Hiroya Takeuchi

Update on the indications and results of sentinel node mapping in upper GI cancer

The clinical utilization of sentinel node (SN) mapping for early esophageal cancer or gastric cancer has been unclear for a long time. However, previous investigations regarding SN mapping of these cancers have shown relatively good results with regard to the detection rate and diagnostic accuracy for determining the lymph node status. SN mapping helps obtain information about individual metastatic status and allows the modification of the operation in early-stage upper gastrointestinal (GI) disease. Radio-guided methods for identifying SNs in early esophageal cancer have been established via endoscopic injection of technetium-99m tin colloid. Previous studies have reported that the SN concept seems valid, and radio-guided SN mapping can be feasible in cT1N0 esophageal cancer. SN navigation surgery are believed to have potential as strategies for minimally invasive modified surgery for early esophageal cancer. A Japanese study group conducted a prospective multicenter trial of SN mapping for early gastric cancer using a dual tracer method with radioactive colloid and blue dyes; they demonstrated a high detection rate and accuracy for determining the metastatic status based on SN mapping. Subsequently, minimized gastrectomy, including partial gastrectomy and segmental gastrectomy with individualized selective and modified lymphadenectomy for early gastric cancer with a negative SN has been performed to evaluate the long-term survival and postoperative quality of life (QOL) in a multicenter prospective trial. This study verified the SN concept in early-stage upper GI disease with cN0 and found that function-preserving esophagectomy or gastrectomy may help maintain patients’ post-surgical QOL.

Stearate-to-palmitate ratio modulates endoplasmic reticulum stress and cell apoptosis in non-B non-C hepatoma cells

The increased prevalence of hepatocellular carcinoma (HCC) without viral infection, namely, NHCC, is a major public health issue worldwide. NHCC is frequently derived from non‐alcoholic fatty liver (NAFL) and non‐alcoholic steatohepatitis, which exhibit dysregulated fatty acid (FA) metabolism. This raises the possibility that NHCC evolves intracellular machineries to adapt to dysregulated FA metabolism. We herein aim to identify NHCC‐specifically altered FA and key molecules to achieve the adaptation. To analyze FA, imaging mass spectrometry (IMS) was performed on 15 HCC specimens. The composition of saturated FA (SFA) in NHCC was altered from that in typical HCC. The stearate‐to‐palmitate ratio (SPR) was significantly increased in NHCC. Associated with the SPR increase, the ELOVL6 protein level was upregulated in NHCC. The knockdown of ELOVL6 reduced SPR, and enhanced endoplasmic reticulum stress, inducing apoptosis of Huh7 and HepG2 cells. In conclusion, NHCC appears to adapt to an FA‐rich environment by modulating SPR through ELOVL6.

Three-field lymph node dissection in esophageal cancer surgery

Although multidisciplinary treatment has improved the prognosis of esophageal cancer, it is commonly associated with one of the worse prognoses. Since lymph node (LN) metastases can primarily occur from the cervical to the abdominal field, a strategy for extended LN dissection has been established. The three field LN dissection (3FD) during a transthoracic esophagectomy which is defined as a procedure for cervico-thoraco-abdominal LN dissection, was established in the 1980s in Japan, and is currently widely accepted throughout the world. To date, various comparative trials between 3FD and two field LN dissections (2FD) have been reported and show that a transthoracic esophagectomy with 3FD is superior to 2FD for prognosis. However, in 3FD, postoperative complications, such as recurrent laryngeal nerve palsy and postoperative gastrointestinal dysfunction can be induced. Furthermore, there are few prospective trials that have compared between 2FD and 3FD. Therefore, to determine the ideal range of LN dissection, various factors (e.g., location of the primary tumor, disease progression, tumor histology, and perioperative treatment) must be considered. Recently, the efficacy of intense perioperative treatment for esophageal cancer has been reported, and the significance of minimally invasive surgical procedures are being verified. The ideal combination of perioperative treatment and feasible surgery must be established to improve the oncological outcome of esophageal cancer patients further.

Analysis of the Effect of Early Versus Conventional Nasogastric Tube Removal on Postoperative Complications After Transthoracic Esophagectomy: A Single-Center, Randomized Controlled Trial

BackgroundAlthough esophagectomy is the only curative option for esophageal cancer, the associated invasiveness is high. Nasogastric (NG) tube use may prevent complications; however, its utility remains unclear, and the decompression period depends on the doctor. This study aimed to reveal the effect of conventional versus early NG tube removal on postoperative complications after esophagectomy.MethodsThis single-center prospective randomized controlled clinical trial enrolled patients aged 20–80xa0years with histologically proven primary esophageal squamous cell carcinoma. Eighty patients admitted for transthoracic first-stage esophagectomy reconstructed with gastric conduit were randomly assigned (1:1) to the conventional and early NG tube removal groups. In the conventional NG tube removal group, the tube was removed on postoperative day (POD) 7; in the other, it was removed on POD 1. The occurrence rate of major complications, length of postoperative hospital stay, and NG tube reinsertion rate were compared between the groups.ResultsThe incidence of postoperative major complications such as pneumonia, anastomotic leakage, recurrent nerve palsy and gastrointestinal bleeding, and the NG tube reinsertion rate was not different between the groups. However, recurrent nerve palsy was more commonly observed in the conventional removal group; this difference was not significant. In terms of postoperative pneumonia, tumor location and field of lymph node dissection were significant risk factors.ConclusionAlthough early NG tube removal did not reduce the rate of postoperative pneumonia, it could be performed safely. Hence, the NG tube can be removed earlier than conventional methods.

Axillo-Axillary Artery Bypass With Coil Embolization of the Innominate Artery for a Traumatic Innominate Artery Aneurysm: A Case Report

Background: Innominate artery aneurysm (IAA) is a rare cervical artery aneurysm. Although atherosclerosis is its most common cause, IAAs due to cervical injury are often reported. Operative indications for IAAs include rupture or symptomatic aneurysm, saccular aneurysm, aneurysm with a diameter of 3 cm or greater, and aneurysmal change of the origin of the innominate artery. Although the ligature of the innominate artery or open surgical repair is well described, the usefulness of endovascular repair has also recently been reported. Herein, we report a case of traumatic IAA with infection in the cervical region after tracheostomy. Case Presentation: A 40-year-old man with cholecystolithiasis planned to undergo laparoscopic cholecystectomy at another hospital. Urgent tracheostomy was performed because of laryngeal edema at the induction of general anesthesia. Enhanced computed tomography angiography 1 week after the tracheostomy revealed a saccular IAA. The patient was deemed to be at high risk for aneurysm rupture and was referred to our hospital. Preoperative Matas test, Allcock test, and innominate arterial stump pressure measurement were performed to assess the cerebral blood flow and ischemic tolerance of the brain. These examinations showed the patency of the circle of Willis. An axillo-axillary artery bypass with coil embolization of the innominate artery was performed to avoid postoperative vascular graft infection. No postoperative complications such as infection or cerebral infarction occurred. Magnetic resonance imaging angiography performed 6 months after surgical treatment showed that the aneurysm had disappeared, and patency of the bypass graft was present. There were no postoperative complications, such as neurological deficits or graft infection, at more than 5 years after surgery. Conclusions: We report a successfully treated case of IAA after tracheostomy. Axillo-axillary artery bypass with coil embolization of the innominate artery is an effective treatment of IAA with cervical infection.

Surgery for limited-stage primary small cell carcinoma of the esophagus: is it feasible and for whom is it indicated?

Small cell carcinoma is a highly malignant cancer that most commonly arises in the lung. Small cell carcinoma arising from outside the lungs was first described by Duguid and Kennedy in 1930 and is referred to as extrapulmonary small cell carcinoma (EPSCC) (1).

Postoperative Pneumonia is Associated with Long-Term Oncologic Outcomes of Definitive Chemoradiotherapy Followed by Salvage Esophagectomy for Esophageal Cancer

Background or PurposeAs we previously indicated, postoperative pneumonia has a negative impact on the overall survival after planned esophagectomy. However, the impact of postoperative pneumonia after salvage esophagectomy on long-term oncologic outcomes still remains unclear. This study aimed to indicate the association between postoperative pneumonia and long-term outcomes of definitive chemoradiotherapy followed by salvage esophagectomy. Furthermore, we determined a prediction model for overall survival (OS) and disease-free survival (DFS) using a survival classification and regression tree (CART).MethodsNinety-three patients who underwent CRT followed by esophagectomy for thoracic esophageal cancer were identified for this study. Forty-nine patients and 44 patients were included in the salvage and neoadjuvant groups, respectively. We investigated the association between postoperative pneumonia and long-term oncologic outcomes following salvage esophagectomy.ResultsPatients from the salvage group tended to have a lower OS compared to neoadjuvant group (median survival: salvage, 24xa0months vs neoadjuvant, 43xa0months, pu2009=u20090.117). Multivariate analyses revealed that postoperative pneumonia adversely affected both OS (pu2009<u20090.001) and DFS (pu2009=u20090.044) after salvage esophagectomy. We generated the prediction model for OS and DFS in the salvage group using survival CART. Postoperative pneumonia was the most important parameter for predicting the OS.DiscussionThe present study demonstrates the long-term outcomes and risk factors for mortality of salvage esophagectomy. To improve OS after salvage surgery, the development of a means of decreasing pulmonary complications is needed.

Esophageal cancer practice guidelines 2017 edited by the Japan Esophageal Society: part 1

Purpose of the guidelines nThe primary objective of these guidelines is to provide general clinicians with information that would guide them to make informed choices of the available diagnosis/treatment strategies for esophageal cancer (intended for malignant esophageal tumors of epithelial origin, not for any other non-epithelial malignant tumors of the esophagus or metastatic esophageal malignant tumors). Furthermore, these guidelines are also intended as an aid for healthcare professionals other than the physicians, patients, and patients’ family members, to obtain an understanding of the fundamental principles of the diagnosis and treatment of esophageal cancer. These guidelines are intended to allow physicians to undertake diagnosis and treatment of esophageal cancer by sharing the information contained in the guidelines and promote mutual understanding among the healthcare professionals, patients, and their family members.

Usefulness of four-dimensional flow-sensitive magnetic resonance imaging to evaluate hemodynamics in the pancreaticoduodenal artery

Pancreaticoduodenal artery (PDA) aneurysm associated with celiac axis compression by the median arcuate ligament (MAL) is a rare disorder, but may be lethal if ruptured. Therefore, prophylactic surgical treatments need to be considered when MAL compresses the celiac axis. We herein report the usefulness of an arterial flow analysis for objectively evaluating this pathophysiology under four-dimensional flow-sensitive magnetic resonance imaging (4D-flow MRI). Celiac artery stenosis was incidentally found under contrast-enhanced CT in a 50-year-old woman with symptomatic solitary pancreatic insulinoma. Under 4D-flow MRI, retrograde blood flow and aberrant wall shear stress were detected in the pancreaticoduodenal artery arcade. After obtaining informed consent, enucleation for insulinoma concomitant with MAL dissection was performed. Hypoglycemic attack completely resolved immediately after surgery. One month after surgery, 4D-flow MRI revealed normalized vectorial flow and wall shear stress in the PDA arcade without hypoglycemic attack. 4D-flow MRI is a very useful and non-invasive modality for objectively evaluating visceral artery hemodynamics.

Role of caveolin-1 in hepatocellular carcinoma arising from non-alcoholic fatty liver disease

The molecular features of hepatocellular carcinoma arising from non‐alcoholic fatty liver disease (NAFLD‐HCC) are not well known. In this study, we investigated the mechanism by which NAFLD‐HCC survives in a fat‐rich environment. We found that caveolin (CAV)‐1 was overexpressed in clinical specimens from NAFLD‐HCC patients. HepG2, HLE, and HuH‐7 HCC cell lines showed decreased proliferation in the presence of the saturated fatty acids palmitic acid and stearic acid, although only HLE cells expressed high levels of CAV‐1. HLE cells treated with oleic acid (OA) showed robust proliferation, whereas CAV‐null HepG2 cells showed reduced proliferation and increased apoptosis. CAV‐1 knockdown in HLE cells attenuated the OA‐induced increase in proliferation and enhanced apoptosis. Liquid chromatography–tandem mass spectrometry analysis revealed that the levels of OA‐containing ceramide, a pro‐apoptotic factor, were higher in HepG2 and CAV‐1‐deficient HLE cells than in HLE cells, suggesting that CAV‐1 inhibits apoptosis by decreasing the level of OA‐containing ceramide. These results indicate that CAV‐1 is important for NAFLD‐HCC survival in fatty acid‐rich environments and is a potential therapeutic target.