Rectal Cancer With Disseminated Carcinomatosis of the Bone Marrow: Report of a Case

We report a rare case of disseminated carcinomatosis of the bone marrow from rectal cancer with disseminated intravascular coagulation (DIC). A 65-year-old man was admitted with melena and low back pain at rest. X-ray examination showed rectal cancer with multiple bone metastases. Laboratory examination showed severe anemia and DIC. Histologic examination showed disseminated carcinomatosis of the bone marrow. The DIC was considered to be caused by disseminated carcinomatosis of the bone marrow from rectal cancer, and we immediately started treatment with anti-DIC therapy and anticancer chemotherapy with the modified FOLFOX6 regimen (mFOLFOX6). After some response to therapy, the patient''s general condition deteriorated, and he died 128 days after admission. This is the first English report showing disseminated carcinomatosis of the bone marrow from colorectal cancer treated with mFOLFOX6.Key words: Bone marrow neoplasms, Rectal neoplasms, Disseminated intravascular coagulationBone metastases diffusely invading the bone marrow with disseminated intravascular coagulation (DIC) and microangiopathic hemolytic anemia (MHA) tend to accompany solid tumors; this condition is called disseminated carcinomatosis of the bone marrow,¹ and it is associated with an extremely poor prognosis. Among solid tumors, DIC is most commonly associated with breast cancer, prostate cancer, and lung cancer^2,3; carcinomatosis arising from colorectal cancer is rare.Herein we report on a patient with disseminated carcinomatosis of the bone marrow with rectal cancer who developed acute DIC and was treated with a modified FOLFOX6 regimen (mFOLFOX6). We also review 11 similar previously reported cases.^4–10     

Definitive Chemoradiotherapy and Salvage Esophagectomy for Esophageal Cancer Associated With Multiple Lung Metastases: A Case Report

The prognosis of esophageal cancer with distant metastasis is dismal. We report a 70-year-old man with esophageal cancer and multiple lung and lymph node metastases. Complete response was achieved following definitive chemoradiotherapy. Twenty-four months after the initial chemoradiotherapy, local recurrence was detected but there was no evidence of distant metastasis. Therefore, the patient underwent salvage esophagectomy. The surgery was well tolerated without any postoperative complications. The patient is still alive 48 months after the salvage surgery. Our experience suggests that salvage esophagectomy is an important component of multimodal therapy for the recurrence of esophageal cancer.Key words: Esophageal cancer, Chemoradiotherapy, Salvage surgeryThe prognosis of esophageal cancer has improved in recent years, but remains poor despite curative resection.¹ The prognosis is extremely dismal in patients with distant metastasis. The Radiation Therapy Oncology Group (RTOG) trial 85-01 showed that chemoradiotherapy (CRT) improved outcomes, with a 5-year overall survival rate of 26% compared with 0% following radiotherapy alone. Moreover, residual cancer was less common following CRT (26%) than following radiotherapy alone (37%).² However, local recurrence occurs in 37% of patients after definitive CRT.³ Salvage esophagectomy is one strategy for residual cancer or local recurrence after definitive CRT. Of note, when R0 resection is achieved, long-term survival can be expected.⁴⁻⁶ On the other hand, this is an invasive procedure associated with high morbidity and mortality⁶ and the patient''s prognosis is extremely poor after R1/R2 resection.⁴⁻⁶ Therefore, salvage esophagectomy should only be performed if complete removal of the tumor is expected.Here, we report a rare case with esophageal cancer and multiple lung metastases, in which complete response (CR) was achieved after definitive CRT and salvage esophagectomy was effective for the local recurrence.     

Primary Esophageal Adenocarcinoma With Distant Metastasis to the Skeletal Muscle

Hematogenous metastasis of esophageal adenocarcinoma to the skeletal muscle is uncommon. We report a rare case of esophageal adenocarcinoma with metastasis to the skeletal muscle. During pretherapeutic examination, a painful mass was detected in the left thigh of a 49-year-old man. Endoscopic biopsy identified poorly differentiated, advanced esophageal adenocarcinoma. Computed tomography (CT) revealed wall thickening in the distal esophagus. Two enlarged lymph nodes were detected—the middle thoracic paraesophageal lymph node in the mediastinum and the right cardiac lymph node. ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography demonstrated left thigh metastasis, which had not been detected by CT 3 weeks previously, with increased accumulation of FDG. Therefore, ultrasound-guided core-needle biopsy was performed. Histologic and immunohistochemical findings supported a diagnosis of poorly differentiated adenocarcinoma. The final diagnosis was primary esophageal adenocarcinoma with distant metastasis to the skeletal (left thigh) muscle. The rate of disease progression in this case emphasizes the malignant potential of esophageal adenocarcinoma. A few cases of skeletal metastasis from advanced esophageal adenocarcinoma have been previously reported. However, rapid metastasis to a distant skeletal muscle with no other hematogenous metastasis is quite rare. Early detection and rapid treatment are especially important in cases of esophageal adenocarcinoma.Key words: Esophageal adenocarcinoma, Skeletal metastasisEsophageal cancer is a common malignant neoplasm worldwide. Despite recent improvements in surgical techniques and adjuvant therapies, the prognosis for patients with advanced disease remains poor.^1,2Diagnosis of esophageal carcinoma is often delayed because of its anatomic inaccessibility. Esophageal cancer is a well-known cause of distant metastases. It initially tends to spread locally, then metastasizes to the lymph nodes, and finally to the distant organs.³ Metastases to the lungs, pleura, liver, stomach, kidney, adrenal glands, bones, and muscles have been reported in a few small series and clinical reports.^3–8 However, skeletal muscle is a rare site of clinically apparent metastasis, despite its rich blood supply. The exact incidence of distant skeletal muscle metastasis from esophageal adenocarcinoma is unknown. Only 4 cases have been described previously in the literature.^5–8The incidence of and mortality due to esophageal adenocarcinoma have been increasing in the United States, several European countries, and Oceanus, whereas in Japan, no increase has been apparent. Obesity, gastroesophageal reflux, and tobacco smoking (to a lesser extent) are the principal factors associated with an increased risk of esophageal adenocarcinoma.⁹ Some data suggest that these factors may act synergistically when present together.^10,11 A previous report demonstrated that infection with Helicobacter pylori markedly reduced the risk of esophageal adenocarcinoma and its precursor lesions.^12,13We report a case of thigh muscle metastasis from primary esophageal adenocarcinoma.     

Prognostic Role of Gastrectomy in Patients With Gastric Cancer With Positive Peritoneal Cytology

This retrospective study identified the optimal treatment strategy for patients with gastric cancer with positive peritoneal cytology. We analyzed clinicopathologic and survival data for 54 patients who had undergone gastrectomy and/or chemotherapy for treatment of gastric cancer with positive peritoneal cytology with (n = 40) or without (n = 14) metastatic disease. The median overall survival did not differ significantly between patients with gastric cancer with positive peritoneal cytology with and without metastatic disease (19 versus 13 months, respectively). Among 14 clinicopathologic variables, the lack of gastrectomy was the only significant independent unfavorable factor for survival (odds ratio, 1.64; 95% confidence interval, 1.04–2.57; P = 0.03). The median overall survival significantly differed among patients who had undergone gastrectomy plus chemotherapy, chemotherapy alone, and gastrectomy alone (25, 10, and 17 months, respectively; P < 0.01). Gastrectomy may be optimal for patients with (gastric cancer with positive peritoneal cytology), considering its favorable prognostic effect with respect to perioperative chemotherapy.Key words: Peritoneal cytology, Gastric cancer, GastrectomyStage IV gastric cancer is generally considered to be incurable, and affected patients are usually ineligible for surgical resection. Treatment options as recommended by the Japanese guidelines include chemotherapy, radiotherapy, palliative surgery, and palliative medicine.¹ However, several case series have suggested the possibility of cure in some carefully selected patients with stage IV gastric cancer, given the improvements in multimodal treatment.^2,3 Patients with cancer cells in the peritoneal cavity (peritoneal cytology positive; CY1) could constitute such a population. A CY1 status is a predictor of peritoneal dissemination⁴ and a poor prognostic factor in patients with gastric cancer.^5–8 However, the recent introduction of chemotherapy has changed the clinical picture to some extent. A phase 2 trial that explored the effect of D2 dissection followed by chemotherapy with S-1 reported a median overall survival (OS) of 24 months in patients with CY1 gastric cancer alone.³However, few studies have investigated stratified treatments for patients with CY1 gastric cancer in the presence or absence of metastatic disease.^5,6 To evaluate the optimal treatment for these patients, we retrospectively examined the clinicopathologic and survival data for patients who had undergone gastrectomy and/or chemotherapy for this type of advanced cancer regardless of the presence of metastatic disease.     

Short-Term Outcomes of Simultaneous Laparoscopic Colectomy and Hepatectomy for Primary Colorectal Cancer With Synchronous Liver Metastases

Although simultaneous resection of primary colorectal cancer and synchronous liver metastases is reported to be safe and effective, the feasibility of a laparoscopic approach remains controversial. This study evaluated the safety, feasibility, and short-term outcomes of simultaneous laparoscopic surgery for primary colorectal cancer with synchronous liver metastases. From September 2008 to December 2013, 10 patients underwent simultaneous laparoscopic resection of primary colorectal cancer and synchronous liver metastases with curative intent at our institute. The median operative time was 452 minutes, and the median estimated blood loss was 245 mL. Median times to discharge from the hospital and adjuvant chemotherapy were 13.5 and 44 postoperative days, respectively. Negative resection margins were achieved in all cases, with no postoperative mortality or major morbidity. Simultaneous laparoscopic colectomy and hepatectomy for primary colorectal cancer with synchronous liver metastases appears feasible with low morbidity and favorable outcomes.Key words: Simultaneous laparoscopic hepatectomy and colectomy, Primary colorectal cancer with synchronous liver metastases, Short-term outcomeColorectal cancer (CRC) is a leading cause of cancer-related death globally, and 14.5% of CRC patients have synchronous liver metastases that are identified during the diagnostic workup or during the course of treatment.¹ Surgical resection of the primary CRC and synchronous colorectal liver metastases (SCRLM) is warranted because this strategy offers the most effective therapy and is potentially curative. However, the optimal treatment schedule and strategy for treating CRC with SCRLM with surgery and chemotherapy remains unclear. Several reports have shown the benefit of simultaneous open resection of primary CRC and SCRLM versus a staged approach.²⁻⁴ In addition, recent improvements in laparoscopic surgery for CRC and liver cancer make this option attractive, and there are several reports of simultaneous laparoscopic colectomy and hepatectomy in the literature.⁵⁻¹⁴ In spite of these promising developments, though, the feasibility of these procedures has been controversial in terms of efficacy, safety, and outcome. The aim of this study was to evaluate the short-term operative and oncologic outcomes of simultaneous laparoscopic colectomy and hepatectomy for patients with primary CRC and SCRLM.     

Substernal Goiter: When is a Sternotomy Required?

The presence of substernal goiter is, per se, an indication for surgical management. Surgical approach of substernal goiter can most commonly be performed using the cervical access, but at times, a sternotomy or thoracotomy is necessary. The aim of this study was to identify the preoperative predictors of a sternotomy in the management of substernal goiter in order to provide better preoperative planning and patient consent. Between 2005 and 2012, 665 patients were referred to our clinic for thyroidectomy, 42 patients (6.3%) had substernal goiter and were included in this study. All substernal goiters were treated surgically, 38 (90.5%) by a cervical approach and 4 (9.5%) by full median sternotomy. All surgeries were successful, with no major postoperative complications. Minor postoperative complications of transient hypocalcemia and transient paralysis of the recurrent laryngeal nerve occurred in 5 (11.9%) and 2 (4.7%) cases, respectively. Indication of median sternotomy was as follows: extension of goiter below the aortic arch, large thyroid tissue extending towards tracheal bifurcation, and ectopic thyroid tissue in the mediastinum. Substernal goiter can be removed through a cervical incision, but on rare occasions, a median sternotomy may be required.Key words: Sternotomy, Substernal goiter, Surgery, TreatmentSubsternal goiter (SG) was first described by Haller in 1749 and first surgically removed by Klein in 1820.¹⁻⁴ There is no uniform definition of substernal goiter.¹⁻³ However, various different criteria have been suggested by authors. These include a thyroid gland extending 3 cm below the sternal notch or extension of the gland below the fourth thoracic vertebra.^5,6 An extension of the thyroid gland below the thoracic inlet has been defined as substernal, retrosternal, intrathoracic, or mediastinal goiter. Drawing upon the relationship of the intrathoracic extension of SG to the arcus aorta and the right atrium and findings from imaging methods, diagnostic classifications have been established that take into account the percentage of goitrous thyroid in the mediastinum.^7,8 Substernal goiters are common, with a reported incidence of 1−20% of all patients undergoing thyroidectomy.^3,5,9−14 Diagnosis of substernal goiter is most frequently made in the fifth or sixth decade of life, with a female/male rate of 4:1.^11,14,15 The vast majority of SGs (85−90%) are located in the anterior mediastinum with the remainder (10−15%) located in the posterior mediastinum.^1,10,16,17Substernal goiters show, in most cases, a slow-growing enlargement, which usually remain asymptomatic for many years; about 20−40% of substernal goiters are discovered as an incidental finding on a radiographic examination.^2,11,18 Patients with mediastinal goiter are rarely asymptomatic. The most common symptoms are related to compression of the airways and the esophagus, and represented by dyspnea, choking, inability to sleep comfortably, dysphagia, and hoarseness.^2,12,14,18 In the diagnostic management of mediastinal goiter, chest computed tomography (CT) was of the highest value. CT scanning is, at present, the most exhaustive examination for assessment of the extent of the goiter and compression effects on adjacent anatomic structures. A preoperative CT scan should be routinely performed in every suspicion of a substernal goiter.^12,19−21 Magnetic resonance imaging (MRI) adds little additional information to that obtained with CT and is not routinely used.¹¹Substernal goiter must be removed surgically due to relation to compressive symptoms, potential airway compromise, and the possibility of an association with thyroid malignancy.¹⁷ There is a general consensus that most can be successfully removed via a cervical approach and that thoracic access is rarely necessary.^9,11,12 Various factors have been reported to increase the likelihood of a median sternotomy being required. These factors include involvement of the posterior mediastinum, extension of the goiter to the aortic arch, recurrent goiter, superior vena cava obstruction, malignancy with local involvement, and emergent airway obstruction.^{6,10,12,16,17,19} In addition, inability to palpate the lowermost extent of the gland also is considered to be an indication for median sternotomy. The incidence of sternotomy in substernal goiter is variable, ranging between 0−11 %.^2,9,11,12 This wide range in incidence might be related to variation in the definition of substernal goiter.In order to improve preoperative planning and patient consent, we aimed to identify the preoperative predictors of a sternotomy in the management of substernal goiter.     

Outcomes of Surgical Treatment of Primary Signet Ring Cell Carcinoma of the Colon and Rectum: 22 Cases Reviewed With Literature

Colorectal primary signet ring cell carcinoma (PSRCCR) is a rare entity with a dismal prognosis, mainly because of delayed diagnosis. The objective of this study was to investigate the clinicopathologic features and prognostic factors for PSRCCR. This is a retrospective study including the data of 22 patients with PSRCCR who underwent surgery. Patients were categorized by age, sex, tumor site, and stage. Fifteen patients were male. Median age was 40 years. Sites for metastases were lymph nodes (86.4%), peritoneum (40.9%), and liver (9.1%). Most of the patients (91%) had stage III or IV tumors. The rates of curative and palliative resections performed were equal. Mean overall survival and mean progression-free survival times were found to be 33.3 ± 7.1 months (95% confidence interval, 19.4–47.2 months) and 11.8 ± 3.5 months (95% confidence interval, 4.9–18.7 months), respectively. It was concluded that site of the tumor, presence of bowel obstruction, peritoneum and lung metastases, adjacent organ infiltration, TNM stage, and efficiency of surgery have significant effects on survival. All in all, these aggressive tumors are generally diagnosed at advanced stages. Depending on the situation, survival is shorter. A high degree of vigilance is required for these patients to avoid the negative impact of late diagnosis on survival.Key words: Signet ring cell, Colorectal cancer, Histopathology, SurvivalPrimary signet ring cell carcinoma is a tumor most commonly located in the stomach, and less frequently in the breast, gallbladder, bladder, and pancreas.¹ Primary signet ring cell carcinoma of the colon and rectum (PSRCCR) is a rare entity, with a reported incidence of less than 1%.² It has a markedly poor prognosis.³ Because symptoms often develop late, it is usually diagnosed at an advanced stage.⁴ Furthermore, it typically appears in young adults.⁵Macroscopically, PSRCCR shows the characteristic appearance of linitis plastica, as a shrunken, rigid structure.^1–5 Histologically, the neoplastic cells resemble signet rings because they contain abundant intracytoplasmic mucin, which pushes the nuclei to the periphery.^1–5 The presence of mucus secretion in microscopic examinations of the tumor is one of the most important parameters determining the biologic behavior of colorectal carcinomas; other factors are age, sex, tumor location, tumor diameter, grade, stage, lymphatic and vascular invasion, periserosal overgrowth, and distant metastasis.^6,7So far, only a limited number of case reports have been published on this subject. Most publications have reported on a small number of patients and have presented controversial results. The objective of this study was to investigate the characteristic clinicopathologic features of colorectal signet ring cell carcinomas and the parameters affecting prognosis within our patient group.     

Peripancreatic Soft Tissue Involvement: Independent Outcome Predictor in Patients With Resected Pancreatic Adenocarcinoma

The impact of cancer involving the peripancreatic soft tissue (PST), irrespective of margin status, following a resection of pancreatic adenocarcinoma is not known. The purpose of this study is to determine such an impact on a cohort of patients. Data from 274 patients who underwent pancreatic surgery by our team between 1998 and 2012 was reviewed. Of those 119 patients who had pancreatic resection for adenocarcinoma were retrospectively analyzed. Patients were categorized into 3 groups: Group 1 = R1 resection (N = 39), Group 2 = R0 with involved PST (N = 54), and Group 3 = R0 with uninvolved PST (N = 26). Demographics, operative data, tumor characteristics and overall survival (OS) were evaluated. Operations performed were: Whipple (N = 53), pylorus sparing Whipple (N = 41), total pancreatectomy (N = 11), and other (N = 14). Median OS for Groups 1, 2, and 3 were 8.5 months, 12 months, and 69.6 months respectively (P < 0.001). Tumor size (P = 0.016), margin status (P = 0.006), grade (P = 0.001), stage (P = 0.037), PST status (P < 0.001), complications (P = 0.046), transfusion history (P = 0.003) were all predictors of survival. Cox regression analysis demonstrated that grade (HR = 3.1), PST involvement (HR = 2.7), transfusion requirement (HR = 2.6) and margin status (HR = 2.0) were the only independent predictors of mortality. PST is a novel predictor of poor outcome for patients with resected pancreatic cancer.Key words: Peripancreatic soft tissue, Novel predictor, pancreas, Malignancy, Outcome, AdenocarcinomaPancreatic cancer is the fourth most common cause of cancer death in the United States.¹ This cancer has the highest mortality among all cancers.¹ The 5-year overall survival (5-year-OS) of the involved patients is reported to be as low as 6%–18%.^1,2 In patients with localized disease, complete surgical resection is the only curative treatment³ and the 5-year-OS can be as high as 25%.^4–7 Due to the often late presentation of pancreatic cancer, only a minority of the patients (10%–20%) are considered to be a candidate for curative resection (CR). At the time of diagnosis, more than 50% of patients have already developed distant metastasis and 35% have locally advanced disease.⁸ Patients with locally advanced disease are believed to benefit from radical surgeries to achieve R-0 resection, where all post resection margins are tumor free. Although the majority of the previous studies have emphasized the importance of surgical margin status as a predictor of survival in these patients,^3,5,7,9 others have not.^10,11 However, the impact of an involved peripancreatic soft tissue (PST), irrespective of resection margin status, following a pancreatectomy is not known. We determined the impact of involved PST on a cohort of patients with pancreatic adenocarcinoma.     

Production of Intraperitoneal Interleukin-6 Following Open or Laparoscopic Assisted Distal Gastrectomy

The interleukin (IL)-6 concentration in plasma or serum has been considered to represent the degree of stress resulting from surgery. However, IL-6 in peritoneal fluid has rarely been considered. The aim of this study was to assess the concentration and amount of IL-6 in peritoneal fluid as indicators of surgical stress. To obtain basic data on peritoneal release of IL-6 during gastric cancer surgery, we measured IL-6 in peritoneal drainage samples, stored for up to 72 hours postoperatively, from patients who had undergone conventional open (ODG group, n = 20) and laparoscopic-assisted (LADG group, n = 19) distal gastrectomy. Within 24 hours, 61 and 77% of the IL-6 was released into the peritoneal cavity in the LADG and ODG groups, respectively. In both groups, the concentration and amount of peritoneal fluid IL-6 were significantly correlated with each other (LADG group: Spearman''s rank correlation test [rS] = 0.48, P = 0.04; ODG group: rS = 0.58, P = 0.01). The concentration and amount of IL-6 in peritoneal fluid was 2.8- and 3.6-fold higher in the ODG than in the LADG group, respectively (P < 0.01). With regard to the relationship between the serum C-reactive protein (CRP) peak and the concentration or amount of peritoneal fluid IL-6 released within 24 hours, only the concentration of peritoneal fluid IL-6 in the LADG group was significantly correlated (rS = 0.60, P = 0.01) with the serum CRP peak. Our findings suggest that the amount and concentration of IL-6 released into the peritoneal cavity for up to 24 hours after surgery can each be a reliable parameter for assessment of surgical stress.Key words: Interleukin (IL)-6, Cytokine, Peritoneal fluid, Surgical stress, Gastric cancer, Laparoscopic surgery, GastrectomyRecent advances in laparoscopy techniques have heralded a new era in the field of abdominal surgery, and laparoscopic approaches are now being employed for the treatment of malignant neoplasms of the stomach, colon and other organs.^1–5It has been reported that levels of circulating proinflammatory cytokines such as interleukin (IL)-1 beta, IL-6, IL-8, and tumor necrosis factor (TNF)-alpha are related to the extent and severity of surgical procedures.^6–8 Interleukin 6 is a sensitive and early marker of tissue damage, and in general the greater the surgical trauma, the greater the response of IL-6.⁹ Many studies have shown that the level of IL-6, as an indicator of surgical stress, is significantly lower after laparoscopic surgery than after open surgery.^9–15 Most of the studies reported so far have measured and analyzed the concentration of IL-6 in plasma or serum,^{9,10,12–16,18} and only rarely in peritoneal fluid,^{11,12,15,17,19,20} and the results have indicated significant correlations between the level of IL-6 and several clinical parameters. However, there is some concern as to whether the concentration of IL-6 in peritoneal fluid adequately reflects the degree of surgical stress. Interleukin 6 is released into the abdominal cavity in response to surgical injury.^16,20,21 Therefore, the total amount of IL-6 contained in peritoneal fluid might be regarded as a gold standard for assessing the severity of local surgical stress. However, this possibility has never been fully addressed.In the present study, we analyzed both the concentration and total amount of IL-6 in peritoneal fluid sequentially in the early postoperative period after distal gastrectomy, and compared laparoscopic and open surgical procedures in terms of intraperitoneal IL-6 production in order to observe the basic pattern of IL-6 release.     

Seminal Vesicle-Rectal Fistula Secondary to Anastomotic Leakage After Low Anterior Resection for Rectal Cancer: A Case Report and Brief Literature Review

We report a case of a patient with seminal vesicle-rectal fistula, an extremely rare complication of low anterior resection of the rectum. A 53-year-old man with rectal adenocarcinoma underwent low anterior resection in our hospital. The patient experienced diarrhea, pneumaturia, and low-grade fever on postoperative day 13. A computed tomography scan showed emphysema in the right seminal vesicle. We concluded that anastomotic leakage induced a seminal vesicle-rectal fistula. The patient underwent conservative therapy with total parenteral nutrition and oral intake of metronidazole. Diarrhea and pneumaturia rapidly improved after metronidazole administration and the patient was successfully cured without invasive therapy such as colostomy or surgical drainage. A seminal vesicle-rectal fistula is a rare complication of low anterior resection, and therapeutic strategies for this condition remain elusive. Our report provides valuable information on the successful conservative treatment of a secondary seminal vesicle-rectal fistula that developed after low anterior resection of the rectum in a patient.Key words: Seminal vesicle-rectal fistula, low anterior resection, rectal cancerSeminal vesicle-rectal fistula is a rarely encountered complication in patients. The reported causes of this condition are Crohn''s disease,^1,2 diverticulitis,^3–6 operative complications of the prostate,^7,8 direct invasion of rectal cancer,⁹ congenital anomalies,¹⁰ iatrogenic perforation by transrectal aspiration or seminal vesicle abcess,¹¹ secondary vesiculitis,¹² and anastomotic leakage after low anterior resection (LAR) of the rectum.^2,13–18 We could find only 9 reported cases of seminal vesicle-rectal fistula after LAR in the PubMed database.Here, we present a case of a seminal vesicle-rectal fistula that developed after LAR in a patient and review the clinical manifestation, radiographic findings, and treatment procedure for this condition.     

High Expression of DARPP-32 in Colorectal Cancer Is Associated With Liver Metastases and Predicts Survival for Dukes A and B Patients: Results of a Pilot Study

The purpose of this study was to investigate prognostic significance of Dopamine and cAMP-Regulated neuronal Phosphoprotein 32 (DARPP-32) expression in primary colorectal cancer. The study material consisted of clinical and histopathological data of 100 patients operated for colorectal cancer between 1994 and 1997. For immunohistochemical analysis, specific rabbit antibodies for DARPP-32 were used and the percentage of stained tumor cells was calculated under gross magnification (400 times) on a sample of 500 tumor cells. DARPP-32 expression in the primary tumor was significantly greater in patients with distant metastases compared to patients with no distant metastases (p=0.002). In multivariate regression analysis, DARPP-32 expression in the primary tumor was a significant predictor of distant metastases. With a cut-off point of 76.5%, DARPP-32 expression in the primary tumor significantly influenced both overall and disease free survival, especially for Dukes A and B patients (p=0.037). The results of this study indicate that DARPP-32 may be a potential marker of worse prognosis and a valuable tool for managing further adjuvant treatment in patients with stages Dukes A and B colorectal cancer.Key words: Colorectal neoplasms, Dopamine and cAMP-regulated phosphoprotein 32, Humans, Nerve tissue proteins, Liver metastasesColorectal cancer is the second most common cause of cancer related death in Western Europe and the United States, with the incidence of 50/100,000 population.¹ In spite of significant developments in surgery and new chemotherapy drugs and protocols as well as radiotherapy regimens, this malignancy still has high mortality.²The 5-year survival rate of colorectal cancer patients with Dukes A cancer ranges from 74 to 93%. Patients with Dukes B cancer have a 5-year survival of 40 to 82%, and those with positive lymph nodes (Dukes C) have a 5-year survival rate of 30 to 59%.^3,4 Recurrences are observed in as much as 34% of patients with Dukes A and B stage, compared with 59% in patients with lymph node metastases.⁵Liver metastases are a well proven major determinant of survival in patients with colorectal cancer.^2,6 Therefore, better selection of patients with potential to develop liver metastases or those having occult metastases may increase the survival of those patients in whom adjuvant therapies would not otherwise be indicated.^2,5,7Recently, overexpression of dopamine and 3′5′-cyclic adenosine monophosphate regulated neuronal phosphoprotein 32 (DARPP-32) has been found in several gastrointestinal adenocarcinomas.⁸ Although most of the research on this protein focused on its role in the central nervous system,^9–11 the finding of overexpression of this protein in cancer tissues brought up the hypothesis of its role in carcinogenesis.^8,12 Genetic studies led to the discovery of frequent 17q DNA amplifications in gastric cancer.⁸ Subsequently, the gene located at this site, called PPP1R1B, has been sequenced and found to encode DARPP-32 molecule, that was brought into connection with several malignancies.^8,13–18 The DARPP-32 molecule is a protein with molecular mass of 32 kDa, consisting of 204 amino acids and 4 phosphorylation sites: Thr34, Thr75, Ser102, and Ser137. Depending on the phosphorylation of 1 of these 4 amino acids, the DARPP-32 molecule is acting as the signal integrator and as the regulator of the phosphorylase and kinase activities in eukaryotic cells.¹⁹Basic research indicates that DARPP-32 may be associated with worse prognosis in some carcinomas.²⁰ However, it is remains unknown if evaluation of DARPP-32 expression in colorectal cancer patients may aid to evaluate prognosis.The purpose of this study was to investigate possible associations of DARPP-32 expression in primary colorectal cancer with known prognostic determinants of colorectal cancer and therefore set the basis for further clinical research.     

Recurrent Cholangitis by Biliary Stasis Due to Non-Obstructive Afferent Loop Syndrome After Pylorus-Preserving Pancreatoduodenectomy: Report of a Case

We report a 71-year-old man who had undergone pylorus-preserving pancreatoduodenectomy (PPPD) using PPPD-IV reconstruction for cholangiocarcinoma. For 6 years thereafter, he had suffered recurrent cholangitis, and also a right liver abscess (S5/8), which required percutaneous drainage at 9 years after PPPD. At 16 years after PPPD, he had been admitted to the other hospital because of acute purulent cholangitis. Although medical treatment resolved the cholangitis, the patient was referred to our hospital because of dilatation of the intrahepatic biliary duct (B2). Peroral double-balloon enteroscopy revealed that the diameter of the hepaticojejunostomy anastomosis was 12 mm, and cholangiography detected intrahepatic stones. Lithotripsy was performed using a basket catheter. At 1 year after lithotripsy procedure, the patient is doing well. Hepatobiliary scintigraphy at 60 minutes after intravenous injection demonstrated that deposit of the tracer still remained in the upper afferent loop jejunum. Therefore, we considered that the recurrent cholangitis, liver abscess, and intrahepatic lithiasis have been caused by biliary stasis due to nonobstructive afferent loop syndrome. Biliary retention due to nonobstructive afferent loop syndrome may cause recurrent cholangitis or liver abscess after hepaticojejunostomy, and double-balloon enteroscopy and hepatobiliary scintigraphy are useful for the diagnosis of nonobstructive afferent loop syndrome.Key words: Nonobstructive afferent loop syndrome, Biliary stasis, Hepaticojejunostomy, Hepatobiliary scintigraphy, Double-balloon enteroscopyIt has been reported that cholangitis occurs in between 6.7% and 14.3% of postoperative pancreatoduodenectomy (PD).¹ Most cases of cholangitis originate due to biliary stasis, which is broadly caused by either anastomotic or nonanastomotic stenosis. In many cases, anastomotic stenosis is accompanied by intrahepatic biliary duct dilatation and obstructive jaundice, making early diagnosis and treatment possible.^2–3 On the other hand, nonanastomotic stenosis, including those of afferent loop syndrome, is performed as a conservative treatment for unexplained fever and cholangitis. However, in many cases, the cause remains unidentified, thereby causing this condition to repeat itself. Since cholangitis can at times be fatal, it is therefore important to identify the cause.It has been reported that afferent loop syndrome occurs in around 13% of postoperative PD patients.⁴ Afferent loop syndrome is generally caused by mechanical occlusion due to the recurrence or metastasis of cancer,^4–6 adhesion,^7–8 torsion,⁹ internal hernia,¹⁰ enterolithiasis,^11–12 etc., and thereafter, leads to a syndrome associated with acute abdominal symptom or acute cholangitis. On the other hand, nonobstructive afferent loop syndrome may also be caused by biliary stasis due to jejunal motility failure or the length of the blind end or jejunum, and thereafter, leads to acute cholangitis, liver abscess, and the formation of enterolithiasis and intrahepatic stones. Nonobstructive afferent loop syndrome occurs in around 37% of all of the afferent loop syndrome,^12–13 but few cases have actually been reported.We herein report a rare case in which the patient experienced recurrent cholangitis and liver abscess by biliary stasis due to nonobstructive afferent loop syndrome after pylorus-preserving pancreatoduodenectomy (PPPD) for cholangiocarcinoma.     

Gastric Metastasis From Renal Cell Carcinoma With Gastrointestinal Bleeding: A Case Report and Review of the Literature

A 61-year-old man presented to our hospital with hypercalcemia and elevated C reactive protein (CRP). Evaluation revealed renal cell carcinoma (RCC) with metastasis to lung, bone, and brain. He underwent partial resection of the right kidney and a left nephrectomy. Histopathologic findings of resected tumors were consistent with clear cell RCC. Whole-brain irradiation was performed for management of brain metastasis. Postoperatively, he was treated with molecularly targeted therapy using a mammalian target of rapamycin inhibitor. Approximately 14 months later, he suffered an episode of upper gastrointestinal bleeding with secondary anemia and melena. Upper gastrointestinal endoscopy revealed a distinctly protruding lesion in the gastric body. Biopsy of the gastric lesion showed metastatic clear cell RCC. He underwent partial gastrectomy. His postoperative course was uneventful. However, 4 months after surgery, he died from brain metastasis. Metastatic RCC to the stomach, although rare, should be suspected in any patient with a history of RCC who presents with gastrointestinal symptoms.Key words: Gastric metastasis, Renal cell carcinoma, Metastatic tumorThe occurrence of metastases to the stomach from various neoplasms is not common. In the autopsy series, the stomach has been reported as a metastatic site in 0.2% to 0.7% of cases.^1–3 Lung cancer, breast cancer, and malignant melanoma were reported most often as primary tumors associated with gastric metastasis.^1,4In the literature, gastric metastases from renal cell carcinoma (RCC) have only rarely been described,^5–22 occurring in 0.2% of RCCs in the clinical setting.⁵ The present report describes an unusual case of a 61-year-old man who presented with gastrointestinal bleeding due to gastric metastasis from RCC. The clinical characteristics, therapy, and outcomes of gastric metastasis from RCC are reviewed.     

Medullary Carcinoma of the Thyroid With Axillary Metastasis: A Case Report

We report a case of axillary lymph node metastasis as a consequence of medullary thyroid carcinoma (MTC) in a 42-year-old man. On January 2009, the patient was referred to us for the management of right cervical lymph node enlargement. Total thyroidectomy was performed with right-sided functional neck dissection. Postoperative histopathology revealed MTC in the right lobe of the thyroid, with extrathyroidal extension and right-sided neck metastases. Multiple left cervical, mediastinal, and right axillary lymphadenopathies were detected at the third year follow-up exam. Left-sided functional neck dissection, axillary lymph node dissection, and mediastinal lymph node dissection were performed, and the pathologic outcomes revealed as the metastatic dissemination of MTC. After a disease-free term for 1 year, multiple metastatic lesions were detected in the patient.Key words: Medullary thyroid cancer, Lymph node metastasis, Axillary involvementMedullary thyroid cancer (MTC) is a rare tumor originating from the parafollicular C cells of the thyroid gland. MTC accounts for approximately 3% to 5% of all thyroid cancers.¹ The frequently used prognostic markers in the follow-up period of MTC patients are serum calcitonin and carcinoembryonic antigen (CEA) levels. Calcitonin hormone is a specific and sensitive biomarker for parafollicular C-cell disorders. The CEA produced by neoplastic C cells is generally considered a marker of dedifferentiation and is associated with worse prognosis for MTC.^2,3 MTC may occur sporadically or may be inherited. Hereditary forms of this cancer account for 25% of all cases and include familial MTC and multiple endocrine neoplasia syndromes (MEN 2A, MEN 2B). Seventy-five percent of cases are sporadic.⁴ The overall prognosis of MTC is affirmative, with a 10-year overall survival rate of approximately 95% for patients with tumors confined to the thyroid gland. However, for patients with distant metastasis at presentation, the 10-year overall survival rate is estimated to be only 40%.⁵ For metastatic cases, lymph node involvement is very common throughout the clinical course. During initial staging, the incidence of pathologically proven cervical lymph node metastasis has been reported as 71% to 80%^6–8; the corresponding value for mediastinal involvement is 36%.^6,8 Whereas, distant metastases have been reported in 20% of MTC patients.⁹ Considering the spectrum of MTC, axillary lymph node metastasis (LNM) is rare, and there are reports of isolated cases.^10–12     

The Role of 3-D Endorectal Ultrasound in Rectal Cancer: Our Experience

In the last 20 years, endorectal ultrasound (ERUS) has been one of the main diagnostic methods for locoregional staging of rectal cancer. ERUS is accurate modality for evaluating local invasion of rectal carcinoma into the rectal wall layers (T category). Adding the three-dimensional modality (3-D) increases the capabilities of this diagnostic tool in rectal cancer patients. We review the literature and report our experience in preoperative 3-D ERUS in rectal cancer staging. In the group of 71 patients, the staging of preoperative 3-D endorectal ultrasonography was compared with the postoperative morphologic examination. Three-dimensional ERUS preoperative staging was confirmed with morphologic evaluation in 66 out of 71 cases (92.9%). The detection sensitivities of rectal cancer with 3-D ERUS were as follows: T1, 92.8%; T2, 93.1%; T3, 91.6%; and T4, 100.0%; with specificity values of T1, 98.2%; T2, 95.4%; T3, 97.8%; and T4, 98.5%. Three-dimensional ERUS correctly categorized patients with T1, 97.1%; T2, 94.3%; T3, 95.7%; and T4, 98.5%. The percentage of total overstaged cases was 2.75% and that of understaged cases was 6.87%. The metastatic status of the lymph nodes was determined with a sensitivity of 79.1% (19 of 24), specificity of 91.4% (43 of 47), and diagnostic accuracy of 87.3% (62 of 71). In our experience, 3-D ERUS has the potential to become the diagnostic modality of choice for the preoperative staging of rectal cancer.Key words: Three-dimensional endorectal ultrasound, Rectal cancerEndorectal ultrasound (ERUS) has been used as a diagnostic tool for evaluation and staging of rectal cancer since the 1980s.¹ According to the literature, in studies with more than 50 patients included, an overall accuracy of approximately 81.8% was reported.² Most of the studies present data between 85% and 95%, but in the studies with more than 200 patients, the accuracy rates are relatively lower—63.3% and 69%, respectively.^3,4 A common disadvantage of ERUS and magnetic resonance imaging (MRI) is the overstaging of T2 tumors owing to an irregular outer rectal wall resulting from transmural tumor extension or inflammation around the tumor. Another challenge for the ERUS, and especially the rigid probes, are the locally advanced, stenotic tumors, where the probe may not be able to pass above the lesion.⁵ The nodal staging accuracy of ERUS ranges from 70% to 75%.^1,5,6 The metastatic lymph nodes are distinguished by hypoechoic appearance, round shape, peritumoral location, and size >5 mm.^7,8 Lymph nodes >5 mm have a 50% to 70% chance of being malignant, while those <4 mm have only a 20% chance.^9,10 A new modality of endorectal ultrasound represents a three-dimensional (3-D) ERUS that provides better visual images of the tumor volume and spatial relations to the adjacent organs and structures, even better than those of MRI, which leads to better diagnostic accuracy than MRI and standard ERUS.^11–15 The unique 3-D–ERUS longitudinal scan can precisely assess the tumor size and location.¹⁶ The most important feature of this upgraded modality is the ability to reduce interpreter errors and offer potential predictive value. Three-dimensional ERUS provides the possibility to distinguish blood vessels from lymph nodes and allow precise fine needle aspiration (FNA) biopsies.^13,17 The infiltration of circumferential margin has been proven to correlate with T category, lymph node metastasis histologic tumor differentiation, and lymphovascular invasion.^13,17 Three-dimensional ERUS gives the possibility of multiplane evaluation of the tumor, allowing visualization of more subtle changes in the tumor characteristics and therefore better T and N categorizing.¹⁸ A review of 86 patients who underwent standard 3-D ERUS, ERUS and 4-channel detector computed tomography (CT) demonstrated T-category accuracy of 78%, 69%, and 57%, respectively.¹⁹ After analysis of the examiner''s error, the accuracy of 3-D ERUS for T category has reached 91% for 3-D ERUS and 88% for standard ERUS, and the N category accuracy improved to 90% and 76%, respectively. Also, ERUS can be used for diagnosis of premalignant lesions such as adenomas and polyps.²⁰ The main goal is to properly identify any chance of tumor invasion in the primary lesion and involvement of the surrounding lymph nodes in case the absence of those alarming characteristics allows for endoscopic resection of the lesion. Using higher-resolution probes, ERUS can distinguish T0 from T1 lesions. According to a meta-analysis of 258 biopsy-negative tumors, ERUS identified tumor mass in 81% of the 24 lesions, which were found to be invasive tumors on morphologic examination.²⁰ Another series of 60 patients with pT0/pT1 lesions demonstrated sensitivity and specificity of ERUS 89% and 88%, respectively.²¹ As with MRI, 3-D ERUS could provide an evaluation of the mesorectal fascia.^14,22The reported data lead to the position that 3-D ERUS combines the high-resolution images of the rectal wall and cost-effectiveness of standard ERUS with the multiplanar and stereoscopic imaging capabilities of MRI. Three-dimensional ERUS may be the future premier imaging modality used in rectal cancer management.     

Clinical Impact of Intraoperative Navigation Using a Doppler Ultrasonographic Guided Vessel Tracking Technique for Pancreaticoduodenectomy

During pancreaticoduodenectomy (PD), early ligation of critical vessels such as the inferior pancreaticoduodenal artery (IPDA) has been reported to reduce blood loss. Color Doppler flow imaging has become the useful diagnostic methods for the delineation of the anatomy. In this study, we assessed the utility of the intraoperative Doppler ultrasonography (Dop-US) guided vessel detection and tracking technique (Dop-Navi) for identifying critical arteries in order to reduce operative bleeding. Ninety patients who received PD for periampullary or pancreatic disease were enrolled. After 14 patients were excluded because of combined resection of portal vein or other organs, the remaining were assigned to 1 of 2 groups: patients for whom Dop-Navi was used (n = 37) and those for whom Dop-Navi was not used (n = 39; controls). We compared the ability of Dop-Navi to identify critical vessels to that of preoperative multi-detector computed tomography (MD-CT), using MD-CT data, as well as compared the perioperative status and postoperative outcome between the 2 patient groups. Intraoperative Dop-US was significantly superior to MD-CT in terms of identifying number of vessels and the ability to discriminate the IPDA from the superior mesenteric artery (SMA) based on blood flow velocity. The Dop-Navi patients had shorter operation times (531 min versus 577 min; no significance) and smaller bleeding volumes (1120 mL versus 1590 mL; P < 0.01) than the control patients without increasing postoperative complications. Intraoperative Dop-Navi method allows surgeons to clearly identify the IPDA during PD and to avoid injuries to major arteries.Key words: Pancreaticoduodenectomy, Doppler ultrasonography, Blood flowmeterPancreaticoduodenectomy (PD) is a standard treatment for malignant tumor of periampullary and pancreas head. As lymphatics (lymph node and lymph vessels) accompany the arteries and are distributed in the surrounding neural plexuses, complete clearance of peripancreatic tissue, including lymphatics and nerve plexus, is necessary for curative resection of the tumor.^1–4 As this operation is considered a complex procedure, a surgeon is required to be well trained in this specific surgical technique and to possess sufficient anatomic knowledge.Despite a low mortality rate and improvements in perioperative care and operative management, there is still a relatively high complication rate following PD.^5,6 Several studies showed that intraoperative bleeding and red blood cell (RBC) transfusion are serious risk factors of postoperative complications in PD.^6,7 Recently, several procedures for artery-first approaches such as posterior, uncinated, and mesenteric approach have been introduced for improving perioperative outcomes such as curability and decreasing blood loss and morbidity.^8–11 Incidentally, it has been well known that early ligation of the inferior pancreaticoduodenal artery (IPDA)—one of the efferent arteries of the pancreas head—considerably reduces intraoperative bleeding and postoperative complications.^12–14 Owing to the various anatomic origins of IPDA, identification is difficult in some patients. Therefore, some groups have attempted to locate the origin of IPDA by preoperative enhanced multi-detector computed tomography (MD-CT) and 3-dimensional angiogram using MDCT data (3D-CT angiography).^12,13 In addition, an augmented reality technique using MD-CT data is being considered an innovative navigation system for PD.¹⁵ However, no simple intraoperative guidance system, which would greatly facilitate the complex procedure of vessel ligation and reduce intraoperative bleeding, has been tested for ligation of the IPDA during PD.Intraoperative ultrasonography provides useful information for diagnosis and for guidance during the hepatobiliary-pancreatic surgery.^16,17 Color Doppler flow imaging facilitates to delineate the anatomy and to identify the vascular structures invading malignant tumors.^18–22 Recently, advanced navigation techniques have been introduced, such as 3D-CT angiography and intraoperative ultrasonography.^21–24 Doppler ultrasonography (Dop-US) has been used as an effective method for detecting the presence of potential bleeders.^25,26 However, Dop-US-assisted intraoperative identification and tracking of critical vessels for pancreatic surgery has not been reported to date.The objective of the present study was to evaluate the potential of intraoperative Dop-US for detection of critical vessels relative to that of preoperative MD-CT, including MPR and 3D angiography, and to clarify the efficacy of vessel navigation surgery using Dop-US-guided tracking for the reduction of intraoperative bleeding.     

The Effects of Dexketoprofen on Endogenous Leptin and Lipid Peroxidation During Liver Ischemia Reperfusion Injury

Hepatic ischemia reperfusion (IR) injury has complex mechanisms. We investigated the effect of dexketoprofen on endogenous leptin and malondialdehyde (MDA) levels. Wistar albino rats were divided into 4 equal groups and were subjected to 1-hour ischemia and different subsequent reperfusion intervals. Dexketoprofen was administered in a dose of 25 mg/kg 15 minutes before ischemia induction and 1-hour reperfusion to the Dexketoprofen one-hour reperfusion group, n = 6 (DIR1) group and 6-hour reperfusion to the Dexketoprofen six-hour reperfusion group, n = 6 (DIR6) group. In the control groups, 0.9% physiologic serum (SF) was administered 15 minutes before ischemia induction and 1-hour reperfusion to the one-hour reperfusion group, n = 6 (IR1) group and 6-hour reperfusion to the six-hour reperfusion group, n = 6 (IR6) group. Although serum leptin (P = 0.044) and hepatic tissue MDA levels (P = 0.004) were significantly higher in the IR6 group than in the IR1 group, there were no significant differences in dexketoprofen pretreatment between the DIR1 and DIR6 groups. There were no differences in serum MDA levels among the 4 groups, and serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) activities were significantly higher in the IR1 (P = 0.026 and P = 0.018, respectively) and IR6 (P = 0.000 and P = 0.002, respectively) groups than in the DIR1 and DIR6 groups. Dexketoprofen pretreatment can protect the liver from IR injury by decreasing inflammation and lipid peroxidation. Our study shows that dexketoprofen has no effects on endogenous leptin during IR injury.Key words: Ischemia-reperfusion injury, Liver, Ketoprofen, Malondialdehyde, LeptinHepatic ischemia reperfusion (IR) injury is a complication of several surgical conditions, such as liver resection and transplantation, and prolonged states of shock that lead to local injury or remote dysfunction of multiple organs.^1,2 Incipient tissue hypoxia; production of reactive oxygen species (ROS); activation of the inflammatory cascade, resulting in inflammatory responses^3,4 and microcirculatory problems⁵ further aggravate injury. Although ischemic stress eventually causes cell death, cell injury often does not manifest itself until after the ischemic liver is reperfused.⁶ ROS are highly reactive ions that include hydrogen peroxide (H₂O₂), lipid peroxides, hypochlorous acid (HOCl), and free oxygen radicals.⁷ Malondialdehyde (MDA) is the end product of lipid peroxidation; increased MDA levels reflect excessive production of free oxygen radicals and indicate organ damage.^8,9The role of polymorphonuclear leukocytes (neutrophils) in the acute inflammatory response during IR injury has been investigated in several studies.^10,11 Vane and Botting described inflammatory response and the role of chemical mediators, such as prostaglandins, platelet-activating factor, interleukin-1, histamine, and bradykinin.¹² That study was followed by studies showing the ROS scavenging effects of nonsteroidal anti-inflammatory drugs (NSAIDs).¹³ Dexketoprofen trometamol, the active enantiomer of racemic ketoprofen, possesses cyclooxygenase inhibitory effects, as do other members of the NSAID family. Properties of this formulation are more rapidly absorbed and have a faster onset of action than does ketoprofen.¹⁴Leptin, an adipose tissue–derived hormone, decreases body weight by both suppressing appetite and promoting energy expenditure.¹⁵ It also regulates inflammatory response, primarily by exerting pro-inflammatory actions.¹⁶ The structure of leptin and its receptor suggest that leptin should be classified as a cytokine. The helical structure of leptin is similar to the structures of the long-chain helical cytokine family, which includes interleukin (IL)-6, IL-11, IL-12, leukemia inhibitory factor (LIF), and granulocyte colony-stimulating factor (G-CSF). Cytokines play an important role in the host response to infectious and inflammatory stimuli. Previous studies have shown the importance of leptin in the activation of the immune system and as a mediator of inflammation.^17–19 Faggioni and colleagues (1998) demonstrated that leptin production does not increase during inflammation in IL-1b-deficient mice.²⁰ Thus, the increase in leptin during infection and inflammation indicates that leptin is part of the immune response and host defense mechanism.²¹ Leptin-deficient (ob/ob) and leptin-receptor–deficient (db/db) mice are not only obese but they also show immune/endocrine abnormalities.²² While dexketoprofen inhibits inflammation, its effects on the level of leptin, which plays an important role in immune response, are unknown.The aim of this study was to evaluate the role of dexketoprofen on endogenous leptin levels and lipid peroxidation at different reperfusion intervals during IR injury.     

Pathologic and Clinical Characteristics of Elderly Patients With Breast Cancer: A Retrospective Analysis of a Multicenter Study (Anatolian Society of Medical Oncology)

There is very little information about breast cancer characteristics, treatment choices, and survival among elderly patients. The purpose of this multicenter retrospective study was to examine the clinical, pathologic, and biologic characteristics of 620 breast cancer patients age 70 years or older. Between June 1991 and May 2012, 620 patients with breast cancer, recruited from 16 institutions, were enrolled in the retrospective study. Patients had smaller tumors at diagnosis; only 15% of patients had tumors larger than 5 cm. The number of patients who had no axillary lymph node involvement was 203 (32.7%). Ninety-three patients (15.0%) had metastatic disease at diagnosis. Patients were characterized by a higher fraction of pure lobular carcinomas (75.3%). The tumors of the elderly patients were also more frequently estrogen receptor (ER) positive (75.2%) and progesterone receptor (PR) positive (67.3%). The local and systemic therapies for breast cancer differed according to age. An association between age and overall survival has not been demonstrated in elderly patients with breast cancer. In conclusion, the biologic behavior of older patients with breast cancer differs from younger patients, and older patients receive different treatments.Key Words: Breast cancer, Elderly patients, Clinical characteristics, Pathologic characteristicsBreast cancer is a major health problem worldwide, and its incidence is increasing.¹ Age is one of the major risk factors for breast cancer: more than 30% of all new breast cancers occur in women aged 70 years or more. Furthermore, breast cancer–related mortality increases with age.^2,3 Despite the high incidence, there is very little information about breast cancer characteristics, treatment choices, and survival among elderly patients. Elderly patients over 70 years of age have generally been excluded from randomized clinical trials of breast cancer treatments.⁴Several studies of breast cancer biology show that older patients are estrogen receptor–positive (ER+) and/or progesterone receptor–positive (PR+), which are predictive factors of response to hormonal therapies; the treatment of these patients with endocrine therapies is the gold standard with which other systemic adjuvant treatments are compared.^5–7 Although little is known about the pathology and biology of breast cancer in older patients, many clinical trials have shown that women who develop breast cancer at an elderly age have less aggressive disease and decreased risk of recurrence.^8–11 In contrast, a few studies have demonstrated that in postmenopausal patients with hormone receptor–positive breast cancer, increasing age is associated with higher disease-specific mortality.^2,3The purpose of this multicenter retrospective study was to examine the clinical, pathologic, and biologic characteristics of 620 breast cancer patients age 70 years or older.     

Sacral Nerve Function in Child Patients After Ileal J-Pouch-Anal Anastomosis for Ulcerative Colitis

To clarify the neurological function of the puborectalis muscle (PM) in child patients with soiling after ileal J-pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), we examined the terminal motor latency in the sacral nerves that regulate the PM. Eight patients after IPAA for UC were studied (6 males and 2 females aged 11 to 13 years with a mean age of 12.8 years). All patients 6 months after IPAA showed soiling (group A) and these patients showed continence at 2 years after IPAA (group B). Group C serving as controls consisted of 16 subjects (10 males and 6 females aged 12 to 17 years with a mean age of 14.4 years). Left- and right-sided sacral nerve terminal motor latency (SNTML) tests were performed at 6 months and 2 years after IPAA in order to measure the latency of the response in the bilateral PM following magnetic stimulation of sacral nerve root segments 2 to 4 (S2–S4) of the spinal column overlying the cauda equina. The following results were obtained. (1) Right-sided SNTML: group A exhibited significant prolongation compared with groups B and C (P < 0.0001 and P < 0.0001, respectively). There was no significant difference between groups B and C (P = 0.2329). (2) Left-sided SNTML: group A exhibited significant prolongation compared with groups B and C (P = 0.0002 and P < 0.0001, respectively). There was no significant difference between groups B and C (P = 0.2315). Note that significant differences were not established between SNTML values measured on the right and left sides. Soiling in child patients 6 months after IPAA may be caused by damage to the bilateral sacral nerves during the operation. However, the damage to the sacral motor nerve improves within 2 years after IPAA.Key words: Soiling, Sacral nerve terminal motor latency, Puborectalis muscle, Ulcerative colitis, ChildThe functional results of total colectomy, mucosal proctectomy, and ileal J-pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) have been acceptable and patient satisfaction has been very high because patients are free from stoma.^1–3 In general, the functional outcomes after IPAA in children are better than those in adults.^4–12 However, some child patients experience defecation function impairments after IPAA, including minor fecal incontinence (soiling), incontinence, increased bowel movement, urgency of defecation, evacuation difficulty, irregular bowel habitus, difficulty in distinguishing gas from feces, and diarrhea.^8–10,12 The most common abnormality is soiling.^8–10 Soiling in both children and adults is usually more severe in the early postoperative period of about 3 to 6 months after operation and improves with time, but may become permanent more than 1 year after IPAA.^3–6,9 Generally, the frequency of soiling in child patients more than 1 year after IPAA is 0 to 12%,^4–6,8,9,12 and in adults 30 to 40%.^2,13,14 Over the past 20 years or so, the function of the anorectum in patients with soiling after IPAA has been studied in depth using anorectal manometry.^15–17 According to the data of anorectal manometry in child patients after IPAA, the anal sphincter complex comprising the internal anal sphincter and external anal sphincter is important to prevent soiling.¹⁷ In contrast, the puborectalis muscle (PM) was considered the most important factor preventing soiling in other studies not using anorectal manometry, which cannot detect the function of the PM, although less is known about the neurological functions in patients with soiling after IPAA in regard to the sacral nerve (SN) that regulates the PM.^18–20 To the best of our knowledge, there are no reports of electrophysiological studies of SN in child patients with soiling after IPAA for UC. We therefore studied bilateral SN function using sacral nerve terminal motor latency (SNTML) in child patients with soiling 6 months after IPAA and the same patients without soiling 2 years after IPAA for UC.