Search

A 66-year-old man diagnosed with rectal cancer underwent high anterior resection and received adjuvant chemotherapy (UFT plus UZEL). One year after the surgery, lung and para-aortic lymph node(PLN)metastases were identified. We chose mFOLFOX6 for first-line chemotherapy. After 7 courses, we changed the regimen to sLV5FU2 because of Grade 3 neuropathy. After 5 courses, to treat progressive disease(PD), we changed the regimen to FOLFIRI. Then, the patient had stable disease (SD), and surgical excision was performed for both lung and lymph node recurrence without adjuvant chemotherapy. Six years after the excision, a CT scan revealed PLNagain. We chose FOLFIRI plus cetuximab. After 9 courses, the lymph nodes decreased in size and there was no other recurrence; thus we performed resection. However, a third PLNrecurrence was identified 20 months after the resection. Chemotherapy has continued for 47 courses, and he has maintained SD for more than 2 years.

Nerve-preservation technique during surgery is important. Intraoperative nerve injury often causes permanent palsy or numbness and/or neurogenic functional disorders. To evade such intraoperative nerve injuries, we proposed a novel manner to specifically visualize peripheral nerve fibers. Low-toxic agents clinically available, amphotericin B(AmB)or fluorescein isothiocyanate(FITC)were used as neuro-indicators. In in vitro, we used Schwann cells as nerve models to basically confirm these agents effectively functioned as neural markers. In in vivo, we examined whether this novel method was clinically applicable. The Schwann cells reacted with AmB or FITC emitted blue or yellow-green fluorescence in a dark environment. The rat nerve models also fluorescently glimmered in blue-tone when each agent was given. These data suggested that we could clinically discriminate nerve fibers from the surrounding tissues. Our fluorescent-imaging methods warrant further studies for clinical applications.

We evaluated the outcome of esophageal stenting for esophagorespiratory fistula in patients with advanced esophageal cancer. Six patients with such fistula underwent esophageal stenting at our department from January 2000 to May 2012. Intraoral ingestion improved in all patients. Cough decreased immediately after stenting in 3 patients, and pneumonia detected by chest radiography improved within 1 week in 2 patients. Ventilation was weaned 2 days after stenting in 1 patient. The median survival duration after stenting was 31 days, and the cause of death was cancer in all patients. The following background factors were identified at the time of death: bleeding(n=3), mediastinitis(n=1), and pneumonia(n=1). Esophageal stenting, which should always be performed with the informed consent of the patient, improves respiratory symptoms, intraoral ingestion, and quality of life. Therefore, it is one of the best palliative therapies for patients with esophagorespiratory fistula associated with advanced esophageal cancer.

Several oncogenes and tumor suppressor genes are involved in the multistep process of carcinogenesis in many cancer types. Recently, global mutational analyses have revealed that the cancer genome has far greater numbers of mutations than previously thought. Furthermore, the next-generation sequencing method, which has a different principle from conventional Sanger sequencing, has provided more information on the cancer genome such as new cancer-related genes and the existence of many rearrangements in solid cancers. Somatic mutations occurring in cancer cells are divided into "driver" and "passenger" mutations. Driver mutations confer a growth advantage upon the neoplastic clone and are crucial for carcinogenesis. The remaining large majority of mutations are passengers, which, by definition, do not confer a growth advantage. Driver genes with low-frequency mutation rates (less than 10%) are also involved in carcinogenesis along with well-known drivers with high-frequency mutations. There are now several celebrated examples of anticancer drugs of which the efficacy in cancer patients can be predicted based on the genotype of several driver genes, such as EGFR, KRAS, and BRAF on the EGFR signaling pathway. The complete catalogs of somatic mutations provided by the sequencing of the cancer genome are expected to prompt new approaches to diagnosis, therapy, and potentially prevention.

The patient was a 72-year-old female with gastric carcinoma. A liver metastatic recurrence was detected 27 months after operation. Although temporary partial responses were obtained by each effective chemotherapy, which was a combination chemotherapy with 5'-DFUR and TXT, TS-1 and TXL, the metastatic lesion proved refractory to all of them. Then we tried combination chemotherapy consisting of CDDP 30 mg/m2 and CPT-11 60 mg/m2, respectively (day 1 and 15, every 4 weeks). A partial response was achieved and continued for 8.5 months, and her complaints abated and quality of life improved. Although gastro-intestinal symptoms and bone marrow suppression were observed as side effects, they were within a tolerable range and did not interfere with the combination therapy. This regimen appears to be feasible and effective for recurrent gastric carcinoma refractory to other regimens.

In elective gastrointestinal (GI) surgery, the patients' nutritional status should be assessed and if protein-energy malnutrition exists, preoperative nutritional support should be scheduled 7 to 14 days before surgery. In malnourished patients in particular, preoperative nutrition with total parenteral nutrition (TPN) reduces postoperative complication rates of infection. Preoperative enteral nutrition (EN) is considered to be as effective as TPN in improving postoperative surgical outcome. Many prospective randomized trials or meta-analyses comparing postoperative EN and TPN have revealed that postoperative EN improves surgical outcomes and lowers postoperative complication rates of infection to a degree similar to TPN. Although two recent prospective multicenter randomized trials in malnourished patients undergoing elective GI cancer surgery are controversial, no evidence that EN was less effective than TPN was recognized. Thus postoperative EN, prior to TPN, is recommended in patients with malnutrition or insufficient oral intake for 7 days or more after surgery. When TPN is administered, hyperglycemia due to overfeeding should be carefully controlled. Patients who undergo distal gastrectomy or colectomy can start oral intake 3 to 4 days after surgery, with pertinent peripheral infusion. Immunonutrition containing immune-enhancing nutrients such as arginine, n-3 polyunsaturated fatty acid, glutamine, etc., especially administered preoperatively, is a promising nutritional therapy for reducing postoperative infectious complications.

It has been suggested that SIRS are triggered by superfluous pro-inflammatory cytokine production, and that organ injury is caused by uncontrolled inflammatory responses. However, the results of clinical studies, on the usefulness of specific cytokine antagonists and anti-TNF antibodies for the treatment of septic shock, have been unsatisfactory. The reason for this might have been that when uncontrolled inflammatory reactions progressed locally, anti-inflammatory reactions were elevated in the circulated blood by way of CARS, thus the timing of administration and pharmacokinetics did not match clinical course. Recent research has shown that SIRS is always accompanied by CARS, and since it seems to do the amplitude of SIRS and CARS to each other so that there may be a deep valley, if there is a high mountain. We introduce the recent knowledge which indicates that SIRS is a preliminary alert for not only organ dysfunction but also immunosuppression after severe injury or major surgery.

From 1987 to 1997, 211 patients with thoracic esophageal carcinoma underwent radical surgery. The 5 year survival rate was 87% in pTNM stage I, 64% in stage II A, 57% in stage II B, and 31% in stage III. The survival curve was improved by postoperative chemotherapy including CDDP/5-FU as compared with surgery alone. Relapse occurred in 59 of these patients (28%). Lymphatic recurrence was recognized in 32 patients, hematogenic recurrence in 19, mixed type in 4, and intramural or local recurrence in 4 patients. In spite of through lymph node dissection, postoperative lymphatic recurrence was most frequent at the upper mediastinum and neck. Among hematogenic metastases, pulmonary and hepatic metastases were observed at equal incidences. The 1 year survival rate and median survival period of the patients with recurrent carcinoma were 36% and 191 days (26-1,122), respectively. There was no significant difference in prognosis between lymphatic and hematogenic recurrence. The prognosis for patients who underwent active therapy for recurrence (42 cases) was significantly better than for those who underwent only palliative therapy (17 cases). Resection of the site of recurrence was performed in 4 cases. The combination therapy of resection or irradiation and combined chemotherapy with CDDP and 5-FU resulted in a better prognosis (median survival period was 504 days) than irradiation alone or chemotherapy alone. In conclusion, early diagnosis and active multimodality therapy were important to improve the prognosis of recurrent esophageal carcinoma.

A series of EMG study of the leg muscles was carried out with a wire electrode in 86 hemiplegic patients of stroke to visualize the role of each muscle either in the development of equinovarus deformity of the foot or in correcting the deformity through tendon transfer. The muscles examined were anterior tibialis, posterior tibialis, gastrocnemius, soleus, flexor digitorum longus and peroneus brevis of the affected side. Tonic discharge of those muscles was recorded as the patients were elevating the affected leg in supine, sitting or standing posture or were standing on legs. On lifting up the affected limb, most patients showed electrical activity of anterior tibialis with or without simultaneous activity of other muscles, most frequently with that of flexor digitorum longus or gastrocnemius. When the patient stood on legs electromyographic discharge appeared most frequently in soleus. Varus deformity of the foot significantly correlated to the lack of the electrical activity of peroneus brevis. Both such abnormal activity of anterior tibialis and the lack of activity of peroneus seemed to be the main causes for the varus deformity. Postoperative EMG study in the patients who underwent Watkins-Barr procedure of anterior transfer of the posterior tibialis tendon, showed that the posterior tibialis was rather inactive both in elevating the leg and in standing on legs. Varus deformity was corrected independent of the discharge of posterior tibialis. The author concluded that the correction of the varus deformity after Watkins-Barr procedure was mainly obtained from the tenodesis effect. The tenodesis provides the checkline effect on the equinus and varus deformity, which reinforces the dorsiflexing action of anterior tibialis and attenuates its inverting action of the same muscle.