Motohito Nakagawa

Clinicopathological and Immunohistochemical Features of Extragastrointestinal Stromal Tumors: Report of Two Cases

CD117 (c-kit proto-oncogene protein product) is expressed in most gastrointestinal stromal tumors (GISTs) and plays a crucial role in the pathogenesis and treatment of this disease. However, the clinicopathological and immunohistochemical features of CD117-positive mesenchymal tumors without connection to the gastrointestinal tract, known as extragastrointestinal stromal tumors (EGISTs), are not well documented because these tumors are rare. We describe the clinicopathological and immunohistochemical features of two cases of EGIST and compare them with those of GIST. Of the 1855 abdominal or esophageal tumors resected during the past 10 years at our hospital, 23 were GISTs and 2 were EGISTs. The clinicopathological or immunohistochemical characteristics do not seem to differ remarkably between EGISTs and GISTs. Although rare, CD117 positivity should be tested in abdominal mesenchymal tumors that have no connection to the gastrointestinal tract. The clinicopathological features of CD117-positive abdominal mesenchymal tumors may not depend on whether the tumor is connected to the gastrointestinal tract.

Intraoperative Endoscopic Resection of Left Ventricular Tumors

Two cases involving patients who underwent a successful endoscopic resection of a left ventricular tumor are presented herein. One was an 82-year-old woman with a left ventricular papillary fibroelastoma, who underwent previous coronary artery bypass grafting. In an attempt to make the procedure less invasive, we used an endoscope. With a full sternotomy, cardiopulmonary bypass, and cardioplegic protection, the endoscope was inserted into the left ventricular cavity through the mitral valve. The other patient was a 63-year-old man with left ventricular papillary fibroelastoma, in whom we performed an endoscopic transaortic resection. The endoscope provided an excellent view, and the tumors were easily extracted in both cases without any complications.

Thoracoscopic enucleation for small-sized gastrointestinal stromal tumor of the esophagus: report of two cases

Gastrointestinal stromal tumors (GISTs) rarely occur in the esophagus. Surgical approaches for such tumors have not been established, since the standard wedge or segmental resection that is used for intra-abdominal GIST is not possible in the esophagus. We report two cases of small esophageal GIST in which thoracoscopic enucleation was performed. Both patients underwent the thoracoscopic surgery using four trocars. The tumor size was 43 and 32 mm in patients 1 and 2, respectively. The operating time was 240 and 238 min. The final diagnosis was as low-risk GIST in both patients. Postoperative course was uneventful and both patients have been disease-free at a follow-up of 40 and 32 months. Considering the special case of the esophagus and the very good prognosis of low-risk tumors, enucleation under the thoracoscopic technique may be feasible for small-sized esophageal GIST as a minimally invasive surgery. We also review the literature in this report.

Endovascular Repair of Abdominal Aortic Aneurysm using Bifurcated Stent-graft in a Patient with Complete Occlusion from the Common to the External Iliac Artery

Extensive iliofemoral occlusive disease can limit the use of endovascular aortic aneurysm repair (EVAR), and the treatment strategy varies depending on severity of the lesion. In cases of mild iliac artery (IA) stenosis, predilation using a balloon catheter before EVAR is relatively common, and for severe IA stenosis, the technique of internal endoconduits has been reported with good results. In contrast, EVAR using an aortouni-iliac stent graft with femorofemoral crossover bypass has traditionally been used for abdominal aortic aneurysm with IA occlusion. However, EVAR using a bifurcated stent graft has some clear advantages over aortouni-iliac stent grafts. In this report, we describe and discuss technical aspects and feasibility of chronically occluded iliac artery recanalization before EVAR to facilitate the use of bifurcated stent grafts in a patient with concomitant complete common to external IA occlusion.

The effects of dopamine infusion on the postoperative energy expenditure, metabolism, and catecholamine levels of patients after esophagectomy

Although dopamine is one of the most widely used vasoactive agents, its postoperative thermogenic and metabolic effects have not been studied. In this study, the effects of low-dose dopamine, given at 5 μ/kg/min, on resting energy expenditure (REE), metabolism, and plasma catecholamine levels were examined in eight postsurgical patients. Dopamine infusion increased REE from 1,839 ± 171 kcal/day to 2,071 ±170 kcal/day, and it decreased to 1,867 ± 141 kcal/day after cessation of the infusion. Dopamine also increased the plasma levels of glucagon from 109.4 ± 8.7 pg/ml to 132.5 ±8.0 pg/ml, and it decreased to 102.9 ± 11.1 pg/ml after cessation of the infusion. The plasma levels of dopamine before, during, and after the infusion were 116.1 ± 18.3, 161.1 ±25.6, and 121.4 ± 17.2 ng/ml, respectively. Insulin and glucose were affected by dopamine, but changes in their plasma levels did not parallel the dopamine levels. Epinephrine and norepinephrine were increased by the infusion of dopamine and continued to increase even after its cessation. The results of this study revealed that low-dose dopamine increased REE in postsurgical patients and that this might be associated with the concomitant increase in plasma glucagon.

Bladder metastasis from primary breast cancer: a case report

BackgroundBreast cancer frequently metastasizes to the bone, lung, and liver. However, metastasis to the bladder is uncommon. Bladder metastasis due to direct infiltration from peripheral organs, such as the colon and rectum, prostate, and cervix, occurs more frequently than metastasis from distant organs, such as the breast.Case presentationWe report a case of bladder metastasis identified during treatment for recurrent breast cancer. Fifteen years after her initial surgery, a known breast cancer patient complained of a left lower abdominal pain, anuria, and body swelling. Computed tomography imaging revealed an irregular thickening of the left bladder wall, left hydronephrosis, and hydroureter. A bladder metastasis from breast cancer was diagnosed based on a histological examination of a cystoscopic biopsy specimen. She is currently receiving chemotherapy with eribulin mesylate.ConclusionsRoutine screening of the lower urinary tract is not necessary for all patients, but women with a history of breast cancer presenting with urinary symptoms should undergo a thorough examination of the urinary tract.

Development of a Rectus Sheath Hematoma following a Lichtenstein Procedure for the Management of Inguinal Hernia—A Case Report—

症例は73歳,男性.胸腹部大動脈瘤に対しステントグラフト内挿術を施行され,心房 細動の既往があるためワルファリンカリウムを内服していた.右鼠径部の膨隆を主訴に 受診し,右鼠径ヘルニアと診断され,術前ヘパリン化の後,Lichtenstein法を行った. 術後 1 日目よりヘパリン投与を再開したところ, 2 日目に創部頭側皮下の腫脹が著明に なり,ヘモグロビンおよび血小板の減少を認めた.造影CT検査で腹直筋鞘血腫(rectus sheath hematoma)と造影剤の漏出所見を認めた.保存的加療は困難と判断し,血管造 影検査を行ったところ,右深腸骨回旋動脈からの出血所見を認め,NBCA-Lipiodolに よる動脈塞栓術を行った.その後,抗凝固薬を再開したが,再出血を認めず現在術後 8 カ月,経過観察中である.鼠径ヘルニア術後の腹直筋鞘血腫は稀な病態ではあるが, IVRにて止血しえた極めて稀な症例を経験したので報告する.

A Case of Gastric Cancer with Intramural Metastasis to the Thoracic Esophagus

症例は64歳の男性で, 食欲低下, 嘔吐を主訴に来院. 上部消化管造影および内視鏡検査で胃噴門より体中部に及ぶ全周性の潰瘍浸潤型病変を, 胸部中部食道に径30, 10mmの2個の隆起性病変を認めた. 胃および食道病変に連続性はなかったが, 生検による病理診断は両病変とも中分化型管状腺癌であった. 食道に壁内転移を伴う胃癌と診断し, 開腹術を施行した. 胃近傍より大動脈周囲に至る多数のリンパ節に腫大を認め予後不良と判断し, 膵体尾部, 脾合併切除を伴う胃全摘を行い食道切除は施行しなかった. 術後CDDP, 5FUを中心とした化学療法, 内視鏡的食道粘膜切除, 鎖骨上・縦隔への放射線照射などを併用し, 術後34か月と比較的長期の生存を得たが, 多臓器転移のため死亡した. 食道壁内転移を伴う胃癌症例の報告は少ないが, 高度進行例が多く, 治療として患者のQOLを考慮した外科的切除, 化学・放射線療法の併用を考慮すべきであると思われた.

A Case Report of the Gallbladder Tuberculosis.

症例は73歳の男性. 主訴は右季肋部痛. 画像検査で胆嚢底部の著しい拡張と胆嚢結石を認めたため, 開腹手術となった. 術中所見では, 胆嚢体部のくびれと底部の著しい拡張と腹壁への浸潤を認めたため, 腹直筋の合併切除を伴う胆嚢摘出術を施行した. 底部の内溶液は米のとぎ汁状で, 培養検査で結核菌が証明された. 術後1年間の抗結核剤の投与を行った. 本症はきわめてまれであるが, 結核を疑うことが診断に結びついた.