Takehiro Sakai

Simultaneous early adenocarcinoma and mucosa-associated lymphoid tissue (MALT) lymphoma of the stomach associated with Helicobacter pylori infection

The simultaneous association of gastric carcinoma with gastric lymphoma is a rare event. Recent studies have suggested that not only gastric cancer but also primary gastric lymphomas, especially those of mucosa-associated lymphoid tissue (MALT) type, are associated with Helicobacter pylori infection. We report on a 51-year-old woman who was referred to our hospital for the evaluation of abnormal shadows revealed by an upper gastrointestinal radiography series. Endoscopy of the upper gastrointestinal tract revealed early cancer in the middle body of the stomach. Biopsy of the lesion subsequently proved it to be a signet-ring cell carcinoma. Total gastrectomy was performed, under a diagnosis of early gastric carcinoma. The resected specimen revealed two grossly separate lesions. Histological examination confirmed that the gastric body lesion was compatible with early moderately differentiated tubular adenocarcinoma of type 0-IIc, while the lesion of the fundus corresponded to MALT lymphoma. H. pylori was detected, and chronic gastritis was also present in the resected gastric specimen. H. pylori infection may have played a major role in the development of both the MALT lymphoma and the adenocarcinoma of the stomach in this patient.

Successfully repaired traumatic tracheal disruption and cardiac rupture with cardiopulmonary support.

A 19-year-old man suffering from dyspnea associated with tracheal and cardiac rupture from a traffic accident was found by bronchoscopy to have a 7.5 cm longitudinal tear in the membranous portion of the trachea. Right posterolateral thoracotomy was conducted and open ventilation through the left main bronchus initiated with standby cardiopulmonary bypass cannulation of the right femoral artery and vein. When oxygenation was poor, extracorporeal circulation was initiated through the cannulated artery and vein. Under the cardiopulmonary bypass, we safely repaired the tracheal laceration and cardiac rupture.

Pulmonary embolism and cerebral venous thrombosis after thoracoscopic surgery for benign pulmonary disease

A-76-year-old woman consulted for open biopsy for a pulmonary mass. Thoracoscopic wedge resection was performed. The lesion was histologically diagnosed as nonspecific inflammation. On the first postoperative day (POD1), the patient lost consciousness transiently. Eleven hours after the first stroke, the patient experienced a second stroke together with hypoxia. Pulmonary perfusion scan on POD2 showed multiple perfusion defects, and the patient was diagnosed with pulmonary embolism (PE). Thrombolitic therapy was started. Neurological symptoms didn’t improve, and cerebral angiography on POD3 showed delayed perfusion in superficial veins. The patient was diagnosed with cerebral venous thrombosis (CVT). Thrombolytic and anticoagulant therapy had been continued, and the patient was found to have hemorrhagic cerebral infarction on POD11. After persistent therapy, the patient was discharged on POD120. Although both PE and CVT are rare complications after thoracic surgery, we must consider these complications in patients undergoing thoracic operations including thoracoscopic surgery.

Metachronous Bilateral Primary Breast Cancer Associated with Dermatomyositis

To the Editor: Malignant lesions have been found in 15–30% of adult patients with dermatomyositis, and 17–18% of them had breast cancer (1). We report an uncommon case of metachronous primary breast cancer associated with dermatomyositis. A 61-year-old woman noticed a left breast mass and was referred to our hospital in August 1999. Pathologically diagnosed as carcinoma, she underwent modified radical mastectomy. Histologic examination revealed invasive ductal carcinoma. Final stage was determined to be T2N0M0, stage IIA. Both estrogen and progesterone receptors were positive. On the 11th day after surgery she developed muscle weakness, dysphasia, and a heliotrope rash on the upper eyelids. According to clinical features and laboratory findings, she was diagnosed with dermatomyositis. Retrospective microscopic examination revealed infiltration of lymphocytes around vessels and edematous changes were detected in the dermis, consistent with the findings of dermatomyositis. After administration of steroids, the symptoms gradually improved. In December 2001, she was withdrawn from steroids. In January 2003, she was diagnosed with right breast cancer and underwent modified radical mastectomy. Histologic examination revealed invasive ductal carcinoma, indicating comedo carcinoma. The findings of the second carcinoma were so inconsistent with those of the first that the final diagnosis of metachronous bilateral primary breast cancer was established. Only progesterone receptor was positive. The final stage was determined to be T3N0M0, stage IIB. The postoperative course was uneventful and administration of steroids was not required. After surgery, endocrine therapy was started. Although 5 months have passed since the second surgery, no recurrence of breast cancer has been detected. The nature of the relationship between dermatomyositis and breast cancer is not well understood. Probably both coincidental and true associations exist. Including our present case, we reviewed the clinicopathologic features of 20 cases of breast cancer associated with dermatomyositis in the Japanese literature. One of them was simultaneous double primary breast cancer in the ipsilateral breast (2). Two cases, including our present case, were metachronous primary breast cancer (3). Others were solitary cancer. As for histopathology, 16 of 23 tumors were invasive ductal carcinoma (69.9%) and 3 were occult carcinoma (13.0%). Treatment for breast cancer was surgery, except in one case of inflammatory breast cancer. Malignancies discovered after onset of dermatomyositis occurred in 8 of 20 patients (40%) and the time to development of carcinoma ranged from 3 months to 11 years (mean 34.8 months). Malignancies preceded by dermatomyositis occurred in 8 of 20 patients (40%) and the time to onset of dermatomyositis ranged from 3 months to 9 years (mean 33.4 months). Simultaneous onset was observed in 4 of 20 patients (20%). In our present case, dermatomyositis may have existed before surgery and symptoms became evident and rapidly progressed after surgery. The most common cause of death in patients with dermatomyositis is from associated malignancies, accounting for 54.6%. Among 20 patients with coexistence of breast cancer and dermatomyositis, eight patients died (40%), and six of them died of progression of cancer. In patients with breast cancer associated with dermatomyositis, periodic examination for recurrence and other malignancies, including second breast carcinomas, should be required.

Comparison of perioperative and oncological outcomes between video-assisted segmentectomy and lobectomy for patients with clinical stage IA non-small cell lung cancer: a propensity score matching study

Background Segmentectomy for lung cancer remains controversial because of the complexity of the procedure and concern about an increased recurrence rate. It is important to compare perioperative and oncological outcomes between segmentectomy and lobectomy. Methods From January 2007 to December 2016, 41 segmentectomies by video-assisted thoracic surgery (VATS) and 122 VATS lobectomies for 163 patients with clinical stage IA non-small cell lung cancer (NSCLC) were performed. Clinicopathological factors, including recurrence rate and survival rate, were compared. In order to reduce biases of outcomes, clinicopathological factors were used for propensity score matching (PSM). Then, 41 VATS segmentectomies and 41 lobectomies were selected and further analyzed. Results No significant differences were seen between the two groups in age, pulmonary function, comorbidity, operative time, blood loss, chest tube duration days, postoperative stay days, complications, histological type, and multiple primary rate. Smoking index resected number of nodes, tumor size, lymph node metastasis rate, and pathological stage were higher in the lobectomy group than in the segmentectomy group (P<0.05). In the lobectomy group, 16 patients (13.1%) had recurrence, and 2 patients (1.6%) died because of cancer progression. There were no significant differences in the recurrence rate and prognosis between the two groups. In addition, Cox regression analysis suggested that sex, lymph node metastasis, and pathology stage were associated with recurrence (P<0.05), but no factor was an independent prognostic factor. After PSM, the two groups had similar clinicopathological factors, and the type of operation still had no relationship with the recurrence rate or the death rate. Conclusions Perioperative and oncological outcomes of VATS segmentectomy are similar to those of VATS lobectomy for patients with clinical stage IA NSCLC. VATS segmentectomy can be considered one of the surgical procedures appropriate for patients with clinical stage IA NSCLC.

A Case of Stercoral Perforation of the Rectum Presented with Binswanger's Disease after Surgery

症例は75歳の男性で, 1週間の便秘と腹痛を主訴に当院救急外来を受診した.左下腹部に軽度の腹膜刺激症状を認めた.腹部造影CTにてS状結腸から直腸に多量の糞便の貯留を認めたが, 穿孔所見なく経過観察とした.翌日, 炎症反応著増, 腹部造影CTにて直腸壁外への糞便の漏出を認め, 宿便性大腸穿孔による汎発性腹膜炎の診断にて緊急開腹術を施行した.上部直腸に4.0cmの穿孔, 腸間膜内への糞便漏出を認め, Hartmann手術を施行した.術後に多臓器不全, 創感染, 腹腔内感染を来したが改善した.中枢神経症状が持続し, 臨床症状, 頭部CTにてBinswanger病の診断を得た.臨床症状が安定したため, 術後80日目に近医へ転院した.痴呆症状を有する高齢者では自覚症状が乏しいことがあり, 便秘を伴う突然の腹痛では宿便性大腸穿孔も念頭におき早期診断・早期治療を行うことが肝要である.

A Case of Primary Biliary Cirrhosis Associated with a Colon Cancer

結腸癌を合併した原発性胆汁性肝硬変 (PBC) の1例を報告する. 症例は58歳の女性で, 全身倦怠感, 黄疸を主訴に当院を受診した. 血液生化学検査で肝機能異常を認めた. HBS抗原, HCV抗体は陰性, 抗ミトコンドリア抗体が陽性で, PBCの診断を得た. 下部消化管精査にてS状結腸に腫瘍を認め, 生検にて腺癌の診断を得た. 肝機能正常化後, 結腸癌に対しS状結腸切除術, D2郭清, さらに肝生検を施行した. 術後経過は良好であった. S状結腸に40×37mmの3型腫瘍を認め, 病理組織的に中分化型腺癌の診断を得た. 深達度はss, リンパ節転移を認めず, Stage IIであった. 肝生検標本ではPBCの診断で, Scheuer分類のII期であった. PBCに肝外悪性腫瘍を合併した症例は散見されるが, 大腸癌との合併症例の報告はまれである. PBC患者では初診時および経過観察時に消化管を含めた肝外悪性腫瘍の検索を行うべきである.