Single-Incision Laparoscopic Surgery for a Small-Intestinal Gastrointestinal Stromal Tumor: Report of a Case

Our report concerns a 64-year-old man with a small-intestinal gastrointestinal stromal tumor (GIST), which was successfully treated with single-incision laparoscopic surgery (SILS). Small-bowel endoscopy detected a submucosal tumor located approximately 10 cm from the ligament of Treitz in the wall of the proximal jejunum. Contrast-enhanced computed tomography revealed a tumor (diameter, 4 cm) containing high- and low-density areas in the proximal jejunum. On 18F-fluorodeoxyglucose (FDG) positron-emission tomography (PET), the tumor demonstrated intense FDG uptake (maximum standard uptake value, 3.82), whereas it displayed high signal intensity on diffusion-weighted magnetic resonance images. No metastatic lesions were observed. The patient was diagnosed with a jejunal GIST. Wedge resection of the jejunum was performed using the SILS procedure. The tumor was histopathologically diagnosed as a low-grade malignant GIST. SILS is a useful resection technique for small-intestinal GIST.Key words: SILS, Small intestine, GIST, Laparoscopic, FDG-PET, DWIA 64-year-old man with a past history of diabetes mellitus was admitted to our hospital because of a suspected tumor in the small bowel, which was subsequently revealed by an abdominal ultrasonography screening examination. He had no digestive symptoms. He had a history of cigarette smoking and alcohol use, but his family history was unremarkable, and he did not display elevated tumor marker levels. Small-bowel endoscopy showed a submucosal tumor located approximately 10 cm from the ligament of Treitz in the wall of the proximal jejunum. Contrast-enhanced computed tomography (CT) revealed a tumor (diameter, 4 cm) containing high- and low-density areas in the proximal jejunum. On 18F-fluorodeoxyglucose positron-emission tomography (FDG-PET)/CT, the tumor showed increased FDG uptake [maximum standard uptake value (SUV) = 3.82; Fig. 1a], whereas it displayed high signal intensity on diffusion-weighted magnetic resonance imaging (DWI Fig. 1b). No metastatic lesions were observed. The patient was diagnosed with a jejunal gastrointestinal stromal tumor (GIST).Open in a separate windowFig. 1(a) FDG-PET/CT scan showing that a tumor (diameter, 4 cm) displayed increased FDG uptake in the proximal jejunum (arrow). (b) Diffusion-weighted MRI showing that the tumor displayed high signal intensity (arrow).We treated the tumor with single-incision laparoscopic surgery (SILS). In this procedure, an extra-small wound retractor (ALEXIS wound retractor XS, Applied Medical, Rancho Santa Margarita, California) was inserted through a 3-cm umbilical incision, and a surgical glove was used as the single port. Three 5-mm trocars were inserted into the surgical glove, which was then fixed to the outer ring of the wound retractor. The section of the small bowel close to the tumor was pulled toward the incision site, and the tumorous area of the jejunum was extracted through the incision. Wedge resection of the jejunum and closure of the enterotomy were performed outside the abdominal cavity (Fig. 2a and ​and2b).2b). The tumor was elastic and had not invaded any adjacent structures. The dimensions of the tumor were 42 × 43 × 20 mm.Open in a separate windowFig. 2(a) Intraoperative appearance after the tumor had been extracted through the umbilical incision. (b) Postoperative appearance of the umbilical incision.A histopathologic examination revealed the bundle-like growth of spindle-shaped tumor cells with a mitotic rate of 3/50 high-power fields (HPF; Fig. 3). In immunohistochemical staining, the tumor was found to be positive for c-kit and CD34, but negative for keratin, smooth muscle actin, and s-100. In addition, 3.5% of the tumor cells were positive for Ki-67. As a result, we diagnosed the tumor as low-grade malignant GIST. After 6 months'' follow-up, the patient is asymptomatic and displays no clinical evidence of tumor recurrence or metastasis.Open in a separate windowFig. 3Histologic examination detected the bundle-like growth of spindle-shaped tumor cells (×66).     

Efficacy and safety of yttrium-90 ibritumomab tiuxetan in Japanese patients with non-Hodgkin lymphoma

Purpose

The aim of this study was to evaluate the efficacy and side effects of radioimmunotherapies with Zevalin^? (RIT-Z) in Japanese patients with low-grade B-cell non-Hodgkin lymphoma (NHL).

Materials and methods

Sixty-two patients with NHL were enrolled. Based on histology, 49 of the patients had follicular lymphoma and 23 had other lesions. The response was assessed at 8?C12?weeks after RIT-Z injection with PET/CT.

Results

The overall response rate was 85?%. Thirty-seven (60?%) patients achieved complete remission, 16 (26?%) had partial remission, 4 (6?%) had stable disease, and 5 (8?%) had progressive disease. There was a significant correlation between the response to RIT-Z, frequency of chemotherapy, and history of prior treatment with fludarabine. There was no significant difference in efficacy according to lymphoma type, years since last chemotherapy, patient age, or disease stage at RIT-Z. Thrombocytopenia of grade 4 was significantly correlated with disease stage at RIT-Z and history of prior treatment with fludarabine. There was also no significant correlation between hematotoxicity and lymphoma type, frequency of chemotherapy, years since last chemotherapy, patient age, or history of bone marrow transplant. Anemia was significantly correlated with frequency of chemotherapy, history of bone marrow transplant, and history of prior treatment with fludarabine.

Conclusions

The response rate was high, and we were able to decrease the hematologic side effects by using RIT-Z earlier.     

Verruciform xanthoma of the oral mucosa: A clinicopathological study with immunohistochemical findings relating to pathogenesis

Verruciform xanthoma is an uncommon benign lesion with unknown aetiology and pathogenesis. In this study, we report ten cases of verruciform xanthoma and document their clinical and histopathological findings. An immunohistochemical investigation was performed using antibodies to macrophage, leukocyte common antigen, T lymphocytes, B lymphocytes, S-100 protein, lysozyme and alpha-l-antichymotrypsin. Our results were similar to the other reported cases. Eighty percent of our cases were found on the gingiva. Candidal hyphae were found in the superficial parakeratotic layers in five cases. The clinical diagnosis of the lesion ranged between papilloma and squamous cell carcinoma. It is important for clinicians to take into consideration the possibility of verruciform xanthoma in the differential diagnosis of papillary and granular lesions of oral mucosa. Immunohistochemically, all foam cells were strongly stained with antimacrophage antibodies. T lymphocytes were the predominant infiltrating lymphocytes in the lesion. Langerhans cells in the epithelia were fewer than those in corresponding normal tissue. Our immunohistochemical findings suggest that verruciform xanthoma is may be a local immunological disorder, with a cell mediated mechanism.     

Severity and predicted outcome of postoperative Pseudomonas aeruginosa infections

The severity and predicted outcome of postoperative Pseudomonas aeruginosa (P. aeruginosa) infections (PPAI) was evaluated using a severity scoring system based on a simplification and modification of the APACHE II system. A total of 86 patients in whom P. aeruginosa was isolated from various sources were examined. PPAI developed in 50 patients, resulting in an overall mortality rate of 24%. An increased severity score (SS) correlated with an increased risk of developing PPAI. Thus, PPAI developed in 33% of the patients with an SS of 0–1, in 66.7% of those with an SS of 2–3, and in 100% of those with an SS of 6 or higher. Moreover, the mortality rate of the patients with an initial score of 6 or higher was 50%. The mean (±SD) initial severity score was 5.4±2.9 for survivors and 2.9±2.6 for nonsurvivors (P<0.01). In the patients who subsequently died, the SS remained high throughout the clinical course despite therapy, whereas in the survivors the SS decreased progressively, reflecting a favorable clinical course. These results suggest that our severity scoring system was useful for predicting outcome and monitoring the response of PPAI to therapy.     

Jaw cysts with orthokeratinization: analysis of 12 cases

The clinico-pathologic, immunohistochemical and radiological features of 12 jaw cysts with a prominent orthokeratinized epithelial lining were studied and compared with those of typical odontogenic keratocysts and dentigerous cysts. They differed significantly from odontogenic keratocysts in terms of biologic behavior and histopathologic findings. Although immunohistochemical staining of the epithelial linings for cytokeratins. EMA, CEA and involucrin has not shed any light on the histogenesis of these lesions, staining patterns for these markers were significantly different from those of odontogenic keratocysts and non-keratinized dentigerous cysts. Radiologically, nine cases appeared as dentigerous cysts; two cases, one with sebaceous differentiation, as non-dentigerous unilocular cysts, and the remaining one was exceptional as it showed multiple epidermal cysts with prominent dermal appendages histologically. It is suggested that most of the orthokeratinized jaw cysts may belong to ctinko-pathological entities different from odontogenic keralocysts with the majority representing dentigerous cysts with orthokeratinization. The possibility of the existence of rare central dermoid or epidermoid cysts is also to be considered.     

HMGB1 attenuates anti-metastatic defence of the liver in colorectal cancer

High mobility group box (HMGB) 1 induces apoptosis of monocyte-lineage cells. We examined the effect of HMGB1 on Kupffer cells (KCs). In 50 Dukes C and 12 liver-metastasised Dukes D colorectal cancers (CRCs), higher HMGB1 concentration in the primary tumours and metastatic foci, and fewer KCs were found in Dukes D cases than in Dukes C cases. The portal blood HMGB1 concentration was higher in Dukes D cases than in Dukes C cases. HMGB1 induced growth inhibition and apoptosis in mouse KCs in a dose-dependent manner, which was associated with the phosphorylation of c-Jun N-terminal kinase (JNK). JNK inhibition and knockdown of HMGB1 receptor abrogated growth inhibition and apoptosis. In a nude mouse liver metastasis model, the caecal administration of HMGB1 decreased the number of KCs and increased the embedment of Colo320 CRC cells in a dose-dependent manner. HMGB1 transfection increased the liver metastasis of Colo320 cells, and the metastasis was inhibited by anti-HMGB1 antibody administration. These results suggest that HMGB1 secreted from primary tumours decreases the number of KCs and attenuates the anti-metastatic defence of the liver in patients with CRCs.     

Health-related quality of life in patients with advanced colorectal cancer: results from a phase II study of S-1 combined with irinotecan (CPT-11)

Background

We carried out this study to examine the health-related quality of life (HRQOL) of patients with advanced colorectal cancer treated with the oral fluoropyrimidine S-1 plus irinotecan (CPT-11).

Methods

HRQOL was assessed at baseline (pretreatment) and at 5-week intervals during treatment, using the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-CR38 questionnaires. The HRQOL data for 12 preselected scales and 21 courses of treatment were then analyzed longitudinally.

Results

Thirty-seven patients completed the baseline and post-treatment HRQOL assessments. Statistically significant differences between the baseline and post-treatment HRQOL scores were observed for the global QOL, social function, and pain scales (all QLQ-C30), as well as the body image, future perspective, gastrointestinal tract symptoms, weight loss, and chemotherapy side effects scales (all QLQ-CR38); favorable post-treatment results were observed for all the scales except for body image and chemotherapy side effects, for which post-treatment deteriorations were observed. The changes in body image, future perspective, weight loss, and chemotherapy side effects were each greater than ten points and seemed clinically significant.

Conclusion

Combined treatment with S-1 plus CPT-11 resulted in an acceptable deterioration in HRQOL functioning and symptoms, compared with baseline levels.