Tsuguaki Kono

The overall prevalence of metastasis in T1 esophageal squamous cell carcinoma: a retrospective analysis of 295 patients.

Objectives:T1 esophageal squamous cell carcinoma (ESCC) has a low, but still present, risk of lymph node (LN) metastasis. Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) is often applied for T1 ESCC. To achieve successful treatment by EMR/ESD, the risk of LN metastases, LN recurrence, and hematological recurrence need to be better understood. The aim of this study was to determine the precise risk for metastasis in T1 ESCC. Methods:We divided 295 patients with T1 ESCC who underwent surgery and/or ESD/EMR into 6 categories (m1, m2, m3, sm1, sm2, and sm3). Their risks of LN metastasis, LN recurrence, hematological recurrence, and the outcome were determined. Results:The rates of LN metastasis and LN recurrence were 0% in m1 and m2, 9% in m3, 16% in sm1, 35% in sm2, and 62% in sm3 cases. The incidence of hematological recurrence was 0% in m1, m2, m3, and sm1 cases; 9% in sm2 cases; and 13% in sm3 cases. The overall risk of metastasis was 9% in m3, 16% in sm1, 38% in sm2, and 64% in sm3 patients. The 5-year disease-specific survival rates were 100% in m1, m2, and m3; 90.9% in sm1; 78.8% in sm2; and 68.6% in sm3 patients. Statistically, both lymphatic and venous invasion were selected as predictive markers for metastasis. In m3 patients, positivity for either of these had an odds ratio for metastasis of 7.333 (P = 0.093). Conclusions:Our study provides a precise assessment of the comprehensive risk of metastasis and feasible predictive markers for T1 ESCC.

Diffusion-Weighted Magnetic Resonance Imaging for Predicting and Detecting the Early Response to Chemoradiotherapy of Advanced Esophageal Squamous Cell Carcinoma

Background: The aim of this study was to investigate the utility of the apparent diffusion coefficient (ADC) value in diffusion-weighted magnetic resonance imaging (DWMRI) for prediction and early detection of treatment response in advanced esophageal squamous cell carcinoma. Method: DWMRI was performed in 27 patients with primary cT4 esophageal carcinoma that were undergoing chemoradiotherapy before treatment and after 20 and 40 Gy. We calculated tumor ADCs and association of the treatment effect between responders and nonresponders. Results: The ADC at the time of 20 Gy was significantly higher in responders compared to nonresponders (1.13 vs. 0.93; p = 0.005). The ADC cut-off value was set at 1.00 × 10-3 mm2/s and the ADC predicted the responders with a sensitivity, positive predictive value and accuracy of 79, 73 and 74%, respectively. The increased rate of the ADC at the time of 20 Gy (ΔADC20) was also significantly higher in responders compared to nonresponders (35.4 vs. 1.5%; p = 0.0007). An ADC cut-off value for ΔADC20 of 15% predicted the responders with a sensitivity, positive predictive value and accuracy of 71, 100 and 85%, respectively. Conclusion: The ADC values predicted the prognosis of patients with advanced esophageal squamous cell carcinoma as well as the treatment response.

The number of pathologic lymph nodes involved is still a significant prognostic factor even after neoadjuvant chemoradiotherapy in esophageal squamous cell carcinoma

The correlation between the number of pathologic metastatic LNs in patients with esophageal squamous cell carcinoma (ESCC) after neoadjuvant chemoradiotherapy (NACRT) and surgical outcome has rarely been reported. We evaluated the correlation between the number of pathologic metastatic lymph nodes (LNs) and the surgical outcome in ESCC after NACRT.

Metastatic Malignant Meningioma of the Liver with Hypoglycemia : Report of a Case

We herein present the case of a 68-year-old male who suffered an episode of hypoglycemic shock 2 years after undergoing total removal of a bifrontal parasagittal malignant meningioma. Imaging studies revealed three giant hypervascular tumors with a cystic portion in the right lobe, but no confirmed preoperative diagnosis could be made. At laparotomy, liver tumors were found in the medial segment of the left lobe as well as in the right lobe, and thus an extended right lobectomy was performed. All the resected tumors were histologically diagnosed as metastatic malignant meningiomas of the liver. Despite subsequent transarterial chemoembolization for a recurrence in the residual liver, the patient died 11 months after surgery. To the best of our knowledge, only one other case of a hepatectomy for liver metastases from an intracranial malignant meningioma has been reported in the literature, but there has never been any report of surgical treatment for a metastatic meningeal tumor in the liver associated with hypoglycemia. Although our surgical treatment provided effective palliation, the prognostic significance of a surgical strategy for such patients has yet to be established.

Clinical Application of 11c-methionine Positron Emission Tomography for Evaluation of Pancreatic Function

Introduction In recent years, it has become increasingly necessary to evaluate pancreatic function after pancreatectomy, but few precise methods are available. Aims To evaluate different surgical techniques for pancreatectomy in terms of the preservation of pancreatic function by 11C-methionine positron emission tomography (PET), which determines amino acid metabolism in the pancreas. Methodology The study included 33 pancreatectomy cases: 5 of distal pancreatectomy, 5 of pancreaticoduodenectomy, 10 of pylorus-preserving pancreaticoduodenectomy, 7 of duodenum-preserving pancreatic head resection, and 6 of inferior pancreatic head resection. The method was as follows. Approximately 370 MBq 11C-methionine was intravenously injected. Cross-sectional imaging of the pancreas was performed by PET after 30 minutes. The images obtained were used to determine the radioactivity concentration in the pancreas. By adjustment of the radioactivity concentration for body weight and dosage, the differential absorption ratio could be determined to indicate the level of accumulation in the pancreas. Each surgical method used was evaluated on the basis of the differential absorption ratio. Postoperative total pancreatic accumulation was divided by preoperative level to calculate the total preserved pancreatic function rate (TPPFR), and postoperative local pancreatic accumulation was divided by preoperative level to calculate the local preserved pancreatic function rate (LPPFR). These rates were then compared for the individual techniques used. Results The results indicated that TPPFR and LPPFR were 61.2 ± 20.0% and 114.6 ± 29.4% for distal pancreatectomy (n = 5), 31.8 ± 20.0% and 58.7 ± 30.0% for pancreaticoduodenectomy (n = 5), 21.6 ± 14.7% and 58.4 ± 29.8% for pylorus-preserving pancreaticoduodenectomy (n = 10), 47.9 ± 35.5% and 67.7 ± 30.6% for duodenum-preserving pancreatic head resection (n = 7), and 48.1 ± 29.5% and 83.9 ± 30.5% for inferior pancreatic head resection (n = 6). TPPFR was highest in distal pancreatectomy cases. Among the pancreatic head resections, TPPFR was quite high for both inferior pancreatic head resection and duodenum-preserving pancreatic head resection. In contrast, TPPFR for pancreaticoduodenectomy and pylorus-preserving pancreaticoduodenectomy was quite low. LPPFR was highest for distal pancreatectomy and only slightly lower for inferior pancreatic head resection. In contrast, LPPFR was markedly lower for pancreaticoduodenectomy and pylorus-preserving pancreaticoduodenectomy. Conclusion In conclusion, this method using 11C-methionine PET is clearly useful for the evaluation of pancreatic function after pancreatectomy.

S-1 Monotherapy as Second- or Third-Line Chemotherapy for Unresectable and Recurrent Esophageal Squamous Cell Carcinoma

Purpose: S-1 is widely used for various cancers. It may be useful for esophageal squamous cell carcinoma (ESCC); however, there are insufficient data. The purpose is to provide results of an analysis of S-1 monotherapy for unresectable and recurrent ESCC. Patients and Methods: Twenty patients with histologically proven ESCC who were previously treated with other chemo(radio)therapies were treated with S-1 alone as second- or third-line chemotherapy. Results: A complete response (CR) was observed in 1 case (5%). A partial response (PR), stable disease (SD), and progressive disease (PD) were seen in 4 (20.0%), 7 (35.0%), and 8 (40.0%) cases, respectively. Two cases (10%) of anemia, 1 case (5%) of leukopenia, 3 cases (15%) of fatigue, and 3 cases (15%) of diarrhea were observed as grade 3 toxicity; however, there were no cases of grade 4 toxicity. The 1-year progression-free survival (PFS) rate was 10.0%, and the median PFS was 100 days. The 1-year overall survival (OS) was 30.5%, and the median OS was 330 days. The 1-year PFS rate in CR/PR/SD and PD was 16.7 and 0%, and the median survival time was 120 and 40 days. Conclusion: S-1 is a promising new drug which can be used as a second- or third-line chemotherapy for ESCC.

Utility of arterial phase of dynamic CT for detection of intestinal ischemia associated with strangulation ileus

AIM To clarify the usefulness of arterial phase scans in contrast computed tomography (CT) imaging of strangulation ileus in order to make an early diagnosis. METHODS A comparative examination was carried out with respect to the CT value of the intestinal tract wall in each scanning phase, the CT value of the content in the intestinal tract, and the CT value of ascites fluid in the portal vein phase for a group in which ischemia was observed (Group I) and a group in which ischemia was not observed (Group N) based on the pathological findings or intra-surgical findings. Moreover, a comparative examination was carried out in Group I subjects for each scanning phase with respect to average differences in the CT values of the intestinal tract wall where ischemia was suspected and in the intestinal tract wall in non-ischemic areas. RESULTS There were 15 subjects in Group I and 30 subjects in Group N. The CT value of the intestinal tract wall was 41.8 ± 11.2 Hounsfield Unit (HU) in Group I and 69.6 ± 18.4 HU in Group N in the arterial phase, with the CT value of the ischemic bowel wall being significantly lower in Group I. In the portal vein phase, the CT value of the ischemic bowel wall was 60.6 ± 14.6 HU in Group I and 80.7 ± 17.7 HU in Group N, with the CT value of the ischemic bowel wall being significantly lower in Group I; however, no significant differences were observed in the equilibrium phase. The CT value of the solution in the intestine was 18.6 ± 9.5 HU in Group I and 10.4 ± 5.1 HU in Group N, being significantly higher in Group I. No significant differences were observed in the CT value of the accumulation of ascites fluid. The average difference in the CT values between the ischemic bowel wall and the non-ischemic bowel wall for each subject in Group I was 33.7 ± 20.1 HU in the arterial phase, being significantly larger compared to the other two phases. CONCLUSION This is a retrospective study using a small number of subjects; however, it suggests that there is a possibility that CT scanning in the arterial phase is useful for the early diagnosis of strangulation ileus.

Diffuse schwannoma involving the entire large bowel with huge extramural development: Report of a case

Schwannoma of the large bowel is a rare clinical entity, which has reportedly been recognized to arise from one place with a submucosal tumor morphology. We present herein the unique case of a 25-year-old woman who suffered from a schwannoma diffusely involving the entire large intestine. The patient complained of abdominal distension and imaging studies revealed a giant tumor occupying the whole abdomen, but no confirmed preoperative diagnosis could be made. A laparotomy proved the huge tumor detected preoperatively to be the markedly wall-thickened entire large bowel itself due to the diffuse extramural development of a neoplasm, but no other organs were involved. Biopsy specimens from the tumor were histologically diagnosed as benign schwannoma. However, because of the possibility of malignancy, we later performed a total proctocolectomy followed by an ileal J-pouch-anal canal anastomosis. The final pathological diagnosis was also that of a benign schwannoma originating from the large intestine. The patient remains well without recurrence 15 months after surgery. To the best of our knowledge, no such case of a schwannoma in the entire large bowel has yet been reported in the literature, and the pathogenesis of its occurrence remains unknown.

Evaluation of pancreatic function in normal pancreas as living-related donors and type 1 diabetic pancreas as recipients for pancreas transplantation using 11c-methionine positron emission tomography.

To the Editor: L iving-donor pancreas transplantation has been developed as one of the effective therapeuticmodalities for patientswith type 1 diabetes. The safety to the donor is a major consideration in this procedure. The donor pancreatic endocrine function has been widely evaluated using both oral and intravenous glucose tolerance tests. Although these tests are useful for evaluation of the endocrine function of the entire organ, they cannot be used to evaluate the segmental pancreatic function. On the other hand, positron emission tomography (PET) can be used to evaluate the segmental pancreatic function, such as the functions of the remnant pancreas head after the donor operation and the pancreas body/tail as a graft for living-related pancreas transplantation. The C-methionine (MET) uptake of the pancreas is correlated not only with acinar cell functions, such as the amylase output, but alsowith the duct cell functions, such as the pancreatic juice bicarbonate concentration and volume. Furthermore, the METuptake was related to the insulinogenic index, which is one of the pancreatic endocrine function tests. Kono et al demonstrated operative preservation of pancreatic function, including exocrine and endocrine functions, by MET-PET. For determination of the potential usefulness of MET-PET in living-donor liver transplantation, the present study was strictly limited to the normal pancreas of donors and diseased pancreas of recipients with type 1 diabetes in living-related pancreas transplantation. Eight living donors and 8 recipients with type 1 diabetes who were scheduled for livingrelated pancreas transplantation were enrolled for the evaluation between February 2006 and December 2007 at the ChibaEast National Hospital for biochemical examination and National Institute of Radiological Sciences for PET studies. The mean (SD) age of the subjects without diabetes was 60 (2) years, and that of the patients with type 1 diabetes was 36 (4) years. The mean (SD) duration of diabetes in the patients with type 1 diabetes was 22 (5) years. The mean (SD) body mass index was 23.1 (2.1) kg/m in the subjects without diabetes and 20.0 (1.8) kg/m in patients with type 1 diabetes. The fasting plasma glucose, hemoglobin A1c, and C-peptide levels in the subjects without diabetes and the patients with type 1 diabetes were 88 (2) mg/dL and 104 (49) mg/dL, 5.2% (0.1%) and 6.5% (1.4%), and 1.82 (0) ng/mL and less than 0.05 ng/mL, respectively. All the datawere acquired with a PET/ computed tomography (CT) system (Biograph Duo; Siemens, Munich, Germany). After 6 hours’ fasting, the standard dose of 740 MBq of MET was injected intravenously 30 minutes before imaging. The following settings were used for the CT: 140 kV, 80 mA; gantry rotation time, 0.5 seconds; collimator width, 2 5 mm; section thickness, 5 mm. Positron emission tomography scanning was performed immediately after the CT. The uptake values of MET in the pancreas were measured and expressed as standardized uptake values (SUVs). The SUVs were compared between the subjects without diabetes and the patients with type 1 diabetes and also between the head of the pancreas and body/tail of pancreas in each of the subjects without diabetes and the patients with type 1 diabetes. The statistical significance of the differences was analyzed using the paired t test, and P G 0.05 was considered to denote significance. The representative MET-PET images of the subjects without diabetes and patients with type 1 diabetes are shown. The MET accumulation was higher in the normal pancreata than in the liver (Fig. 1A), whereas it was lower in the diabetic pancreata than in the liver (Fig. 1B). The MET SUVs in the normal pancreata and type 1 diabetic pancreata were 16.1 (0.4) and 8.4 (1.9), respectively. Thus, the normal pancreata showed significantly higher SUVs than the type 1 diabetic pancreata (P G 0.001). The SUVs in all the normal pancreata were more than 14, and those in all the diabetic pancreata were less than 12. The SUVs in the pancreas head and body/tail in the subjects without diabetes were 16.0 (0.4) and 16.0 (1.5), respectively, and the corresponding values in the patients with type 1 diabetes were 8.4 (1.9) and 7.6 (2.1). The SUVs both in the pancreas head and body/tail accumulated equally in the subjects without diabetes and those with type 1 diabetes. Methionine is a precursor of Sadenosylmethionine, which is the universal methyl donor of transmethyl reactions. It is an essential substance for almost all physiological reactions resulting in the formation of methylated products, such as the informational macromolecules of DNA and RNA. Several experimental studies suggest that hypomethylation can influence cellular differentiation and growth. A recent study indicates that advanced diabetes with renal failure may induce changes that predispose to hypomethylation. The hypomethylation metabolic state, which is associated with a low uptake of MET, may be involved in the metabolic disorder associated with severe diabetes, particularly type 1 diabetes. Although the impairment of exocrine functions can occur in both subjects without diabetes and patients with type 1

A 3-step gradual dilation method: a new safe technique of percutaneous endoscopic gastrostomy for obstructive esophageal cancer.

Although percutaneous endoscopic gastrostomy (PEG) is the preferred method to provide enteral nutrition for a longer time period, in obstructive esophageal cancer, we cannot safely perform endoscopic access to the stomach even with the ultrathin endoscope. We experienced 1 fatal case due to esophageal perforation caused by balloon dilation, and hence, we developed a safer method. We treated 4 patients with obstructive esophageal cancer using a 3-step gradual dilation method with nasogastric tubes (from 8 to 16 Fr). After about 2 weeks of initial dilation, we could safely perform endoscopic access to the stomach with the ultrathin endoscope and PEG placement using the introducer technique. The 3-step gradual dilation method is a safe and easy procedure for endoscopic access to the stomach. It can be used to provide enteral access as a palliative treatment for patients with obstructive esophageal cancer that is not suitable for conventional PEG placement.