Naoshi Kubo

Geriatric Nutritional Index (GNRI) was shown to be closely associated with nutrition-related complications and mortality in elderly hospitalized patients. Impact of GNRI on postoperative outcomes in surgically treated esophageal squamous cell carcinoma (ESCC) patients has not been evaluated extensively.

Common complications of pelvic fractures include visceral injury, large-volume hemorrhage, genitourinary injury, rectal injury, and pulmonary embolism. On the other hand, traumatic hernia is a rare complication, especially in association with pelvic fractures. We report a case of bowel perforation due to traumatic hernia at a pelvic fracture site. A 65-year-old female was presented at our hospital for further examination and treatment of ileus. She was diagnosed with bowel perforation due to traumatic hernia at a pelvic fracture site, and an emergency operation was thus immediately performed. We performed segmental jejunum resection and constructed jejunostomy, and the iliac bone fracture was fixed with four pins. In the postoperative course, she received antibiotics and vasopressors for septic shock. However, there was no need for either a ventilator, dialysis or admission to the ICU. At seven days after the operation, a residual abscess was detected in the pouch of Douglas. We performed percutaneous drainage (Clavien-Dindo IIIa) and jejunostomy closedown 35 days after the first operation. The postoperative course was without complication, but she received rehabilitation until she was able to walk unaided. She was discharged 64 days after the first operation. The occurrence of traumatic hernia is rare, especially in association with pelvic fractures. Although its rarity, traumatic hernia follows a severe course. Thus, proper diagnosis and effective treatment are necessary. Surgeons treating patients with pelvic injuries should consider the possibility of any complications and perform a work-up examination in order to achieve an accurate diagnosis at an earlier time point.

A 60-year-old man underwent laparoscopic total proctocolectomy with ileostomy for advanced ulcerative colitis-associated rectal cancer. The final diagnosis was advanced cancer pT3, pN2 and M0 (pStage Ⅲb). Adjuvant therapy with XELOX was performed. However, abdominal CT revealed a liver metastasis and lymph node metastases in the pelvis 6 months after surgery. The patient was treated with FOLFIRI plus bevacizumab. After 20 courses of chemotherapy, the patient was considered to have experienced a clinical CR, which has been maintained for 3 years 5 months.

A 66-year-old man underwent laparoscopic right nephrectomy for renal cell carcinoma (T2b, N0, M1, clear cell, Grade 3). He was treated with targeted therapy for lung metastases after nephrectomy. Despite the targeted therapy, he was paralyzed in the lower half of the body due to the spinal metastases. Therefore, an osteoplastic laminectomy and domelaminectomy for the spinal metastases was performed. The FDG-PET examination, which was performed after the operation, revealed lung, liver, bone, and small intestinal metastases. After a while, he suffered from continuous massive melena. Double balloon enteroscopy revealed a hemorrhagic tumor in the small intestine, and an emergency operation was performed. A partial resection of the small intestine was performed for the 3 tumors. The histopathological diagnosis was small intestinal metastasis from renal cell carcinoma. It is well known that renal cell carcinoma often develops metastases to the lung, bone, and liver. However, small intestinal metastasis from renal cell carcinoma is rare. Although small intestinal metastasis from renal cell carcinoma often accompanies metastases to other organs, a palliative operation might improve the quality of life in patients with symptomatic tumors.

It is important in the clinical setting to integrate all of the findings when diagnosing and making treatment decisions. We report a case of particular interest for managing cancer patients. A 69-year-old man underwent endoscopic resection for an Rb rectal tumor. The tumor showed a positive vertical margin and required laparoscopy-assisted super low anterior resection with ileostomy for histopathological stage Ⅰrectal cancer. His postoperative course was uneventful. The follow-up computed tomography (CT) scan revealed a tumor locating close to the left common iliac artery. Although positron emission tomography (PET) showed 18F-fluorodeoxyglucose (FDG) accumulation in the tumor, none of the other clinical findings indicated a recurrence of rectal cancer. FDG is not specific to malignant neoplasias, but the location of the tumor and the FDG uptake suggested the possibility of malignancy. No other tests found any evidence of a recurrence. Tumor resection was performed concurrently with ileostomy closure. Histopathology demonstrated it was an asymptomatic abscess in a lymph node. Tumor recurrence and metastases have to be kept in mind even if the primary lesion is in an early stage. This case shows the difficulty in deciding how to manage patients when clinical results are not consistent, especially in cases needing surgical procedures.

The cell surface receptor programmed death-1 (PD1) and its ligand (PDL1) have been detected in various cancer types. It has been reported that expression of PDL1 and PD1 in a tumor is associated with poor prognosis of the patient. In the present study, we retrospectively examined tumor expression of PDL1 and intratumoral PD1(+) cell infiltration, and assessed their relationship with patient prognosis according to the pathological stage of gastric cancer. PDL1 and PD1 expression in primary tumors from 431 patients was evaluated using immunohistochemistry. The association between the expression of PDL1/PD1 and clinicopathological features was assessed. High expression of PDL1 was observed in 128 (29.6%) patients. PDL1 expression was correlated with tumor infiltration of PD1(+) cells. In multivariate analysis, PDL1 expression was associated with worse overall survival. In subset analysis, PDL1 expression was significantly associated with survival in patients with stage II/III gastric cancer. In conclusion, PDL1 was an independent prognostic factor for patients with stage II/III gastric cancer. Our results suggested that patients with stage II/III gastric cancer might be appropriate for PD1/PDL1-targeted therapy.

The prognosis of patients with locally advanced esophageal squamous cell carcinoma (LAESC) is extremely poor. The impact of adverse effects of chemoradiotherapy (CRT), particularly myelosuppression, on postoperative long-term results has remained unclear. A total of 44 patients with LAESC who underwent CRT followed by esophagectomy were enrolled. We compared long-term survival by various clinical variables, including myelosuppression (Grade 3 and 4 leukopenia) due to CRT, response to CRT, performance status, postoperative complications, and pathological nodal status. Finally, multivariate analysis of prognostic factors was assessed by the Cox proportional hazards model. The mean age of patients was 62.8 years and the male/female ratio was 32/9. The response rate to CRT was 75% (33/44), which included five cases with complete response and 28 cases with partial response. Grade 3 and 4 leukopenia was 43% (19/44). Mortality and postoperative pneumonia occurred in 3 (7.3%) and 14 cases (31.8%), respectively. Multivariate analysis demonstrated that myelosuppression was a significant negative prognostic factor in overall survival (OS) [hazard ratio (HR)=4.758, p=0.005]. The 5-year OS rate was significantly poorer in the group with myelosuppression than in the group without (15.4% vs. 69.0%, p=0.003). Discontinuation of the preoperative CRT schedule and dose reduction of chemotherapeutic agents was significantly more frequent in the group with myelosuppression than in the group without (p=0.003), and peripheral lymphocyte counts after surgery was significantly lower, which may explain poor prognosis in the group with myelosuppression. Pre-operative CRT-induced myelosuppression has a negative impact on the prognosis of patients with LAESC. Our findings indicate that a careful postoperative follow-up is required for patients who develop myelosuppression after neoadjuvant CRT followed by curative resection for locally advanced esophageal cancer.

Patients with clinical T4 esophageal squamous cell carcinoma (ESCC) have an unfavorable prognosis, mainly indicated by the response to chemoradiotherapy (CRT), crucial to estimating long-term survival. Other prognostic measures include systemic inflammatory or immunonutritional indices such as the Glasgow Prognostic Score (GPS) and Prognostic Nutritional Index (PNI) that have not been sufficiently documented. This study retrospectively evaluated 91 patients with T4 ESCC treated at our Hospital between 2000 and 2013. All patients initially received CRT, including 5-fluorouracil (5FU) and cisplatin or nedaplatin with concurrent 2-Gy/fraction radiation (total dose, 40-60 Gy). Curative tumor resection was undertaken in suitable patients on completing CRT. Patients were classified as GPS0, GPS1, or GPS2 based on C-reactive protein (CRP) ≤ 10 mg/l and albumin ≥ 35 g/l, CRP >10 mg/l or albumin 10 mg/l and albumin <35 g/l, respectively. PNI was calculated as 10-times the serum albumin (g/dl)+0.005 × total lymphocyte count (/mm(3)). The impact of the pre-treatment GPS and PNI on the prognosis of patients with T4 ESCC was investigated in univariate and multivariate analyses. Sixty (67%) patients responded to CRT (9 complete responses and 51 partial responses). Forty-one (45%) patients also underwent surgical resection of the residual tumor. The overall 5-year survival rate and median survival time were 27.0% and 11.8 months, respectively. In the cohort of CRT-plus-surgical resection, the 5-year survival rate was significantly higher than in the groups treated with CRT-alone (51.1% vs. 6.5%; p < 0.01). On multivariate analysis, good response to CRT [hazard ratio (HR) =0.449, p<0.01], GPS1/2 (HR=2.151, p=0.015), and surgical resection (HR=0.282, p<0.01) were significant prognostic factors, whereas PNI was not. The GPS is a useful, simple survival marker for patients with T4 ESCC undergoing multimodal therapy.