Tomohiro Kunishige

A defect of the abdominal wall with intestinal fistulas after the repair of incisional hernia using Composix Kugel Patch

INTRODUCTION In the present paper, we show a rare case of the large abdominal wall defect and enterocutaneous fistulas after the tension free repair using prostheses for incisional hernia. PRESENTATION OF CASE The patient, a 70-year-old man, had a history of a hemicolectomy for a perforating colon cancer, complicated by a large incisional hernia that was closed primarily but recurred. Three years later, the hernia was repaired at the time of a second colectomy using a Composix Kugel Patch. His course was complicated by a chronic postoperative wound infection with eventual development of enterocutaneous fistulas. The patient was successfully treated with extirpation of the prosthesis, resection of the fistulized bowel, and placement of a tensor fasciae latae myocutaneous flap. DISCUSSION Enterocutaneous fistulas are a known complication of incisional hernia repairs using prostheses. Additional clinical data are required to confirm the safety and efficacy of this procedure as it becomes more widely adopted. CONCLUSION Extirpation of the prosthesis should be performed without delay to prevent serious complications. Reconstruction with a tensor fasciae latae myocutaneous flap was useful for the large abdominal wall defect.

Prognostic Significance of the Prognostic Nutritional Index in Patients with Recurrent Esophageal Squamous Cell Carcinoma

ABSTRACT The aim of this study was to evaluate the prognostic impact of the prognostic nutritional index (PNI) in patients with recurrent esophageal squamous cell carcinoma (ESCC). We retrospectively reviewed 76 ESCC patients who developed recurrence after curative subtotal esophagectomy at Nara Medical University Hospital between January 2001 and October 2016. The PNI at ESCC recurrence was calculated as 10 × serum albumin (g/dl) + 0.005 × total lymphocyte count (/mm3). The cutoff value of the PNI was set at 45. Multivariate analysis was performed to identify the prognostic factors. The mean PNI was 44.0 ± 5.8, and 42 (55.3%) patients had a PNI <45 at recurrence. The multivariate analysis identified a low PNI (P = 0.047), multiple recurrence sites (P = 0.002), and no treatment for recurrence (P = 0.034) as independent factors for a short survival time after recurrence. A low PNI was significantly associated with a high performance status score, high C-reactive protein level, and short duration of treatment for recurrence. In conclusion, the PNI at recurrence can predict the survival time in patients with recurrent ESCC.

Overexpression of E3 ubiquitin ligase tripartite motif 32 correlates with a poor prognosis in patients with gastric cancer

Tripartite motif protein (TRIM) 32 belongs to the TRIM family, which is composed of RING finger, B-box and coiled-coil domains. TRIM32 has been reported to function as an enzyme 3 ubiquitin ligase and is overexpressed in numerous types of cancer. The present study evaluated the clinical significance of TRIM32 expression levels in gastric cancer. The current study also investigated the TRIM32 expression levels in 142 patients with gastric cancer using immunohistochemistry and examined its clinical importance and potential as a prognostic marker. Furthermore, the function of TRIM32 was examined in vitro. High TRIM32 expression levels were detected in gastric cancer tissues. The postoperative overall and relapse-free survival rates were significantly reduced in patients with tumors with high levels of TRIM32 expression compared with those with tumors expressing low levels of TRIM32. Tumors expressing high levels of TRIM32 were associated with an increased risk of postoperative recurrence, particularly hematogenous recurrence. Multivariate analysis identified TRIM32 status as an independent prognostic factor. Furthermore, TRIM32 gene silencing induced apoptosis and inhibited the proliferation of gastric cancer cells in vitro. Therefore, TRIM32 expression levels may be of potential prognostic value in gastric cancer.

The Prognostic Significance of the Geriatric Nutritional Risk Index in Patients with Esophageal Squamous Cell Carcinoma

Abstract The aim of this study was to investigate the impact of the geriatric nutritional risk index (GNRI) on the long-term outcomes in 137 esophageal squamous cell carcinoma (ESCC) patients who underwent curative esophagectomy. The GNRI was calculated from the serum albumin value and the body weight. The cutoff value of the GNRI was set at 98. A multivariate analysis was performed to identify prognostic factors for the overall survival (OS). The mean preoperative GNRI was 99.9 ± 7.8. Forty-five (32.8%) patients had a GNRI of <98. The GNRI was significantly associated with the tumor depth (p = 0.001), level of carcinoembryonic antigen (CEA; p = 0.009) and level of C-reactive protein (CRP; p = 0.028). The GRNI was significantly associated with the OS (p < 0.001). The multivariate analysis identified the GNRI as an independent predictor for the OS. Death due to EC was more frequent in the patients with a low GNRI than in the patients with a high GNRI (p = 0.004). Our results suggest that the GRNI is a simple and reliable predictor of the postoperative survival in ESCC patients. A low preoperative GNRI may indicate a higher risk of EC death.

A decrease in the prognostic nutritional index is associated with a worse long-term outcome in gastric cancer patients undergoing neoadjuvant chemotherapy

PurposeThe aim of this study was to evaluate the prognostic impact of the prognostic nutritional index (PNI) in gastric cancer patients undergoing neoadjuvant chemotherapy (NAC).MethodsThis study reviewed 54 patients with gastric cancer who underwent NAC and a subsequent R0 gastrectomy. The PNI before starting NAC and before gastrectomy were calculated using the following formula: 10 × serum albumin (g/dl) + 0.005 × total lymphocyte count (per mm3). A multivariate analysis was performed to identify the predictors of overall survival (OS).ResultsThe mean pre-NAC and preoperative PNI were 48.3 ± 5.1 and 48.2 ± 4.7, respectively (p = 0.934). The PNI decreased after NAC in 31 patients (57.4%). The pre-NAC PNI and preoperative PNI were not significantly associated with the OS rate. The 3-year OS rate in patients with the decreased PNI values was significantly lower than that in the patients whose PNI values were either maintained or increased (41 vs. 76.4%, p = 0.003). A multivariate analysis revealed that a decreased PNI value was an independent predictor of a poor OS (p = 0.006).ConclusionsDecreased PNI values were associated with worse long-term outcomes in gastric cancer patients undergoing NAC.

Usefulness of computed tomography density of a tumor in predicting the response of advanced esophageal cancer to preoperative chemotherapy

Background. In Japan, preoperative chemotherapy is considered essential for resectable stage II or III esophageal cancers. It is important to identify nonresponders for preoperative chemotherapy because continuing ineffective chemotherapy is not beneficial for them. We investigated the correlation between the computed tomography number of tumor and the effect of preoperative chemotherapy in patients with esophageal cancer. Methods. This retrospective study included 50 patients receiving preoperative chemotherapy with docetaxel, cisplatin, and 5‐fluorouracil for stage II or III esophageal cancer. The computed tomography number of tumor was measured as the mean of Hounsfield Units of the primary lesion on a plain computed tomography measured within a freehand region of interest drawn around the tumor border. For analysis, the patients were classified into responders and nonresponders to chemotherapy, with the pathologic response evaluated using the Japanese and Mandard classification. We analyzed the associations between the computed tomography number of tumor and clinical factors; histopathologic features, including the tumor size, depth of tumor invasion, capillary invasion, Ki‐67, p53, and CK5/6 expression; the pathologic response to chemotherapy and prognosis. Results. There was a significant association between the computed tomography number of tumor and the response to chemotherapy. The cut‐off value of the computed tomography number of tumor in predicting responders to chemotherapy was 40 Hounsfield Units (area under the receiver operating characteristic curve = 0.73, P = .009); patients with computed tomography number of tumor greater than this value significantly responded to chemotherapy (P = .02 in the Japanese and P = .009 in the Mandard classification) with good postoperative prognosis (P = .04). Only Ki‐67 expression among the histopathogic features were associated with the computed tomography number of tumor in histopathologic features (P = .01). Conclusion. The computed tomography number of tumor may be useful to predict the efficacy of preoperative chemotherapy and subsequent prognosis for patients with advanced esophageal cancer.

Barrett’s Esophageal Adenocarcinoma with CREST Syndrome

Scleroderma is a systemic and connective tissue disease. Gastrointestinal manifestations including esophageal dysmotility are common in scleroderma patients. The relationship between esophageal reflux and scleroderma has been well described; however, the complication of Barrett’s esophagus and adenocarcinoma due to chronic esophagitis is rare. In addition, there are no detailed reports on the treatment of esophageal adenocarcinoma or the pathological findings in patients with scleroderma. We report the case of a 55-year-old woman who presented with chronic cough and a dilated esophagus. The patient was diagnosed with Barrett’s adenocarcinoma and CREST syndrome, which is a form of scleroderma. Subtotal esophagectomy was performed, and the patient’s chronic cough was relieved. A surgical specimen revealed histological changes at the dilated parts of the esophagus that showed the thinning of the muscular layer with fibrotic changes.

Pseudosarcomatous myofibroblastic proliferation of the gallbladder mimicking early carcinoma.

To the Editor: Pseudosarcomatous myofibroblastic proliferation (PMP) is a very rare benign lesion, which is diagnosed in the genitourinary tract. PMP may develop after trauma, surgery or spontaneously. Grossly, the lesions are polypoid or nodular. Histologically, proliferative spindle cells are observed. Furthermore, PMPs harbor various inflammatory components. To date, the true etiology of PMP remains unknown. PMP has also been reported in a few other organs and tissues, including heart, breast and rectum. However, due to the rarity of this disease entity, limited clinical information is available. We herein report a case of PMP of the gallbladder in a patient with suspected early carcinoma. A 49-year-old woman had no past medical history and no symptoms. A small polyp in the gallbladder was detected by an ultrasound (US) examination 5 years before she was referred to our hospital. Six months later, a repeat examination showed no change in the size and shape of the polyp. She did not undergo any medical checkup for 4 and a half years thereafter. Due to the enlargement of the gallbladder polyp by a follow-up US examination, she was referred to our hospital for further evaluation and treatment. Laboratory findings were within normal ranges, although the serum carbohydrate antigen 19–9 (CA19–9) level was slightly elevated to 44 U/mL (normal range, <37.0). Ultrasonography of the abdomen showed an irregular mass lesion in the gallbladder. Color Doppler ultrasonography demonstrated a blood flow within the mass lesion. Contrasted computed tomography revealed an enhanced mass lesion with a slightly thickened surrounding wall in the gallbladder (Fig. 1a). Because we suspected the tumor to be early gallbladder cancer, we performed laparoscopic cholecystectomy. The postoperative course was uneventful. The has patient survived for more than 8 years without recurrence. The tumor measured 10 mm in size, and a sessile polypoid lesion was observed in the gallbladder (Fig. 1b). The polypoid lesion showed smooth surface and yellowish appearance. There were no stones in the gallbladder. A tissue specimen was fixed in 10 % formalin and subsequently cut into 5 mm serial slices, and then the tumor portion was separated for a histopathological evaluation. Histological sections revealed that the majority of the surface of the tumor showed erosion and only small part of the surface near the margin was covered with the gallbladder epithelium (Fig. 1c). There was a proliferation of spindle-shaped myofibroblastic cells associated with relatively mild infiltrations of chronic inflammatory cells, including lymphocytes, plasma cell and eosinophils (Fig. 1d). Although there was mild nuclear atypia, mitoses were inconspicuous. There was no