[Early Duodenal Cancer Resected by Using Laparoscopic and Endoscopic Assistance Surgery in a Patient with Peutz-Jeghers Syndrome]

A 28-year-old female with a history of treatment for small intestinal polyps and characteristic pigmentation of her lip was clinically diagnosed with Peutz-Jeghers syndrome(PJS). Her sister had the pathogenic variant of STK11 upon genetic testing. A 20-mm polyp was identified in the second part the patient's duodenum on routine gastrointestinal surveillance, and biopsy revealed a well-differentiated adenocarcinoma. Laparoscopic partial duodenectomy with endoscopy was planned. After confirming the location of the tumor and Kocherization using a laparoscope, the polyp was resected via submucosal dissection under direct visualization with a small incision. The polyp was diagnosed as well-differentiated adenocarcinoma in situ and was resected without remnants. PJS is characterized by a high incidence of malignant tumors, and lifelong surveillance for gastrointestinal and extra-gastrointestinal tumors is necessary. The incidence of duodenal cancer is not high among patients with PJS. However, surgery for advanced cancer is highly invasive. It is desirable to detect the tumors at an early stage so that they can be resected via a less invasive treatment method such as endoscopic resection or laparoscopic surgery with an endoscope.

[Development of Cancer of the Remnant Colorectal Segment after Ileal-Pouch Anal Anastomosis/Ileorectal Anastomosis in Patients with Familial Adenomatous Polyposis]

PURPOSE

This retrospective study was performed to investigate the recent trend of occurrence of cancer of the remnant colorectal segment(RCRS)after ileal-pouch anal anastomosis(IPAA)/ileorectal anastomosis(IRA)and to consider the optimal surveillance methods in patients with familial adenomatous polyposis(FAP)undergoing(procto)colectomy.

PATIENTS AND METHODS

The subject was a total of patients with FAP undergoing IPAA or IRA between 2005 and 2022. Clinicopathological data were extracted from medical charts and analyzed. Cumulative incidence of cancer in the RCRS and overall survival after treatment of such tumors were calculated by the Kaplan-Meier method.

RESULTS

There were 45 male and 56 female. IPAA was performed in 49 patients(hand-sewn; n=33, stapled; n=16)and IRA was performed in 52 patients. The median age at initial colorectal surgery was 32 years old(range, 13-66 years old). Median postoperative follow-up was 11 years(range, 1-48 years). Eighty-one patients were confirmed to have pathogenic variant of APC by genetic test. The cumulative incidence of cancer of the RCRS did not differ between patients undergoing IPAA and those undergoing IRA(p= 0.73, 4.1% versus 1.9% at 10 years). The cumulative 5-year overall survival rate after additional surgery for the tumor of RCRS was 82%.

CONCLUSION

This study has several limitations due to single institutional retrospective study with small cases and non-standardized postoperative endoscopic surveillance. However, our results seem to show satisfactory oncological outcomes of patients with FAP in terms of the control of cancer of the RCRS under postoperative periodic surveillance, regardless of the type of colorectal resection.

[A Rare Case of Cronkhite-Canada Syndrome Associated with Gastric Cancer and Gastric Outlet Obstruction]

Cronkhite-Canada syndrome(CCS)is a rare non-inherited disease characterized by gastrointestinal polyposis and ectodermal abnormalities. We report a rare case of CCS associated with gastric cancer and gastric outlet obstruction with a review of the literature. A 75-year-old man was admitted because of frequent vomiting and hypoproteinemia. He was diagnosed with CCS due to typical clinical and laboratory findings including alopecia, nail atrophy, hypoproteinemia, and typical gastrointestinal polyposis. Upper endoscopic examination also pointed out a large gastric cancer mainly located in the antrum and the reversible pyloric obstruction caused by the gastric tumor. Biopsy of the tumor revealed tubular adenocarcinoma. Computed tomography demonstrated the dilated duodenum caused by packing of the gastric tumor. 1.5 months after prednisolone therapy, he underwent total gastrectomy with complete resection of the dilated duodenal bulb. Histological examination revealed gastric cancer(pap>tub1)classified into Stage ⅢC. Postoperative course was uneventful and he moved to another hospital. To our knowledge, including the present case, there were 20 reported cases of CCS associated with gastric cancer from Japan(1979-2022). Also, 7 cases of CCS associated with gastric outlet obstruction was reported.

[Complete Response to Immune Checkpoint Inhibitors in Unresectable Gastric Cancer-A Report of Five Cases]

Immune checkpoint inhibitors(ICIs)are widely used for the treatment of unresectable gastric cancer. We treated approximately 70 patients with ICIs. ICI treatment with pembrolizumab was administered for MSI-high cases and nivolumab for MSS cases in the second- or third-line chemotherapy. We observed 5 cases of complete response. Among these, 2 patients presented with liver metastases, 2 with peritoneal disseminations, and 1 with pulmonary metastasis. In 1 patient, the primary tumor invaded the diaphragm and descending aorta; whereas, in another patient the primary tumor invaded the pancreas and liver. All patients had progressive disease after first-line chemotherapy.

Gastric Emptying is Accelerated in Patients With Gastric Tube Reconstruction Following Laparoscopic Proximal Gastrectomy

BACKGROUND

Laparoscopic proximal gastrectomy (LPG) is an attractive option for the treatment of early gastric cancer in the upper third of the stomach. No optimal method of reconstruction after LPG has been established because of problems associated with postoperative reflux. Gastric tube reconstruction, a type of esophagogastrostomy, is a simple procedure, but it is associated with a high frequency of reflux esophagitis (RE). We investigated the relationship between RE and gastric emptying, along with nutritional parameters.

SUBJECTS AND METHODS

We compared gastric emptying in patients who had undergone curative LPG with gastric tube reconstruction for gastric cancer with that of patients after total gastrectomy (TG), distal gastrectomy (DG) and of healthy volunteers and patients after DG. The LPG group was divided into an RE LPG-RE (+) group and a non-reflux esophagitis (non-RE) an LPG-RE (-) group, and we compared gastric emptying and indices of nutrition, such as body weight and laboratory findings, between those among LPG-RE (+), LPG-RE (-), and TG groups.

RESULTS

The time lag between ingestion and peak 13 CO 2 expiration (T lag) in the healthy volunteer group was significantly shorter in the LPG group longer than those in the healthy volunteer LPG group and TG group. The T lag was significantly shorter in the RE LPG-RE (+) group than in the non-RE LPG-RE (-) group. The percentage change in body weight percentage in the non-RE LPG-RE (-) group was significantly larger than that in the RE LPG-RE (+) group at 12 months after surgery. Both the serum albumin and hemoglobin levels in the non-RE LPG-RE (-) tended to be preserved compared with those in the RE LPG-RE (+) group and TG group.

CONCLUSIONS

Gastric emptying was accelerated after LPG, and was associated with RE. Our data suggest that RE could be associated with body weight loss after LPG.

AI analysis and modified type classification for endocytoscopic observation of esophageal lesions

Endocytoscopy (EC) facilitates real-time histological diagnosis of esophageal lesions in vivo. We developed a deep-learning artificial intelligence (AI) system for analysis of EC images and compared its diagnostic ability with that of an expert pathologist and nonexpert endoscopists. Our new AI was based on a vision transformer model (DeiT) and trained using 7983 EC images of the esophagus (2368 malignant and 5615 nonmalignant). The AI evaluated 114 randomly arranged EC pictures (33 ESCC and 81 nonmalignant lesions) from 38 consecutive cases. An expert pathologist and two nonexpert endoscopists also analyzed the same image set according to the modified type classification (adding four EC features of nonmalignant lesions to our previous classification). The area under the curve calculated from the receiver-operating characteristic curve for the AI analysis was 0.92. In per-image analysis, the overall accuracy of the AI, pathologist, and two endoscopists was 91.2%, 91.2%, 85.9%, and 83.3%, respectively. The kappa value between the pathologist and the AI, and between the two endoscopists and the AI showed moderate concordance; that between the pathologist and the two endoscopists showed poor concordance. In per-patient analysis, the overall accuracy of the AI, pathologist, and two endoscopists was 94.7%, 92.1%, 86.8%, and 89.5%, respectively. The modified type classification aided high overall diagnostic accuracy by the pathologist and nonexpert endoscopists. The diagnostic ability of the AI was equal or superior to that of the experienced pathologist. AI is expected to support endoscopists in diagnosing esophageal lesions based on EC images.

[Changes in Renal Function and Feasibility of Adjuvant Chemotherapy for Colorectal Cancer Patients with Diverting Ileostomy after Ileal Pouch-Anal Anastomosis]

We investigated changes in estimated glomerular filtration rate(eGFR)in 11 colorectal cancer patients(6 familial adenomatous polyposis, 5 ulcerative colitis)who underwent restorative proctocolectomy with ileal pouch-anal anastomosis(IPAA) and diverting ileostomy(DI), the tolerability and adverse events of adjuvant chemotherapy(ACT)in 4 cases. After IPAA, eGFR decreased significantly(p=0.02)and did not return to the preoperative level even after stoma closure(p<0.01). mFOLFOX6 was selected as the regimen in 4 candidates, and no significant changes in eGFR after ACT were observed. The relative dose intensity of oxaliplatin was 91.7%, and no gastrointestinal adverse events of Grade 3 or higher were observed. Although in a small number of cases, mFOLFOX6 as ACT after IPAA and DI may be feasible.

[Three Cases of Conversion Surgery for Unresectable Gastric Cancer with Multiple Liver Metastases]

We herein report 3 cases of advanced gastric cancer with multiple liver metastases who was successfully treated with systemic chemotherapy and underwent conversion surgery with liver resection. There were 2 males and 1 female patients with a range 68 to 74 years of age. Two patients received S-1 plus oxaliplatin therapy and 1 received S-1 plus cisplatin therapy. All patients survived after 5-49 months postoperatively.

[Conversion Surgery following Second-Line Chemotherapy for Unresectable Gastric Cancer]

We retrospectively analyzed clinicopathological and survival data of 8 patients with unresectable gastric cancer who underwent conversion surgery(CS)following second-line chemotherapy from April 2013 to December 2020. There were 7 males and 1 female patients with a median age of 69(64-76)years old. Five patients had 1 unresectable factor, 2 had 2 unresectable factors, and 1 had 3 unresectable factors. All patients achieved R0 resection. The median survival time(MST) of patients with CS following second-line chemotherapy was significantly longer than that without CS(73.4 vs 12.3 months, respectively). The MST of patients with CS following first-line chemotherapy was significantly longer than that without CS (22.9 vs 12.3 months, respectively). This study suggested that CS following first- or second-line chemotherapy may improve survival duration for unresectable gastric cancer.

[Two Cases of Esophageal Neuroendocrine Carcinoma That Were Successfully Controlled by Multi-Modality Therapy]

Esophageal neuroendocrine carcinoma is extremely rare, and its treatment strategy has not been established. We report 2 cases esophageal neuroendocrine carcinoma. Case 1: A 74-year-old man was diagnosed as having esophageal neuroendocrine carcinoma(clinical T3N4M0, Stage Ⅳa). He received 60 Gy of radiation therapy with etoposide(100 mg/m2)plus cisplatin(80 mg/m2). No recurrence has been detected 1 year after treatment. Case 2: A 78-year-old man was diagnosed as esophageal neuroendocrine carcinoma(clinical T3N0M0, Stage Ⅱ). He underwent esophagectomy with 3 field lymph nodes dissection. Adjuvant chemotherapy was administered with irinotecan(60 mg/m2)plus cisplatin(60 mg/m2). After chemotherapy, he survived 1 year without recurrence.

Clinical outcomes of gastric tube reconstruction following laparoscopic proximal gastrectomy for early gastric cancer in the upper third of the stomach: experience with 100 consecutive cases

BACKGROUND

Gastric tube reconstruction is a form of esophagogastrostomy performed after laparoscopic proximal gastrectomy (LPG). It is a simple and safe technique, but it may cause reflux esophagitis (RE) and impair postsurgical QOL. For several years, we have developed the gastric tube reconstruction and performed it on more than 100 patients. This study aimed to determine whether gastric tube reconstruction can be a feasible choice after LPG in regard to surgical safety and postoperative nutritional status.

METHODS

The subjects consisted of 171 patients who underwent LPG (n = 102) or laparoscopic total gastrectomy (LTG) (n = 69). We compared the two groups in terms of surgical outcomes, incidence rate of RE, and nutritional status including postoperative weight loss and hemoglobin levels.

RESULTS

There were no significant differences with regard to the surgical duration and blood loss between the two groups. The incidence of RE was not significantly higher with LPG than with LTG (16.7% vs. 10.1%, respectively; P = 0.07). Later than 2 years and 6 months after surgery, the body weight percentage of preoperative body weight in the LPG group was significantly higher than that in the LTG group. Hemoglobin and ferritin levels in the LPG group were significantly higher than those in the LTG group, later than one after surgery. The overall survival rates were similar between the two groups (5-year survival rates: 97.1% vs. 94.2% in the LPG and LTG groups, respectively; P = 0.69).

CONCLUSIONS

Gastric tube reconstruction after LPG is simple and had better outcomes than LTG in terms of postoperative nutritional status.

[A Case of Papillary Carcinoma of Thyroid Associated with Familial Adenomatous Polyposis in a Younger Woman]

Familial adenomatous polyposis(FAP)is an autosomal dominantly inherited disorder, and the result of a germ line variant in the adenomatous poplyposis coli(APC)gene. FAP can be associated with various extracolonic lesions including thyroid cancer, which frequently occurs in women. We report the case of a 15-year-old woman diagnosed as FAP with multiple thyroid papillary carcinomas. Her mother had been treated for FAP with colorectal cancer and thyroid cancer in our department. Multiple tumors with a maximum diameter of 17 mm were detected in the right lobe of the thyroid gland during the preoperative examination. Papillary carcinoma was suspected based on fine-needle aspiration cytology. She was diagnosed with FAP because of multiple polyps on colonoscopy. We performed a subtotal thyroidectomy. Pathological findings revealed a cribriform-morular variant of papillary thyroid carcinoma. We report a rare case of papillary carcinoma of thyroid associated with FAP in a younger woman.

[Idea of Treatment Method for Upper and Lower Rectal Cancer Avoiding Irradiation to Internal and External Sphincter]

BACKGROUND

Preoperative chemoradiotherapy(CRT)followed by total mesorectal excision(TME)is used for locally advanced rectal cancer, but it can induce postoperative anorectal function. The primary objective of this study is to confirm the efficacy and safety of preoperative CRT and TME without irradiation to the internal and external sphincter muscles.

SUBJECTS AND METHODS

Patients were eligible for this study if they met the following inclusion criteria: histologically proven rectal cancer, clinical T3T4N0-2 disease, and a distance between anal margin of tumor and the rental line is more than 2 cm. Twelve patients who underwent preoperative CRT and TME between 2013 and 2017 were enrolled. The primary endpoint was completion rate of sphincter-preserving surgery.

RESULTS

All patients completed preoperative CRT without Grade 3 or higher adverse effect. Sphincter-preserving surgery was performed in all cases. The 5-year disease-free survival rate was 46.7%, and the local recurrence-free survival rate was 75%, and the overall survival rate was 90.9%.

CONCLUSION

It is suggested that preoperative CRT and TME without irradiation to the internal and external sphincter muscles is effective and safe therapy for locally advanced rectal cancer.

Efficacy of Irinotecan as Third-line Chemotherapy for Unresectable or Recurrent Gastric Cancer

AIM

To evaluate the efficacy and safety of third-line chemotherapy (CTx) for patients with unresectable or recurrent gastric cancer (GC) refractory to S-1 with or without platinum and taxanes.

PATIENTS AND METHODS

We retrospectively analyzed clinicopathological and survival data of 26 patients who underwent third-line CTx.

RESULTS

Irinotecan therapy (odds ratio=0.12, 95% confidence interval=0.02-0.38; p<0.01) and ≥2 cycles of third-line CTx (odds ratio=0.01, 95% confidence intervaI=0.01-0.11; p<0.01) were independent predictors of longer progression-free survival in multivariate Cox regression analysis. In 18 patients (69%) receiving irinotecan, the overall response rate was 11%, and the disease control rate was 44%. Median progression-free and overall survival were 3.5 and 11.3 months, respectively. Ten patients (56%) had grade 3-4 toxicities, which were managed.

CONCLUSION

Irinotecan therapy may become optimal and tolerated in the third-line setting to prolong progression-free survival by increasing the number of treatment cycles.

[A Case of Advanced Recurrent Colorectal Cancer with Complete Response to Pembrolizumab Chemotherapy]

The efficacy of pembrolizumab has been demonstrated for all solid tumors showing high frequency microsatellite instability- high(MSI-High). It is a possible treatment option even in cases which do not respond to other forms of chemotherapy. We report a case of a 69-year-old man with MSI-High recurrent colorectal cancer with complete response(CR)after pembrolizumab therapy. Sigmoidectomy, extensive lymph node dissection, and partial bladder resection were performed for sigmoid colon cancer at another hospital. Histopathological examination revealed a T4a, N0, M0, Stage Ⅱb tumor. Six months after the operation, Hartmann's operation and partial resection of the small intestine were performed for local recurrence. However, the tumor invading the retroperitoneum was unresectable. Postoperative SOX therapy was performed, but it was discontinued due to Grade 3 diarrhea during the first course. The laboratory test showed MSI-High during the first course. Pembrolizumab chemotherapy was introduced as second-line therapy. Computed tomography examination after 2 courses (6 weeks)revealed reduction in the major axis of the tumor by 30% or more. After 4 courses(12 weeks), the tumor was further reduced, and a partial response(PR)was diagnosed. The tumor completely disappeared after 6 courses, and a complete response was achieved after 8 courses. The CR has been maintained for about 7 months.

[A Family with Lynch Syndrome Diagnosed after a Proband of Elderly Multiple Colorectal Cancers]

The proband was a 77-year-old man who had been admitted to a local hospital for fecal occult blood. He was diagnosed with descending colon carcinoma, T4a, N1, M0, Stage Ⅲb, and rectal adenoma. He had undergone surgeries for rectal cancer at 52 years of age and cecum colon cancer at 57 years of age. Regarding his family history, 5 first-degree and 3 second- degree relatives had a history of gastrointestinal and gynecological cancers, thus meeting 2 of the 5 criteria of the revised Bethesda guidelines. The microsatellite-instability(MSI)test performed using preoperative biopsy tissues demonstrated high-frequency MSI(MSI-H). Hartmann's procedure was performed for MSI-H colon cancer under a strong suspicion of Lynch syndrome. Pathological findings were consistent with descending colon carcinoma, tub2, pT3, pN0, M0, pStage Ⅱa. He was then referred to our hospital. We performed the immunohistochemistry(IHC)analysis of the mismatch repair protein using surgical specimens. The IHC analysis revealed defective expression of the MSH2/MSH6 protein. We found a pathogenic variant in the mismatch repair gene, MSH2(c.1510+2T>G), through genetic testing and finally diagnosed the patient with Lynch syndrome. After disclosure of the results to the proband, 7 relatives underwent genetic testing for the MSH2 variant. Four relatives had the same variant and were also diagnosed with Lynch syndrome. They subsequently underwent surveillance for Lynch syndrome-associated cancers. In 2 variant carriers with a history of early colorectal cancer, an early colon cancer was identified and successfully resected endoscopically. Surveillance for Lynch syndrome-associated cancer is ongoing for the proband and variant carriers.

[A Family of Attenuated Familial Adenomatous Polyposis]

The proband was a 49-year-old woman who had undergone total colectomy, ileorectostomy, and bilateral ovariectomy for the treatment of cecal(T3N0)and sigmoid colon(T4a, N2b, M1c2[Ova], Stage Ⅳc)cancers. Pathological findings revealed 6 adenomas and 2 adenocarcinoma-in-adenomas in the right colon, other than advanced colon cancers. She had a family history of colorectal cancer meeting the Amsterdam Criteria I, but none of her relatives had definite polyposis. Considering the possibility of Lynch syndrome, the microsatellite-instability test and immunohistochemistry(IHC)examination of the mismatch repair protein were performed, leading to the results of microsatellite stable and proficient mismatch repair protein expression. Therefore, we performed the multigene panel test containing 26 genes using the next-generation sequencing technology. In the APC(5q22.2)gene, a pathogenic variant(exon 12 c.994C>T/p.Arg332*)was identified, leading to a diagnosis of attenuated familial adenomatous polyposis(AFAP). After disclosure of the results to the proband, the single-site variant analysis was performed on her 3 daughters. In her second and third daughters, the same variant was confirmed, and laparoscopic total colectomy was performed 23 and 35 months after the disclosure of the genetic analysis results, respectively. Currently, we are conducting periodical surveillance for the residual rectum.

Cauda Equina and Filum Terminale Arteriovenous Fistulas: Anatomic and Radiographic Features

Intradural AVF below the conus medullaris may develop either on the filum terminale or the cauda equina (lumbosacral and coccygeal radicular nerves). Although not a few filum terminale AVFs are found in the literature, only 3 detailed cauda equina AVFs have been reported. Here, we analyze the angiographic and MR imaging findings of our cauda equina and filum terminale AVF cases, supplemented with literature research to characterize the radiologic features of the 2 entities. On angiography, filum terminale AVFs were invariably supplied by the extension of the anterior spinal artery accompanied by a closely paralleling filum terminale vein. Cauda equina AVFs were fed by either a radicular or a spinal artery or both arteries, often with a characteristic wavy radicular-perimedullary draining vein. On thin-section axial MR imaging, the filum terminale AVF draining vein joined the spinal cord at the conus medullaris apex, but that of the cauda equina AVF joined above the conus medullaris apex.

[Does Colonic Stenting Affect the Long-Term Prognosis of Colorectal Cancer ?]

The impact of colonic stenting on long-term prognosis has not yet been clarified. We compared background factors, progression-free survival, and overall survival between patients with stents(stent group)who underwent surgery after colonic stenting as a bridge to surgery and patients without stents(non-stent group)who underwent emergency surgery for left-sided colorectal cancer ileus. There was no difference between the 2 groups in the induction of adjuvant chemotherapy, but the use of oxaliplatin-base was highly introduced in the stent group(p=0.03). The 5-year DFS rates were 55.1% and 70.3%(p=0.21)and the 5-year OS rates were 90.7%and 70%(p=0.35)in the stent and non-stent groups, respectively. In the present study, colon stent placement did not affect long-term prognosis.

[A Case of Synchronous Gallbladder Metastasis Originating from Advanced Gastric Cancer]

Gallbladder metastasis from gastric cancer is often found accidentally during postoperative pathological examinations, and its preoperative diagnosis is very difficult. There are a few reports in diagnostic imaging, and it is well known to have a very poor prognosis. There have been 13 reports on gallbladder metastasis from gastric cancer in the Japanese literature. Among the 13 reports, 10 cases were diagnosed with gallbladder metastasis synchronously and only 1 case was diagnosed as gallbladder metastasis before surgery. One case was reported as hematogenous metastasis, and 9 cases were reported as lymphoid metastasis. In total, 7 patients died, all within the first year after surgery. We experienced a case of synchronous gallbladder metastasis from gastric cancer.

[The Outcome of Preoperative Chemoradiotherapy for Advanced Lower Rectal Cancer-The Possibility of an Omission of the Lateral Dissection]

The objective of this study was to evaluate the outcomes of selective LPLN dissection(LPLD)based on pretreatment imaging in patients with advanced low rectal cancer treated with pre-operative CRT. We reviewed 32 patients without suspected LPLN metastasis based on the MDCT or MRI results before CRT. These patients underwent total mesorectal excision (TME)without LPLD. The clinical characteristics and oncological outcomes were examined. In all cases, the per-protocol treatments were completed. Tumor recurrence occurred in 14 patients at the liver(3 cases), the lung(7 cases)and the local sites(4 cases). Of the 4 cases with pelvic recurrence, no recurrence was found in the lateral lymph node area. Under the condition that pre-operative chemoradiotherapy is to be performed for advanced lower rectal cancer with negative lateral lymph node metastasis, a lateral dissection could be omitted.

[Analysis of Palliative Stents for Colonic Stenosis Due to Extracolonic Cancers]

We retrospectively reviewed 13 patients in whom endoscopic stenting for colonic stenosis due to extracolonic cancers(non- CRC group)was attempted between July 2012 and January 2018. There were 5 men and 8 women, with a median age of 69 years. Primary malignancies causing colonic stenosis were gastric cancer(n=4), cholangiocarcinoma(n=2), pancreatic cancer(n=2), lung cancer(n=2), uterine cancer(n=2), and ovarian cancer(n=1). The non-CRC group patients demonstrated a significantly lower technical success rate than those who received palliative stents for colonic stenosis for primary colorectal cancer(n=51)(69% vs 98%, p<0.01). In addition, the non-CRC group patients(n=13)also demonstrated a significantly lower technical success rate(69% vs 99%, pp<0.01)than those who received stents aiming to subsequently undergo a bridge to surgery. Nonetheless, colorectal stenting for extracolonic malignancies appears to be a minimally invasive treatment and could offer patients rapid relief. Thus, it could be an effective alternative to some palliative therapies.

[A Case of Peritoneal Metastasis of Appendiceal Mucinous Carcinoma Successfully Managed by Multidisciplinary Treatment]

There is no established treatment for appendiceal mucinous adenocarcinoma. When this condition is complicated by pseudomyxoma peritonei(PMP), multidisciplinary treatment is often administered. A 40-year-old woman was diagnosed with right ovarian cancer for which laparotomy was performed. At the time of laparotomy, we considered the tumor to be an appendiceal carcinoma infiltrating the right ovary and performed ileocecal resection with lymph node dissection(D3)and right salpingo-oophorectomy. The pathological diagnosis was stage pT3, pN0, pM0, pStage Ⅱ mucinous adenocarcinoma of the appendix. Fourteen months later, the patient underwent abdominal total hysterectomy and left salpingo-oophorectomy because a CT scan suggested recurrence in the uterus, left fallopian tube, and ovary. Seventeen months after the second operation, despite adjuvant chemotherapy, CT revealed a peritoneal nodule in the pelvic cavity. Therefore, we administered chemotherapy comprising 5 lines for 32 months, which resulted in failure. CT showed an enlarged tumor and ascites and the patient became terminally ill. We repeatedly performed cytoreduction surgery and intraperitoneal chemotherapy, which improved her QOL. One year after discharge, abdominal CT showing an abdominal wall and intraperitoneal mass. We performed again cytoreduction surgery and intraperitoneal chemotherapy. Her postoperative course is good and she is currently an outpatient.

[A Case of Low-Grade Appendiceal Mucinous Neoplasm Complicated by Pseudomyxoma Peritoneri Successfully Treated with Cytoreductive Surgery and Intraperitoneal Chemotherapy]

We experienced a case of low-grade appendiceal mucinous neoplasm complicated by pseudomyxoma peritonei that was successfully treated with cytoreductive surgery and early postoperative intraperitoneal chemotherapy. The patient was a 26- year-old man with massive ascites and a swollen appendix on the computed tomography(CT). The appendix was a cystic mass of 5 cm in size. The entire parietal peritoneum, omentum, stomach, spleen, gall bladder, and entire colon were covered with numerous mucous nodules. Total colectomy, total gastrectomy, splenectomy, cholecystectomy, total omentectomy, parietal peritonectomy, ileostomy, and intraperitoneal irrigation were performed. The pathological diagnosis was low-grade appendiceal mucinous neoplasm. Postoperative intraperitoneal chemotherapy with cisplatin and mitomycin C was performed. A residual tumor was found on the dorsal side of the hepatoduodenal ligament 3 months postoperation on the CT. The residual tumor was successfully excised via a concomitant resection of the hepatic caudate lobe. Postoperative intraperitoneal chemotherapy was then performed. No recurrence was found at 8 months postoperation. The addition of early postoperative intraperitoneal chemotherapy improved the patient's quality of life in a short period. This could be one of the treatment options.

[Benefit of Adjuvant Chemotherapy after Curative Resection of Liver and Lung Metastases in Colorectal Cancer]

The survival benefit of adjuvant chemotherapy after resection of liver and pulmonary metastases in colorectal cancer(CRC) remains controversial. We enrolled9 0 CRC patients who underwent hepatic metastasectomy and2 5 CRC patients who underwent pulmonary metastasectomy between April 2005 and March 2017 to clarify the efficacy of adjuvant chemotherapy after hepatic andpulmonary metastasectomy. Forty-two patients receivedad juvant chemotherapy after hepatic metastasectomy, and1 0 patients receivedad juvant chemotherapy after pulmonary metastasectomy. Patients who underwent hepatic metastasectomy andreceivedad juvant chemotherapy hadlonger overall survival(OS)(p=0.043)andrelapse -free survival (RFS)(p=0.043)than those who underwent surgery alone. There were no significant differences in OS(p=0.84)andRFS (p=0.87)between patients receiving adjuvant chemotherapy after pulmonary metastasectomy and those receiving surgery alone. On multivariate analysis, adjuvant chemotherapy was independently associated with favorable OS in patients who underwent hepatic metastasectomy(hazardratio: 0.473, 95% confidence interval: 0.23-0.97, p=0.04). No prognostic factor associatedwith OS andRFS was identifiedin patients undergoing pulmonary metastasectomy. These results suggest that patients who undergo hepatic metastasectomy couldhave an OS andRFS benefit from adjuvant chemotherapy, but those who undergo pulmonary metastasectomy would not.

Indocyanine green fluorescence angiography of the reconstructed gastric tube during esophagectomy: efficacy of the 90-second rule

By examining the reconstructed gastric tube during esophagectomy using indocyanine green fluorescence (ICG) angiography, we have established a '90-second rule' to confirm good blood perfusion at the anastomosis site. We examined the surgical outcome (rate of anastomotic leakage) of 70 consecutive patients who underwent esophagectomy with gastric tube reconstruction using ICG fluorescence angiography. All of the anastomoses were made in the area where less than 90 seconds was needed for enhancement using ICG fluorescence angiography (i.e. within the 90-second rule). In 18 cases for which the time until enhancement of the gastric tube tip exceeded 60 seconds, the anastomosis site was decided by reference to the ICG fluorescence angiogram, and the hypoperfused area was excised, and this significantly shortened the median time until enhancement of the gastric tube tip from 95.5 (60.0-204.0) seconds to 41.0 (9.0-77.0) seconds (P < 0.001). In three cases, the anastomosis was made at the site where more than 60 seconds was needed for ICG enhancement. In one case where ICG enhancement had taken 77 seconds, minor anastomotic leakage occurred. The overall rate of anastomotic leakage in this series was 1.4%. Blood flow in the reconstructed gastric tube is sufficient if the anastomosis is made in the area where ICG fluorescence angiography demonstrates enhancement within 60 seconds. Gastric tube necrosis can be avoided if the area showing an enhancement time exceeding 90 seconds is excised. The 90-second rule is a safe and effective method for deciding the site of anastomosis.

[Does the Sidedness of Perforative Colorectal Cancer Influence the Prognosis of Patients ?]

We examined the influence of the sidedness of the primary tumor on survival of patients with colon cancer perforation. The subjects of this retrospective study were 52 patients who underwent surgery for colon perforation between April 2005 and December 2016 at our institution and survived more than 30 days. Patients with perforation of the oral side of the tumor were included. The background data and survival times were compared between 9 patients whose primary tumors were located in the cecum, ascending colon, or transverse colon(right-side group)and 43 patients whose primary tumors were located in the descending colon, sigmoid colon, or rectum(left-side group). There was no significant difference in terms of age, sex, Stage, or rate of chemotherapy, but Hinchey stage was significantly higher in the left-side group(p<0.05). The median survival time tended to be longer in the left-side group(68.2 months vs 21.2 months, p=0.05). These results suggest that right-side perforation might cause a poorer prognosis than left-side perforation in patients with perforative colorectal cancer.

[A Case of Giant Retroperitoneal Liposarcoma Resected after Trabectedin Chemotherapy]

The basic treatment for retroperitoneal liposarcoma is surgical therapy. Since the administration of trabectedin for soft tissue sarcoma has been approved, another option for soft tissue sarcoma treatment has been added. We report a case of radical resection after trabectedin therapy for initially unresectable retroperitoneal liposarcoma. A 61-year-old man was admitted to our hospital with an abdominal tumor. A tumor, about 50 cm in maximal diameter, that was not movable throughout the abdomen was observed. Computed tomography revealed a giant tumor almost occupying the entire abdomen, and he was diagnosed with retroperitoneal liposarcoma based on histopathological examination of a puncture specimen. Chemotherapy containing trabectedin was administered. At the end of 8 courses, he achieved stable disease. However, the movability improved, and surgery was performed. The procedure was tumor resection with right kidney, adrenal gland, and inferior vena cava resection. Histopathological examination revealed a mixed type of well differentiated type and dedifferentiated type. The patient is alive without recurrence 10 months after the surgery.

Prognostic Significance of Conversion Surgery Following First- or Second-line Chemotherapy for Unresectable Gastric Cancer

BACKGROUND/AIM

Advances in chemotherapy for gastric cancer have encouraged surgeons to perform conversion surgery following a response to first-line chemotherapy in patients with initially unresectable gastric cancer. In this study we evaluated the efficacy of conversion surgery following first- or second-line chemotherapy for unresectable gastric cancer.

PATIENTS AND METHODS

We retrospectively analyzed clinicopathological and survival data of 94 patients with unresectable gastric cancer treated with first- (n=94) or second-line (n=43) chemotherapy.

RESULTS

Patients who converted to surgery following first- (n=26) or second-line (n=5) chemotherapy had significantly longer survival times than those treated with chemotherapy alone (n=63) (p<0.01). Survival length did not differ significantly between patients converted to surgery following first- and second-line chemotherapy. Among 31 patients who underwent conversion surgery, one initial non-curative factor (odds ratio(OR)=0.49; 95% confidence interval (95%CI)=0.22-0.95; p=0.03) was the only significant independent predictor of longer survival in multivariate Cox regression analysis.

CONCLUSION

Patients with unresectable gastric cancer initially exhibiting one noncurative factor may obtain survival benefit from conversion surgery after a response to both first- and second-line chemotherapy.

[Clinicopathological Study of Perforated Gastric Cancer Treated with Surgery]

This retrospective study evaluated an appropriate surgical treatment in patients with perforated gastric cancer. The clinicopathological and survival data on 17 perforated gastric cancer patients treated with surgery were analyzed. The one-stage or two-stage gastrectomy was performed in 8 and 5 patients, respectively. The omental patch repair was performed in 4 patients. In univariate analysis, non-curative(R2)resection with gross residual tumor(p<0.01)and postoperative complications( p=0.01)were found to be significant unfavorable factors for overall survival(OS). In multivariate analysis, R2 resection was identified to be an only independent significant unfavorable factor for OS. Patients who underwent curative(R0) resection had long-term survival, while patients with R2 resection and postoperative complication had limited survival times. These results suggest that R0 resection may be optimal to improve survival in patients with perforated gastric cancer, regardless of whether patients underwent a one-stage or two-stage gastrectomy based on the patient's condition.

[Status of Hepatic Lymph Node Involvement in Patients with Resectable Liver Metastasis of Colorectal Cancer after Preoperative Chemotherapy]

The liver is the most common metastatic site for colorectal cancer(CRC).The 5-year survival rate of resected cases has been reported to be about 40%.Hepatic lymph node metastasis is reportedly associated with a poor prognosis in patients with liver metastases of CRC.The incidence of hepatic lymph node involvement in patients with liver metastases of CRC ranges from 5% to 28%.However, few reports have focused on hepatic lymph node involvement in patients with resectable liver metastasis who have undergone preoperative chemotherapy.This retrospective study was undertaken to address this issue.The subjects were 33 consecutive patients who had undergone the resection of liver metastases of CRC with hepatic lymph node sampling after preoperative chemotherapy between 2001 and 2016. Hepatic lymph node metastasis was confirmed in only one patient(3%).There was no significant difference in the frequency of hepatic lymph node metastasis between the cases with or without preoperative chemotherapy.The further collection of data is warranted to elucidate the significance of hepatic lymph node involvement in patients with liver metastases of CRC treated with preoperative chemotherapy.

Prognostic Impact of Splenectomy in Patients with Esophagogastric Junction Carcinoma

BACKGROUND/AIM

We evaluated the survival benefit of splenectomy in patients with esophagogastric junction (ECJ) carcinoma.

PATIENTS AND METHODS

We retrospectively examined clinicopathological and survival data for 60 surgically-treated patients with ECJ carcinoma.

RESULTS

The 5-year overall survival (OS) rate was 47%. Splenectomy was performed in 20 patients (30%). Multivariate Cox regression analysis revealed splenectomy (odds ratio (OR), 2.70; 95% confidence interval (CI)=1.06-7.17; p=0.04) and venous invasion (OR=3.03; 95%CI=1.20-9.27; p=0.02) as significant independent predictors of poorer OS. Splenic hilar lymph node metastasis was not observed. Multivariate logistic regression analysis identified perioperative blood transfusion (BTF) as a significant independent factor associated with splenectomy.

CONCLUSION

The survival benefit of splenectomy in ECJ carcinoma patients may decrease with increasing frequency of perioperative BTF for blood loss. We recommend that splenectomy should be performed carefully when indicated by the extent or invasion of EGJ carcinoma.

[Prognostic Impact of Tumor Location of Colorectal Cancer in Patients with Resected Liver Metastasis]

Recently, metastatic colorectal cancer(CRC)patients with a left-side primary tumor have been reported to have a significantly longer survival period than those with a right-side primary tumor. However, the impact of the location of the primary lesion on the survival outcomes of patients with resectable liver metastases of CRC has not yet been fully investigated. The subjects of this retrospective study were 113 consecutive patients who underwent a hepatic metastatectomy for CRC between 2001 and 2016 at our institution. The background data and survival times were compared between 32 patients whose primary lesions were located in the cecum or the ascending colon(right-side group)and 81 patients whose primary lesions were located in the descending colon, sigmoid colon, or rectum(left-side group). No significant differences in various clinicopathological variables were observed between the 2 groups. The 5-year overall and relapse-free survival rates after hepatectomy were 62.1% for the right-side group vs 49.2% for the left-side group(p=0.55)and 37.1% for the right-side group vs 33.4%for the left-sided group(p=0.76), respectively. In conclusion, colorectal liver metastasis should be resected regardless of the primary tumor location.

[The Characteristics and Treatment Outcomes for Desmoid Tumors Associated with Familial Adenomatous Polyposis]

INTRODUCTION

The characteristics of desmoid tumors(DTs)associated with familial adenomatous polyposis(FAP)and relationships between the development of DTs and the sites of APC germline mutation have not closely been examined Japan.

PATIENTS AND METHODS

This retrospective study was performed to address these issues by examining patients with FAP who underwent proctocolectomy between 1981 and 2015.

RESULTS

The cumulative 2-year incidence of DT development was 50%. The DTs developed in the abdominal wall only in 2, in the abdominal wall plus intra-abdominally in 4, and intra-abdominally in 2. Clinical stages according to the Church's classification included Stage I in 3, Stage II in 2, Stage III in 1, and Stage IV in 2. Among 31 patients with a confirmed pathogenic germline APC mutation, patients with mutation in 3' site of codon 1400 (n=7)tended to develop DTs more frequently than those with mutation in 5' site of codon 1400(n=24)(p=0.08). The cumulative 5-year survival rate in patients with DT development was 73.3%. Including 2 patients undergoing initial colectomy at other institutions, the therapeutic efficacy in 4 patients with severe intraabdominal DTs(Stage III /Stage IV )who were given chemotherapy comprising doxorubicin plus dacarbazine(DOX plus DTIC)revealed partial response in 3 and complete response in 1. Febrile neutropenia was recorded in 2 of these patients.

CONCLUSION

The frequency of DTs development and genotype-phenotype relationship of FAP patients seems to concur with those reported from Western countries. Since the DOX plus DTIC therapy for severe DTs is valid but toxicity is high, the development of less toxic regimens are warranted.

[Outcomes of Elderly Patients with Perforated Colorectal Cancer]

We retrospectively investigatedoutcomes in surgically treatedeld erly patients with perforatedcolorectal cancer. The clinicopathological andsurvival data on 54 perforatedcolorectal cancer patients treatedwith surgery were analyzed. They included 12 patients≥75 years old(elderly group)and4 2 patients<75 years old(non-elderly group). There were no significant differences in terms of clinicopathological features, the severity of peritonitis and classification of sepsis, the development of disseminatedintravascular coagulopathy, andmortality within 30days between the 2 groups. The frequency of using chemo- therapy for Stage IV disease did not differ significantly in the 2 groups. The use of adjuvant chemotherapy for Stage II / III disease was significantly less frequent in elderly group than in non-elderly group(p=0.01). The progression-free and overall survival time for Stage II / III diseases did not significantly differ between the 2 groups. In conclusion, the prognosis of elderly patients with perforated colorectal cancer seems to be equivalent to that of the non-elderly patients. The indication of (adjuvant)chemotherapy may be controversial in such elderly patients.

[A Case of Local Recurrence with Negative FDG/PET Findings after a Total Proctocolectomy for Ulcerative Colitis Associated with Colon Cancer with Retroperitoneal Penetration]

We report the case of a 55-year-old man who successfully underwent resection of a recurrence of ulcerative colitis(UC)- associated colon cancer located in the pancreatic body and left kidney. The patient had undergone an emergency laparotomy (total proctocolectomy with stapled ileal-pouch anal anastomosis)for the treatment of a descending colon cancer with retroperitoneal penetration associated with UC at the age of 50 years. At that time, histological examinations revealed a mucinous carcinoma that was classified as Stage II colon cancer. Three years after the patient's initial operation, a CT scan revealed a small mass located between the pancreatic tail and the left kidney. However, the accumulation of FDG was not observed during a positron emission tomography(PET)examination, resulting in close observation. As the size of the tumor and the levels of serum carcinoembryonic antigen and carbohydrate antigen 19-9 gradually increased, recurrence was highly suspected. A distal pancreatectomy and left nephrectomy were performed. Pathological examination showed findings concurrent with a local recurrence of colon cancer. Special histological types, such as mucinous carcinoma, often occur in some colitic cancers. For the postoperative surveillance of patients with colitic cancer, it should be noted that the sensitivity of FDG/PET is lower for mucinous carcinoma of the colon than it is for more common colon cancers.

Efficacy of Conversion Surgery Following S-1 plus Cisplatin or Oxaliplatin Chemotherapy for Unresectable Gastric Cancer

BACKGROUND/AIM

To evaluate the efficacy of conversion surgery following S-1 plus cisplatin (CS) or oxaliplatin (SOX) chemotherapy.

PATIENTS AND METHODS

We retrospectively analyzed clinicopathological and survival data of 74 patients with unresectable gastric cancer receiving CS or SOX.

RESULTS

Fifty-five and nineteen patients received CS and SOX, respectively. Conversion surgery (odds ratio (OR), 0.17; 95% confidence interval (CI), 0.04-0.64; p=0.01) was the only significant independent predictor of longer survival in multivariate Cox regression analysis. Patients (median age, 74 years) receiving SOX were significantly older than those receiving CS (median age=67 years) (p<0.01), although the rates of response, severe toxicity or conversion surgery did not differ significantly between the two treatment groups.

CONCLUSION

Conversion surgery after a response to CS or SOX chemotherapy may have survival benefit in selected unresectable gastric cancer patients, for both non-elderly and elderly patients responding to SOX.

A newly developed continuous zoom-focus endocytoscope

Background and study aims We report the features of a newly developed endocytoscopy system (ECS), the GIF-Y0074. Patients and methods The GIF-Y0074 offers high-definition resolution with a consecutive increase of magnification to × 500. Using ECS, we observed 32 cases of esophageal squamous cell carcinoma (ESCC), 11 cases of gastric cancer, and five cases of duodenal adenoma. Results The images of cells obtained using the GIF-Y0074 at maximum magnification were brighter and clearer than those obtained with previous ECS systems. For diagnosis of ESCC, clearer visualization of the nucleus made nuclear abnormality easier to recognize. Cancer cells were visualized in 10/11 cases of gastric cancer, but removal of mucus still remained a problem. Duodenal adenomas were found to have atypical cells with villi and tubules at the mucosal surface, thus assisting their histological diagnosis in vivo. Conclusion The GIF-Y0074 is an excellent ECS in terms of ease of use, satisfactory resolution, and magnification power, and therefore achieves a level of utility that makes its commercial release justifiable. This ECS heralds a new era of endoscopic and histological diagnosis.

[A Case of Advanced Gastric Cancer Successfully Treated with Curative Conversion Surgery after Chemotherapy with S-1 plus Oxaliplatin]

This report describes a patient with unresectable advanced gastric cancer who was successfully treated with potentially curative conversion surgery after chemotherapy with S-1 plus oxaliplatin(SOX). An 82-year-old man was diagnosed with type 5 gastric cancer(por1, HER2-negative)with multiple granular mucosal necroses that had metastasized throughout his body. Computed tomography revealed multiple lymph node metastases, tumor thrombosis in the splenic and portal veins, and peritoneal dissemination. After 9 courses of first-line chemotherapy with SOX, there was no tumor thrombosis in the splenic and portal veins or peritoneal dissemination, and the primary tumor and lymph node metastases were markedly reduced in size, indicative of a partial response(PR). The patient subsequently underwent total gastrectomy as curative conversion surgery. The histological diagnosis was ypT2N0M0, ypStage I B, and the primary lesion was categorized as Grade 2 gastric cancer. At present, 1 year after surgery, the patient remains alive without tumor recurrence.

[A Case of Familial Adenomatous Polyposis with a Desmoid Tumor Probably Communicating to the Intestinal Lumen That Was Successfully Treated with Non-Surgical Therapy]

A 44-year-old man with familial adenomatous polyposis underwent laparoscopic-assistedtotal proctocolectomy with ilealpouch anal anastomosis(IPAA). Computed tomography conducted 21 months after IPAA demonstrated bilateral hydronephrosis andan intra-abdominal mass with a maximal diameter of 22 cm, leading to a diagnosis of stage IV desmoid disease, according to the classification by Church and associates. Six courses of combination chemotherapy with doxorubicin plus dacarbazine were administered. Computed tomography after chemotherapy demonstrated marked shrinkage of the desmoidtumor with intraabdominal air andfluidcollection extending just below the skin of the ileostomy closure site. Stoollike fluidoverflowedspontaneously through the site of the ileostomy closure andthe abscess cavity was successfully drained. The patient was discharged 30 days after the start of drainage. The patient is doing well 10 months after the drainage without regrowth of the desmoid tumor, even though a cavity-like lesion encapsulatedby a thick wall remains.