Takashi Ogata

Amelanotic malignant melanoma of the esophagus: report of a patient with recurrence successfully treated with chemoendocrine therapy

We report a case of primary amelanotic malignant melanoma of the esophagus, an extremely rare disease. A 58-year-old man was diagnosed as having middle esophageal cancer with lymph node metastasis, which was classified as esophageal cancer, Stage III:T3N1M0, by International Union Against Cancer (UICC) criteria. Preoperative chemotherapy was performed, but the response assessment was no change (NC). The patient underwent a subtotal esophagectomy via right thoracotomy and laparotomy. Reconstruction was performed by pulling up the stomach via the retrosternal route; the site of anastomosis was the neck. Adjuvant chemotherapy consisted of five courses of dacarbazine (DITC), nimustine (ACNU), vincristine (VCR), and interferon-β. Eleven months after the surgery, computed tomography (CT) demonstrated recurrence in the upper mediastinum. The patient received chemoendocrine therapy, consisting of the first planned course of DITC, ACNU, and cisplatin (CDDP), given intravenously; and tamoxifen (TAM), given orally. Subsequently with a modified regimen of this therapy he attained a complete response (CR). In general, the prognosis of esophageal malignant melanoma is very poor. Although our patient had a recurrence, he is alive 4 years and 5 months after the surgery and 3 years and 6 months after the recurrence. The chemoendocrine therapy probably contributed to this outcome.

Laparoscopic esophagojejunostomy using the EndoStitch and a circular stapler under a direct view created by the ENDOCAMELEON

Laparoscopic esophagojejunostomy using a circular stapler is associated with technical difficulties in the purse-string sutures used to insert the anvil head and in obtaining an adequate visual field to prevent rolling the mesentery and the wall of the jejunum on the mesenteric side into the anastomosis. To overcome these difficulties, we used the EndoStitch to create the purse-string suture and the ENDOCAMELEON to create the visual field to stretch the jejunum. After resecting the esophagus, purse-string sutures were placed using the EndoStitch. A total of five to six needle deliveries were performed. Next, the anvil head was inserted into the esophagus. The main unit of the EEA was inserted from the end of the resected jejunum. Then, the scope was changed to the ENDOCAMELEON. The main unit was slowly moved toward the anvil head. After making sure that the mesentery and the wall of the jejunum on the mesenteric side were not rolled into the anastomosis under the visual field created by the ENDOCAMELEON, the main unit was then fired. Thereafter, esophagojejunostomy was successfully completed. This technique was applied in 20 patients between April 2010 and May 2012. Laparoscopic esophagojejunostomy after total gastrectomy for gastric cancer was completed in all 20 patients. No case required conversion to open surgery. Neither anastomotic leakage nor stenosis was observed. This method is simple and useful for laparoscopic esophagojejunostomy after total gastrectomy for gastric cancer.

Laparoscopy-Assisted Distal Gastrectomy for an Early Gastric Cancer Patient With Situs Inversus Totalis

Situs inversus totalis (SIT) is a congenital condition in which there is complete right to left reversal of the thoracic and abdominal organs. This report describes laparoscopy-assisted distal gastrectomy (LADG) for an early gastric cancer patient with SIT. The preoperative diagnosis was c-stage IA (cT1a cN0 cH0 cP0 cM0). LADG with D1+ dissection and Billroth-I reconstruction was successfully performed by standing at the opposite position. The operating time was 234 minutes and blood loss was 5 mL. Although a mechanical obstruction occurred after surgery, the patient recovered after re-operation with Roux-en-Y bypass.

Small bud of probable gastrointestinal stromal tumor within a laparoscopically-resected gastric schwannoma

Submucosal tumors (SMTs) of the gastrointestinal (GI) tract can be potentially difficulty to diagnose pathologically. We report a case of a gastric SMT that was resected by laparoscopic partial gastrectomy. Although the initial histological and immunohistochemical examinations considered the tumor as a schwannoma, mRNA-based KIT genotyping indicated that the tumor included cells with KIT gene expression, and that a small number of cells carried a deletion mutation in exon 11. Additional histopathological investigations revealed small aggregates of enlarged spindle to epithelioid cells, which were positive for KIT, CD34 and DOG1, and negative for S-100, scattered among the S-100-positive schwannoma cells. We consider that the cells carrying the KIT gene mutation are microscopic buds of a gastrointestinal stroma tumor (GIST), and to the best of our knowledge, this is the first report of probable GIST tissues identified in a schwannoma. Our observations raised the significance of genotyping for diagnosis of GI tract SMTs.

Infectious complication and recurrence after surgery for gastric cancer.

85 Background: There are many known prognostic indicators following surgery for gastric cancer. However, the impact of infectious complication on prognosis is less clear. The aim of the present study was to evaluate the relationship between infectious complication and relapse-free survival in patients undergoing potentially curative resection of gastric cancer. METHODS A consecutive series of 657 patients who underwent macroscopically curative resection between 2000 and 2005 in Kanagawa Cancer Center were retrospectively studied. Five-year relapse-free survival rates in each stages (TNM7th) were calculated. Infectious complications (≥Grage2 by Clavien-Dindo classification) were classified as pneumonia, anastomotic leakage, intra-abdominal abscess, septicaemia, colitis, pancreatic-fistula, and wound infection. RESULTS Mean age was 61 years; male-female ration was 4:1; the number of patients in TNM7th stages were I :389, II :93, III :116, and IV :59. Infectious complications occurred in 57 patients (8.7%) including 8.5% in stage I, 3.2% in stage II, 12.1% in stage III, and 11.9% in stage IV, respectively. Five-year relapse-free survival rates in patients without infectious complications and with infectious complications were 93.1% vs 81.6% in stage I, 84.4% and 100% in stage II, 55.8% and 28.6% in stage III, and 9% and 0% in stage IV, respectively. In stage III, patients with infectious complication had significantly poorer outcome in relapse-free survival compared with those without one (p<0.05). CONCLUSIONS This study indicates a correlation between infectious complications and cancer recurrence in advanced but localized gastric cancer. Immunologic response of the host against postoperative infection could influence the viability of microscopic residual disease. Further clinical and basic study are needed to improve outcome for this category of patients.

Macroscopic tumor size as an independent prognostic factor for patients with stage II/III gastric cancer who underwent D2 gastrectomy followed by adjuvant chemotherapy with S-1.

56 Background: In patients with stage II/III gastric cancer, tumors often recur even after curative D2 gastrectomy followed by adjuvant S-1 chemotherapy. The objective of this retrospective study was to clarify the prognostic factors in these patients that might be useful for future patients. METHODS Overall survival was examined in 82 gastric cancer patients who underwent curative D2 surgery, were diagnosed with stage IIA, II B, IIIA, IIIB, or IIIC pathologically, and received adjuvant S-1 after surgery between June of 2002 and March of 2010. RESULTS When overall survival was compared by the log-rank test, a significant difference was observed with regard to macroscopic tumor diameter and the depth of tumor invasion. A macroscopic tumor diameter greater than 70mm was regarded as a critical point of classification considering the survival. Uni- and muliti-variate Coxs proportional hazard analyses demonstrated that macroscopic tumor diameter was the only significant independent prognosticator. The five-year survival was 64.9% in patients with a macroscopic tumor diameter <70mm, and 33.1% in patients with a macroscopic tumor diameter ≥70mm (P=0.022). CONCLUSIONS The macroscopic tumor diameter was the most important prognostic factor for survival in patients with stage II/III gastric cancer who underwent D2 gastrectomy followed by adjuvant S-1 chemotherapy. Prognostic factors can be affected by adjuvant chemotherapy.