[Regimen Selection by Narrative Approach in Patients with Advanced Gastric Cancer-Paclitaxel or Nab-Paclitaxel?]

BACKGROUND

According to the sixth Gastric Cancer Treatment Guideline, the regimen included nab-paclitaxel(nab-PTX) is a conditional recommendation as second-line treatment for advanced gastric cancer. However, the selection criteria of nab-PTX is not clear.

METHOD

Questionnaire survey as narrative approach on the problems of paclitaxel premedication, the symptoms due to paclitaxel containing alcohol, and infusion time was conducted for patients who had been treated with paclitaxel.

RESULTS

Thirty-six patients answered the questionnaire. Nonelderly patients(<65 years)or patients without comorbid medications complained of dissatisfaction with the inconvenience due to premedication significantly more than elderly patients(≥65 years)or patients with comorbid medications. Females or nonelderly patients were significantly more troubled by sleepiness due to premedication than males or elderly patients. Eight out of 11 patients who had visited hospital by driving a car for first-line treatment were troubled by prohibition of driving on the day of treatment. Thirty out of 36 patients answered that they would feel benefits from 30-minutes shortening of infusion time.

CONCLUSION

Questionnaire survey suggests that we may select the patients for nab-PTX properly by clarifying the inconvenience of daily life associated with premedication, the way of transportation for visiting hospital, and the benefits by shortening of infusion time.

[Questionnaire Survey on Oral Care and Oral Troubles for Patients with Gastric Cancer Received Chemotherapy]

BACKGROUND

The actual situation of oral care and oral troubles for patients with gastric cancer received chemotherapy is not clear.

METHODS

Questionnaire survey in the form of oral questions was performed for patients with gastric cancer who received chemotherapy from December 2021 to February 2022. The relevance between the survey results and background factors was examined using the χ2 test.

RESULTS

We performed the questionnaire survey for 36 patients. Of the 36 patients, 29 patients received dental check-up before starting chemotherapy. Fourteen of the 29 patients(48%)continued the dental check-up. Of 14 patients who continued the dental check-up, 9 patients were 65 years or older, while 14 of 15 patients who discontinued the dental check-up were 65 years or older. Continuity of dental check-up was low among the elderly patients. The rate of dysgeusia were 78 vs 30% in the patients who adopted and who did not adopt oral care other than toothbrushing(p=0.01). The frequency of oral troubles was dysgeusia(47%), stomatitis(42%), and dry mouth(36%). The severity of the oral troubles was, in order, dysgeusia, dry mouth, and pain. The most common side effect due to chemotherapy causing decreased food intake was dysgeusia.

CONCLUSIONS

Dysgeusia was the most frequent and severe oral trouble.

Effects of postoperative oral elemental nutritional supplement on skeletal muscle loss after gastrectomy for gastric cancer

BACKGROUND

We previously showed that daily nutritional intervention with an oral elemental diet (ED) at 300 kcal/day for 6-8 weeks postoperatively decreased the percentage of body weight loss (%BWL), and that the effect was maintained for 1 year. This post hoc analysis aimed to determine whether this intervention decreased skeletal muscle mass loss 1-year post-gastrectomy.

METHODS

Data from consecutive, untreated patients with histopathologically confirmed stage I-III gastric adenocarcinoma who planned to undergo total gastrectomy (TG) or distal gastrectomy (DG) and were enrolled in a previously published randomized trial were used. The primary endpoint was the percentage of skeletal muscle mass index (%SMI) loss from baseline at 1 year postoperatively, based on abdominal computed tomography images obtained preoperatively and at 1 year postoperatively.

RESULTS

The overall median %SMI loss was lower in the ED versus control group, but the difference was not significant. The difference in %SMI loss in the ED and control groups was greater in patients with TG (10.1 vs. 13.0; P = 0.12) than in those with DG (5.5 vs. 6.8; P = 0.69). A correlation was observed between %BWL and %SMI loss in both groups (ED group, coefficient 0.591; control group, coefficient 0.644; P < 0.001 for both). Type of gastrectomy (coefficient 7.38; P = 0.001) and disease stage (coefficient - 6.43; P = 0.04) were independent predictors of postoperative skeletal muscle mass loss.

CONCLUSION

ED administration for 6-8 weeks following gastrectomy had no inhibitory effect on skeletal muscle loss at 1 year postoperatively.

CLINICAL TRIAL REGISTRATION

UMIN000023455.

Phase II study of S-1 plus docetaxel as first-line treatment for older patients with advanced gastric cancer (OGSG 0902)

BACKGROUND

Although there is insufficient evidence for the treatment of older patients with advanced gastric cancer, fluorouracil combined with platinum chemotherapy has been recognized as a standard first-line treatment for such populations in Japan despite the lack of efficacy and toxicity data.

METHODS

Patients aged 75 years or older with advanced gastric cancer were enrolled. S-1 plus docetaxel (docetaxel: 40 mg/m2, day 1; S-1: 80 mg/m2, days 1-14; q21 days) was repeated every 3 weeks. The primary endpoint was overall response rate. Secondary endpoints were safety, progression-free survival, time to treatment failure, and overall survival. The sample size was calculated as 30 under the hypothesis of an expected response rate of 40% and a threshold response rate of 20%, at a power of 90% and a two-sided alpha value of 5%.

RESULTS

From February 2010 to January 2015, 31 patients were enrolled and assessed for efficacy and toxicity. The response rate was 45.2% (95% CI 27.3%-64.0%; p = 0.001) and it exceeded the expected response rate set at 40%. Median progression-free survival was 5.8 months, the 1-year survival rate was 58.1%, and the median survival time was 16.1 months. The major grade 3/4 adverse events were neutropenia (58%), febrile neutropenia (13%), anemia (10%), anorexia (10%), and fatigue (6%).

CONCLUSIONS

These findings indicate that S-1 plus docetaxel as first-line treatment for older patients is feasible and that it has promising efficacy against advanced gastric cancer.

[A Case of 30s Female with Advanced Anal Canal Adenocarcinoma Managed with Adolescent-And-Young-Adult Team]

A 30s female complaining of anal pain and melena was referred to our hospital. The support by adolescent-and-young- adult(AYA)team was initiated after the first encounter. Colonoscopic examination revealed an ulcerated tumor on the anterior wall of anal canal with its anal margin on anal verge and the tumor was diagnosed as an adenocarcinoma. Contrast- enhanced CT and MRI revealed adjacency of tumor and vagina, enlarged lymph nodes and multiple pulmonary nodules. 18F-fluorodeoxyglucose(FDG)-positron emission tomography(PET)additionally revealed tracer accumulation in left sciatica, which led us to the diagnosis of advanced anal cancer. We planned and safely performed concomitant partial vaginal resection in robot-assisted laparoscopic abdominoperineal resection for the palliative purpose after discussion on physical and psychosocial issues including stoma and fertility with the patient, her family and AYA members. The pathological diagnosis was pT4b(vagina)N1aM1b, pStage ⅣB, and the local margin was pathologically negative. The postoperative course was smooth and she was discharged on postoperative day 16. Fifty one days after operation, she started systemic chemotherapy after decision on not to take ovarian samples and continues systemic chemotherapy as of writing. Support by AYA team was effective to facilitate the patient's decision-making and the communication between the patient and the medical team.

[A Case of Diffuse Large B-Cell Lymphoma Which Was Diagnosed during the Best Supportive Care of Recurrent Ascending Colon Cancer]

A 70s male, who had undergone single-incision laparoscopic ileocecal resection for ascending colon cancer with pathological diagnosis of T3N3M0, Stage Ⅲc(without adjuvant chemotherapy), had enhanced-computed tomography(CT)for 3-month follow-up and a hepatic low-density area, an newly emergent nodule behind inferior vena cava and distal ileal tumor were found. Three months later, enhanced CT showed that the distal ileal tumor got exponentially larger and the diagnosis of"malignant lymphoma"was suspected. The patient became sepsis, so we planned and safely performed partial resection of the tumor. The pathological diagnosis was diffuse large B-cell lymphoma. Postoperative course was smooth except for the Clostridium difficile colitis and he was discharged on postoperative day 19. Although the regrowth of the remnant tumor was observed soon after surgery, partial response was confirmed after introduction of systemic chemotherapy. When we cope with malignant lymphoma of small intestine, we need to keep it in mind that surgery is an option for the prevention of perforation and bacterial translocation.

[A Case of Fibromatosis-Like Tumor Which Was Difficult to Differentiate from Local Recurrence of Ascending Colon Cancer]

A 60s female, who had undergone single-incision laparoscopic ileocecal resection for ascending colon cancer with pathological diagnosis of T3N1bM0, Stage Ⅲb, followed by adjuvant therapy with 8 courses CAPOX 2 years ago, had enhanced- computed tomography(CT)for follow-up and a 15-mm nodule near anastomotic site was found. 18F-fluorodeoxyglucose (FDG)-positron emission tomography(PET)CT revealed abnormal accumulation of 18F-FDG only to the lesion and diagnosis of"anastomotic recurrence"was made. We planned and safely performed resection of the anastomotic site and the nodule. The pathological diagnosis was fibromatosis-like tumor without evidence of recurrence, and margin was negative. Postoperative course was smooth and she was discharged on postoperative day 9. When we diagnose local recurrence, we need to keep it in mind that fibromatosis is one of the differential diagnoses, although its incidence rate is low.

[Our Experience with Atezolizumab plus Bevacizumab for Unresectable Hepatocellular Carcinoma]

We report our experience with atezolizumab plus bevacizumab for unresectable hepatocellular carcinoma.

METHODS

Fourteen patients with unresectable hepatocellular carcinoma treated with atezolizumab plus bevacizumab at our department were retrospectively evaluated for antitumor efficacy and adverse events.

RESULTS

Age ranged from 66-91 years(median 77.5 years), 11 males and 3 females, number of doses ranged from 2-26(median 13), and observation period ranged from 31-790 days (median 427 days). Antitumor efficacy was CR in 3 patients, PR in 3, SD in 6, and PD in 2. One patient with PD died 650 days after the start of treatment, but the others are still alive. Adverse events included proteinuria in 9 patients who discontinued bevacizumab, hypothyroidism requiring levothyroxine sodium hydrate in 7 patients, dermatitis in 2 patients, and colitis requiring hospitalization in 2 patients.

DISCUSSION

Despite the small number of cases, a high antitumor effect was observed with a CR rate of 21%. Although proteinuria and hypothyroidism were observed relatively frequently as adverse events, they were easily controlled and did not pose a major clinical problem.

[A Case of Preoperative Chemotherapy for Advanced Gastric Cancer, Laparoscopic Total Gastrectomy, Pancreaticoduodenectomy, and Para-Aortic Lymph Node Dissection]

Bulky N+ gastric cancer has a poor prognosis. The results of JCOG0405 showed the efficacy of neoadjuvant chemotherapy with S-1 plus cisplatin combination therapy for Bulky N+ gastric cancer. JLSSG0901 demonstrated the safety and efficacy of laparoscopic surgery for advanced gastric cancer. But the safety of laparoscopic surgery for locally advanced and extensive nodal metastasis cancer(T4b, para-aortic lymph node metastasis)is not apparent. After DOS therapy, we performed total laparoscopic gastrectomy, DP(distal pancreatectomy), D2+ #16a2/b1 lat, and Roux-en-Y reconstruction, and histopathological results showed that the aortic lymph node metastasis disappeared. We controlled extensive lymph node metastasis using preoperative triplet chemotherapy. Laparoscopic surgery after preoperative chemotherapy for Bulky N+ gastric cancer can be a treatment option because we performed laparoscopic resection and para-aortic lymph node dissection with no complications, including pancreatic complications.

[A Case Report of SOX Therapy for an Elderly Patient with Hemorrhagic Primary Duodenal Carcinoma]

BACKGROUND

Although pancreatoduodenectomy is recommended as a radical surgery for duodenal carcinoma, it has been reported that pancreatoduodenectomy in elderly patients has a high risk of surgical complications.

CASE PRESENTATION

A man in his 80's was diagnosed with advanced duodenal carcinoma, presenting with anemia(Hb 5.4 g/dL). Computed tomography scanning showed wall thickening in the descending leg of the duodenum, pancreatic invasion was suspected, and clinical diagnosis was Stage ⅡB(cT4N0M0). Although radical surgery was possible, the patient refused surgery considering the risks of surgical complications. The gastroduodenal bypass surgery was performed to control bleeding, and the patient was treated with S-1 plus oxaliplatin(SOX; S-1 100 mg/body, days 1-14; oxaliplatin 100 mg/m2, day 1 q21 days). After 6 courses of the SOX regimen, the wall thickening of duodenum disappeared, and SOX was switched to S-1 monotherapy (S-1 100 mg/body, days 1-28, q42 days)according to Grade 2 thrombocytopenia and decreased performance status. After 11 courses of S-1, upper gastrointestinal endoscopy showed that the tumor had disappeared, the biopsy of duodenum showed no evidence of malignancy, and chemotherapy was terminated. The patient has been followed up for 7 months without recurrence.

CONCLUSIONS

SOX for elderly patient showed efficacy against hemorrhagic duodenal carcinoma.

[Tolerability and Outcome of Neoadjuvant GS Therapy for Resectable Pancreatic Cancer]

INTRODUCTION

Neoadjuvant chemotherapy with gemcitabine plus S-1(NAC GS)has been reported to prolong the prognosis of resectable pancreatic cancer, and is now being used in daily practice. In this study, we investigated the tolerability and outcome of neoadjuvant GS therapy for resectable pancreatic cancer in our hospital.

PATIENTS

Fifty-two patients who underwent NAC GS for resectable pancreatic cancer between November 2019 and March 2023 were included in this study.

RESULTS

The mean age of all 52 patients was 75 years, 28 were male and 24 were female. Tumor site was pancreatic head cancer in 32 patients, pancreatic body cancer in 13 patients, and pancreatic tail cancer in 8 patients. Only 2 patients of the 52 patients completed 2 cycles of GS therapy with full dose, and dose reduction and treatment deferral were performed in remaining 50 patients. The dose intensity was 78.4% for gemcitabine and 66.7% for S-1. Grade 3 or higher adverse events included neutropenia in 21 patients(40.4%), biliary tract infection in 6 patients(11.5%), fatigue, anorexia, hepatic dysfunction, and constipation in 1 patient each(1.9%). 47 patients(90.4%)underwent R0 resection. 4 patients had pancreatic fistula, which was classified as Grade Ⅲ by Clavien-Dindo, and one of them died in the hospital due to bleeding from a pseudoaneurysm.

CONCLUSION

NAC GS therapy for resectable pancreatic cancer was considered feasible with appropriate management of adverse events.

[Conversion Surgery Performed after SOX plus Nivolumab Therapy for Advanced Gastric Cancer with Para-Aortic Lymph Node Metastasis]

The patient was a 78-year-old woman. She presented with anemia and a positive fecal occult blood test. Endoscopic findings revealed type 3 advanced gastric cancer. As it had metastasized to the para-aortic lymph node(PALN: No. 16a2 lat), it was diagnosed as gastric cancer at cardia cT4aN1(No.1)M1(No.16a2 lat), cStage Ⅳ. She was administered S-1, oxaliplatin, and nivolumab(SOX plus Nivo)therapy as a first-line treatment. SOX plus Nivo resulted in a remarkable reduction of the lymph nodes, which were PR. After 3 courses of chemotherapy, a laparoscopic proximal gastrectomy was performed, with D2 plus No. 16a2 int/lat lymph nodes dissection as conversion surgery. Histopathological examination was pT3N0M0, and R0 resection was pStage ⅡA. She was discharged at POD21 and started S-1 from POD69. The patient is alive with no signs of recurrence 10 months postoperatively.

[Clinical Outcome of Five Patients with Perforated Colorectal Cancer]

We studied the clinicopathological findings of 5 patients with perforated colorectal cancer. Three patients were male, and the primary cancer site was left side colon in 4 patents. Two patients had endoscopy-related perforation. The chief complaint was abdominal pain in all cases. All patients underwent emergency surgery. Two patients had Stage Ⅱ cancer, 3 had Stage Ⅳ. The mean ICU stay was 2.8 days. The average postoperative hospital stay was 71.8 days. Three patients were discharged home and 2 were transferred to other hospitals. The 3 patients who were discharged home received chemotherapy. Perforation of the cancer site is a risk factor for recurrence, and early recovery and additional treatment should be considered.

[A Case Report of the Ascending Colon Cancer with Bullous Pemphigoid]

The patient was a 70-year-old man. The patient had progressive anemia while taking 10 mg/day of prednisolone and 100 mg/day of mizoribine orally for bullous pemphigoid, a colonoscopy diagnosed ascending colon cancer. Adenocarcinoma, Group 5 was detected on biopsy. Abdominal computed tomography showed no metastases. The tumor was diagnosed as ascending colon cancer, cT4aN0M0, cStage Ⅱb. We performed laparoscopic right hemicolectomy and D3 dissection. Histopathological examination revealed pT3N0M0, pStage Ⅱa. In the present report, we describe a case of the ascending colon cancer with bullous pemphigoid, and discuss the case with a review of the literature.

The effect of specimen processing time on HER2 expression in gastric cancer and esophagogastric junction cancer: a single-center retrospective observational study

BACKGROUND

Recent developments in the field of companion diagnosis and molecular-targeting therapeutic agents have helped in developing treatments targeting human epidermal growth factor receptor 2 (HER2) in gastric cancer (GC) and esophagogastric junction cancer (EGJC), and the importance of accurate diagnosis of HER2 expression is increasing. However, the HER2-positivity rate significantly differs among reports in GC and EGJC, and factors that affect HER2-positivity require elucidation.

METHODS

The present study retrospectively examined factors related to HER2-positivity in a single institution, including age, sex, body mass index, the American Society of Anesthesiologists physical status, tumor information, and surgery information, including time to specimen processing.

RESULTS

Our study included 165 patients tested for HER2 using GC and EGJC surgery specimens among the 1,320 patients who underwent gastrectomy from January 2007 to June 2022. In total, 35 (21.2%) and 130 (78.8%) patients were HER2-positive and -negative, respectively. Multivariate analysis revealed that intestinal type (odds ratio [OR]: 3.41, 95% confidence interval [CI]: 1.44-8.09, p = 0.005), pM1 (OR: 3.99, 95% CI: 1.51-10.55, p = 0.005), and time to specimen processing of < 120 min (OR: 2.65, 95% CI: 1.01-6.98, p = 0.049) were independent factors that affected HER2-positivity.

CONCLUSIONS

The outcomes of the present study indicated that intestinal type, pM, and time to specimen processing are important factors affecting HER2-positive rates in GC and EGJC. Therefore, the risk of false-negative HER2 results may be reduced by decreasing the time required to process the resected specimen. Additionally, accurate diagnosis of HER2 expression may increase the opportunity to administer molecular-targeted drugs that can expect therapeutic effects to patients appropriately.

TRAIL REGISTRATION

Retrospectively registered.

[A Case of Peritoneal Recurrence from Ascending Colon Cancer Successfully Treated with Laparoscopic Concomitant Right Seminal Vesiculectomy in Low Anterior Resection]

A 60s male, who had laparoscopic ileocecal resection for ascending colon cancer 2 years ago, had enhanced computed tomography(CT)for follow-up and a 12-mm nodule in Douglas' pouch adjacent to right seminal vesicle and rectum was found. 18F-fluorodeoxyglucose(FDG)-positron emission tomography CT revealed abnormal accumulation of 18F-FDG only to the lesion(standardized uptake value max 2.60)and the diagnosis of peritoneal recurrence of ascending colon cancer was made. We planned and safely performed laparoscopic concomitant right seminal vesiculectomy in low anterior resection. The pathological diagnosis was peritoneal dissemination of colon cancer and the margin was pathologically negative. The postoperative course was smooth except for temporary dysuria and he was discharged on postoperative day 17. As of writing 1 year after surgery, the patient continues to do well with no sign of recurrence. Laparoscopic concomitant seminal vesiculectomy in low anterior resection can be a good option for the curative resection of peritoneal recurrence.

Phase 2 trial of neoadjuvant docetaxel, oxaliplatin, and S‐1 for clinical stage III gastric or esophagogastric junction adenocarcinoma

Background

Although perioperative treatment has been the standard of care for resectable gastric cancer in the West, postoperative adjuvant chemotherapy is still the standard in Japan. We conducted the first phase 2 trial to investigate the efficacy and safety of neoadjuvant docetaxel, oxaliplatin, and S-1 (DOS) chemotherapy for cStage III gastric or esophagogastric junction (EGJ) adenocarcinoma in Japan.

Methods

Eligibility criteria included cStage III adenocarcinoma of the stomach or EGJ. Patients received docetaxel (40 mg/m², day 1), oxaliplatin (100 mg/m², day 1), or S-1 (80 mg/m², days 1-14) during a 3-week cycle. After two or three cycles of DOS, patients underwent surgical resection. The primary endpoint was progression-free survival (PFS).

Results

Between June 2015 and March 2019, 50 patients were enrolled from four institutions. Of 48 eligible patients (37 gastric and 11 EGJ adenocarcinoma), 42 (88%) completed two or three DOS cycles. Grade 3-4 neutropenia and diarrhea occurred in 69% and 19% of patients, respectively, but there were no treatment-related deaths. R0 resection was achieved in 44 (92%) patients, and the pathological response rate (≥ grade 1b) was 63% (30/48). The 3-year PFS, overall survival, and disease-specific survival rates were 54.2%, 68.7%, and 75.8%, respectively.

Conclusion

Neoadjuvant DOS chemotherapy had a sufficient antitumor effect and tolerable safety profile in patients with gastric or EGJ adenocarcinoma. The survival benefit of a neoadjuvant strategy using our DOS regimen should be validated in phase 3 trials.

Robot-assisted laparoscopic surgery with a fluorescent near-infrared ray ureteral catheter for a rectal cancer patient with pelvic kidney: A case report

An 85-year-old woman presented with a stomachache after a meal and was admitted to the previous clinic. Multi-detector computed tomography (CT) of the abdomen showed wall thickening in the rectum and right ectopic pelvic kidney. Colonoscopy revealed a mass at the rectum, and a biopsy showed adenocarcinoma. CT showed no lymphadenopathy or distant metastasis. Hartmann's procedure with fluorescent near-infrared ray ureteral catheters was used to avoid causing urinary injury. Robotic surgery was performed while checking the route of the ureter in near-infrared mode. The patient was discharged on postoperative day 14 without specific complications. This case appears to be the first of robot-assisted laparoscopic surgery for a rectal cancer patient with pelvic kidney.

Real-world effectiveness of third- or later-line treatment in Japanese patients with HER2-positive, unresectable, recurrent or metastatic gastric cancer: a retrospective observational study

Background

Real-world evidence on the preference for and effectiveness of third- or later-line (3L +) monotherapy for HER2-positive gastric cancer is limited in Japan. This study evaluated the utility of nivolumab, irinotecan, and trifluridine/tipiracil (FTD/TPI) monotherapy as 3L + treatment in Japanese patients with HER2-positive gastric/gastroesophageal junction (G/GEJ) cancer who were previously treated with trastuzumab.

Methods

In this multicenter, retrospective, observational study (20 centers), data of eligible patients were extracted from medical records (September 22, 2017–March 31, 2020), with follow-up until June 30, 2020. Outcomes included overall survival (OS), real-world progression-free survival (rwPFS), time to treatment failure (TTF), objective response rate (ORR; complete response [CR] + partial response [PR]), and disease control rate (DCR).

Results

Of 127 enrolled patients, the overall analysis population comprised 117 patients (median [range] age, 71 [38–89] years). The most commonly prescribed 3L + monotherapy was nivolumab (n = 100), followed by irinotecan (n = 12) and FTD/TPI (n = 5). The median (95% confidence interval [CI]) OS, rwPFS, and TTF were 6.2 (4.5–8.0), 1.9 (1.5–2.3), and 1.8 (1.5–2.2) months, respectively, at median (range) 150 (25–1007) days of follow-up. The ORR (CR + PR) and DCR were 9.0% (1% + 8%) and 32.0%, respectively. Factors such as higher neutrophil–lymphocyte ratio (≥ 2.54), Glasgow prognostic score (≥ 1), Eastern Cooperative Oncology Group performance status (ECOG PS; ≥ 2), and hepatic metastasis significantly impacted OS.

Conclusions

The observed OS in this study for HER2-positive G/GEJ cancer was shorter than that reported previously, suggesting that the effectiveness of nivolumab, irinotecan, or FTD/TPI as 3L + therapy may be limited.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10147-022-02162-4.

Higher Body Mass Index Is a Simple Favorable Non-cancer Prognostic Marker for Japanese Elderly Colorectal Cancer Patients after Curative Resection

Objectives:

In elderly colorectal cancer (CRC) patients, preoperative surgical indications can be controversial in some cases depending on the patient's physical condition. In comparison with younger patients, both cancer-specific survival (CSS) and non-CCS (NCSS) have an impact on the prognosis and both CSS and NCSS should be considered in the preoperative assessment. We aimed to investigate the impact of body mass index (BMI) on CSS and NCSS in Japanese elderly CRC patients.

Methods:

We retrospectively collected data from 471 Japanese elderly patients (≥80 years) with stage I-III CRC who underwent curative surgery from 1998 to 2017. A Kaplan-Meier survival analysis with propensity score matching (PSM) and a multivariate Cox regression analysis were performed.

Results:

After PSM, 123 higher BMI (≥23) and 123 lower BMI (<23) cases were matched. The higher BMI group had significantly better survival than the lower BMI group regarding NCSS and overall survival (OS; P < .001 and P < .001, respectively). The multivariate survival analysis further confirmed that the higher BMI group had significantly better survival than the lower BMI group regarding CSS, NCSS, and OS (P = .027, P < .001, and P < .001, respectively).

Conclusions:

In Japanese elderly patients with stage I-III CRC who underwent curative surgery, preoperative higher BMI was a significant and simple favorable prognostic predictor, especially for NCSS and OS.

Effectiveness of third- or later-line therapy in patients with HER2-positive advanced gastric cancer: Results from an observational retrospective study in Japan

277

Background: The real-world effectiveness of third- or later-line (3L+) therapies in patients (pts) with HER2-positive gastric cancer remains unknown. We report a multicenter, retrospective, observational study at 20 centers in Japan to investigate the outcomes of 3L+ therapy in pts with HER2-positive advanced gastric/gastroesophageal junction (G/GEJ) cancer previously receiving trastuzumab (UMIN000040853). Methods: Pts aged ≥20 years with HER2-positive advanced G/GEJ cancer who were previously treated with trastuzumab and newly initiated on nivolumab, irinotecan, or trifluridine/tipiracil monotherapy as 3L+ therapy (Sep 2017 to Mar 2020) were evaluated for overall survival (OS), progression-free survival (PFS), duration of response (DOR), time to treatment failure (TTF), objective response rate (ORR), and disease control rate (DCR). An exploratory analysis for factors affecting OS was conducted using a multivariate Cox regression model, with HER2 status as a covariate. Results: The overall analysis population was 117 pts (median: age, 71 years; number of prior treatment lines, 2; days since the initiation of first-line treatment, 431 days). Median (95% confidence interval) OS, PFS, and TTF were 6.2 months (4.5–8.0), 1.9 months (1.5–2.3), and 1.8 months (1.5–2.2), respectively, at a median follow-up of 150 days. Outcomes by treatment groups are shown in the Table. ORR and DCR in 100 pts with evaluable target lesions were 9.0% and 32.0%, respectively, and median DOR was 8.4 months. A higher neutrophil-lymphocyte ratio (≥2.540), Glasgow prognostic score (≥1), ECOG PS (≥2), and hepatic metastasis significantly impacted OS. Conclusions: The real-world effectiveness of 3L+ therapies was limited in this study. New HER2 treatment agent is expected to improve outcomes in pts with HER2-positive G/GEJ cancer.[Table: see text]

[A Case of Improvement by SOX Therapy for DIC Caused by Gastric Cancer]

Disseminated intravascular coagulation(DIC)has a poor prognosis in gastric cancer. The patient was a 78-year-old man. He had been diagnosed with Stage Ⅳ gastric cancer. Before chemotherapy, thrombocytopenia and elevated D-dimer occurred, and we diagnosed DIC. We started SOX therapy to treat gastric cancer with DIC. DIC improved on the 10th day after the onset of DIC. But developed DIC again on the 21st day. We started SOX therapy again. However, the DIC did not improve. The patient died 32 days after the initial DIC. Oxaliplatin regimen may be a potential treatment for DIC.

Effects of an oral elemental nutritional supplement in gastric cancer patients with adjuvant S-1 chemotherapy after gastrectomy: A multicenter, open-label, single-arm, prospective phase II study (OGSG1108)

AIM

Post-surgical weight loss influences chemotherapy compliance and may be a risk factor for survival. Intake of an oral elemental nutritional supplement (OENS) can reduce weight loss after gastric cancer (GC) surgery. We assessed whether therapy completion levels would increase in patients receiving postoperative adjuvant chemotherapy in combination with an OENS.

METHODS

This was a multicenter, open-label, single-arm, phase II study in GC patients who underwent curative total or distal gastrectomy (TG/DG) and received adjuvant S-1 chemotherapy. The primary endpoint was the S-1 completion rate for 1 year with a relative performance (RP) value of ≥70%; secondary endpoints included factors affecting the completion rate of S-1, RP value after eight S-1 courses, S-1 and OENS persistence rates, nutritional index, OENS compliance, and safety.

RESULTS

In 71 efficacy-evaluable patients, the S-1 completion rate was 69.0% (TG, 68.0%; DG, 69.6%) and the RP value was 87.5 (TG, 89.1; DG, 87.5). Over eight treatment courses, median persistence rates were 89.0% for S-1 and 93.8% for the OENS. The mean OENS compliance was 81.8% at the fourth S-1 course and 52.9% at the eighth course. The incidence of Grade 3 or 4 adverse events was 27.2%, most commonly neutropenia (12.3%).

CONCLUSIONS

The completion rate of S-1 for 1 year in patients who could take the OENS exceeded the pre-defined threshold level. Randomized controlled trials are warranted to confirm the role of OENS in adjuvant chemotherapy.

Left paraduodenal hernia treated by single-incision laparoscopic surgery: a case report

Background

Paraduodenal hernia is a rare internal hernia which accounts for only 1% of all intestinal hernias. There have been limited reported cases of paraduodenal hernia treated by laparoscopic surgery. We report a case of left paraduodenal hernia that was successfully treated by single-incision laparoscopic surgery (SILS).

Case presentation

A 17-year-old woman presented with left upper abdominal pain. An abdominal enhanced multi-detector computed tomography demonstrated encapsulated cluster of small bowel loops in the left upper quadrant which passed through the dorsal side of the inferior mesenteric vein, and showed that blood flow of the prolapsed small bowel was preserved. We preoperatively diagnosed left paraduodenal hernia without ischemia or necrosis. We performed elective SILS because she was a young actress training school student and cosmetic benefit was thought to be important. We pulled out the protruded small bowel and closed a defect with a running suture by SILS. The patient was discharged 3 days after the surgery with no complications.

Conclusions

We reported the case of left paraduodenal hernia successfully diagnosed and treated by SILS.

Randomized phase II study of CPT-11 versus PTX versus each combination chemotherapy with S-1 for advanced gastric cancer that is refractory to S-1 or S-1 plus CDDP: OGSG0701

BACKGROUND

To compare irinotecan-alone, paclitaxel-alone, and each combination chemotherapy with S-1 in patients with advanced gastric cancer (AGC) that is refractory to S-1 or S-1 plus cisplatin (SP).

METHODS

Patients with AGC after first-line chemotherapy with S-1 or SP, or patients during adjuvant chemotherapy or within 26 weeks after adjuvant chemotherapy completion with S-1 with confirmed disease progression were eligible. Patients were randomly divided into four groups based on treatment: irinotecan-alone (irinotecan; 150 mg/m², day 1, q14 days), paclitaxel-alone (paclitaxel; 80 mg/m², days 1, 8, 15, q28 days), S-1 plus irinotecan (irinotecan; 80 mg/m², days 1, 15, S-1; 80 mg/m², days 1-21, q35 days), and S-1 plus paclitaxel (paclitaxel; 50 mg/m², day1, 8, S-1; 80 mg/m², days 1-14, q21 days). The primary endpoint was overall survival (OS) and secondary endpoints were progression-free survival (PFS), response rate, and safety.

RESULTS

From July 2008 to March 2012, 127 patients were enrolled. No difference in median OS was observed in the irinotecan vs. paclitaxel groups or in the monotherapy groups vs. the S-1 combination therapy groups. Median PFS was longer in the paclitaxel group compared with the irinotecan group (4.1 vs. 3.6 months, p = 0.035), although no difference was observed when comparing monotherapy vs. S-1 combination. The most common grade 3 to 4 hematological adverse events were neutropenia with no difference in incidence rate across the treatment groups.

CONCLUSIONS

There was no difference in OS between irinotecan and paclitaxel no in OS prolongation of S-1 combination therapy in second-line chemotherapy.

[A Case of Anastomotic Recurrent Descending Colon Cancer Successfully Treated with Single-Incision Laparoscopic Partial Colectomy with Intracorporeal Anastomosis]

A 60s-year-old male, who had laparoscopic partial colectomy with resection of left colic artery for descending colon cancer 8 years ago and completed 5-year-follow-up without the evidence of recurrence, was diagnosed as anastomotic recurrence of descending colon cancer, and referred to our hospital. We planned and safely performed single-incision laparoscopic colectomy(SILC)with intracorporeal anastomosis(ICA)(operation time of 390 min and estimated blood loss of 60 g). Following the adhesiolysis, the intracorporeal resection of the lesion was performed with automatic stapling device preserving middle colic and inferior mesenteric arteries and veins. Then, after the recovery of the specimen, ICA was performed as follows; after making a small hole just below the staple line at the opposite side of mesenteric attachment, the oral and the anal stump of colon was pulled-up and placed side-by-side with temporary strings and automatic suturing device was inserted into the holes and fired to form a side-to-side anastomosis, then the common stab incision was pulled- up with 3 temporary strings and closed with a stapler. The postoperative course was smooth and discharged on postoperative day 8. The ICA can be a good option for SILC when colonic and vascular tension would be the limiting factor of anastomosis.

Cell and platelet composition assays by flow cytometry: basis for new platelet-rich fibrin methodologies

Platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) are selective blood fractions obtained by cen¬trifugation. They act locally on inflammation and immunity as adjuvant homeostatic modulators during tissue regeneration. In recent years, many methods for achieving these blood concentrates have emerged, whose parameters of time and force of centrifugation presented themselves as critical, conflicting, and poorly understood points. Thus, the present study aimed to evaluate the effect of different centrifugal experimental parameters on the concentration of cells and platelets in samples of anticoagulated blood. Blood samples were centrifuged by forces of 200, 400 and 800 x g for 5, 10 and 15 minutes of centrifugation times to obtain three fractions: a) platelet-poor plasma (PPP), b) leukocyte-rich plasma (L- PRP) and c) red blood cell sed¬iment (RBC). The leukocyte and platelet content of each centrifuged fraction was measured by automated flow cytometry associated with the peroxidase reaction for differential leukocyte count. The application of 200 x g generated a more significant dispersive content of leukocytes and platelets in the supernatant fraction of PPP when compared to the other two strength ranges. However, it presented the highest concentration of platelets in the sediment (P <0.05 ANOVA), representing a loss of total mass during processing. The 400 and 800 x g forces showed leukocytes and platelets condensed in the L-PRP fraction and lower levels in the sedi¬ment, demonstrating the greater effectiveness of buoyancy in the resuspension of these sedimented elements. Our experimental data showed that the concentration and organization of leukocytes and platelets in the centrifuged blood matrices are very sensitive to variations in g force and centrifugation time, thus generating products with different biological composition and characteristics, and with specific potential therapeutic effects. The present study did not focus on comparing authoring methods, but on presenting the impact of methodological variations on the biological nature of centrifuged blood matrices. Further in vivo studies are needed to assess the specific clinical effect of each methodological change.

[A Case of Locally Advanced Rectal Cancer with Multiple Liver Metastases Could Be Resected after Triplet Chemotherapy]

The patient was a 60's man, whose chief complaints were melena and weight loss. He visited our hospital, and further evaluation revealed rectal cancer(Ra)invading the abdominal wall with multiple liver metastases. The clinical diagnosis was cT4b(abdominal wall)N2bM1a(H1), cStage Ⅳ. We performed a transverse colostomy on the day prior to chemotherapy administration. He was administered 8 courses of FOLFOXIRI plus bevacizumab. After the chemotherapy, the primary tumor and liver metastases showed PR, with a diagnosis of ycT3N1bM1a(H1), Stage Ⅳ. We performed a robot-assisted laparoscopic low anterior resection for the primary tumor. Two months later, the partial resection of liver S6 and S8 was performed. The patient has been cancer-free for 6 months now.

[Long-Term Survival in a Case of Colon Cancer with Peritoneal Dissemination and Ovarian Metastasis after Multimodality Therapy]

A 70-year-old woman underwent treatment for cecal cancer(pT4bN1M0, Stage Ⅲb)in 2010. Four years and 2 months after the first surgery, she underwent ileum resection for stenosis due to perineal dissemination(P3). Two years after this recurrence, during which time she had completed 26 courses of FOLFIRI plus bevacizumab(Bmab), 9 courses of capecitabine plus oxaliplatin(CapeOX)plus Bmab, and 3 courses of Cape, no peritoneal dissemination was detected by computed tomography( CT). Thereafter, an additional 19 courses of Cape plus Bmab were introduced, but CEA continued to increase. Right ovarian metastasis was suspected based on CT and FDG-PET/CT examination. Four years and 1 month after the initial recurrence of perineal dissemination, the patient underwent bilateral ovarian resection, during which the lack of peritoneal dissemination was confirmed. Pathologically, right ovarian metastasis was diagnosed. The patient is still alive 4 years and 6 months after the first operation.

[A Resected Case of Hemorrhagic Hepatic Cyst Difficult to Differentiate from Mucinous Cystic Neoplasm of the Liver]

CASE

A 77-year-old woman was referred to our hospital for detailed examination of a cystic liver tumor. Contrast-enhanced CT and MRIshowed a cystic liver tumor with an enhanced mural nodule in S6 of the liver. Under a preoperative diagnosis of hemorrhagic hepatic cyst and mucinous cystic neoplasm(MCN)of the liver, extended posterior segmentectomy was performed. Histological examination of the tumor revealed no neoplastic cells, and the tumor was finally diagnosed as a hemorrhagic hepatic cyst of the liver.

CONCLUSION

Similar to previous reports of hemorrhagic hepatic cysts, preoperative differential diagnosis from MCN of the liver was difficult in this case. Hemorrhagic hepatic cysts are rare and are sometimes confused with MCN of the liver, especially when an enhanced mural nodule is found in the cyst. The possibility of hemorrhagic hepatic cysts should be considered during diagnosis of liver cystic tumors.

Neoadjuvant chemotherapy with docetaxel plus oxaliplatin and S-1 for locally advanced, resectable gastric or gastro-esophageal junction adenocarcinoma: Short-term results from a phase II trial

397

Background: In locally advanced, resectable gastric or gastro-oesophageal junction (EGJ) adenocarcinoma, perioperative the docetaxel-based triplet FLOT (fluorouracil plus leucovorin, oxaliplatin and docetaxel) is the standard chemotherapy in Europe. However, there is no evidence of neoadjuvant chemotherapy for resectable gastric cancer in Japan. Therefore, we conducted a phase II trial of neoadjuvant chemotherapy with docetaxel plus oxaliplatin, and S-1 (DOS) for locally advanced, resectable gastric or EGJ adenocarcinoma. Methods: Eligible patients had histologically confirmed gastric or EGJ adenocarcinoma of a clinical Stage III according to the 14th Edition of Japanese Classification of Gastric Carcinoma. DOS was administered for two or three preoperative cycles followed by eight postoperative cycles of S-1. Each 3-week cycle of DOS consisted of docetaxel 40 mg/m2 and oxaliplatin 100 mg/m2 on day 1 plus S-1 80-120 mg/body on days 1 to 14. Primary endpoint was 3-year progression-free survival rate, and secondary endpoints included overall survival, progression-free survival, response rate, histological response rate, R0 resection rate, and adverse events. Results: Of 50 enrolled patients, 48 (37 gastric and 11 EGJ) were eligible for the analysis. 42 (88%) patients completed two or three preoperative cycles of DOS. The most common grade 3-4 adverse events of DOS were neutropenia (69%), leukopenia (56%), diarrhea (19%), and febrile neutropenia (13%). Of 45 patients who underwent gastrectomy, postoperative morbidities (Clavien-Dindo ≥Grade II) occurred in 12 (27%) patients. R0 resection could be achieved in 43 (90%) patients. 12 (27%) and 30 (67%) of 45 patients achieved pathological response rate of Grade2-3 and Grade1b-3, respectively. There was no treatment-related death. Conclusions: Neoadjuvant DOS for locally advanced, resectable gastric or EGJ adenocarcinoma might be favorable. Long-term results will be published in two years. Clinical trial information: 000017652.

[A Case of Resection of a Metastatic Tumor Combined with the Spleen, Preserving the Remnant Stomach, for Recurrent Gastric Cancer of the Splenic Hilar Region after Distal Gastrectomy]

We describe a case of residual stomach preserving surgery performed under evaluation of residual gastric blood flow with indocyanine green(ICG)fluorography, for gastric cancer with recurrence of splenic lymph node metastasis after distal gastrectomy( DG)in a 65-year-old man. After 4 courses of S-1 plus CDDP(SP)therapy for advanced gastric cancer with ascites, DG, D2 dissection, and Billroth Ⅰ reconstruction were performed and radical resection was obtained(L, Type 3, pap/tub, ypT3N1H0P0CY0M0, ypStage ⅡB). Three years and 6 months after the surgery, a mass 4 cm in diameter was found in the splenic hilum, and a pancreatosplenial resection was performed to remove the tumor for diagnosis and treatment purposes. We confirmed that there was no problem with blood flow, and we were able to preserve the stomach. Intraoperative ICG fluorescence imaging was considered a promising method for evaluating residual gastric blood flow.

[Gastric Gastrointestinal Stromal Tumor Appearing Nine Years after Resection of a Duodenal Gastrointestinal Stromal Tumor-A Case Report]

Multiple sporadic gastrointestinal stromal tumor(GIST)are rare, except for those restricted to von Recklinghausen disease or hereditary conditions.We reported a case of a gastric GIST resected 9 years after the resection of a duodenal GIST.The patient was a 58-year-old male who had been followed-up with computed tomography scans after pancreatoduodenectomy for a duodenal GIST when he was 49-years-old.The patient was admitted to our hospital for anemia examination.A CT scan detected a tumor in the stomach, with a diameter of over 10 cm, and necrosis.Esophagogastroduodenoscopy revealed the presence of a delle on the gastric SMT.Due to suspected invasion of the spleen and left diaphragm by the tumor, we performed subtotal gastrectomy with splenectomy and left diaphragm segmental resection.In the pathological diagnosis, the tumor was diagnosed as a gastric GIST, because the cell type of the tumor was spindle and tested positive for c-kit.Based on the tumor size and mitotic count, the patient was diagnosed with high-risk GIST by the modified-Fletcher classification, and imatinib 400mg/day was administered.There have been no signs of recurrence for 2 years since the operation.

[A Case of Resected Primary Hepatic Neuroendocrine Tumor]

A 70s man presented with a solitary liver tumor measuring 4.5 cm on CT. On contrast-enhanced CT, the tumor appeared partly well-enhanced in the late phase, and the remaining part was enhanced in the early phase and washed out in the late phase. Contrast-enhanced MRIshowed fused multiple nodules, and the enhancement/washout pattern was clearer than that of the contrast-enhanced CT. The tumor showed a defective image in the hepatobiliary phase and a high signal on diffusionweighted imaging. Then, the tumor was diagnosed as hepatocellular carcinoma, and thus, left liver lobectomy was performed. On histological examination of the resected specimen, the tumor was found to be composed of uniform and small tumor cells with solid or trabecular growth fashion. On immunohistochemical staining, synaptophysin and chromogranin A positivity was noted, and the Ki-67 index was 14%. Finally, the tumor was diagnosed as a NET G2. Postoperatively, somatostatin receptor scintigraphy was performed to identify the primary site; however, no obvious primary site could not be identified, and thus a diagnosis of primary hepatic NET was made. Eighteen months postoperatively, the patient is alive without relapse. Preoperative diagnosis of primary hepatic NETs is difficult because NETs present various imaging findings and are rare. Moreover, no accurate preoperative diagnosis was reached in our case, suggesting the difficulty in the preoperative diagnosis of NETs.

[A Case with Three Resections of the Pulmonary Metastases of a Distal Bile Duct Carcinoma]

A 68-year-old man underwent a subtotal stomach-preserving pancreatoduodenectomy(SSPPD)for a distal bile duct carcinoma(BDC)pT3aN1M0, pStage ⅡB and adjuvant chemotherapy with gemcitabine. One year 7 months after the initial surgery, CT revealed a nodule with an increasing tendency in the left lung. As it was difficult to distinguish primary lung cancer from BDC lung metastasis, we performed a thoracoscopic left wedge resection. The histopathology of the resected specimen was BDC lung metastasis. In the follow-up with adjuvant chemotherapy with S-1 for 10 months, 2 nodules were found in the right lung, and we performed thoracoscopic right S6 segmentectomy. Eight months later, another nodule was found in the left lung, and we performed thoracoscopic left wedge resection. The histopathology was BDC lung metastasis for all the resected specimens. The patient is alive with no evidence of recurrence after 9 months of the latest surgery(4 years 11 months after the initial surgery). Although the standard treatment for metastatic recurrence of BDC is systemic chemotherapy, some cases treated with surgical resection had relatively good prognosis, such as the present case. Surgical resection might be feasible as a treatment option for metastatic recurrence of BDC.

P4760New minimally invasive and tailor-made strategy for cryoballoon ablation in patients with paroxysmal atrial fibrillation

Background

Currently, cryoballoon ablation (CBA) has proven to be highly effective in achieving free from atrial fibrillation (AF), especially paroxysmal AF. However, the optimal freezing protocol for each patient to achieve successful pulmonary vein isolation by only CBA is still uncertain. The aim of this study was to evaluate the clinical implications of a reduction in the freezing duration (<180s) during CBA guided by the time to target temperature.

Methods

From November 2015 to August 2018, 286 consecutive paroxysmal AF patients undergoing CBA were enrolled. We compared 107 patients undergoing a tailor-made CBA procedure (Group A; August 2017-August 2018) to 179 patients with a standard CBA procedure (Group B; November 2015–July 2017). In Group A, the freezing duration was reduced to 150s when the temperature reached ≤−40°C within 40s. Furthermore, we reduced it to 120s when it reached ≤−50°C within 60s. In the other patients, the freezing time was 180s except for excessive freezing over −60°C and/or emergent situations while monitoring the esophageal temperature and for phrenic nerve injury as in Group B.

Results

The baseline clinical characteristics were similar between two groups. In Group A, 89 patients (83%) underwent CBA with a reduction in the freezing time. The rate of having reduction time in left inferior PV (LIPV) and right inferior PV (RIPV) was lower compared with left superior PV (LSPV) and right superior PV (RSPV) (respectively 17%, 29%, 56%, and 63.5%). However, for right inferior PV, in 31 patients having the reduced freezing time, none of them required touch-up ablation. Although the procedure time and frequency of touch-up ablation did not differ between the 2 groups, total freezing time for each PV was significantly shorter in Group A than Group B as shown in figure (LSPV: 164±28s vs. 216±67s; p<0.001, LIPV: 187±44s vs. 218±69s; p<0.001, RSPV: 147±31s vs. 192±51s; p<0.001, RIPV: 180±50 vs. 218±73s; p<0.001). The AF free survival rate during the follow-up period (356±167 days) was similar between the 2 groups (log-rank test, p=0.38). Furthermore, the complication rate was similar 2 groups.

The freezing time for each PV

Conclusion

The safety and efficacy of the new tailor-made CBA strategy were non-inferior to the standard procedure. This study showed that the unnecessary freezing time could be reduced in most of paroxysmal AF patients.

Long-term effects of an oral elemental nutritional supplement on post-gastrectomy body weight loss in gastric cancer patients (KSES002)

Aim

The present study aimed to evaluate the efficacy of short‐term nutritional intervention with an oral elemental diet (ED; Elental; EA Pharma Co., Ltd, Tokyo, Japan) at 300 kcal/day for 6‐8 weeks in the early post‐gastrectomy period on postoperative long‐term body weight loss (BWL).

Methods

We analyzed consecutive patients who were randomly divided to receive the regular diet with or without ED. The control group received regular diet alone post‐gastrectomy, whereas the ED group received 300 kcal ED plus regular diet for 6‐8 weeks. Primary endpoint was percentage (%) BWL (body weight loss; body weight before surgery minus that at postoperative 1 year) by surgical type. Secondary endpoints included changes in nutrition‐related blood parameters.

Results

Of the patients in the original trial, 106 were eligible for efficacy analyses. %BWL at postoperative 1 year was significantly lower in the ED group than in the control group among patients who underwent total gastrectomy (TG) (n = 19 and n = 17, respectively; 9.66 ± 5.98% [95% confidence interval, CI: 6.77‐12.54] vs 15.11 ± 6.78% [95% CI: 11.63‐18.60], P = .015), but not in patients who underwent distal gastrectomy (n = 38 and n = 32, respectively; 5.81 ± 7.91% [95% CI: 3.21‐8.41] vs 5.96 ± 6.20% [95% CI: 3.72‐8.19], P = .933). In multivariate analysis, ED was the only factor affecting %BWL at postoperative 1 year among patients who underwent TG.

Conclusions

Daily nutritional intervention (300 kcal/day ED) for 6‐8 weeks reduced %BWL not only at postoperative 6‐8 weeks but also at 1 year in patients who underwent TG.

Daily nutritional intervention (300 kcal/day elemental diet) for 6‐8 weeks reduced %body weight loss not only at postoperative 6‐8 weeks but also at 1 year in patients who underwent total gastrectomy.

P2694Early and late restenosis after excimer laser coronary angioplasty and paclitaxel-coated balloon combination therapy for drug-eluting stent restenosis

Background

Drug-eluting stent restenosis (DES-ISR) is associated with poorer outcomes than those of bare-metal stent restenosis after treatment with paclitaxel-coated balloon (PCB), and late restenosis after PCB angioplasty for DES-ISR is a residual problem. Excimer laser coronary angioplasty (ELCA) is thought to be advantageous for ISR treatment by removing neointima. However, whether the combination of ELCA and PCB angioplasty is more effective than the use of PCB only angioplasty in DES-ISR has not been studied so far.

Purpose

We evaluated the efficacy of ELCA and PCB combination therapy for DES-ISR at mid-and late-term after revascularization.

Methods

From January 2014 to March 2016, 166 DES-ISR lesions were treated with ELCA and no-ELCA prior to PCB. Two serial angiographic follow-ups were planned for the patients (at 6–12 and 18–24 months after procedure). Acute procedural and follow-up angiographic results were assessed by quantitative coronary angiography. ELCA and no-ELCA group included 74 lesions and 92 lesions, respectively.

Results

There was no significant difference between the two groups in the clinical characteristics except the prevalence of hemodialysis, the rate of first-generation DES (37.9% vs 36.8%, p=0.897), previous stent size (2.90±0.39 mm vs 2.77±0.39 mm, p=0.063), and reference vessel diameter (2.65±0.46 mm vs 2.60±0.65 mm, p=0.593). Early follow-up angiography was performed in 66 lesions (89.1%) of ELCA group, and was done in 76 lesions (82.6%) of no-ELCA group. In the ELCA group, percentage diameter stenosis (%DS) just after procedure and at 6–12 months later were significantly smaller than those of no-ELCA group. Besides, target lesion revascularization (TLR) rate at 6–12 months after procedure was tended to be lower in the ELCA group. Late follow-up angiography was performed for 93 lesions (81.6%) of the remaining 114 lesions (excluding TLR lesion), late restenosis was found 9 lesions (18.6%) in the ELCA group and 11 lesions (24.4%) in the no-ELCA group (p=0.504). Late luminal loss was similar in both groups (0.37±0.71 mm vs 0.24±0.82 mm, p=0.438), and %DS at 12–18 months after revascularization was not different between the two groups.

Changes of %DS and TLR rate

Conclusions

%DS in the ELCA group was smaller at just after procedure and the advantage was kept even after 1-year. However, late restenosis and TLR at 2-year after revascularization for DES-ISR could not be reduced by ELCA and PCB combination therapy.

Staged deep brain stimulation of ventral intermediate nucleus of the thalamus for suppression of essential tremors

Deep brain stimulation (DBS) of the ventral intermediate nucleus (VIM) of the thalamus is a powerful surgical option in the treatment of essential tremors (ETs). However, its therapeutic efficacy depends on the tremor distribution. DBS is highly efficient in the relief of distal appendicular tremor but not other types of tremor. We report a case of staged DBS of ventral intermediate nucleus (VIM) of thalamus for the suppression of ETs.

Combined Endovascular and Microsurgical Hybrid Management of Cerebral Aneurysms: The Preliminary Fujita Experience

Introduction:

A subgroup of complex aneurysms demands multimodal treatment by microscopic and endovascular means. Partial obliteration or remnant postprocedure demands to go further to the other modality.

Materials and Methods:

All patients between July 2016 and January 2017 who had to undergo multimodality measures for complete obliteration of the aneurysms were included in the study. The patients who had either undergone clipping or coiling for their aneurysms, but with incomplete obliteration of the aneurysm, were also included in the study.

Results:

Between July 2016 and January 2017, a total of three patients had to undergo coiling after clipping of the aneurysm for complete obliteration. Two patients had to go for clipping following coiling. All five patients had complete obliteration of the aneurysm sac.

Conclusion:

Both microscopic and endovascular means are complementary measures instead of competing procedures. It is important to realize the technical difficulties when surgical therapy follows initial endovascular treatment. Similarly, coiling a previously clipped aneurysm can be difficult, if the clip obscures normal working projections.

Long-term effects of an oral elemental nutritional supplement on post-gastrectomy body weight loss in gastric cancer patients

94

Background: Postoperative weight loss could have a negative effect on quality of life and prognosis of gastric cancer patients. We have already shown that daily nutritional intervention with an oral elemental diet (ED) attenuated the short-term postoperative percentage of body weight loss (% BWL) in post-gastrectomy patients, especially in underwent total gastrectomy (TG). This study was conducted to evaluate the postoperative long-term BWL of nutritional intervention. Methods: This study was conducted in a cohort of consecutive patients which were randomly allocated to receive the control or ED diet in the original trial. Control group received the regular diet alone after gastrectomy, while ED group received 300 kcal of ED plus their regular diet for 6–8 weeks. The primary endpoint was the % BWL from the presurgical bodyweight to that at 1 year after surgery by surgical type. Secondary endpoints were changes in nutrition-related blood parameters. Results: One hundred six of registered patients in the original trial were eligible for efficacy analyses. There was not significant difference in the % BWL between the two groups (9.13 ± 7.72 % vs. 7.09 ± 7.49 %, respectively; p = 0.171). The % BWL at one year after surgery was significantly lower in ED group than in control group among patients who underwent TG (n = 19 and 17, respectively; 9.66 ± 5.98% vs. 15.11 ± 6.78%, respectively; p = 0.015), but not in patients who underwent distal gastrectomy (DG) (n = 38 and 32, respectively; 5.81 ± 7.91% vs. 5.96 ± 6.20%, respectively; p = 0.933). A multivariate analysis revealed that only type of gastrectomy was independently associated with % BWL at 1 year after surgery. And in total gastrectomy, ED administration was independently associated with % BWL. Total lymphocyte count in ED group increased more than that in control group at 1 year after surgery. Conclusions: Nutritional intervention with ED at 300 kcal per day for 6–8 weeks reduced body weight loss at 1 year as well as 6-8 weeks after surgery in patients who underwent total gastrectomy. Clinical trial information: 000023455.

[A Case of Successful Control of Advanced Duodenal Cancer with Liver Metastasis Receiving Paclitaxel Chemotherapy and Potential Radical Resection]

We report a case of successful control of advanced duodenal cancer with paclitaxel chemotherapy. A woman in her 70s with epigastralgia was diagnosed with hemorrhagic duodenal ulcer upon upper gastrointestinal endoscopy. A type 3 tumor was found in the duodenal bulb upon upper gastrointestinal endoscopy and biopsy at our hospital. By contrast CT, we found wall hypertrophy of the duodenal bulb, lymph node metastasis, and liver metastasis and started chemotherapy. Four courses of SOX therapy were first administered. The wall hypertrophy of the duodenal bulb worsened, and new lesions appeared in the liver, so we diagnosed progressive disease. Next, 4 courses of wPTX therapy were administered. The wall hypertrophy of the duodenal bulb improved, and all liver metastatic lesions shrunk and became obscure. The reduction rate was 75%, so we diagnosed partial response. Accumulation in the primary tumor was observed on PET-CT, and the lymph node and liver metastases disappeared, so we considered radical curative resection. The patient underwent subtotal stomach preserving pancreatoduodenectomy, D2 lymph node dissection, reconstruction of the digestive tract by the modified CHILD method, partial hepatectomy, and Brawn's anastomosis. No cancer cells were found in the hepatectomized area. Paclitaxel chemotherapy may be useful for advanced duodenal cancer.

[A Resected Case of Lymph Node Metastasis at the Splenic Hilum from Lung Cancer Invading the Pancreas and Spleen]

A 72-year-old man received chemoradiotherapy for lung squamous cell carcinoma(T4N2M0, Stage Ⅲb). Nine months after the start of chemoradiotherapy, a 60 mm sized mass was identified in the spleen on abdominal CT. FDG-PET/CT examination revealed abnormal FDG accumulation in the tumor, and no obvious accumulation was observed in other sites. By endoscopic ultrasound-guided fine needle aspiration cytology, the tumor was diagnosed as splenic metastasis from lung cancer. Since the primary lung tumor was well controlled by the chemoradiotherapy and no metastatic lesions were found except in the spleen, laparoscopic excision of the splenic metastasis was planned. Since the tumor was suspected to have infiltrated the tail of the pancreas, laparoscopic distal pancreatectomy and splenectomy were performed. There were no severe postoperative complications. The resected tumor was histopathologically diagnosed as not splenic metastasis, but lymph node metastasis at the splenic hilum from lung cancer invading the pancreas and spleen. Brain metastasis and bone metastasis were observed 3 months postoperatively. He did not undergo any treatments for the metastatic lesions, and he died because of the cancer 11 months after the operation. This case suggests the clinical significance of surgical treatment for distant metastatic lesions from lung cancer.

[A Case of Intrahepatic Cholangiocarcinoma with Tumor Thrombus in the Left Portal Branch]

A 63-year-old man was referred to our hospital for detailed examinations and treatment of a hepatic tumor. Abdominal contrast-enhanced CT examination showed a huge mass measuring 12 cm in diameter with ring enhancement in the left liver lobe. The liver tumor was accompanied by a macroscopic tumor thrombus in the left portal branch. Under preoperative diagnosis of intrahepatic cholangiocarcinoma with portal vein tumor thrombus, left liver lobectomy, removal of the tumor thrombus, extrahepatic bile duct excision, and lymph node dissection were performed. Histopathological examination of the resected specimens revealed moderately differentiated adenocarcinoma concomitant with tumor thrombus in the left portal branch. Adjuvant chemotherapy with S-1 was administered. However, 3 months after the surgery, CT examination revealed postoperative recurrences in the liver, lung, and bone. Systemic chemotherapy with gemcitabine and cisplatin was administered with radiotherapy for the bone metastasis. However, the chemotherapy was not effective, and 6 months after surgery, he died of the cancer. There have been few reports of cases with ICC accompanied by a macroscopic portal vein tumor thrombus. Based on the reported cases and the present case, prognosis of the disease seems very poor.

[A Case of Locally Advanced Gastric Cancer Treated with Chemoradiotherapy before Surgical Resection]

A 70-year-old woman presented to our hospital because of stomach pain. She was diagnosed as having clinical Stage ⅢC gastric cancer with invasion into the pancreas and treated with S-1+oxaliplatin(SOX)as neoadjuvant therapy, after palliative radiotherapy for tumor bleeding. After 4 courses of SOX therapy and 7 courses of S-1 therapy, the tumor size reduce and the invasion into the pancreas disappeared. Subsequently, she underwent distal gastrectomy. The pathological diagnosis was ypStage ⅢB, with no findings of tumor invasion into the pancreas. As of 1 year 9 months after the surgery, no metastasis or recurrence was observed.

[A Case of Unresectable Advanced Gastric Neuroendocrine Cell Carcinoma Treated with Nivolumab]

A 69-year-old man was administered S-1/oxaliplatin/trastuzumab as induction chemotherapy for advanced gastric cancer (cT4b[liver, pancreas], N2M1(H1P0CYX), cStage IV). After 4 courses, because contrast-enhanced computed tomography showed remarkable reduction of the tumor, distal gastrectomy, partial hepatectomy, and radiofrequency ablation for the liver metastasis were performed. The patient was histopathologically diagnosed with gastric neuroendocrine carcinoma(NEC). S- 1/oxaliplatin/trastuzumab was continued after surgery; however, recurrence in the remnant liver was observed after 4 cours- es. For recurrence, cisplatin/irinotecan as first-line and paclitaxel/ramucirumab as second-line treatment were administered, but progression of liver metastasis and ascites due to peritoneal dissemination were observed. As third-line treatment, nivolumab was initiated. Ascites decreased after 3 courses, but after 2 more courses, progression of ascites, liver recurrence, and multiple metastasis in the lumbar vertebra were observed.

[A Case Report of SOX Treatment for Primary Duodenal Carcinoma with Liver Metastasis]

We report a case of effective S-1 plus oxaliplatin (SOX) treatment for duodenal cancer with liver metastases. The patient was a 70-year-old female diagnosed with duodenal carcinoma that was unresectable because of liver metastasis(cT4N1M1, cStage IV in UICC 7th). She received SOX treatment(100mg/m / 2 of oxaliplatin on day 1 combined with 40 mg/day of S-1 twice daily on days 1-14, was repeated every 3 weeks). After 4 courses, a partial response was confirmed by computed tomography and no severe adverse events were observed. However, during the 5th courses, several new liver metastases were observed, so we changed to weekly paclitaxel treatment. This case suggests that SOX treatment may be an effective chemotherapy for advanced primary duodenal carcinoma.