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Background/aim: Recent studies have reported that the C-reactive protein (CRP) to albumin ratio (CAR) may be a useful prognostic biomarker in various types of cancer patients. However, the mechanism underlying this observation is unclear. The present study aimed to clarify why the CAR can predict post-esophagectomy prognosis, the relationship between pre- and postoperative CAR, and whether postoperative CAR can predict the prognosis of esophageal cancer patients., Patients and Methods: We investigated 158 esophagectomy patients with esophageal squamous cell carcinoma. Hematological examinations were performed on postoperative days (POD) 1, 3, 5, 7, 10, and 14., Results: Preoperative CAR was a significant independent prognostic factor of overall survival (OS) [hazard ratio (HR)=2.247; p=0.0005], and there was a strong correlation between preoperative CAR and tumor depth. The preoperative high-CAR (pre-high-CAR) group had significantly higher CAR on all postoperative days (POD). We then divided the patients as follows: those with at least two low-CAR days on POD 5, 7, and 10 were assigned to the modified post-low-CAR (mPost-low-CAR) group, and others were assigned to the modified post-high-CAR (mPost-high-CAR) group. The 5-year OS rate was significantly higher in the mPost-low-CAR group than in the mPost-high-CAR group, which predicted a more accurate prognosis (p<0.0001, HR=2.769)., Conclusion: Preoperative CAR was associated with tumor depth and diameter, and patients in the pre-high-CAR group continued to have significantly higher CAR postoperatively. These factors were presumed to reflect disease prognosis. Furthermore, grouping by CAR on POD 5, 7, and 10 reflected patient prognosis more accurately than preoperative CAR., (Copyright © 2023 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background/aim: The aim of this study was to determine the association between post-esophagectomy pneumonia and the presence of pathogenic organisms in the sputum or pharynx and postoperative systemic inflammatory response syndrome (SIRS)., Materials and Methods: This retrospective study included 98 patients diagnosed with esophageal cancer who had undergone esophagectomy., Results: Postoperative pneumonia was observed in 24 patients (24.5%). Of the total 98 patients, 45 (45.9%) were tested positive for pathogenic organisms preoperatively, and 16 of those (35.6%) developed postoperative pneumonia; postoperative pneumonia occurred at a higher rate in these patients compared to pathogenic organism-negative patients (p=0.019). Postoperative SIRS was observed in 62 patients (63.3%), and 21 of these (33.9%) developed postoperative pneumonia, a significantly higher rate compared to patients without SIRS (p=0.007)., Conclusion: Postoperative pneumonia was significantly associated with the presence of pathogenic organisms in the sputum or pharynx and postoperative SIRS., (Copyright© 2019, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Three-field lymph node dissection is now performed in operations for advanced thoracic esophageal cancer, with an associated improvement in outcomes. However, reconstructive surgery following resection of the esophagus is frequently associated with the occurrence of anastomotic leakage. Once it occurs, major problems can arise such as decreased quality of life, protracted hospitalization, or even death. This is why there has been a large number of innovations in and modifications to reconstructive surgery. The standard procedures in our Department for advanced thoracic esophageal cancer are subtotal esophagectomy and three-field lymph node dissection. The thin gastric tube along the greater curvature is used as the reconstructed organ in reconstructive surgery, performing a cervical esophagogastrostomy. Innovations have been made to reconstructive surgery in order to prevent anastomotic leakage. This procedure markedly reduces anastomotic leakage, and also reduces anastomotic stricture, which likely makes it an extremely useful procedure that any surgeon can perform., (Copyright© 2018, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background/aim: Pancreaticoduodenectomy (PD) treatment outcomes in elderly patients have been reported to be acceptable, but the eligibility criteria are not clear. To elucidate the importance of PD in octogenarians in particular, we set five eligibility criteria for elderly patients based on preoperative cardiac and pulmonary function, nutritional status, daily activity status, and psychological independence status for the first time and evaluated prospectively whether the validity of patient selection was adaptable., Patients and Methods: The study population consisted of 222 patients with pancreaticobiliary cancer aged over 70 years. The patients were divided into two groups: 192 patients as septuagenarians and 30 as octogenarians. Postoperative morbidity and long-term outcome were compared between the two groups, and prognostic factors relating to survival time were identified., Results: Octogenarians had a significantly higher frequency of two or more comorbidities (p<0.0001). The difference in the mortality rates between the two groups was not significant, being 3.3% and 4.2%, respectively. No difference between the two groups was found in overall survival rate, including deaths due to other diseases, for any type of pancreaticobiliary cancer. Independent prognostic factors relating to survival duration were intraoperative blood loss (p=0.0004) and duration of surgery (p=0.0093)., Conclusion: These five eligibility criteria for PD in elderly patients are also satisfactorily applicable to octogenarian patients. These criteria may be helpful when uncertainties arise regarding the selection of PD., (Copyright© 2017, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Neoadjuvant chemotherapy (NAC) with docetaxel, nedaplatin and 5-fluorouracil (5-FU) in esophageal cancer may adversely affect the postoperative clinical course following esophagectomy., Patients and Methods: We investigated the perioperative white blood cell count (WBC), C-reactive protein (CRP), serum albumin, body temperature (BT), heart rate (HR), respiratory rate (RR), water balance, partial pressure of oxygen in arterial blood (PaO 2 )/fraction of inspired oxygen (FiO 2 ) ratio, postoperative complications and systemic inflammatory response syndrome (SIRS) in patients who underwent NAC or surgery alone (SA group)., Results: In the NAC group, the preoperative WBC (p=0.015) and postoperative day (POD) 3 BT (p=0.049), as well as RR (p=0.037) were lower, whereas the POD 2 PaO 2 /FiO 2 ratio was higher (p=0.047), compared to the SA group. No differences in the incidence of postoperative complications and SIRS were observed between the groups., Conclusion: NAC using docetaxel, nedaplatin and 5-fluorouracil was tolerated and feasible in esophageal cancer., (Copyright© 2016 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

Aim: The appropriate additional surgery after non-curative resection of Endoscopic Mucosal Resection (ESD) for early gastric cancer is herein discussed., Patients and Methods: Data on 54 patients after non-curative resection of ESD were evaluated. These patients were broadly classified according to the risk of lymph node metastasis with lesions into group A (without risk) (n=26) and group B (with risk) (n=28). Their treatment results were evaluated., Results: The incidence of residual lesion was 7.7% in group A and 14.3% in group B. Risk factors were piecemeal resection, involvement of the horizontal margin (HM1) or unclear involvement of the horizontal margin (HMX) and with ulceration. Lymph node metastasis was detected in one patient with lymphatic invasion, total diameter of 3 cm or more and submucosal invasion over 0.5 mm (SM2). The 5-year survival rate was 93% and none of the patients died of gastric cancer., Conclusion: Follow-up observation was reasonable in group A. Patients who are judged as having undergone piecemeal resection, HM1 or HMX and with ulceration, should be treated by additional surgery and patients judged with SM2 or total diameter of 3 cm or more or lymphatic invasion should be treated by additional surgery with lymphadectomy in group B., (Copyright© 2015 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

Low-grade myofibroblastic sarcoma (LGMFS) is a fusiform cell tumor which develops in bone or soft tissues. This type of tumor frequently occurs in the oral cavity and extremities, while it is extremely rarely found in the abdominal cavity. This article reports a case of LGMFS exceeding 20 cm in diameter in the abdominal cavity observed in a 65-year-old male patient. The patient visited our hospital complaining of a heavy feeling of the stomach and abdominal distension. Imaging examinations revealed a giant solid tumor in the abdomen, and surgical treatment was scheduled. During the operation, a tumor about 20 cm in diameter with its anterior aspect covered with the greater omentum was found. The tumor had firm adhesions to the surrounding tissues, and it was excised with concomitant resections of the tail of the pancreas and the spleen. Histopathologically, fusiform cells were arranged in a complicated or storiform pattern, and immunohistochemical staining revealed that the tumor was positive for α-smooth muscle actin, negative for S100β, H-caldesmon and c-KIT, and a diagnosis of LGMFS was made.

Nephrotic syndrome associated with a malignant tumor may remit following resection of the tumor. This report documents a case of esophageal cancer with concurrent nephrotic syndrome in which a surgical resection of the tumor resulted in a complete remission of nephrotic syndrome. A 78-year-old male patient noticed edema of his lower legs in February 2009 and was diagnosed with nephrotic syndrome. An endoscopic examination revealed an indented lesion with a nearly semiannular low elevation on the posterior wall of the esophagus at 31 to 34 cm from the upper incisors, and a diagnosis of esophageal cancer was made. A two-stage operation was planned. In March 2009, a subtotal resection of the thoracic esophagus through a right thoracic approach and cervical external esophagostomy were performed, and in April 2009, antethoracic route esophagogastrostomy was performed. The urinary protein levels were negative by the 86th day of hospitalization, and the patient progressively improved and was discharged on the 91st hospital day. There has been no recurrence of esophageal cancer or relapse of nephrotic syndrome at 12 months following the operation. In esophageal cancer patients with nephrotic syndrome, surgical treatment should be undertaken because the remission of nephrotic syndrome may be expected following tumor resection. For this purpose, selecting the appropriate operative procedures and careful perioperative management, including nutritional management, are of profound importance.

It is difficult to perform radical surgery for esophageal cancer with multiple lymph node metastases. Therefore, effective neoadjuvant adjuvant treatment is necessary to achieve successful radical resection. The use of neoadjuvant chemotherapy of docetaxel, cisplatin (CDOP) and 5-fluorouracil (5-FU) (DCF) in an advanced case is reported. The patient (a 67-year-old female) was diagnosed with esophageal cancer, T3, N4, M0, stage IVa with a large number of lymph node metastases in the mediastinum and in the abdominal cavity. Neoadjuvant DCF chemotherapy was initiated in August 2006. Adverse events were mild. A complete response of the lymph node metastases in the abdominal cavity and a partial response of the esophageal lesion were achieved. The surgical procedure included a right thoracolaparotomy followed by a subtotal excision of the esophagus and two-field lymph node dissection. The cancer was diagnosed to be moderately differentiated squamous cell cancer, pT2, pN4(3c) and pstage IVa. The histological efficacy of the chemotherapy was determined to be grade 1a. Two additional courses of DCF therapy were administered followed by postoperative adjuvant chemotherapy.

Background: We developed a modified method of endoscopic aspiration mucosectomy (m-EAM) which includes the pre-cutting of the peripheral mucosa before aspiration, and which has been employed in this department since 1998. An endoscopic submucosal dissection (ESD), which enables the resection of a larger area of the lesion using newly-developed surgical devices, has also been employed here since March 2003. This study was performed to investigate the efficacy of ESD at the present time by assessing the short-term therapeutic results for the procedure in patients with a preoperative diagnosis of early-stage differentiated gastric mucosal cancer, by tumor diameter, as well as by comparing these results with those obtained previously with m-EAM., Patients and Methods: The study included 110 patients with a preoperative diagnosis of early-stage differentiated gastric mucosal cancer (57 underwent m-EAM and 53 received ESD). A comparison was made between these two groups regarding the short-term therapeutic response (en bloc resection rate, curability, complications, and days of postoperative hospitalization) by the tumor diameter., Results: The en bloc resection rate was significantly higher for patients with a tumor measuring 21 mm or larger who underwent ESD in comparison to that for those with a similar tumor size who underwent m-EAM (p<0.05). Complications were reported significantly more frequently in patients treated with ESD for a tumor measuring 11 mm or larger (p<0.05) in comparison those treated with m-EAM. There was no significant difference between the two groups with regard to the curability and the days of postoperative hospitalization., Conclusion: This study confirmed the efficacy of the ESD procedure which enables surgeons to perform a more reliable en bloc tumor resection.

This study was performed to assess the usefulness and safety of neoadjuvant chemotherapy utilizing the FAP regimen consisting of 5-fluorouracil, cisplatin and adriamycin for the treatment of highly advanced esophageal cancer. Twenty-seven patients with Stage III or more advanced esophageal cancer were enrolled in the study. The patients generally received two cycles of FAP. The response rate was as high as 55.6% and the resectability rate as high as 85.2%. All adverse events reported were mild in intensity. The histological effect was assessed as follows: Grade 1 in 18 patients, Grade 2 in 3 patients and Grade 3 (a pathological complete response) in 2 patients. All patients with nonresectable tumors died within 6 months, whereas of the 5 patients who responded with Grade 2 or better histological effects, all survived without recurrence for a follow-up period up to 60 months. The results of this study therefore showed the usefulness and safety of FAP therapy, which is considered to be a treatment method worth aggressively trying for highly advanced esophageal cancer in which a curative resection can hardly be expected.

A 70-year-old male was admitted to our hospital because of advanced esophageal squamous cell carcinoma and early gastric adenocarcinoma. A esophagectomy and partial gastrectomy with three-field lymph node dissection (neck, mediastinum and abdomen) was performed. Both tumors had lymph node metastases. In addition, three mediastinal lymph nodes (two subcarinal lymph nodes and a middle thoracic paraesophageal lymph node) were involved with adenocarcinoma. To elucidate whether they were metastases from the gastric cancer, an immunohistochemical analysis was performed. The cancer cells in these lymph nodes were positive for cytokeratin (CK) 7 and negative for CK 20, thus suggesting metastasis from a nondigestive organ. Interestingly, they were positive for thyroid transcription factor 1 (TTF-1), indicating metastasis from a lung cancer. Since the preoperative computed tomographic scan showed no evidence of lung cancer, a diagnosis of metastases from an occult lung cancer was finally recorded. Ten months after surgery, the patient was alive without a recurrence or the appearance of a lung cancer.

A case of intractable cutaneous fistula in an esophagogastrostomized region complicated by osteomyelitis is reported. A three-stage operation was performed, and gratifying results were obtained. The patient was a 74-year-old man who received a subtotal esophagectomy and a cervical esophagogastrostomy through a retrosternal approach for advanced esophageal cancer. Following subsequent radiotherapy, the anastomosed region in the neck was found to have been stenosed. Endoscopic balloon dilatation was then performed and perforation of the stenosed region occurred to form an intractable fistula. A chest computed tomography scan revealed osteolysis of the sternum, clavicular head and left first rib. Treatment comprised an initial control of the infective foci including osteomyelitis and, after achieving stabilization of the wounds, the subsequent step of reconstruction. The patient's postoperative course was satisfactory without involvement of any leakage or stenosis of the anastomosed regions, or wound infection. It is considered feasible to cure even a cutaneous fistula in the neck complicated by osteomyelitis, as in the present case, by sufficient control of infection and procedural contrivance.

Surgical treatment of esophageal cancer is substantially invasive and often entails some postoperative complications. Perioperative management for patients with liver cirrhosis involves great difficulties. Recently, we conducted an esophagectomy for the treatment of superficial esophageal cancer in a 52-year-old male patient with liver cirrhosis and esophageal varices, with gratifying results. Although the hepatic function was impaired, as indicated by a reduced indocyanine green R15 value of 27.4%, the patient was assessed as capable of tolerating operative procedures. The procedures comprised a subtotal esophagectomy through a transhiatal approach, an anastomosis of the cervical esophagus with a gastric tube via the posterior mediastinal route, and super drainage of the short gastric vein of the gastric tube. The patient had an uneventful postoperative course without any complications such as anastomotic leakage or pneumonia. It is considered practicable to accomplish an esophagectomy by careful appraisal of liver function and planning of the operative procedure and perioperative management even in patients with liver cirrhosis.

A case of collision carcinoma (squamous cell carcinoma and Barrett's adenocarcinoma) in the residual cervical esophagus of a 68-year-old woman at 27 years after subtotal esophagectomy for thoracic esophageal carcinoma is reported. The patient initially noticed cervical dysphagia in 2002, but did not seek treatment. In April 2004, the patient was referred to our department by a local physician with the diagnosis of carcinoma of the cervical esophagus. In September 2004, the patient underwent resection of the cervical esophagus and partial resection of the gastric tube combined with cervical lymph node dissection under a diagnosis of double cancer (i.e., metachronous cervical esophageal carcinoma and carcinoma of the gastric tube). Esophagogastric continuity was restored by transplantation of a free jejunal graft with vascular anastomosis. Pathological examination showed squamous cell carcinoma on the esophageal side of the esophagogastric anastomosis and columnar epithelium with a tongue-shaped extension across the anastomotic line that included Barrett's epithelium, as well as adenocarcinoma, on the gastric tube side. The squamous cell carcinoma and adenocarcinoma were contiguous, but there was a distinct border between them and no morphological transition. Immunohistochemical staining showed positivity for p53 in the squamous carcinoma cells, while it was negative in the adenocarcinoma cells. In contrast, HER2 (c-erb-2) was strongly positive in the adenocarcinoma cells, but negative in the squamous carcinoma. Based on these findings, it was concluded that two separate carcinomas had arisen at different sites and grown independently until they collided and merged to form a collision carcinoma.

Background: A cDNA microarray analysis of anaplastic thyroid cancer cell lines (ACL) was recently performed and the down-regulation of phosphatidylethanolamine-binding protein (PBP) [RAF kinase inhibitor protein (RKIP)] in ACL compared to normal thyroid tissues was identified., Materials and Methods: The expression levels of PBP in primary anaplastic and papillary thyroid cancer, thyroid cancer cell lines (anaplastic, papillary and follicular) and several normal human organs were examined. To examine the function of PBP, cell-growth assays were performed., Results: PBP expression was reduced in anaplastic thyroid cancers, compared to either normal thyroid tissues or differentiated thyroid cancers. PBP was expressed ubiquitously in normal human tissues. Exogenous PBP expression suppressed ACL growth, and suggested a tumor suppressive function of PBP in ACL., Conclusion: This is the first report demonstrating that PBP may be a tumor suppressor whose loss is associated with development of anaplastic thyroid cancer from differentiated thyroid cancer.