[A Case of Resected Combined Pancreatic Mixed Ductal Adenocarcinoma and Neuroendocrine Tumor]

A 63-year-old man was followed-up for diabetes mellitus. During follow-up, computed tomography(CT)showed dilatation of the main pancreatic duct in the tail of the pancreas. Abdominal enhanced CT revealed a 25 mm tumor in the body of the pancreas. Endoscopic ultrasound-fine needle aspiration(EUS-FNA)was performed, and the pathological diagnosis was adenocarcinoma. Therefore, based on the diagnosis of pancreatic body carcinoma, distal pancreatectomy with splenectomy was performed. The postoperative course was uneventful. Histological and immunohistochemical examination revealed that the tumor consisted of a ductal carcinoma and a neuroendocrine component. Therefore, combined pancreatic tumor (fT3N1M0, StageⅡB)was diagnosed. The patient subsequently received postoperative adjuvant chemotherapy(S-1 100mg/ day), and survived without recurrence 6 months after the operation. We report this case of combined pancreatic tumors with a review of the literature.

Immobilization of Plasminogen Activator, Urokinase, on Nylon

Urokinase (UK), a fibrinolytic enzyme activator purified from human material was immobilized on nylon using different procedures. One was a modified method of immobilization of antigen or antibody initially carried out by Edelman and others in 1971 (Procedure I). The other was our newly devised method (Procedure II) (Sugitachi et al. 1976).

Major specificities of the immobilized UK are as follows:

1. The UK revealed properties of a plasminogen activator and the optimum pH of the immobilized UK was between 7.2 and 7.4, these values being in good parallel with that of soluble UK. The immobilized UK maintained a stable fibrinolytic activity after long-term preservation and heat-treatment.

2. As the fibrinolytic activity of immobilized UK was found to be inhibited by the antiplasmin in human plasma, an antiplasmin inhibitor was immobilized on the nylon together with the UK.

The antiplasmin activity was to some extent prevented using this procedure.

3. Nylon tubes immobilized with UK and antiplasmin inhibitor were used for thrombotic coagulation studies carried out according to the method of Chandler. Thrombus formation time (TFT) of UK-immobilized tubes was 30 min, while that of the non-treated tubes was no longer than 10 min.

Heterozygous Abnormal Fibrinogen Osaka III with the Replacement of γ Arginine-275 by Histidine Has an Apparently Higher Molecular Weight γ-Chain Variant

Congenitally abnormal fibrinogen Osaka III with the replacement of γ Arg-275 by His was found in a 38-year-old female with no bleeding or thrombotic tendency. Release of fibrinopeptide(s) by thrombin or reptilase was normal, but her thrombin or reptilase time in the absence of calcium was markedly prolonged and the polymerization of preformed fibrin monomer which was prepared by the treatment of fibrinogen with thrombin or reptilase was also markedly defective. Propositus' fibrinogen had normal crosslinking abilities of α- and γ-chains. Analysis of fibrinogen chains on sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) in the system of Laemmli only revealed the presence of abnormal γ-chain with an apparently higher molecular weight, the presence of which was more clearly detected with SDS-PAGE of fibrin monomer obtained by thrombin treatment. Purified fragment D1 of fibrinogen Osaka III also seemed to contain an apparently higher molecular weight fragment D1 γ remnant on Laemmli gels, which was digested faster than the normal control by plasmin in the presence of [ethy-lenebis(oxyethylenenitrilo)]tetraacetic acid (EGTA).

[A Case of Xanthogranulomatous Cholecystitis That Changed Over Time and Was Difficult to Distinguish from Advanced Gallbladder Cancer]

A 70-year-old man was referred because of suspected gallbladder cancer and gallstones. Contrast-enhanced CT, EOB-MRI and PET-CT could not completely rule out gallbladder cancer. The patient preferred follow-up without surgery. At 4 months after initial examination, the gallbladder wall thickening showed improvement, but appeared worse at 9 months after initial examination. Therefore, we decided to perform surgery. Since malignant findings were not observed on rapid intraoperative pathology, we performed a cholecystectomy and right hemicolectomy because of inflammation in the transverse colon. Pathological examination diagnosed xanthogranulomatous cholecystitis. The imaging appearance of xanthogranulomatous cholecystitis varies, and also changes over time, making it difficult to distinguish from advanced gallbladder cancer. We experienced a case of xanthogranulomatous cholecystitis that changed over time, and report this case with a review of the literature.

[A Case of an IgG4-Related Inflammatory Pseudotumor of the Liver Showing Enlargement That Was Difficult to Differentiate from Hepatic Cancer]

A 60-year-old man was admitted for a liver mass(S3), which rapidly increased in size during intraductal papillary mucinous neoplasm(IPMN)follow-up. Although EOB-MRIwas performed, the mass could not be accurately diagnosed as hepatic cancer. Thus, we performed a lateral segmentectomy. In the resected specimen, a solid tumor mass was clearly bound in segment 3 of the liver. Since histopathology revealed no malignant cells and many IgG4-positive cells, we confirmed the diagnosis as IgG4-related inflammatory pseudotumor of the liver. IgG4-related diseases occur in various organs in the body, and they are known to associate with autoimmune pancreatitis and sclerosing cholangitis, but an IgG4-related inflammatory pseudotumor of the liver is a rare disease. It is often difficult to distinguish from hepatic cancer and surgical resection is performed.

[A Case of Resected Metachronous Cholangiocarcinoma after Pancreaticoduodenectomy]

The patient was a 79-year-old woman, who had undergone pancreaticoduodenectomy(PD)for lower bile duct carcinoma in our hospital(pT3N0H0P0M0, fStage III ). Four years 6 months after the initial operation, abdominal CT revealed left bile duct expansion and hilar bile duct thickening. Therefore, based on the diagnosis of perihilar cholangiocarcinoma originating from the left hilar duct, we performed left lobectomy with caudate lobectomy and biliary tract reconstruction. The surgical specimen showed a tumor in the left hilar bile duct. Histopathological diagnosis of the tumor was a moderately differentiated adenocarcinoma(pT2aN0H0P0M0, fStage II ). Surgical margins were histologically negative. Since the tumor was located away from the anastomosed site of the cholangiojejunostomy, we determined that the tumor was not a recurrence but a metachronous cholangiocarcinoma. The postoperative course was uneventful. The patient survived without recurrence 2 years after the second operation. The possibility of heterochronic biliary carcinomas should be considered during follow-up evaluation. We report this case of metachronous cholangiocarcinoma that occurred 4 years 6 months after PD, with a review of the literature.

[Resected Focal Nodular Hyperplasia That Was Difficult to Differentiate from Hepatocellular Carcinoma--A Case Report]

We report a case of a 62-year-old woman with a growing liver tumor that was difficult to differentiate from hepatocellular carcinoma (HCC). Abdominal CT revealed a hypervascular tumor (36 mm in diameter) in segment 3 of the liver that showed early enhancement and which had grown from 30 mm to 36 mm over the previous year. A fatty liver and gallstones were also detected. Magnetic resonance imaging (MRI) showed high intensity staining of the tumor on both T1- and T2-weighted images, and EOB-MRI revealed a mass that showed high signal intensity in the hepatobiliary phase. The imaging findings were not typical for HCC; however, the possibility of malignancy could not be ruled out due to the enlargement of the mass. Therefore, in February 2015, we performed a laparoscopic left lateral segmentectomy with cholecystectomy. After a good postoperative course, the patient was discharged from the hospital 11 days after surgery. Histological assessment revealed the tumor was focal nodular hyperplasia (FNH).

[The Implications of Primary Tumor Resection during Recent Chemotherapy of Unresectable Colon Cancer]

Some patients with unresectable colorectal cancer can be treated by chemotherapy leaving the primary tumor unresected, but indications and implications of a later resection of the primary tumor (RPT) are often controversial. We investigated 5 patients whose primary tumors were resected during chemotherapy, either panitumumab or bevacizumab. The median age of these patients was 63 years and all were men. The unresectable disease was liver metastases in 4 patients and a primary tumor in 2 patients. A diverting stoma was constructed before initiation of chemotherapy in 2 patients. The median interval until RPT was 8.3 months and the reasons for resection were the appearance of obstructive symptoms in 3 patients and a desire for stoma closure in 2 patients. The size of the primary tumor had decreased until RPT in all patients. RPT was performed successfully in all patients, but 2 of the 3 operations that were initiated laparoscopically had to be converted to open surgery. Intensive chemotherapy was resumed in all patients and median survival after RPT was 19 months, including a patient whose liver metastasis was also resected later. RPT can relieve obstructive symptoms and close stomas. Because intensive chemotherapy is still possible and a lengthy survival can be expected after RPT, it should be considered not merely as a palliative option but also as a treatment strategy.

[A case of curatively resected advanced intrahepatic cholangiocellular carcinoma through effective response to neoadjuvant chemotherapy]

A 67-year-old-man came to our hospital for further evaluation of a liver tumor detected by abdominal ultrasonography at another hospital. Abdominal computed tomography showed a tumor (8 cm in diameter)in the left lobe of the liver, with invasion of the left and middle hepatic veins, and multiple lymph node metastases. Liver biopsy examination revealed intrahepatic cholangiocellular carcinoma (cStage IVB). Therefore, chemotherapy with gemcitabine(GEM)was administered. The hepatic tumor and multiple lymph nodes were reduced in size after eight courses of GEM chemotherapy. In May 2013, we performed an extended left hepatectomy with biliary tract reconstruction and extended lymph node dissection. The histological diagnosis was intrahepatic cholangiocellular carcinoma, pT3N0H0P0M (-), fStage III. The patient's postoperative recovery was good, and 1 month after surgery, the patient received 6 course of postoperative adjuvant GEM chemotherapy. No serious adverse events occurred during the postoperative adjuvant therapy period. The patient is alive without recurrence 14 months after surgery and 23 months after diagnosis.

[A case of curative resected pancreatic cancer coincident with a retroperitoneal abscess]

A 64-year-old man presented with a chief complaint of abdominal pain. An abdominal computed tomography (CT) scan showed a mass 30-mm in diameter at the splenic flexure, and we diagnosed a retroperitoneal abscess. Conservative therapy was successful, and the patient was discharged. However, 1 month later, he again experienced abdominal pain. To reassess the abscess, contrast-enhanced abdominal CT was performed. In addition to the retroperitoneal abscess, the CT scan showed an approximate 30-mm mass in the head of the pancreas with no contrast uptake. The abscess was also detected by endoscopic retrograde pancreatography. We suspected but could not confirm pancreatic cancer. Two months later, the patient developed obstructive jaundice. At this time, we diagnosed pancreatic cancer, and subtotal stomach-preserving pancreaticoduodenectomy was performed. The histopathologic diagnosis was pancreatic cancer, T4, N0, M0, Stage IVa. The postoperative course was favorable, and the patient received postoperative adjuvant chemotherapy. He remains alive without recurrence 15 months after surgery.

[Adjuvant therapy with WT1 peptide-pulsed dendritic cell therapy in combination with TS-1 for pancreatic cancer with positive peritoneal cytology after curative operation]

A 66-year-old woman was diagnosed with pancreatic tail cancer, and she was referred to our hospital. Abdominal computed tomography(CT)revealed a tumor(2.5 cm in diameter)in the pancreatic tail, with invasion to the spleen and splenic vein. In February 2013, we performed distal pancreatectomy with splenectomy, left adrenal gland resection, and D2 lymph node dissection. Diagnostic peritoneal lavage cytology during surgery was positive; however, we performed curative resection because there were no signs of peritoneal dissemination and distant metastasis. The patient was discharged from the hospital 23 days after the operation, with good postoperative course. Histological diagnosis was pancreatic tail cancer, pT4N0H0P0M(-) fStage IVa. Subsequently, the patient received postoperative adjuvant chemotherapy(TS-1: 100mg/day, 4 courses)combined with Wilms'tumor 1(WT1)peptide-pulsed dendritic cell therapy. No serious adverse events occurred during the postoperative adjuvant therapy. The patient remains alive without recurrence 16 months after the operation.

Serum antibody titers against hepatitis C virus and postoperative intrahepatic recurrence of hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is the seventh most common cancer and the third leading cause of cancer deaths worldwide. Hepatitis C virus (HCV) infection is a major risk factor for HCC recurrence after curative resection. This study evaluated anti-HCV antibody (Ab) titer as a prognostic indicator of HCC recurrence after curative hepatic resection.

METHODS

A total of 82 patients with HCC (anti-HCV Ab positive and hepatitis B surface antigen negative) who underwent curative hepatic resection were evaluated. Anti-HCV Ab titers were measured using a third-generation enzyme immunoassay, and patients were divided into high (n = 41) and low (n = 41) titer groups to compare their clinicopathological characteristics and disease-free survival. Univariate and multivariate analyses were conducted to identify risk factors for early or late recurrence.

RESULTS

Multivariate analysis showed that anti-HCV Ab titer and vascular invasion were independent prognostic factors of disease-free survival [odds ratio (OR) 1.9, p = 0.03, and OR 1.8, p = 0.04, respectively]. Subgroup analysis identified only vascular invasion as an independent prognostic factor for early recurrences that were considered residual intrahepatic metastases. Subgroup analysis identified anti-HCV Ab titer and fibrosis grade as independent prognostic factors of late recurrences that were considered to be metachronous multicentric liver carcinogenesis (OR 4.8, p = 0.04, and OR 5.2, p = 0.03, respectively).

DISCUSSION

Anti-HCV Ab titer is a predictive factor for HCC recurrence, especially the risk of late recurrence due to multicentric carcinogenesis. Prevention of liver carcinogenesis after hepatic resection for HCC might be appropriate for patients with high anti-HCV Ab titers.

[Efficacy of stereotactic radiotherapy for primary and metastatic liver cancer]

Twenty patients( 30 nodules) with metastatic liver cancer( MLC) and 10 cases with hepatocellular carcinoma( HCC) treated by stereotactic radiotherapy (SRT) were analyzed. SRT was administered at 48.0 or 52.8 Gy/4 Fr/1 wk. The response rate (RR) in MLC patients was 78%, and 11 patients survived longer than 1 year and 9 patients survived as long as 2 years. Clinical analysis suggests that the ideal indications for SRT in MLC are solitary nodules in patients without extrahepatic disease who have undergone systemic chemotherapy. Although RR of SRT for HCC was as high as 85%, intrahepatic recurrence was observed in all patients and 6 patients died within 1 year. Further analysis is needed to determine the indication for SRT in HCC patients.

[HER2 testing for advanced recurrent gastric cancer in a general hospital]

The Japanese gastric cancer treatment guidelines(published as a web supplement for version 3)recommend the implementation of HER2 testing prior to the selection of chemotherapy. Since we had not yet implemented HER2 immunohistochemistry(IHC)methods for gastric cancer, we tried to compare the HER2 testing results from a reference laboratory(ref lab) and our hospital(in-house). The HER2 concordance rates were calculated between the results from in-house and ref lab using 26 cases(31 samples)which were from patients with advanced, metastatic unresectable, or Stage IV resectable gastric cancer. The HER2 expression(in-house/ref lab)was distributed as follows: negative/negative, 18 cases; negative/equivocal, 2 cases; negative/positive, 1 case;equivocal/equivocal, 2 cases; and positive/positive, 3 cases. The concordance rate was 88. 4%(23/26), and the mismatch rate was 11. 6%(3/26)between in-house and ref lab. Although IHC test results with in-house and ref lab had been generally consistent, it is still necessary to improve and standardize diagnostic accuracy in the near future.

[Stereotactic radiotherapy for metastatic liver cancer]

Twenty cases (27 therapeutic sites/30 nodules) of metastatic liver cancer treated with stereotactic radiotherapy (SRT)were analyzed. The original sites of cancer were colorectal(8 cases), breast(4 cases), stomach(3 cases), esophagus(2 cases), and other organs (3 cases). SRT was performed with 52.8 Gy·4 fr·-1·wk-1. The response rate was 78%, including complete response (CR) at 8 sites, partial response (PR) at 10 sites, stable disease (SD) at 2 sites, progressive disease(PD) at 3 sites, and not detected(ND) at 4 sites, thus demonstrating a potent local therapeutic effect. Ten patients survived for more than 1 year, 8 patients survived for 2 years, and 4 died before 6 months. Clinical analysis suggests that the ideal indications for SRT are patients with a solitary nodule and without extrahepatic disease who have undergone systemic chemotherapy.

[A case of paraaortic lymph node metastasis of gastric cancer resistant to chemotherapy successfully treated with chemoradiation therapy]

We report a case of recurrent gastric cancer with paraaortic lymph nodes (No.16LNs) that was effectively controlled with chemoradiation therapy. A 63-year-old man underwent distal gastrectomy, cholecystectomy, and D2 dissection in July 2004 for advanced gastric cancer in the lower third area that was diagnosed as moderately differentiated stage II adenocarcinoma [T1(SM), N2, H0, P0, CY0, M0]. He suffered from No.16LNs metastasis with serum CEA elevation in October 2007, and therefore, 4 courses of S-1, followed by 3 courses of CPT-11 as second-line treatment, 14 courses of docetaxel as third-line treatment, and 15 courses of paclitaxel+cisplatin as fourth-line chemotherapy, were administrated. Enlargement of No.16LNs with serum CEA elevation was observed in October 2010. Other metastases were not observed, and hence, chemoradiotherapy (CRT; S-1: 80 mg/body+total of 65 Gy per 26 Fr) for No.16LNs was performed. A partial response and reduction of serum CEA level were noted, and the patient is alive with no sign of progression 18 months after CRT. Grade 1 adverse events including anemia, fatigue, and anorexia were recognized. It is thought that chemoradiation therapy is an effective treatment for localized LN metastasis originating from gastric cancer resistant to chemotherapy.

[Complications associated with the placement of subcutaneous central venous access port devices: reasons for removal and complications observed]

OBJECTIVE

To clarify the complications associated with subcutaneous central venous access port devices, we investigated the patients who underwent placement of central venous access port devices in our hospital.

METHODS

Overall, 171 cancer patients who underwent placement of subcutaneous central venous access port devices (119 for chemotherapy and 52 for home parenteral nutrition) between February 2006 and December 2011 and who were followed up for 1 month, were retrospectively analyzed in this study. Univariate analysis was performed on complications related to clinical factors, including age, gender, insertion sites, intended purposes, duration of catheterization, surgeons, catheter materials, and use of bevacizumab.

RESULTS

The mean follow-up time was 213 days (range, 31-1,873), and 35 patients (20.5%) required the port device to be extracted due to complications, including infection in 24(14.0%), wound dehiscence at the port site in 2 (1.2%), obstruction of the catheter in 6 (3.5%), catheter-induced venous thrombosis in 1 (0.6%), and catheter fracture in 2(1.2%). No statistically significant differences were observed between the frequency of complications and age, gender, insertion sites, intended purposes, duration of catheterization, surgeons, catheter materials, or use of bevacizumab.

CONCLUSION

The incidences of complications related to implantation and management of these devices are relatively high and early. Patients should be followed carefully by chest radiography at regular intervals.

[Effects of stereotactic radiotherapy targeting for recurrent gastric cancer]

We report the effects of stereotactic radiotherapy (SRT) targeting for distant solitary metastases from gastric cancer that were uncontrollable with chemotherapy. SRT(52.8 Gy per 4 fractions) was performed in 3 patients with liver metastasis and 1 patient with lung metastasis. Although SRT showed no effect in the patient with lung metastasis, complete remission from liver metastasis with cystic change was observed in all 3 patients. One patient died due to multiple liver metastasis, and the other 2 patients are alive 27 and 41 months after SRT without liver metastasis. Although pneumothorax and pleural effusion were recognized in 1 case, grade 3 or 4 adverse events were not recognized in all 4 cases. SRT showed excellent local therapeutic effects without serious complications, suggesting that this is an effective treatment for localized metastasis from gastric cancer.

[A case of advanced gastric cancer with splenic vein thrombus successfully treated with S-1 plus CPT-11 neoadjuvant chemotherapy]

A 63-year-old male admitted for hematemesis was diagnosed with type 3 advanced gastric cancer located in the upper and middle body of the stomach in an endoscopic examination. Abdominal computed tomography demonstrated lymph nodes metastasis and a splenic vein thrombus. Since curative resection was not deemed possible, we performed neoadjuvant chemotherapy using S-1 (120 mg, day 1-21) plus CPT-11 (135 mg, day 1 and 15) except for down-staging. After 4 courses of chemotherapy, gastric tumor and metastatic lymph nodes were reduced in size and the splenic vein thrombus was disappeared, and then total gastrectomy was performed (tub2, T2 (MP) N0 H0 M0 P0 CY0, Stage IB). S-1 medication was applied as adjuvant chemotherapy. Forty months passed from the operation, the patient remains alive with no signs of relapse.

[Re-resection for local recurrence in the remnant pancreas after pancreaticoduodenectomy for pancreatic cancer- a case report]

A 70-year-old female suffered from jaundice was admitted to our hospital for a tumor in the pancreas head. CA19-9 and DUPAN-2 levels were increased in laboratory test. Enhanced abdominal computed tomography (CT) scan revealed a low density area of pancreas head. Cytology of pancreatic juice was performed by ERCP, and malignant cells were detected. Pancreaticoduodenectomy was performed under a diagnosis of pancreatic cancer (T3N1M0, stage III). Despite of adjuvant chemotherapy (gemcitabine) after surgery, CT scan revealed a low density area in the cut end of remnant pancreas at 3 months, which was accompanied with elevation of and CA19-9 and DUPAN-2 levels. We diagnosed as a recurrent pancreatic cancer of remnant pancreas without any other side of recurrence and re-resection was performed. Because of chylous ascites and depression following a second surgery, postoperative adjuvant chemotherapy could not be started. Re-recurrence was detected at 3 months after the second surgery, and she died 6 months after the surgery. Remnant or repeated pancreatectomy for local recurrent pancreatic carcinomas is extremely rare with limited number of cases reported in the literature. We report our experience, and discuss the significance of re-resection for recurrence of remnant pancreas.

[Complete remission of liver metastasis from gall bladder carcinoma after stereotactic radiotherapy-a case report]

A 75-year-old man was diagnosed as gall bladder carcinoma by postoperative histological examination following laparoscopic cholecystectomy. He underwent the second surgery of resection of liver bed and port sites with lymph node dissection. Isolated hepatic metastasis of 20 mm in diameter was found in S4/8 by MRI 18 months postoperatively, and stereotactic radiotherapy (52.8 Gy/4 Fr) was done for the metastatic lesion. The lesion could not be detected by CT 7 months after the radiotherapy, and thereafter no local recurrence has been observed for 24 months. However, lymph node metastasis of #9 was diagnosed 31 months postoperatively. Liniac radiotherapy (60 Gy/20 Fr)was performed and stable disease has been obtained for 9 months. The patient is alive at present of 43 months after surgery without any other site of the disease, and his quality of life is well maintained. Stereotactic radiotherapy showed an excellent local therapeutic effect without any serious complications, suggesting that this is a potent modality for isolated liver metastasis of gall bladder carcinoma.

[A case of recurrent gastric cancer successfully treated with radiation therapy]

We report a case of recurrent gastric cancer that was effectively controlled with radiation therapy. A 63-year-old man underwent total gastrectomy, cholecystectomy and D2 dissection in February 2006 for early gastric cancer in the upper third area that was diagnosed with papillary adenocarcinoma and Stage IA (T1 (SM), N0, H0, P0, CY0, M0). He underwent lateral segmentectomy of the liver for liver metastasis of S2/3. He suffered from No. 12 lymph node(LN)metastasis in February 2009, so CPT-11, next to S-1, was administered. Portal tumor thrombosis (PTT) and liver S8 metastasis were observed in September 2009. First, chemoradiotherapy (CRT) ( S-1 80 mg/body+total of 65 Gy per 26 Fr) for #12 LN and PTT was performed and, in turn, stereotactic radiation therapy (SRT: total of 52.8 Gy per 4 Fr) was performed. A complete response in all of tumors was noted and he was presently alive with no sign of recurrence after 19 months after CRT and SRT. Grade 3 or 4 adverse events were not recognized. It is thought that radiation therapy is one of effective treatments for localized metastasis from gastric cancer.

Curative-intent stereotactic body radiation therapy for residual breast cancer liver metastasis after systemic chemotherapy

Liver metastases from breast cancer are generally treated with systemic therapy such as chemotherapy or hormonotherapy. However, local treatment options such as resection, radiofrequency ablation (RFA), and radiotherapy can also be considered to treat oligometastases. We report the case of a 45-year-old female treated with stereotactic body radiotherapy (SBRT) after chemotherapy against a solitary liver metastasis from primary breast cancer. A liver metastasis with diameter of 35 mm developed 3.5 years after surgery for primary breast cancer in 2004. Fourteen courses of triweekly docetaxel treatments considerably decreased the metastatic lesion, but there still remained a tiny lesion radiographically. Chemotherapy was stopped because of the side-effects of docetaxel, and then SBRT was selected for additional treatment, aiming at complete cure of metastasis. X-ray irradiation (52.8 Gy/4 fractions) was applied to the remaining metastatic lesion, and magnetic resonance imaging (MRI) showed no evidence of residual tumor 4 months after irradiation. Neither regrowth nor recurrences have been found until now, 24 months after SBRT. SBRT for oligometastases of breast cancer may be one of the possible curative-intent options, being less invasive than surgical resection or RFA.

A phase I study of bi-weekly docetaxel for recurrent or advanced gastric cancer patients whose disease progressed by prior chemotherapy

OBJECTIVE

Although docetaxel is active against gastric cancer, Grade 3 or 4 neutropenia occurs in the majority of patients in Japan when administered at 60 mg/m(2) every 3 weeks. To determine a more convenient and tolerable schedule than the tri-weekly schedule, we conducted a dose-escalation study of bi-weekly docetaxel. In this study, we investigated the maximum-tolerated dose and recommended dose.

METHODS

Patients with advanced gastric cancer who had received prior chemotherapy were enrolled between April 2004 and March 2007. This study was designed to evaluate the escalated dose of docetaxel starting at 35 mg/m(2) (Level 1) given every 2 weeks. The dose was escalated in a stepwise fashion to 40 mg/m(2) (Level 2), 45 mg/m(2) (Level 3) and 50 mg/m(2) (Level 4).

RESULTS

Fifteen patients completed at least two cycles of the therapy. Three episodes of Grade 3 neutropenia occurred in all patients and Grade 4 neutropenia was observed at Level 4 in six patients. Grade 3 or 4 thrombocytopenia and anemia were not observed. Grade 3 aspartate aminotransferase/alanine aminotransferase elevation (n= 1) and Grade 3 stomatitis (n = 1) were noted at Level 4. There was no other Grade 3 or 4 non-hematologic toxicity. The definition of dose-limiting toxicities of this docetaxel schedule at Level 4 are Grade 4 neutropenia, Grade 3 aspartate aminotransferase/alanine aminotransferase elevation and Grade 3 stomatitis.

CONCLUSIONS

The maximum-tolerated dose of docetaxel when administrated following the bi-weekly schedule was 50 mg/m(2) and the recommended dose was 45 mg/m(2). Bi-weekly administration of docetaxel may provide a better tolerated and efficacious use in gastric cancer.

[A case of recurrent gastric cancer with lymph node metastasis successfully treated by CPT-11/CDDP therapy]

We report a case ofa 76-year-old man suffering from advanced gastric cancer with lymph node recurrence. Distal gastrectomy was performed for gastric cancer with pylorus stenosis in April 2001. Pathological staging was III A(T3, N1, M0, Cur B). He underwent outpatient treatment with oral administration of UFT 400mg/day as postoperative adjuvant chemotherapy, but stopped after two months because of loss of appetite and general fatigue. Partial liver resection(S4/5)was performed for liver metastasis(S4)in June 2002, and S-1 was administered 80mg/day as adjuvant chemotherapy. However, obstructive jaundice was detected for lymph node recurrence in March 2003, and conducted bile duct stent after PTCD. He started to undergo a biweekly combination chemotherapy of irinotecan (CPT-11)60mg/m / 2 and cisplatin(CDDP)30mg/m2. Three months later, the lymph node had decreased in size. We reduced this therapy, extended the interval, and discontinued it after 24 courses due to adverse reactions, such as leucopenia(grade 3)and general fatigue(grade 2). Afterward, he had no recurrence for over 5 years.

Paclitaxel-resistant recurrent gastric cancer responsive to docetaxel: a case report

We present the case of a 58-year-old man who underwent distal gastrectomy for Stage III A advanced gastric cancer, identified as poorly-differentiated adenocarcinoma. He was diagnosed with recurrent peritoneal metastasis 11 months after surgery. S-1(80mg/m / 2)was administered as first-line chemotherapy, followed by weekly paclitaxel(80mg/m2)as secondline chemotherapy. Although a partial response was obtained, a peritoneal tumor in the upper abdomen, ascites, and an elevation in the serum carcinoembryonic antigen(CEA)level were observed. As the tumor proved resistant to paclitaxel, making the treatment ineffective, bi-weekly docetaxel(45mg/m2)was initiated. The tumor showed a partial response, the ascites disappeared, and the serum CEA level decreased. The time to progression was seven months until the appearance of ileus and ascites due to tumor re-growth. This paclitaxel-resistant gastric cancer with peritoneal recurrence proved responsive to docetaxel as third-line chemotherapy. Docetaxel may be active against gastric cancer that is resistant to paclitaxel because of the different effects of these two agents. Further clinical studies on the efficacy of docetaxel against paclitaxel-resistant gastric cancer are needed.

[S-1 treatment for elderly patients over 75 years with gastric cancer]

BACKGROUND

In our hospital, the starting dose of S-1 for patients over 75 years of age with advanced gastric cancer was determined by body surface of area, creatinine clearance, performance status(PS)and the presence of complications. The objective of this retrospective study was to investigate the proper administration of S-1 in elderly patients by comparing patients given a standard dose of S-1 to those given a reduced dose.

METHODS

Twenty patients participated. Six patients were administered S-1 at a standard dose(standard group)and fourteen patients with at a reduced dose(reduced group). Safety, feasibility and anti-tumor effects were assessed.

RESULTS

Three cases of grade 3 adverse events were found in the standard group, and one case was found in the reduced group. Time to treatment failure was 4. 4 months for the standard group and 8. 2 months for the reduced group. The overall response rate was 25% in the standard group and 30% in the reduced group.

CONCLUSIONS

It is important to reduce S-1 administration to patients over 75 years of age with caution, and take into account the patient's renal function, PS and Ccr complications.

[A case of advanced gastric cancer successfully treated with chemoradiotherapy targeting for recurrent lymph node metastasis]

The patient was a 75-year-old male, who was diagnosed with type 3 advanced gastric cancer and bulky lymph node metastasis. Two courses of neoadjuvant chemotherapy (S-1, CDDP) which showed a partial remission and distal gastrectomy were performed. Although he received S-1 medication as adjuvant chemotherapy, lymph node recurrence appeared 6 months after the operation. Radiation therapy at a total dose of 65 Gy (10MV X ray, 2.5 Gy/day × 26 Fr) selectively targeting for recurrent lymph node metastasis with S-1 medication were applied. There were no adverse effects during chemoradiation therapy and the metastatic node showed regression (30 mm to 15 mm). Sixteen months passed from chemoradiation, and the patient remains alive with no signs of relapse without any treatment after the chemoradiation. Therefore, our case suggests that chemoradiation therapy could be an effective treatment for recurrent lymph nodes metastasis in gastric cancer.

[A case of liver metastasis from gastric cancer treated with stereotactic radiation therapy]

We report a case of liver metastasis from gastric cancer that was effectively controlled with stereotactic radiation therapy (SRT). A 77-year-old man underwent total gastrectomy, splenectomy, cholecystectomy and D2 dissection in February 2007 for type 3 gastric cancer in the upper third area that was diagnosed well to moderately differentiated adenocarcinoma and Stage II (T3 (SE) N0 H0 P0 CY0 M0). He suffered from the liver and peritoneal metastases with ascites in December 2007, so S-1 was administered. Ascites was disappeared, but liver metastasis was enlarged. Therefore, SRT (total of 52.8 Gy per 4 fractions) was performed for the liver metastasis. A clear reduction in tumor size was noted and he was presently alive with no sign of recurrence after 2 years. Immediately after SRT, grade 3 neutropenia and grade 2 AST/ALT elevation were occurred. Grade 2 pneumothorax and pleural effusion were recognized in August 2009 as tardive adverse event. It is thought that SRT is one of effective treatments for liver metastasis from gastric cancer.

[A case of successfully treated lower rectal cancer with both inguinal lymph nodes by chemoradiotherapy]

We report a case of successfully treated lower rectal cancer with both inguinal lymph nodes by chemoradiotherapy. A 59-year-old man presented with anal pain. A colonoscopy revealed primary rectal cancer. The histological diagnosis was well to moderately differentiated adenocarcinoma. A computed tomography showed metastases to pararectal, both inguinal lymph nodes and right external iliac. After a ileostomy construction was done, he was treated with intensity modulated radiotherapy (a total 50.4 Gy) and chemotherapy with FOLFOX. The primary tumor had completely disappeared, and metastases to lymph nodes showed a remarkable shrinkage after the chemoradiotherapy. Nine months after radiation therapy, however, multiple lung and liver metastases were observed by a computed tomography, which were treated by systemic chemotherapy with FOLFOX and bevacizumab. The primary tumor and metastases to lymph nodes are still controlled well for 2 years after the initial chemoradiotherapy.

[Adjuvant chemotherapy with FOLFOX4 regimen after curative resection of liver metastases from colorectal cancer]

Only a partial benefit of adjuvant chemotherapy administered after curative resection of colorectal cancer (CRC) metastases has been demonstrated. We report here our experience of 7 cases that were administered FOLFOX4 regimen as adjuvant chemotherapy after a curative resection of liver metastases from CRC. Five patients received 6 cycles of FOLFOX4 after prophylactic hepatic arterial infusion of 5-FU, and 2 remaining patients simply received 8 cycles of FOLFOX4. All patients completed the planned cycles of FOLFOX4 without any dose reduction of oxaliplatin. No patients developed a severe adverse effect greater than grade 2 except for grade 3 neutropenia observed in 4 cases. Although lung metastases occurred in 2 cases 28.1 and 21.3 months after liver resection, respectively, all patients are alive after a median follow up of 23.5 months. Our experience indicates that adjuvant chemotherapy with six to eight cycles of FOLFOX4 regimen is safe with a high dose intensity of oxaliplatin and expected to provide a survival benefit.

[Evaluation of hepatic arterial infusion chemotherapy using removable W-spiral catheter]

The authors analyzed the 62 patients who underwent hepatic arterial infusion (HAI) chemotherapy using W-spiral (WS) catheter. The catheter was successfully inserted into the hepatic artery without a coil fixation in 57 cases. After cessation of chemotherapy, the catheter was removed in 32 cases without difficulty, which resulted in improved patients' quality of life as well as preservation of patency of hepatic arteries. This catheter has a special shape-memory alloy in its tip, which allows preferable fixation without coils and removal of the catheter if desired. HAI using this catheter and subsequent removal of it is a reasonable strategy in the era with potent systemic chemotherapy.

Upper extremity deep vein thrombosis treated by a filter in the superior vena cava placed intraoperatively to allow safe esophageal surgery: report of a case

Upper extremity deep vein thrombosis (UEDVT) is an infrequent but dangerous vascular event, especially for patients undergoing thoracic surgery. However, there is no standard perioperative management to reduce the risk of pulmonary thromboembolism in such patients. We describe how we performed successful esophagectomy in a patient with UEDVT treated by placing a filter in the superior vena cava during surgery.

A novel image-guided surgery of hepatocellular carcinoma by indocyanine green fluorescence imaging navigation

BACKGROUND AND OBJECTIVES

The clear delineation between tumor and normal tissue is ideal for real-time surgical navigation imaging. We present a novel indocyanine green (ICG) fluorescence imaging technique to visualize hepatocellular carcinoma (HCC).

METHODS

Ten patients with solitary HCC underwent hepatectomy between February and September 2007 at Osaka Medical Center for Cancer and Cardiovascular Diseases. ICG had been injected intravenously several days before surgery at a dose of 0.5 mg/kg body weight. After laparotomy, the liver was inspected with intraoperative ultrasonography (IOUS), and then with a near-infrared (NIR) fluorescence imaging system (PDE; Hamamatsu Photonics K.K. Hamamatsu, Japan).

RESULTS

All the 10 primary tumors showed bright fluorescent signals and could be completely removed with negative margins under the guide of PDE. In four cases (40.0%), new HCC nodules that were not detected by use of any preoperative examinations including IOUS were detected by PDE. These newly identified HCC nodules were very small in size and most of the tumors were well-differentiated HCCs.

CONCLUSIONS

This novel technique is simple and safe, and is therefore considered to be a promising tool for routine intraoperative imaging during a hepatic resection and further clinical exploration for HCC.

Real-time intraoperative assessment of residual liver functional reserve using pulse dye densitometry

BACKGROUND

For a safe major hepatectomy, preoperative methods that can reliably estimate postoperative liver function are necessary. The aim of this study was to assess the utility of ICG-R15 measured by pulse dye densitometry to predict residual liver function prior to hepatectomy.

PATIENTS AND METHOD

In 29 patients who underwent various types of hepatectomies, indocyanine green (ICG)-R15 was measured by pulse dye densitometry at the time of opening the abdomen (laparotomy phase), clamping the Glisson's pedicles to cutting (clamping phase), and closing abdomen after hepatectomy (resection phase). The relationships among these measurements and postoperative liver function were examined.

RESULTS

The mean ICG-R15 was 12.3 +/- 6.0% preoperatively (+/-SD), 9.3 +/- 7.0% at laparotomy, 18.8 +/- 11.6% at clamping, and 20.1 +/- 10.9% at resection. The preoperative and laparotomy and the clamping and resection ICG-R15 values correlated significantly. Eleven (38%) patients developed postoperative hyperbilirubinemia [total bilirubin (T-Bil) >3.0 mg/dl]. The postoperative peak T-Bil correlated significantly with clamping ICG-R15 (r = 0.637, p = 0.0002), but not with preoperative ICG-R15 (r = 0.283, p = 0.137), total clamp time (r = 0.005, p = 0.975), and blood loss (r = 0.097, p = 0.615). Multivariate analysis identified ICG-R15 measured at clamping as the only determinant of postoperative peak T-Bil (r = 0.612). ICG-R15 measured at clamping correlated with the postoperative hospital stay (p = 0.046).

CONCLUSIONS

ICG-R15 can be measured in real time during surgery by pulse dye densitometry. ICG-R15 measured by this technique before hepatectomy provides a direct and reliable measure of postoperative residual liver function, thus helping in surgical decision making regarding the extent of hepatectomy.

Usefulness of the CLIP scoring system for prediction of postoperative prognosis of patients with large hepatocellular carcinoma

BACKGROUND

Some patients with large hepatocellular carcinoma (HCC > 10 cm in diameter) have favorable surgical outcome, but the selection criteria are controversial. The relationship among various staging systems [(AJCC/UICC TNM classification, Liver Cancer Study Group of Japan TNM classification, the Cancer of the Liver Italian Program (CLIP) scoring system and the Japan Integrated Staging scoring system] and postsurgical prognosis of patients with large HCC is unknown. The aim of this study was to identify the staging system with the best prognostic value for such patients.

METHODS

The subjects of this retrospective study were 42 patients with large HCC. Various prognostic factors were assessed by multivariate analysis. The disease state was staged by the above four staging systems. The accuracy of prediction of 1-year, 3-year and 5-year mortality for each system was evaluated by the area under the receiver operating characteristic curve.

RESULTS

Serum alpha-fetoprotein and curability were identified by multivariate analysis as the only significant prognostic factors. The discriminatory ability of the CLIP scoring system was superior to other systems. Patients with CLIP scores <2 had better prognosis (score = 0, 100% of 1-year survival rate; score = 1, 75%) than those with scores >2 (score = 2, 3 and 4; 50%, 46% and 33%, respectively).

CONCLUSIONS

The CLIP scoring system is the best for classifying patients with large HCC and prediction of their prognosis after surgery.

Myelotoxicity of preoperative chemoradiotherapy is a significant determinant of poor prognosis in patients with T4 esophageal cancer

PURPOSE

Currently, preoperative chemoradiotherapy followed by surgery is the only promising strategy for patients with T4 esophageal cancer. This study retrospectively analyzed the prognostic factors in patients with curatively resected cancer after chemoradiotherapy.

PATIENTS AND METHODS

Between September 1989 and December 2003, 42 patients with T4 esophageal cancer received preoperative chemoradiotherapy (CRT) followed by curative surgery. Chemotherapy consisted of 5-fluorouracil/cisplatin (FP) or 5-fluorouracil/adriamycin/cisplatin (FAP). A total dose of 40 Gy of radiation was delivered concurrently. Surgery was scheduled 4 weeks after the completion of CRT. The treatment response was categorized using general criteria. Toxicities of the CRT were assessed according to National Cancer Institute of Common Toxicity Criteria (NCI-CTC). Univariate and multivariate analyses were performed to identify significant prognostic clinicopathological factors.

RESULTS

The overall survival rate was 38.4% at 5 years. The toxic grade for leukopenia (grade 0-2/3-4) and pathological effect (grade 3/1-2) were significantly different by univariate analysis (P = 0.03 and 0.05, respectively). Multivariate analysis identified the toxic grade for leukopenia as the only significant and independent determinant of prognosis (P = 0.05).

CONCLUSION

In patients with T4 esophageal cancer who receive CRT followed by curatively resection, myelogenic chemotoxicity is a significant prognostic factor.

[A case of an older adult patient with recurrent gastric cancer successfully treated by low-dose S-1 for a long time]

An 88-year-old woman, who had undergone distal gastrectomy for Stage IIIA gastric cancer, was diagnosed with recurrent abdominal lymph node metastasis 11 months after surgery. Creatinine clearance of this patient calculated by Cockcroft-Gault method was 44 mL/min and renal function was impaired, so we reduced the administration dosage to 50 mg/day. S-1 was administered for two weeks followed by one week rest. This schedule induced grade 2 anorexia and fatigue after one week administration, so it was converted to one week administration followed by one week rest. By this dosage and administration schedule, a partial response(PR)was continued for about four years without any adverse reaction. This successful case might indicate that it was important for older adult patients with gastric cancer to consider not only appropriate reduction of the dosage but also shortening of S-1 administration.

Effects of neoadjuvant chemotherapy on primary tumor and lymph node metastasis in esophageal squamous cell carcinoma: additive association with prognosis

Neoadjuvant chemotherapy (NACT) is widely used to treat esophageal squamous cell carcinoma with lymph node metastasis (ESCC). However, NACT frequently has differential effects on primary tumor (PT) and lymph node metastasis (LNM). The clinical significance of this phenomenon remains unclear. Reduction in tumor size of PT and LNM was evaluated separately in 47 node-positive ESCC patients undergoing NACT, followed by surgical resection. We analyzed the prognostic significance and various clinicopathological parameters. NACT resulted in an average reduction rate of 45.5% for PT and 36.6% for LNM; the correlation between these rates was weak but significant (r(2) = 0.122, P = 0.016). The reduction rates in both PT and LNM were significant prognostic factors, with the maximal significance with cut-off at 30% size reduction for PT (3-year survival, 47.3 vs. 8.3%, P = 0.0004) and 20% for LNM (51.3 vs. 7.1%, P = 0.0013). When these cut-off values were used to define NACT response, 28 patients (59%) were deemed responders for both PT and LNM, while 7 (15%) were nonresponders for both, and the response was inconsistent in 12 patients (26%). Only both PT/LNM responders showed good survival rates, with the remaining categories showing poor survival (3-year survival 60.5 vs. 5.3% P < 0.0001). Multivariate analysis identified neither the PT nor the LNM response alone as an independent prognostic factor; however the combined PT/LNM response was identified as an independent prognostic factor (hazard ratio [HR] 2.861, P = 0.0255) in addition to the number of histological lymph node metastases (HR 2.551, P = 0.0328). The response to NACT in LNM and PT correlates closely with postoperative survival. A good response in both enhances the postoperative prognosis.

[A complete response of locally-advanced poorly differentiated adenocarcinoma of the rectum to pre-operative chemo-radiation therapy]

A 71-year-old woman with peri-anal pain and anal bleeding was found to have a tumor in lower rectum in colonoscopic examination, which was histologically diagnosed as poorly differentiated adenocarcinoma. Computed tomography and magnetic resonance imaging showed a tumor 5 cm in diameter deeply infiltrating mesorectum, and swelling of intra-pelvic lymph nodes. At the first operation, infiltration of the tumor was so deep that a complete surgical resection was considered to be difficult, and only a sigmoid colostomy construction was done. After chemo-radiation therapy of 50.4 Gy and 5-FU plus levofolinate calcium (Isovorin) infusion, the tumor was reduced in size and lymph nodes were extremely decreased. The patient underwent an abdominoperinial resection 6 weeks after the end of chemo-radiation, and pathological examination revealed a complete replacement of tumor with necrosed tissue, and no viable tumor cell was found. Poorly differentiated adenocarcinoma of the colon is reported to be highly malignant and associated with poor prognosis. Preoperative chemo-radiation therapy can be a promising candidate for adjuvant treatment of locally-advanced poorly differentiated adenocarcinoma of the rectum.

[A case of successfully treated orbital metastasis from breast cancer by radiation therapy]

Orbital metastasis from breast cancer is relatively rare. We report a case of successfully treated orbital metastasis from breast cancer by radiation therapy. This 50-year-old female patient underwent a mastectomy (Bt+Ax) of her left breast in October 2000. The diagnosis was invasive lobular carcinoma, Stage IIB (T2N1M0). Retroperitoneal and bladder metastases were found five years after the operation, and chemohormonal therapy was done. Right orbital swelling appeared 8 months after chemohormonal therapy, and orbital metastasis from breast cancer was diagnosed by MRI. Radiation therapy (a total 30 Gy) was administrated, and the swelling disappeared. An MRI was performed 16 months after radiation therapy and did not detect any metastases. A complete response (CR) was achieved. No sign of recurrence was found, and a sufficient local control has remained for 2 years after radiation therapy.

Evaluation of the lateral sentinel node by indocyanine green for rectal cancer based on micrometastasis determined by reverse transcriptase-polymerase chain reaction

The significance of dissecting the lateral pelvic lymph node (LN) for lower rectal cancer remains controversial. We detected the lateral sentinel node (SN) by indocyanine green (ICG) and micrometastases using carcinoembryonic antigen (CEA)-specific reverse transcriptase-polymerase chain reaction (RT-PCR). Twenty-five patients who underwent curative surgery with a dissection of the lateral pelvic LNs between 2003 and 2005 were examined. We investigated the existence of lateral SNs and any associations between pathological metastases and micrometastases by RT-PCR. Lateral SNs were detected in 7 (28%) of the 25 patients. The number of lateral SNs was 13 LNs, or 1.9 nodes per case. Of the 25 cases, 7 had lateral LN metastases based on pathological examinations in dissected lateral LNs. Three cases had massive lateral LN swelling by pre-operative pelvic CT and the SNs were not detected in them. The SNs were detected in two cases and were negative based on pathological examinations and positive according to a genetic diagnosis. SNs were detected in one case, which was positive based on pathological examinations and a genetic diagnosis. SN was not detected in one case. There were five SNs in which CEA was positive by RT-PCR, though only one of them was positive based on pathological examinations. No SNs were observed that were negative based on a genetic diagnosis, but were positive according to the pathological diagnosis. We detected the lateral SNs using ICG. The sensitivity of identifying lateral LN metastasis was improved by the use of a genetic diagnosis. However, the detection rate was still low, therefore we need to develop a new method for detecting SNs.

Doubling time of carcinoembryonic antigen is a significant prognostic factor after the surgical resection of locally recurrent rectal cancer

BACKGROUND

Patients undergoing a curative rectal cancer resection have a risk of developing locoregional recurrence. A curative resection for local recurrence is the option of improvement in prognosis. However, a curative resection is sometimes too invasive and should be considered in selected patients.

METHODS

A total of 43 patients with locally recurrent rectal cancer who had been treated by operation between 1989 and 2007 were retrospectively reviewed and the factors, including doubling time of carcinoembryonic antigen (CEA-dt), were analyzed.

RESULTS

The 5-year overall survival rate after the operation for local recurrence was 50.8%. Gender, presence of distant metastasis, tumor size, CEA-dt and curability were found to be significant prognostic factors. A multivariate analysis demonstrated the presence of distant metastasis, CEA-dt and tumor size to be significant prognostic factors for overall survival. The 5-year overall survival rates of patients with a CEA-dt > or =150 days and a tumor size <5 cm were 76.9%.

CONCLUSIONS

The tumor size and CEA-dt were useful prognostic factors that were recognizable before surgery. Patients with locally recurrent rectal cancer with a CEA-dt > or =150 days and a recurrent tumor size <5 cm are considered to be good candidates for surgery.

Metastatic tumor doubling time is an independent predictor of intrapulmonary recurrence after pulmonary resection of solitary pulmonary metastasis from colorectal cancer

BACKGROUND

Several investigators have previously reported the prognostic factors affecting survival after a surgical resection of pulmonary metastasis from colorectal cancer (CRC). However, there have so far been no reports describing prognostic factors related to the tumor doubling time (TDT) of pulmonary metastasis.

METHODS

65 patients with solitary pulmonary metastasis from CRC were retrospectively reviewed and the prognostic factors after pulmonary resection including TDT were analyzed.

RESULTS

The 5-year intrapulmonary recurrence-free survival rates after pulmonary resection was 59.9%. The TDT of pulmonary metastasis (<100 vs. 100 days or higher) was only a significant prognostic factor in intrapulmonary recurrence after the pulmonary resection (p = 0.0006). The 5-year overall survival rate after the pulmonary resection was 64.2%. Preoperative serum carcinoembryonic antigen (CEA) level (<5 vs. 5 ng/ml or higher) was the only significant prognostic factor in overall survival after the pulmonary resection (p = 0.0049). The overall survival of patients whose TDT was 100 days or higher tended to be better than that of patients whose TDT was <100 (p = 0.0631).

CONCLUSIONS

The TDT of solitary pulmonary metastasis is a significant prognostic factor after surgery for solitary pulmonary metastasis from CRC.

Correlation between pretherapeutic d-dimer levels and response to neoadjuvant chemotherapy in patients with advanced esophageal cancer

Neoadjuvant chemotherapy may improve survival of responders in esophageal cancer patients but is useless and harmful in non-responders. Thus, it is important to predict the effect of the chemotherapy, and that any predictor must be applicable clinically. The aim of this study is to examine the correlation between pretherapeutic hypercoagulopathy as determined by plasma d-dimer levels and response to chemotherapy. In 71 patients with esophageal cancer who underwent neoadjuvant chemotherapy (cisplatin, adriamycin and 5-fluorouracil) followed by surgery, plasma d-dimer levels were measured before chemotherapy and the clinical and pathological responses to chemotherapy were assessed at 4 weeks after therapy (after surgery). Pretherapeutic plasma d-dimer level was significantly lower in clinical responders (complete response/partial response [CR/PR]; 0.62 +/- 1.10 microg/mL, mean +/- SD) than in non-responders (no change/progressive disease [NC/PD]; 1.15 +/- 1.08 microg/mL, P = 0.0491), and in pathological responders (Grade 1b-3; 0.62 +/- 1.11 microg/mL) and non-responders (Grade 0-1a; 1.15 +/- 1.05 microg/mL, P = 0.0107). The optimal cut-off level of the plasma d-dimer levels for predicting clinical and pathological responses was 0.6 microg/mL. Then, sensitivity and specificity for the prediction of CR/PR were 68% and 73%, and those for Grade 1b-3 were 91% and 69%, respectively. Our results suggested that pretherapeutic plasma d-dimer level correlated significantly with clinical and pathological responses to chemotherapy. Pretherapeutic plasma d-dimer level can be used as a predictor for chemosensitivity.

Surgical usefulness of indocyanine green as an alternative to India ink for endoscopic marking

BACKGROUND

India ink has been commonly used for preoperative colonic tattooing, but various complications have been reported. This study aimed to evaluate the usefulness of indocyanine green (ICG) marking as a replacement for India ink.

METHODS

This study enrolled 40 patients who between January 2005 and February 2006 underwent laparoscopic or open surgery for colorectal lesions considered difficult to locate intraoperatively. Because one patient had a history of allergy to iodinated contrast material, metal clipping was used instead of ICG to mark the lesion. Endoscopists injected 5 ml of ICG suspension and saline solution adjacent to the lesion at duplicate locations to evaluate the visibility, duration, and adverse effects of the dye. For 39 patients, the date of the preoperative colonoscopy was not set for examination of the appropriate interval between endoscopic marking and the surgical operation.

RESULTS

The median interval between ICG marking and surgery was 4 days (range, 1-73 days). All 29 patients who underwent surgery within 8 days after marking had positive green ICG staining at the time of surgery. After 9 days or more, however, positive staining was seen clearly in only two of the remaining 10 patients. The staining tended to grow weaker and fainter over the time course, eventually dissipating. No perioperative adverse reactions to the dye were observed.

CONCLUSION

This study supports the use of ICG as a safe technique that can be identified reliably during operations performed within 8 days after endoscopic injection.