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mtDNA Heteroplasmy: Origin, Diagnosis, Importance, along with Transformative Outcomes.
A 76-year-old man with a past history of liver transplantation because of liver cirrhosis visited a hospital in October 2018 because of vomiting and abdominal pain. Although the patient underwent conservative medical treatment, no improvement of the symptoms was observed, and he received consultation at our hospital. After thorough examination, and because of the policy of inpatient treatment after the diagnosis of adhesion ileus obstruction post liver transplantation surgery, intestinal decompression was performed using an ileus tube. However, there was no improvement in the symptoms even after inserting the ileus tube, and intestinal obstruction was diagnosed in November 2018. During the preoperative examination, a tumorous shadow was found in the right lung, although it became a policy of scrutiny after improvement of the bowel obstruction. During the laparotomy, a macroscopic tumor exposed on the serosal surface was observed on the anal side at 120 cm from the Treitz ligament, and this site was considered to be the blocking origin. Partial resection of the small intestine including the blockage site was performed. The pathological result revealed the diagnosis of adenosquamous carcinoma. Furthermore, immunostaining was CK7 positive, CK20 negative, TTF-1 negative, and Napsin negative, suggesting the possibility of a metastatic tumor derived from lung cancer. The postoperative course was uneventful, and the patient was discharged on postoperative day 9. On day 30 after surgery, the left pleural effusion increased and pleural effusion cytology revealed a diagnosis of primary lung adenocarcinoma Stage Ⅳ. Considering the patient's PS, it became a best supportive care(BSC)policy after consultation with the family, and it ended on postoperative day 70. Here, we report about a case diagnosed with metastatic small bowel cancer and intestinal obstruction and conduct a literature review.A 68-year-old woman was receiving chemotherapy and endocrine therapy for right breast cancer postoperative pulmonary metastasis and local lymph node recurrence. However, she developed interstitial pneumonia 12 weeks after initiating treatment with everolimus and exemestane. Treatment with everolimus and exemestane was discontinued and steroid pulse therapy was initiated; however, she required ventilator management because of the severity of the pneumonia. The patient's condition improved 9 days after ventilator management. Everolimus-induced interstitial pneumonia is often mild, but it can be severe in rare cases. buy IWR-1-endo In our case, everolimus-induced diffuse alveoli damage was successfully treated with ventilator management.A 63-year-old-woman was diagnosed with gastric cancer cStage ⅠA after ESD, and then, underwent robot-assisted distal gastrectomy. She vomited on the postoperative day 2 and then was inserted nasogastric tube. The amount of drainage from the tube was increased on the postoperative day 5, therefore, abdominal computed tomography scan was performed, which showed herniation of small bowel at the 8 mm port site in the left upper abdomen. The emergent surgery was performed because of difficulty in manual reduction. Intraoperative findings showed that small intestine was incarcerated at the left 8 mm port-site. The intestine was released by incising the fascia of hernia orifice, then, the fascia was repaired. There was no recurrence of gastric cancer and port-site hernia for 34 months after surgery. In general, the fascia of over 10 mm port site is sutured and closed to avoid port-site hernia, however, it is unclear whether the fascia of 8 mm port-site should be closed after robotic surgery. Since we experienced this case, we have also performed fascia suture on the 8 mm port-site in all cases. And then, we could prevent occurrence of port-site hernia in the 8 mm port-site.Case 1 The patient was a 74-year-old man with a performance status(PS)of 0. He was referred to our department for pyloric gastric cancer with multiple liver, lung, and lymph node metastases. We started chemotherapy after making the diagnosis of an unresectable gastric cancer. During chemotherapy, the hemoglobin level dropped due to bleeding from the tumor. We attempted endoscopic hemostasis, which was not successful; therefore, we attempted a palliative radiotherapy. The total dose was 30 Gy in 10 Fr and hemostasis was achieved on the 10th day from the start of the radiotherapy. There were no adverse events due to the radiation, and the chemotherapy could be restarted 5 days after the end of the radiotherapy. Case 2 The patient was a 78-year-old man with a PS of 2. He was referred to our department because of vomiting and anemia. As a result of a close inspection, we made the diagnosis of an unresectable gastric body cancer with para-aortic lymph node metastasis and peritoneal dissemination, for which chemotherapy was initiated. Anemia was observed at the first visit, and we started radiotherapy to stop the tumor bleeding. The total dose was 30 Gy in 10 Fr, and hemostasis was achieved on the 12th day. There were no adverse events during the radiotherapy, and chemotherapy could be continued. Palliative radiotherapy is an available method of hemostasis that is less invasive than surgery or transcatheter arterial embolization and can be expected to have a certain effect for gastric cancer bleeding, although it takes several days to obtain a therapeutic effect.A 96-year-old woman was brought to our hospital for epigastric pain. Abdominal contrast-enhanced CT and MRCP showed wall thickness of the fundus and extravasation in the gallbladder. With a diagnosis of gallbladder hemorrhage from the tumors, we performed laparoscopic cholecystectomy. The histopathological diagnosis was gallbladder cancer. Herein, we report on this case and also provide a literature review.A 50's man was referred to our hospital because of sigmoid colon cancer with multiple liver metastases and para-aortic lymph node metastases. Although blood test showed elevated D-dimer(50 μg/mL), there was no significant thrombus in contrast-enhanced CT scan. Since cancer pain and symptoms of bowel obstruction had continued after endoscopic stent placement, we resected primary lesion. Despite anemia and elevated D-dimer level had persisted after the operation, there were no obvious bleeding source nor thrombus. Continuous intravenous heparin infusion was started for hypercoagulability. Then, D-dimer and CRP levels were promptly decreased. Since schizocyte and giant platelets were observed in peripheral blood smear, he was eventually diagnosed with thrombotic microangiopathy as a paraneoplastic syndrome. However D- dimer and CRP levels were re-elevated, and it seemed to be necessary to control cancer progression. Thus, cetuximab monotherapy was started considering his performance status. After starting cetuximab, fever and CRP level were immediately improved.
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