to survival after hepatectomy. Conclusions: A lower expression of PAFR correlated with poor differentiation and a poor prognosis, and may therefore be used as a prognostic marker in HCC after hepatectomy.

Flare hypercalcemia after letrozole in a patient with liver metastasis from breast cancer: a case report

IntroductionTamoxifen may occasionally precipitate serious and potentially life-threatening hypercalcemia. However, to date, this has not been documented with aromatase inhibitors.Case presentationA 65-year-old Japanese woman with liver metastasis from breast cancer was admitted to our hospital with vomiting, anorexia, fatigue, arthralgia, muscle pain and dehydration. She had started a course of letrozole five weeks earlier. Our patients calcium level was 11.6 mg/dL. She was rehydrated and elcatonin was administered. Our patients parathyroid hormone and parathyroid hormone-related protein levels were not increased and a bone scintigram revealed no evidence of skeletal metastasis. After our patients serum calcium level returned to within the normal range, letrozole was restarted at one-half of the previous dose (1.25 mg). There were no episodes of hypercalcemia. However, 84 days after restarting letrozole, our patient again complained of arthralgia and treatment was changed to toremifene. During these periods, repeated ultrasonograms revealed no progression of liver metastasis.ConclusionTo the best of our knowledge, this is the first case report of flare hypercalcemia after treatment with letrozole in a patient with metastatic breast cancer.

Physical assessment immediately after lobectomy via miniposterolateral thoracotomy assisted by videothoracoscopy for non-small cell lung cancer

PurposeWe evaluated the invasiveness of videothoracoscopy-assisted mini-posterolateral thoracotomy (VAmPLT) for non-small cell lung cancer (NSCLC).MethodsThis study prospectively analyzed 50 NSCLC patients who underwent VAmPLT lobectomy. We measured maximal negative inspiratory pressure (PImax), maximal positive expiratory pressure (PEmax), quadriceps strength (QS), 6-min walk test (6mWT), and postoperative pain during the perioperative period. We then compared the results of the 6mWT and the postoperative pain of the VAmPLT lobectomy patients with those of a control group of 50 NSCLC patients who underwent standard posterolateral thoracotomy (PLT) techniques just prior to implementation of the VAmPLT lobectomy.ResultsThe PImax and PEmax at the baseline, then on postoperative days (PODs) 1, 7, and 14 were 125% ± 5% and 120% ± 4%, 69% ± 4% and 62% ± 4%, 115% ± 5% and 100% ± 4%, and 123% ± 4%, and 110% ± 4%, respectively. The QS at the baseline, then on PODs 7 and 14 was 138% ± 5%, 129% ± 6%, and 133% ± 5%, respectively. Improvement from the baseline was seen in PImax by POD 7, and in PEmax and QS by POD 14. The 6mWT results and the level of postoperative pain after VAmPLT lobectomy were superior to those after PLT.ConclusionsThe advantages of VAmPLT lobectomy over PLT include less postoperative pain and earlier recovery of physical function.

Preoperative diagnostic value of single-balloon enteroscopy for successful surgical treatment of three independent-origin gastrointestinal malignant tumors: Report of a case

A 67-year-old woman with bloody stools underwent esophagogastroduodenoscopy and colonoscopy, which revealed the presence of a submucosal tumor in the stomach and an adenocarcinoma in the ascending colon. Preoperative screening disclosed an additional 10-cm tumor in the abdomen between the gastric and colonic lesions. Single-balloon enteroscopy was therefore performed. A nonstenotic, circumferential, bleeding ulcerative lesion was found in the jejunum, and the biopsy revealed malignant lymphoma (ML). A partial resection of the small intestine, ascending colectomy, and wedge resection of the stomach were performed, then systemic chemotherapy for ML was started 2 weeks after surgery. Triple gastrointestinal malignant tumors with different histologies are extremely rare, and have not been previously reported. Single-balloon enteroscopy in this case led to a definite diagnosis by biopsy, thus allowing the patient to receive chemotherapy as soon as possible after surgery.