Takasuke Harada

Laparoscopic and endoscopic cooperative surgery for duodenal neuroendocrine tumor (NET) G1: Report of a case.

Highlights • Endoscopic treatment is generally recommended for G1 NETs <10 mm in diameter and extending only to the submucosal layer in gastrointestinal tract.• Some cases are difficult to resect endoscopically in duodenal tumor because the wall is thinner than that of stomach, and endoscope maneuverability is limited within the narrow working space.• We resected duodenal NET G1 using LECS technique and we demonstrated that LECS is a safe and feasible procedure for duodenal G1 NETs.

A study of increase in leg volume during complex physical therapy for leg lymphedema using subcutaneous tissue ultrasonography

OBJECTIVE The purpose of this study was to discuss the mode of increase in leg volume during complex physical therapy (CPT) for lymphedema using subcutaneous tissue ultrasonography. METHODS Thirty-eight patients (51 legs) with secondary lymphedema who were treated by CPT for longer than 2 years (3.0 ± 0.8 years) at our clinic were studied. The leg circumferences were measured at every visit. Subcutaneous tissue ultrasonography was performed at the initial and latest visits. RESULTS The overall change in leg volume was -284 ± 915 (range, -4588 to 1139) mL. Among them, the increase in leg volume was found in 18 legs; of those, 9 (1 in stage I, 7 in stage II, 1 in stage III) were adherent to hosiery use. In the legs whose average volume was decreased (group A, n = 33; mean, -821 [-4588 to -19] mL), the circumference had decreased in all the leg levels. However, in the legs whose average volumes had increased (group B, n = 18; mean, +449 [18-1139] mL), the circumference had increased in the thigh but remained unchanged or even decreased in the lower leg. In group B, subcutaneous thickness (SCT), subcutaneous echogenicity (SEG), and subcutaneous echo-free space (SEFS), assessed by ultrasonography, were found to have increased particularly in the lower medial thigh compared with those in group A (SCT change: group A, -1.5 ± 5.9 cm vs group B, 3.7 ± 5.4 cm [P < .05]; SEG grade change: group A, -0.3 ± 0.7 vs group B, 0.3 ± 0.7 [P < .05]; SEFS grade change: group A, -0.1 ± 0.7 vs group B, 0.4 ± 0.6 [P < .05]), whereas these remained unchanged or even decreased in the lower leg. CONCLUSIONS Increase in leg volume during CPT might not be caused simply by noncompliance to hosiery use and seemed closely related to the increase in thigh circumferences, particularly the lower thigh, in which SCT, SEG, and SEFS were increased.

Skin and Subcutaneous Tissue Ultrasonography Features in Breast Cancer-Related Lymphedema

Objective: To investigate skin, subepidermal low echogenic band (SELEB), and subcutaneous tissue (SCT) thickness as well as the degree of increase in subcutaneous echogenicity (SEG) and subcutaneous echo-free space (SEFS) in arms with lymphedema (LE). Materials and Methods: The skin and SCT of both arms of 30 patients with unilateral stage II breast cancer-related LE were scanned at five points (medial/lateral upper arm/forearm and dorsum of the hand). SEG and SEFS grades were determined according to severity (range: 0-2). Results: All measured parameters, except the SEFS in the medial upper arm, were significantly higher on the LE side than on the normal (N) side. The parameters differed most remarkably in the medial forearm (MFA; skin: LE 1.7 ± 0.8 mm vs. N 0.8 ± 0.2 mm; SELEB: LE 1.0 ± 0.6 mm vs. N 0.3 ± 0.1 mm; SCT: LE 8.7 ± 3.4 mm vs. N 3.8 ± 2.0 mm; SEG: LE 0.9 ± 0.5 vs. N 0.1 ± 0.3; and SEFS: LE 0.5 ± 0.7 vs. N 0). Conclusion: The differences in the thickness of the skin, SELEB, and SCT and the SEG and SEFS grades between the LE and N arms seemed most evident in the MFA.

Skin and Subcutaneous Tissue Strain in Legs with Lymphedema and Lipodermatosclerosis

We compared skin and subcutaneous tissue strains in legs with lymphedema (LE) of varying severity and legs with lipodermatosclerosis (LDS) using real-time tissue elastography. Strain was assessed at the inner thigh and calf in 62 legs with LE (International Society of Lymphology [ISL] stage 0: 16, stage I: 5, stage II: 28, late stage II: 7, stage III: 6) and 15 legs with LDS. In thighs and calves with LE, skin strain and subcutaneous tissue strain did not significantly differ between ISL stage 0, that is, asymptomatic legs, and other stages. However, strain values in calves with LDS were lower than values in calves with stage 0, II and late II LE. These results indicate that skin and subcutaneous tissue strains were not lower in legs with symptomatic LE than in asymptomatic legs until an advanced stage.

Possible Dual Role of Decorin in Abdominal Aortic Aneurysm

Abdominal aortic aneurysm (AAA) is characterized by chronic inflammation, which leads to pathological remodeling of the extracellular matrix. Decorin, a small leucine-rich repeat proteoglycan, has been suggested to regulate inflammation and stabilize the extracellular matrix. Therefore, the present study investigated the role of decorin in the pathogenesis of AAA. Decorin was localized in the aortic adventitia under normal conditions in both mice and humans. AAA was induced in mice using CaCl2 treatment. Initially, decorin protein levels decreased, but as AAA progressed decorin levels increased in all layers. Local administration of exogenous decorin prevented the development of CaCl2-induced AAA. However, decorin was highly expressed in the degenerative lesions of human AAA walls, and this expression positively correlated with matrix metalloproteinase (MMP)-9 expression. In cell culture experiments, the addition of decorin inhibited secretion of MMP-9 in vascular smooth muscle cells, but had the opposite effect in macrophages. The results suggest that decorin plays a dual role in AAA. Adventitial decorin in normal aorta may protect against the development of AAA, but macrophages expressing decorin in AAA walls may facilitate the progression of AAA by up-regulating MMP-9 secretion.

Adherence to and efficacy of different compression methods for treating chronic venous insufficiency in the elderly.

Objectives To investigate the adherence to and efficacy of different compression methods in elderly patients. Methods A retrospective review of compression therapy in 120 elderly patients (≥65 years) with chronic venous insufficiency was performed to study the initially preferred compression method, adherence to each method, and its efficacy. Results Initially, an oversize strong stocking (24%), an appropriate size moderate stocking (19%), and bandages (37%) were equally preferred. Adherence at 1 month was 69%, 96%, and 91%, respectively, and they reduced ankle circumferences in C3 patients by 1.8 ± 1.9 cm, 0.3 ± 1.7 cm, and 2.9 ± 1.7 cm, respectively. The improvement rates of C4 symptoms were 79%, 60%, and 91%, respectively. Only three patients (2%) preferred an appropriate size strong stocking. Conclusions In elderly patients, an appropriate size strong stocking was not preferred. The best adherence was achieved by using a moderate stocking, while the best efficacy was achieved by using bandages.

Invasive micropapillary carcinoma of the breast in a male patient: Report of a case

INTRODUCTION We report a rare case of invasive micropapillary carcinoma in the male breast. PRESENTATION OF CASE A 63-year-old man was referred to our hospital for investigation of a left breast tumor, which could be palpated in the upper lateral quadrant of the left nipple-areola complex. The tumor invaded the areola skin. Ultrasonography showed a 14.8 × 15.0 × 12.4 mm low echoic mass, with an irregular lobulated border. Core needle biopsy indicated invasive ductal carcinoma, but the subtype could not be accurately determined. Mastectomy with axillary lymph node dissection was performed. Pathological examination indicated invasive micropapillary carcinoma, no lymph node metastasis, and a nuclear grade of 2. Immunohistochemical examination showed positive staining for estrogen and progesterone receptors, but negative staining for HER2. The Ki67 index was 5%. Tamoxifen was administered, and recurrence has not been noted for 1 year. DISCUSSION Womens IMPC generally shows a high HER2 positivity rate. However, HER2 positivity was noted in only 1 male patient with IMPC (14%) according to our literature review. Furthermore, in all cases of the mixed type that were reviewed, IMPC was associated with papillotubular carcinoma. These findings may be specific to IMPC in male patients. CONCLUSION IMPC is associated with a high rate of lymph node metastasis or recurrence and advanced vessel invasion, aggressive adjuvant chemotherapy following surgical resection should be selected for patients with IMPC.

Focal Adhesion Kinase Promotes the Progression of Aortic Aneurysm by Modulating Macrophage Behavior.

Objective— Abdominal aortic aneurysm (AAA) is a life-threatening vascular disease that is associated with persistent inflammation and extracellular matrix degradation. The molecular mechanisms underlying the macrophage-mediated progression of AAA remain largely unclear. Approach and Results— We show that focal adhesion kinase (FAK) expression and activity are enhanced in macrophages that are recruited to AAA tissue. FAK potentiates tumor necrosis factor-&agr;–induced secretion of matrix-degrading enzymes and chemokines by cultured macrophages. FAK also promotes macrophage chemotaxis. In mice, the administration of a FAK inhibitor that tempers local macrophage accumulation markedly suppresses the development and progression of chemically induced AAA. Conclusions— FAK plays a key role in macrophage behavior, which underlies the chronic progression of AAA. These findings provide insights into AAA progression and identify FAK as a novel therapeutic target.

Treatment Options for Celiac Stenosis and Pancreaticoduodenal Artery Aneurysms

Celiac stenosis may result in a pancreaticoduodenal artery aneurysm (PDAA). Celiac stenosis with a PDAA is rare and treatment guidelines are absent. Here, we report 4 cases of celiac stenosis treated using different methods. Of these, 3 involved PDAAs. The PDAAs were successfully treated with coil embolization. For celiac stenosis, we performed open surgery for decompression in 1 patient, stenting in 2 patients, and bypass grafting in 1 patient. In the patients who underwent stenting, stent-associated thrombosis occurred. PDAAs can be treated with coil embolization; however, treatment of celiac stenosis with the endovascular approach might be difficult.

Immediate Changes to Skin and Subcutaneous Tissue Strains Following Manual Lymph Drainage in Legs with Lymphedema.

OBJECTIVES To study the immediate impact of manual lymph drainage (MLD) on skin and subcutaneous tissue strains in legs with lymphedema using free-hand real-time tissue elastography (RTE). METHODS Skin and subcutaneous tissue strain measurements were taken at the middle of the inner thigh and calf by RTE in 20 legs with lymphedema of 18 patients (stage II: 11, late stage II: 7, stage III: 2) and in 70 legs of 35 normal subjects. In patients with lymphedema, the same measurements were repeated immediately following MLD. RESULTS Significant negative correlations were found between pre-MLD strains and the MLD-induced changes in thigh and calf skin strains (thigh skin: p <0.01, calf skin: p = 0.05), but not in subcutaneous tissue strains. Pre-MLD intercepts of these regression lines were closer to normal values as compared to mean pre-MLD values (normal thigh skin: 0.54% ± 0.30%, calf skin: 0.25% ± 0.18%, Pre-MLD thigh skin: 0.39% ± 0.20%, calf skin: 0.17% ± 0.12%, Pre-MLD intercept of thigh skin: 0.48%, Pre-MLD intercept of calf skin: 0.31%). CONCLUSIONS It appears that MLD did not simply soften the skin, but rather normalized it in terms of strain. However, this was not confirmed in the subcutaneous tissue.