Transanal Total Mesorectal Excision for Extended Surgery in the Early Stage After Introduction

BACKGROUND/AIM

The effectiveness of transanal total mesorectal excision (Ta-TME) in extended surgery (ES) has been discussed. This study examined the short-term outcomes of the first 31 patients who underwent Ta-TME after its introduction and verified the safety of Ta-TME in ES in the early stage following its introduction.

PATIENTS AND METHODS

Thirty-one consecutive patients who underwent Ta-TME between December 2021 and January 2023 at our institution were included. The indications for Ta-TME were rectal tumors that could be palpated during rectal examination and bulky tumors that were deemed unresectable without Ta-TME. Short-term outcomes were retrospectively compared between patients who underwent normal Ta-TME, (n=27, TME group) and patients who underwent ES beyond TME (n=4, ES group). The data are shown as the median and interquartile range. Statistical analysis was performed with the Mann-Whitney U-test and Fisher's exact test.

RESULTS

Total pelvic exenteration (TPE) was performed in the 4^th and 8^th patients; the 9^th patient underwent a combined resection of the right adnexa and urinary bladder wall. The 31^st patient underwent a combined resection of the uterus and the right adnexa. The operative time was 353 [285-471] vs. 569 [411-746] min for the TME and ES groups (p=0.039). Blood loss was 8 [5-40] vs. 45 [23-248] ml (p=0.065); postoperative hospital stay was 15 [10-19] vs. 11 [9-15] days (p=0.201); postoperative complications (higher than grade III) were 5 (19%) vs. 0 (p=1.000). Negative CRM was achieved in all cases.

CONCLUSION

Ta-TME in ES was as safe as normal Ta-TME in the early stage after its introduction.

Exploring the role of nerves in asthma; insights from the study of cough

Cough in asthma predicts disease severity, prognosis, and is a common and troublesome symptom. Cough is the archetypal airway neuronal reflex, yet little is understood about the underlying neuronal mechanisms. It is generally assumed that symptoms arise because of airway hyper-responsiveness and/or airway inflammation, but despite using inhaled corticosteroids and bronchodilators targeting these pathologies, a large proportion of patients have persistent coughing. This review focuses on the prevalence and impact of cough in asthma and explores data from pre-clinical and clinical studies which have explored neuronal mechanisms of cough and asthma. We present evidence to suggest patients with asthma have evidence of neuronal dysfunction, which is further heightened and exaggerated by both bronchoconstriction and airway eosinophilia. Identifying patients with excessive coughing with asthma may represent a neuro-phenotype and hence developing treatment for this symptom is important for reducing the burden of disease on patients' lives and currently represents a major unmet clinical need.

Laparoscopic completion gastrectomy in elderly patients with remnant gastric cancer: a case series

Background

Open completion gastrectomy (OCG) has been selected to treat remnant gastric cancer (RGC) due to severe adhesions and difficulty recognizing anatomical orientation after primary gastrectomy. In general, elderly individuals’ physiological reserves gradually decrease. Moreover, elderly patients (EPs) often have multiple complicating factors (i.e., frailty and comorbidities), leading to more postoperative complications after abdominal surgery. Recently, several trials revealed the advantages of laparoscopic surgery for EPs with gastric cancer in early recovery. However, there are limited studies investigating the use of laparoscopic completion gastrectomy (LCG) for RGC in EPs. This study aims to assess the efficacy of LCG in EPs aged ≥ 70 years. We compared the short- and long-term outcomes of LCG with those of OCG.

Case presentation

Twenty-one EPs who underwent completion gastrectomy for RGC between 2007 and 2017 were enrolled and classified into two groups according to the surgical approach, namely the LCG (n = 6) and OCG (n = 15) groups. We adopted the G8 geriatric screening tool to comprehensively evaluate the EPs’ physical, mental, and social functions. Patient characteristics, clinicopathological characteristics, surgical outcomes, and survival were retrospectively reviewed and compared between groups.

Results

There was no significant difference in the preoperative modified G8, indicating that the EPs’ backgrounds between the groups were comparable. Of note, blood loss during surgery was significantly reduced in the LCG group [median (range); LCG, 50 ml (20.0–65.0); OCG, 465 ml (264.5–714.0); p = 0.002]. The median number of retrieved lymph nodes in the LCG and OCG groups were 7 (range 4–10) versus 3 (range 1–6), respectively. There were no statistically significant differences in postoperative hospitalization, intake of solid food, and Clavien–Dindo grade ≥ II postoperative complications. In patients with a history of gastrectomy for gastric cancer in the LCG group, operative time tended to be longer in patients who underwent D2 lymph node dissection as primary surgery.

Conclusions

LCG was comparable to OCG for the treatment of RGC in EPs with significantly reduced blood loss. While LCG should be selected with caution in patients who have undergone D2 lymph node dissection as primary surgery, it could be considered as a surgical procedure in EPs with RGC.

Laparoscopic total gastrectomy for remnant gastric cancer: A single-institution experience

INTRODUCTION

The incidence of remnant gastric cancer is increasing because of past use of subtotal gastrectomy to treat peptic ulcer and increased survival rates after radical gastrectomy for gastric cancer. The feasibility and advantages of laparoscopic total gastrectomy (LTG) for remnant gastric cancer remain unclear. Therefore, we aimed to investigate the safety, feasibility, and clinical short-term outcomes of LTG for remnant gastric cancer.

METHODS

Patients who underwent completion total gastrectomy for remnant gastric cancer between April 2007 and October 2017 were divided into two groups: the open total gastrectomy (OTG) group and the LTG group. Clinicopathological data and short-term outcomes were analyzed.

RESULTS

A total of 31 remnant gastrectomies (23 OTG, 8 LTG) were performed. Blood loss was significantly lower in the LTG group than in the OTG group (135.5 vs 568.3 mL, P = 0.013). However, there was no significant difference in the operation time, days to food intake, or length of hospital stay between the two groups. Additionally, there was no significant difference in the postoperative complications, number of retrieved lymph nodes, or pathological findings. Two LTG patients (25.0%) required conversion to open surgery. There was no mortality in either group.

CONCLUSIONS

LTG for remnant gastric cancer can be a safe treatment option and may have an advantage of less blood loss than OTG.

Life-threatening giant esophageal neurofibroma with severe tracheal stenosis: a case report

BACKGROUND

Benign esophageal tumors are relatively rare, and a neurofibroma in the esophagus is extremely rare. Dysphagia is the most common clinical manifestation in patients with esophageal neurofibroma, and no cases of giant esophageal neurofibroma with severe tracheal stenosis have been reported.

CASE PRESENTATION

A 73-year-old woman presented with shortness of breath, and computed tomography scan exhibited a giant mediastinal tumor causing severe tracheal stenosis. An upper gastrointestinal endoscopy revealed a giant submucosal lesion without mucosal changes located 18-23 cm from the incisor teeth. ¹⁸F-fluorodeoxyglucose (FDG)-positron emission tomography image revealed an upper mediastinal homogeneous mass and left supraclavicular lymph node with increased FDG accumulation. We performed endoscopic ultrasound-guided fine-needle aspiration biopsy; however, a definitive diagnosis could not be determined. During further investigation, her shortness of breath suddenly worsened and she suffered from wheezing. Because of risk of smothering, we decided to perform quasi-urgent lifesaving surgery. Under the preparation of extracorporeal membrane oxygenation (ECMO) when tracheal intubation fails, bronchial blocker was inserted over the tracheal stenosis and the left-lung ventilation was performed via intubation alone. Under general anesthesia, the patient was placed in the left lateral position and we performed right thoracotomy. The tumor strongly adhered to the trachea; however, the trachea or recurrent laryngeal nerves were not damaged in the surgery. Following esophagectomy, we performed gastric conduit reconstruction through the posterior mediastinum, and hand-sewn anastomosis was performed in the left neck. Immunohistochemical staining was positive for S-100 but negative for c-KIT, CD34, α-SMA, and desmin; these morphological and immunohistochemical characteristics were consistent with the diagnosis of neurofibroma.

CONCLUSIONS

It is often difficult to diagnose esophageal neurofibroma preoperatively. The preparation of ECMO could be considered in patients with severe airway obstruction for safe tracheal intubation. This is the first case of life-threatening giant esophageal neurofibroma with severe tracheal stenosis.

[A Case of Small Bowel Adenocarcinoma That Was Diagnosed and Treated using Laparoscopic Surgery]

A 40-year-old man presented to our department with chief complaints of nausea and abdominal pain, and was diagnosed with small intestine ileus. After hospitalization, he underwent intestinal tract decompression using an ileus tube. A small bowel tumor was suspected as the cause of the intestinal obstruction. We then performed laparoscopic surgery for diagnosis and resection. In the intraoperative findings, stenosis near the small intestine tumor could be confirmed. The patient therefore underwent laparoscopic resection of a segment of the small intestine. Following rapid intraoperative pathological examination, the tumor was identified as well-differentiated adenocarcinoma with metastasis of the intermediate mesenteric lymph nodes. We then performed dissection of the main lymph nodes using small laparotomy incisions. Adjuvant chemotherapy with XELOX(130mg/m2 L-OHP on day 1 and 2,000 mg/m2 capecitabine on days 1-14)was administered for 6 months. Currently the patient is in relapse-free survival.

Postoperative Delirium in Patients after Pancreaticoduodenectomy

BACKGROUND/AIMS

Postoperative delirium (POD) is one of the most common complications after various types of surgery. The aim of this study was to investigate the incidence and risk factors for delirium after pancreaticoduodenectomy (PD).

METHODS

This was a retrospective study of 146 consecutive patients who underwent PD between April 2007 and June 2015 at Saiseikai Yokohamashi Tobu Hospital.

RESULTS

Twenty-nine patients (19.9%) were diagnosed with delirium. Patients who were >70 years were divided into a delirium group (n = 24) and a non-delirium group (n = 41). Multivariate analysis showed that only the Charlson Age Comorbidity Index (CACI) (OR 1.8; 95% CI 1.067-3.036; p = 0.028) was an independent risk factor of delirium for patients >70 years. The receiver operating characteristic curve revealed an optimal cutoff value of 4.5 for the CACI score in all patients (sensitivity 62.1%; specificity 82.9%; area under the curve 0.782). The higher CACI score (≥5) is significantly different from the lower CACI score (p < 0.0001) with respect to POD occurrence.

CONCLUSIONS

The CACI, especially in elderly patients, was associated with the incidence of POD. Therefore, utilizing this validated and practical tool preoperatively might be useful for POD.

[Local Control of Advanced Breast Cancer with Mohs Paste and Systemic Therapy]

Unresectable locally advanced breast cancer results in a decline in patient quality of life because of the presence of bleeding, exudates, and strong odor. The clinical application of supportive care using Mohs paste for improving quality of life has become widespread. We report 2 cases of locally advanced breast cancer treated with systemic therapy and chemosurgery. Case 1 was a Japanese woman in her fifties who had a locally advanced left breast cancer. She had continuous bleeding and exudates, and received Mohs chemosurgery and endocrine therapy. One month later, the surface healed and dried up. The bleeding, exudates, and strong odor disappeared almost completely. Case 2 was a Japanese woman in her forties who had a locally advanced left breast cancer with massive exudates and oozing blood. She underwent Mohs chemosurgery 20 times, but the exudates and bleeding were not controlled. According to pathological findings, we confirmed her breast cancer to be of the triple negative subtype. After 2 courses of therapy with 5-fluorouracil, epirubicin, and cyclophosphamide, the tumor immediately decreased in diameter by 65%. The bleeding, exudates, and strong odor disappeared. Although Mohs chemosurgery is useful for local control of locally advanced breast cancer, this alone is insufficient to treat the disease. Early introduction of systemic therapy is considered essential in breast cancer treatment.

[Stereotactic Body Radiotherapy with CyberKnife®for Liver Metastases from Colorectal Cancer]

For treatment of colorectal liver metastases, liver resection is recommended for resectable cases in the clinical guidelines for colorectal cancer. On the other hand, there are currently no data supporting the efficacy of radiation therapy as a topical treatment, and this treatment can therefore not presently be recommended. With CyberKnife®, it is possible to perform stereotactic radiation therapy using a linear accelerator with high accuracy, even for lesions in the trunk area such as liver metastases. Between December 2009 and September 2014 in our hospital, we performed radiation treatment using CyberKnife® for 14 cases with 22 colorectal liver metastases. As a result, we obtained response and local control rates of 76.2%and 81.0%, respectively. Moreover, no advanced adverse events were observed. Thus, we consider that CyberKnife® treatment for colorectal liver metastases is effective as a topical treatment, with low invasiveness and high safety.

Utility of Intraductal Ultrasonography as a Diagnostic Tool in Patients with Early Distal Cholangiocarcinoma

BACKGROUND/AIMS

It is difficult to diagnose cholangiocarcinoma in the early stages because most patients present with jaundice, which is generally thought to be the most important symptom at diagnosis. Despite improvements to surgical instruments and techniques, these rates are not quite satisfactory. Intraductal ultrasound (IDUS) is easy to handle due to the wire-guided, thin-caliber, and high-frequency probe. The purpose of the present study was to assess the efficacy of IDUS as a diagnostic tool for patients with early distal cholangiocarcinoma.

METHODOLOGY

We enrolled 23 with early distal cholangiocarcinoma. The cholangiography and IDUS findings were retrospectively analyzed. The morphology of the tumors detected by IDUS was also classified including localized wall thickening, polypoid lesion, and sessile tumor.

RESULTS

The morphologies on IDUS were as follows: five (21.7%) localized wall thickenings, five (21.7%) polypoid lesions, and 13 (56.5%) sessile tumors.

CONCLUSIONS

Since forceps biopsy complemented by IDUS can substantially improve the diagnostic rate, pathological investigations should be performed simultaneously after detection by IDUS. We believe that noninvasive modalities should be followed by IDUS and used as a decisive approach to distinguish between benign and malignant status.

[Nanoparticle albumin-bound Paclitaxel for unresectable or recurrent gastric cancer]

The efficacy and safety of nanoparticle albumin-bound paclitaxel(nab-paclitaxel)administered every 3 weeks for unresectable or recurrent gastric cancer was evaluated retrospectively. Nab-paclitaxel was intravenously administered at 260 mg/ m² on day 1 of each 21-day course without anti-allergic premedication until disease progression or discontinuation. Nine patients received nab-paclitaxel. The overall response rate was 11.1%, and the disease control rate was 55.6%. Grade 3/4 toxicities included neutropenia(44.4%), leukopenia(33.3%), and peripheral sensory neuropathy (33.3%). It is important to manage both neutropenia and peripheral neuropathy. Although only few cases were analyzed, therapeutic effect can be obtained even with the starting dose of 180 mg/m² suggesting management of toxicities will be feasible. In view of the toxicities observed, a reduced starting dose of 180 mg/m² should be considered in the case of poor performance status patients. Nab-paclitaxel is a promising drug because of its convenience and may replace weekly paclitaxel for unresectable or recurrent gastric cancer.

[A case of gastric cancer showing response to first-line XP regimen after lymph node recurrence during the administration of S-1 as postoperative adjuvant chemotherapy]

We report on a patient who underwent total gastrectomy with D2 lymph node dissection for metastatic gastric cancer. We administered S-1 at 60 mg/m² as postoperative adjuvant chemotherapy. Six months after surgery, recurrence was detected in the para-aortic lymph node. As a first-line treatment for the recurrent cancer, the patient underwent capecitabine/CDDP therapy(capecitabine 1,800 mg/m², CDDP 60 mg/m²). A significant reduction in the recurrent lymph nodes was observed by CT after 6 months of administration, resulting in 24 months of progression-free survival. S-1/CDDP therapy is recommended as a first-line chemotherapy for recurrent gastric carcinoma in the Japanese gastric cancer treatment guidelines. Likewise, single agent S-1 administration is recommended as postoperative adjuvant chemotherapy for advanced gastric cancer patients. However, in cases of recurrence after S-1 therapy, there is insufficient evidence on the efficacy of S-1/CDDP; thus, the type of administration and time to recurrence could be considered for optimization. We identified a case of gastric cancer showing response to first-line capecitabine/CDDP therapy after lymph node recurrence following the administration of S-1 as postoperative adjuvant chemotherapy. Since capecitabine and S-1 differ in their mechanisms of action and as predictive factors for therapeutic effect, capecitabine may be an efficient option in cases of S-1 failure. The present case suggests that capecitabine/CDDP therapy may be an effective treatment for S-1 pretreated patients with advanced or metastatic gastric cancer.

[A case of metastatic rectal cancer with fulminant hepatitis caused by XELOX therapy]

We report a case of fulminant hepatitis that was caused by XELOX therapy administered for metastatic rectal cancer. A 69- year-old man with metastatic rectal cancer received 4 courses XELOX therapy. He was subsequently admitted to our hospital with general fatigue. Shenzhen flapping and altered consciousness were noticed on the fifth day of hospitalization. A liver biopsy was subsequently performed. The patient was diagnosed with liver failure due to sinusoidal obstruction syndrome caused by oxaliplatin. This case provides valuable information as there are only a few reports of fulminant hepatitis caused by oxaliplatin.

Examination of clinical efficacy of keishibukuryogan on non-specific complaints associated with varicose veins of the lower extremity

The subjective symptoms of varicose veins of the lower extremity often include malaise, numbness, coldness, pain, and pruritus of the lower extremity, and relieving these complaints is important in managing the quality of life of patients. We have examined the clinical efficacy of keishibukuryogan, a Kampo prescription for improving oketsu (impaired microcirculation, congestion), on non-specific complaints associated with varicose veins of the lower extremity. Keishibukuryogan was administered to 30 patients with non-specific complaints associated with varicose veins of the lower extremity for 12 weeks, resulting in improvements in the scores of subjective symptoms, severity of varicose veins, and oketsu as well as an increase in skin perfusion pressure. And especially the effect was remarkable in female. In addition, oketsu was shown to be involved in the subjective symptoms associated with varicose veins of the lower extremity, demonstrating efficacy of keishibukuryogan. No adverse drug reaction or abnormal laboratory result was observed in patients receiving keishibukuryogan, and the rate of general improvement and usefulness was 73.3%. It was suggested that keishibukuryogan was useful to improve the symptoms of patients with non-specific complaints associated with varicose veins of the lower extremity especially in female patients. (English translation of Jpn J Phlebol 2013; 24: 303-310).

Evaluation of Predictive Factors in Patients with Nonalcoholic Fatty Liver Disease after Pancreaticoduodenectomy

Patients who undergo pancreaticoduodenectomy (PD) are at risk of steatosis because resection of the pancreatic head causes pancreatic exocrine and endocrine insufficiency. We investigated the clinicopathological features and the risk factors of nonalcoholic fatty liver disease (NAFLD) after PD. This was a retrospective study of 100 patients who underwent PD between April 2007 and December 2012 in our institution. Preoperative demographic and clinical data, surgical procedures, pathological diagnosis, postoperative course findings, and complication details were collected prospectively. The patients were divided into the following two groups: Group A consisted of 12 patients who developed postoperative NAFLD, and Group B consisted of 88 patients who did not develop postoperative NAFLD. Pancreatic carcinoma and pancreatic texture showed similar findings. Additionally, we found that blood loss significantly correlated with the incidence of nonalcoholic steatohepatitis after PD. In multivariate analysis, only blood loss was identified as the most influential risk factor for NAFLD (hazard ratio, 1.0001; P = 0.016). Blood loss was identified as an independent risk factor for the development of NAFLD after PD. Further prospective studies are needed to identify factors that put patients at risk for NAFLD after PD. Continuing efforts should be made to improve patient outcomes and understand the pathogenesis of postpancreatectomy NASH.

Evaluation of predictive factors in patients with nonalcoholic fatty liver disease after pancreaticoduodenectomy

Patients who undergo pancreaticoduodenectomy (PD) are at risk of steatosis because resection of the pancreatic head causes pancreatic exocrine and endocrine insufficiency. We investigated the clinicopathological features and the risk factors of nonalcoholic fatty liver disease (NAFLD) after PD. This was a retrospective study of 100 patients who underwent PD between April 2007 and December 2012 in our institution. Preoperative demographic and clinical data, surgical procedures, pathological diagnosis, postoperative course findings, and complication details were collected prospectively. The patients were divided into the following two groups: Group A consisted of 12 patients who developed postoperative NAFLD, and Group B consisted of 88 patients who did not develop postoperative NAFLD. Pancreatic carcinoma and pancreatic texture showed similar findings. Additionally, we found that blood loss significantly correlated with the incidence of nonalcoholic steatohepatitis after PD. In multivariate analysis, only blood loss was identified as the most influential risk factor for NAFLD (hazard ratio, 1.0001; P = 0.016). Blood loss was identified as an independent risk factor for the development of NAFLD after PD. Further prospective studies are needed to identify factors that put patients at risk for NAFLD after PD. Continuing efforts should be made to improve patient outcomes and understand the pathogenesis of postpancreatectomy NASH.

Reintroduction of oxaliplatin for patients with metastatic colorectal cancer refractory to standard chemotherapy regimens

630

Background: Reintroduction of oxaliplatin seems to have clinical benefits for patients with metastatic colorectal cancer refractory to standard chemotherapy regimens. A interim analysis of RE-OPEN study reported 38.9% of disease control rate (DCR) in ASCO GI 2013, but it is still unknown who will receive benefits from reintroduction of oxaliplatin. Methods: Among patients in whom oxaliplatin was reintroduced in the 7 participating hospitals, we retrospectively studied patients who had previously received oxaliplatin and irinotecan and patients who had a response of stable disease or better during initial treatment with oxaliplatin. Results: From June 2009 through January 2013, oxaliplatin was reintroduced in 53 patients (31 men and 22 women). The median age was 64 years, and the performance status was 0 in 24 patients and 1 in 29. The reasons for discontinuing initial treatment with oxaliplatin were progressive disease in 36 patients, adverse events in 14 and others in 3. The response rate (RR), DCR, the median progression-free survival (PFS), and the median overall survival were 3.8%, 47.2%, 105 days, and 313 days, respectively. As for adverse events, allergic reactions to oxaliplatin (grade 1 or higher) occurred in 26% of the patients. RR, DCR, and PFS in 44 patients with the oxaliplatin-free-interval (OFI) over 6 months were 4.6%, 54.6%, and 119 days, respectively, and were statistically better than those in 9 patients with OFI less than 6 months (0%, 11.1%, and 84 days). Reintroduction of oxaliplatin with bevacizumab showed better PFS than that without bevacizumab (114 days and 78 days, respectively). Conclusions: Reintroduction of oxaliplatin was suggested to be one option for the management of colorectal cancer that is resistant to standard therapy, especially in patients with OFI over 6 months. Bevacizumab may enhance the results of reintroduction treatment.

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

A 70-year-old woman was diagnosed as having advanced lower thoracic esophageal cancer with abdominal lymph node metastases(T3N1M0, Stage III). After administering 2 courses of neoadjuvant chemotherapy with 5-fluorouracil(5- FU)( 800 mg/m2)and cisplatin(80 mg/m2), we performed curative surgery with D2 lymph node dissection. The patient could not receive adjuvant chemotherapy because of her poor performance status. After curative surgery, liver metastasis appeared in segment 8. The liver metastasis(S8)was treated with stereotactic body radiation therapy(SBRT)( 60 Gy/3 Fr). After SBRT, we administered systemic chemotherapy with docetaxel and nedaplatin as second-line chemotherapy. The patient had no recurrence for 12 months after SBRT. SBRT exhibited an excellent local therapeutic effect without any serious complications, suggesting that it is an effective treatment for liver metastasis from esophageal cancer.

[A case of metachronous ovarian metastasis after curative surgery of colon cancer with simultaneous hepatic metastasis]

The patient was a 51-year-old woman who presented with nausea, vomiting, and abdominal pain. Detailed examination revealed a carcinoma of the descending colon with simultaneous hepatic metastasis. Because the carcinoma comprised a circumferential stenotic lesion and resection of the hepatic metastasis was feasible, combined left hemicolectomy and hepatectomy were initially performed. During postoperative adjuvant chemotherapy, the hepatic metastasis was observed to increase in size, and therefore, a second hepatectomy was performed approximately 2 years and 6 months after the initial surgery. Adjuvant chemotherapy was subsequently continued for approximately 1 year. A metastatic ovarian tumor was identified on abdominal computed tomography (CT) approximately 1 year after chemotherapy was discontinued. Bilateral salpingo-oophorectomy was performed approximately 3 years and 6 months after the initial surgery. Histopathological examination revealed the lesion to be a colon carcinoma metastasis.

[Neoadjuvant chemotherapy with capecitabine plus oxaliplatin and bevacizumab for the treatment of patients with resectable metastatic colorectal cancer]

We analyzed the clinical efficacy and safety of capecitabine plus oxaliplatin( XELOX) and bevacizumab( BV) as neoadjuvant chemotherapy, administered for the treatment of patients with resectable metastatic colorectal cancer between October 2009 and December 2012. Of the 15 patients who received chemotherapy, 9 received XELOX plus BV and 6 patients received XELOX alone. The median number of therapy courses was 4. The overall response rate was 73.3%. All patients underwent R0 resection. The median disease-free survival was 522 days. The median follow-up time was 607 days. No major Grade 3 or 4 adverse events occurred during chemotherapy and no perioperative complications were noted. Our findings suggest that XELOX (plus BV) as neoadjuvant therapy is useful for the prevention of early recurrence and is clinically efficacious and safe for the treatment of colorectal cancer with resectable metastases.

UDP-glucuronosyltransferase (UGT) 1A1*28 polymorphism-directed phase II study of irinotecan with 5'-deoxy-5-fluorouridine (5'-DFUR) for metastatic colorectal cancer

AIM

We performed a phase II study of irinotecan with 5'-deoxy-5-fluorouridine (5'-DFUR) for metastatic colorectal cancer based on UDP-glucuronosyltransferase (UGT) 1A1 polymorphism.

PATIENTS AND METHODS

A total of 28 patients were enrolled. The dose of irinotecan was 150 mg/m(2) for patients with the *1/*1 wild-type genotype, and 70 mg/m(2) for those with the *1/*28 mutated genotype. The primary end-point was the response rate (RR); secondary end-points were safety, time to treatment failure (TTF), and overall survival (OS).

RESULTS

In 28 patients total, genotype was wild-type in 22 and mutated in six. The RR was *1/*1 (22.7%; wild-type) vs. *1/*28 (16.7%; mutated); the median TTF was 5 months vs. 4.5 months, and the median OS was 13 months vs. 17.5 months, respectively. None of these differences were significant. Toxicities of grade 3 or higher were neutropenia (9.0% vs. 0%, respectively) and diarrhea (13.6% vs. 0%, respectively).

CONCLUSION

This genotype-oriented therapy was effective and safe, and thus appears useful for patients who have complications or advanced age.

Fermentation of xylose causes inefficient metabolic state due to carbon/energy starvation and reduced glycolytic flux in recombinant industrial Saccharomyces cerevisiae

In the present study, comprehensive, quantitative metabolome analysis was carried out on the recombinant glucose/xylose-cofermenting S. cerevisiae strain MA-R4 during fermentation with different carbon sources, including glucose, xylose, or glucose/xylose mixtures. Capillary electrophoresis time-of-flight mass spectrometry was used to determine the intracellular pools of metabolites from the central carbon pathways, energy metabolism pathways, and the levels of twenty amino acids. When xylose instead of glucose was metabolized by MA-R4, glycolytic metabolites including 3- phosphoglycerate, 2- phosphoglycerate, phosphoenolpyruvate, and pyruvate were dramatically reduced, while conversely, most pentose phosphate pathway metabolites such as sedoheptulose 7- phosphate and ribulose 5-phosphate were greatly increased. These results suggest that the low metabolic activity of glycolysis and the pool of pentose phosphate pathway intermediates are potential limiting factors in xylose utilization. It was further demonstrated that during xylose fermentation, about half of the twenty amino acids declined, and the adenylate/guanylate energy charge was impacted due to markedly decreased adenosine triphosphate/adenosine monophosphate and guanosine triphosphate/guanosine monophosphate ratios, implying that the fermentation of xylose leads to an inefficient metabolic state where the biosynthetic capabilities and energy balance are severely impaired. In addition, fermentation with xylose alone drastically increased the level of citrate in the tricarboxylic acid cycle and increased the aromatic amino acids tryptophan and tyrosine, strongly supporting the view that carbon starvation was induced. Interestingly, fermentation with xylose alone also increased the synthesis of the polyamine spermidine and its precursor S-adenosylmethionine. Thus, differences in carbon substrates, including glucose and xylose in the fermentation medium, strongly influenced the dynamic metabolism of MA-R4. These results provide a metabolic explanation for the low ethanol productivity on xylose compared to glucose.

Clinicopathological features of early distal cholangiocarcinoma

BACKGROUND/AIM

The purpose of this study was to evaluate the clinicopathological features of early distal cholangiocarcinoma compared with advanced tumors.

METHODOLOGY

This was a retrospective study of 45 patients who underwent resection for distal cholangiocarcinoma. There were 17 cases of early and 28 cases of advanced tumors. Data on demographic and clinical features, surgical procedures, and pathological diagnoses were collected retrospectively.

RESULTS

Preoperative mean serum levels of bilirubin, alkaline phosphatase, and gamma-glutamyltransferase were statistically different between the early and advanced groups. There were no significant differences in the diameter of the common hepatic duct between groups, and there were significant differences in all tests but intraductal ultrasonography (IDUS) in tumor detection, meaning that IDUS is a very useful modality for detecting early and advanced cancer although early cancer is difficult to detect using other modalities.

CONCLUSIONS

We believe that early cancer detection will generally lead to better prognosis. Further studies are needed, and efforts should continue to identify patients with suspicious findings.

[Efficacy and safety of cetuximab+irinotecan for unresectable advanced or recurrent colorectal cancer]

BACKGROUND

In July 2008, cetuximab treatment for unresectable advanced or recurrent colorectal cancer was approved in Japan, but there have been few reports on this therapy in Japan.

PURPOSE

We retrospectively analyzed the efficacy and safety of cetuximab(Cmab)+irinotecan(CPT-11)for unresectable advanced or recurrent colorectal cancer from October 2008 to April 2010 at 5 centers in the Kanagawa region.

PATIENTS AND METHODS

The number of patients enrolled was 38, all of whom were treated after second-line therapy.

RESULTS

The RR was 24%. DCR was 68%. TTF was 105 days and OS was 242 days.

CONCLUSION

At 5 centers, Cmab+CPT-11 was an effective and safe treatment after second-line therapy.

Strategies to prevent pancreatic fistula after pancreaticoduodenectomy

BACKGROUND/AIMS

We evaluated the prevention of pancreatic fistula after pancreaticoduodenectomy in a retrospective clinical study.

METHODOLOGY

Eighty patients undergoing pancreaticoduodenectomy between April 2007 and August 2011 were recruited.In all patients, the pancreas was reconstructed first,followed by reconstruction of the hepatic duct and the duodenum or stomach.

RESULTS

Pancreatic fistulae were observed in 21 of 80 patients (26.3%; Grade A/B/C: 9/12/0). The incidence of pancreatic fistula in patients with soft pancreas was higher than that inpatients with hard pancreas (p<0.01). We investigated 54 patients with soft pancreas and pancreatic fistulae were diagnosed in 19 patients (35.2%; Grade A/B/C: 8/11/0). We evaluated pancreatic drainage methods (internal stent/external stent: 20/34) and in patients with soft pancreata, pancreatic fistulae were observed in 11 patients (55%) with internal stents vs. eight patients (23.5%) with external stents(p<0.05).

CONCLUSIONS

We evaluated the management of pancreatic drainage methods and external stents were associated with a significantly lower incidence of pancreatic fistula compared with internal stents.We expect that external drainage of soft pancreas will decrease pancreatic juice leakage into the abdominal cavity. Many randomised control trials on pancreatic drainage have been reported recently; we plan to study them.

[A comparative study of S-1 plus cisplatin and S-1 plus weekly cisplatin for unresectable gastric cancer]

Clinical efficacy and safety were analyzed in patients with unresectable gastric cancer receiving S-1 plus CDDP(CS) therapy or S-1 plus weekly CDDP (w-CS) therapy as first-line treatment between April 2007 and December 2010. Fifteen patients received CS therapy and 17 received w-CS therapy. CS therapy was used according to the SPIRITS regimen, and w-CS therapy of S-1 80 mg/(m2·day) was administered for 2 weeks followed by a 1-week rest, with CDDP 20 mg/m2 being injected intravenously on days 1 and 8. In the CS therapy group and w-CS therapy group, the overall response rates were 33.3% and 70.1%, the median overall survival periods were 135 and 174 days (p=0.113), and the median follow- up times were 196 and 352 days (p=0.196), respectively. The w-CS therapy group showed less adverse events than did the CS therapy group. This study suggested that the w-CS regimen is a useful treatment modality showing clinical efficacy and safety for unresectable gastric cancer.

The impact of obesity on perioperative outcomes of pancreaticoduodenectomy

BACKGROUND/AIMS

The purpose of this study was to evaluate the impact of obesity on pancreaticoduodenectomy (PD) outcomes.

METHODOLOGY

Subjects were 97 patients undergoing PD at our institution between April 2005 and April 2011. All patients had data including body mass index (BMI). Patients were divided into two groups based on BMI; normal group (BMI <25kg/m2) and overweight group (BMI >25kg/m'). Perioperative outcomes were collected prospectively.

RESULTS

There were no significant differences between the two groups in terms of intraoperative data, surgical time, blood loss and blood transfusion rates. The over-all complication rate was 50.0% (53.6% in the over- weight group and 47.1% in the normal group; p=0.55).The most common complication overall was pancreatic fistula (34.7%). There was also a significant difference in the rate of intra-abdominal fluid collection (four patients in the overweight group (14.3%) vs. two patients in the normal group (2.9%), respectively; p<0.05).There was no significant difference in the mortality rate between the normal group and the overweight group(3.6% vs. 0%, p=0.11).

CONCLUSIONS

Management of overweight patients in the perioperative period should therefore address any modifiable risk factors for operative complications.

[Two cases of retroperitoneal liposarcoma]

We report 2 cases of retroperitoneal liposarcoma. Case 1: A 53-year-old woman with severe abdominal distension and dyspnea was admitted to our hospital. Abdominal computed tomography(CT) and magnetic resonance imaging(MRI) revealed a large mass that occupied almost the entire abdominal cavity. She underwent surgery under the diagnosis of retroperitoneal liposarcoma. The tumor originated from the left lower pelvis. The tumor weighed 18 kg, and the histopathological diagnosis was well-differentiated liposarcoma. Seven years after the operation, local recurrence was found without any complaints. The operation was performed again. The tumor weighed 750 g, and it originated from the same area as observed in the first operation. The histopathological diagnosis was well-differentiated liposarcoma. Case 2: An 82-year-old woman complained of abdominal distension. A new dumbbell-like solid tumor was identified as retroperitoneal liposarcoma by CT and MRI findings, and it was growing rapidly. The tumor was removed with the cecum and right kidney in a curative operation. The tumor weighed 2.6 kg, and the histopathological diagnosis was dedifferentiated liposarcoma. The best treatment for retroperitoneal liposarcoma is curative resection. However, dedifferentiation occasionally occurs over time and in recurrent cases. It is important to follow-up strictly for retroperitoneal liposarcoma.

[Adjuvant chemotherapy with S-1 plus docetaxel for highly advanced gastric cancer patients]

BACKGROUND

Adjuvant chemotherapy with S-1 monotherapy might be insufficient for Stage IIIB highly advanced gastric cancer patients. Our retrospective study was to evaluate the feasibility and safety of adjuvant chemotherapy with S-1 plus docetaxel.

METHODS

S-1 (80 mg/m2) was administered orally for 2 weeks then followed by a 1-week rest period. Docetaxel (40 mg/m2) was simultaneously administered on day 1. The treatment was administered for 1 year and began 6 weeks after D2 curative surgery.

RESULTS

Five patients tolerated adjuvant chemotherapy with S-1 plus docetaxel for 1 year (17 courses of treatment). Grade 3/4 hematological toxicities were observed in 10% patients (n=1). Grade 3/4 non-hematological toxicities were observed in 20% patients (n=2).

CONCLUSIONS

We concluded that S-1 plus docetaxel as adjuvant chemotherapy is a promising strategy for patients with highly advanced gastric cancer.

Endoscopic management of pancreatic duct injury by endoscopic stent placement: a case report and literature review

Recently, the diagnostic evaluation of pancreatic injury has improved dramatically. On the other hand, it is occasionally difficult to diagnose pancreatic injury, because there are no specific signs, symptoms, or laboratory findings. Radiological imaging also often fails to identify pancreatic injury in the acute phase. Delayed diagnosis results in significant morbidity and mortality. Most cases of pancreatic injury with suspicion or pancreatic duct disruption require surgery. Endoscopic retrograde cholangiopancreatography is one of the most accurate modalities for ductal evaluation and therapy and might enable one to avoid unnecessary surgery. We describe endoscopic management of pancreatic duct injury by endoscopic stent placement. A 45-year-old woman was admitted after a traffic accident. A computed tomography scan showed pancreatic parenchyma disruption at the pancreatic head. Endoscopic retrograde cholangiopancreatography demonstrated disruption of the pancreatic duct with extravasation into the peripancreatic fluid collection. A 5-French endoscopic nasopancreatic drainage (ENPD) tube was placed. Her symptoms dramatically improved. ENPD tube was exchanged for a 5-French 5-cm pancreatic stent. Subsequent follow-up CT revealed remarkable improvement. On the 26th day, the patient was discharged from the hospital without symptoms or complications. In this report, a pancreatic stent may lead to rapid clinical improvement and enable surgery to be avoided. On the other hand, the reported complications of long-term follow-up make the role of stenting uncertain. Thus, close attention should be paid to stenting management in the follow-up period. A pancreatic stent is useful for pancreatic ductal injury. If pancreatic ductal injury is managed appropriately, a pancreatic stent may improve the clinical condition, and also prevent unnecessary surgery.

Clinicopathological feature of extrahepatic cholangiocarcinoma without jaundice: a single-center experience

BACKGROUND/AIMS

The prognosis remains unsatisfactory even if the patient undergoes extensive surgery, which is the only curative treatment for these tumors. Therefore, early detection and diagnosis are needed to improve long-term survival. To investigate the clinicopathological feature of extrahepatic cholangiocarcinoma in patients presenting without jaundice compared with the features of tumors in patients presenting with jaundice.

METHODOLOGY

This was a retrospective study of 50 patients resected for extrahepatic cholangiocarcinoma. There were 15 non-jaundiced (Group A) and 35 jaundiced patients (Group B). Data on demographic and clinical features, surgical procedures and pathological diagnoses were collected retrospectively.

RESULTS

Preoperative mean serum levels of total bilirubin, aspartate aminotransferase, alanine aminotransaminase, alkaline phosphatase and gamma-glutamyltranspeptidase were statistically different between the groups. There was also a significant difference in the location of tumors. The distal tumors occurred in 9 non-jaundiced and 31 jaundiced patients (p=0.048). There were no significant differences between the characteristics and preoperative laboratory data of the patients with perihilar tumors and those with distal tumors.

CONCLUSIONS

We believe that finding the disease in asymptomatic and non-jaundiced patients is very important for their prognosis. Further studies are needed and efforts should also continue to identify patients with suspicious findings.

[Laparoscopic partial gastrectomy for gastric submucosal tumor-indications and limitations of single-incision laparoscopic surgery]

Because gastric submucosal tumors can be treated by local resection without lymph-node dissection, laparoscopic local resection is widely used to manage relatively small tumors less than 5 cm in diameter. On the other hand, single-incision laparoscopic surgery (SILS) to perform laparoscopic cholecystectomy was feasible. SILS requires only a single incision in the umbilical region; it has better cosmetic outcomes than conventional laparoscopic surgery. The relative difficulty and ease of local gastric resection depends to a large part on tumor location and morphologic characteristics. Extraluminal submucosal tumor of the stomach can be locally resected by SILS using an automated suturing device regardless of tumor location. Intraluminal tumor located in the greater curvature of the gastric body can be treated by SILS, whereas intraluminal lesions located in the lesser curvature and near the gastric cardia or pylorus are difficult to manage by SILS. Laparoscopic and endoscopic cooperative surgery (LECS) is useful for resecting an appropriate amount of tissue at any site. In patients with lesions located near the gastric cardia or pylorus, closure with an automatic suture device may be difficult. Such patients should be switched to reduced-port surgery with a coaxial port, and hand-sewn closure is useful.

[Efficacy and safety of biweekly nedaplatin in combination with docetaxel as second-line chemotherapy in patients with unresectable or recurrent esophageal cancer]

There is no standard approach for second-line chemotherapy after a failure of the first-line regimen, fluorouracil and cisplatin -based chemotherapy in patients with unresectable or recurrent esophageal cancer. We have treated with biweekly nedaplatin (CDGP 40 mg/m²) in combination with docetaxe (l DOC 30 mg/m²) as second-line chemotherapy and investigated its efficacy and safety. Fifteen patients were retrospectively assessed in this study. Response rate (RR) and disease control rate (DCR) were 0 and 6.7%, respectively. Median time to progression( TTP) and median survival time( MST) were 2.1 and 7.0 months. Neutropenia and thrombocytopenia of grade 3 were seen in 4 (26.7%) and 1 (6.7%) patients, but no other serious adverse effects were detected. Based on the results, a biweekly nedaplatin/docetaxel regimen was safely received on an outpatient basis but not enough to provide a significant survival benefit. Quality of life and minimization of adverse effects are key considerations in second-line chemotherapy. Thereby, future trials should assess a quality of life in conjunction with different combination of active drugs and doses.

[Treatment of S-1 plus weekly CDDP for advanced gastric cancer]

We analyzed the clinical efficacy and safety of chemotherapy using S-1 plus weekly CDDP( w-CS therapy) for unresectable gastric cancer. Twenty one patients were treated with this treatment. S-1 80 mg/m²/day was administered for 2 weeks followed by a 1-week rest. CDDP 20 mg/m² was injected intravenously on day 1 and 8. The overall response rate was 52. 3%. The disease control rate was 85.7%. Grade 3 or 4 major toxicity comprised neutropenia (14.2%), thrombocytopenia (4.7%) and plasma creatinine elevation (4.7%). w-CS therapy is satisfied resulting with efficacy and safety. Thus, future clinical trials and accumulation of futher cases are warranted.

[A case report-highly advanced gastric cancer leading to perforation during neoadjuvant chemotherapy with docetaxel, cisplatin and S-1]

A 70-year-old man was found to have advanced gastric cancer with a deep ulcer and multiple lymph-node metastases. Although the tumor was resectable, we predicted that the patient would have a poor outcome. We therefore administered neoadjuvant chemotherapy with docetaxel, cisplatin, and S-1 to improve the prognosis before curative resection. On day 15 of chemotherapy, sudden abdominal pain occurred, and we performed an emergency surgery for a diagnosis of panperitonitis due to gastric cancer perforation. The defect in the gastric wall was about 2 cm in diameter and was located in the anterior wall of the antrum, consistent with the center of the tumor. The operative findings suggested that the perforation was caused by chemotherapy-induced necrosis of gastric cancer cells. We saved the patient's life, but intensive care with high-dose catecholamine therapy was needed for several days after the surgery. Gastric cancer perforation induced by neoadjuvant chemotherapy appeared to be more severe than perforation caused by other factors. The adverse effects of chemotherapy apparently increased the severity. Our findings suggest that the risk of gastric cancer perforation should be borne in mind when we administer neoadjuvant chemotherapy to patients who have advanced gastric cancer with a deep ulcer.

The impact of surgical outcome after pancreaticoduodenectomy in elderly patients

BACKGROUND

The elderly population has increased in many countries. Indications for cancer treatment in elderly patients have expanded, because surgical techniques and medical management have improved remarkably. Pancreaticoduodenectomy (PD) requires high-quality techniques and perioperative management methods. If it is possible for elderly patients to withstand an aggressive surgery, age should not be considered a contraindication for PD. Appropriate preoperative evaluation of elderly patients will lead to their safer management. The purpose of the present study was to evaluate the safety of PD in patients older than 75 years and to show the influence of advanced age on the morbidity and mortality associated with this operation.

PATIENTS AND METHODS

Subjects were 98 patients who underwent PD during the time period from April 2005 to April 2011. During this study, 31 patients were 75 years of age or older (group A), and the other 67 patients were less than 75 years old (group B). Preoperative demographic and clinical data, surgical procedure, pathologic diagnosis, postoperative course and complication details were collected prospectively and they were analyzed in two group.

RESULTS

There was no statistical difference between patient groups in terms of gender, comorbidity, preoperative drainage, diagnosis, or laboratory data. Preoperative albumin values were lower in group A (P = 0.04). The mean surgical time in group A was 408.1 ± 73.47 min. Blood loss and blood transfusion were not significantly different between both groups. There was no statistical differences in mortality rate (P = 0.14), morbidity rate (P = 0.43), and mean length of hospital stay (P = 0.22) between both groups. Long-term survival was also no statistically significant difference between the two groups using the log-rank test (P = 0.10).

CONCLUSION

It cannot be ignored that the elderly population is getting larger. We must investigate the management of elderly patients after PD and prepare further for more experiences of PD. If appropriate surgical management is provided to elderly patients, we suggest that PD will lead to no adverse effects after surgery, and PD can be performed safely in elderly patients. We conclude that age should not be a contraindication to PD.

Delayed pancreatic fistula after pancreaticoduodenectomy. A case report

CONTEXT

Pancreatic fistulas still occur despite refinements in both surgical technique and perioperative management after a pancreaticoduodenectomy. However, the occurrence of delayed pancreatic fistulas is very rare.

CASE REPORT

A 62-year-old woman diagnosed with a lower biliary carcinoma had undergone a pylorus-preserving pancreaticoduodenectomy. The postoperative course was uneventful and the patient was discharged from the hospital after 16 days. One year after surgery, she was admitted to our hospital with a fluid collection around the pancreaticojejunal anastomosis. A catheter was inserted percutaneously and the fluid collection was drained. The amylase value of the discharge was significantly elevated (119,500 IU/L). One week later, a fistulography showed no significant collection and the tube was clamped. The patient was discharged from the hospital without symptoms.

CONCLUSIONS

It is important to consider the occurrence of a delayed pancreatic fistula if the patient suffers from any symptoms. It is then necessary to proceed rapidly.

Metabolomic anatomy of an animal model revealing homeostatic imbalances in dyslipidaemia

Metabolomics is an emerging technology that reveals homeostatic imbalances in biological systems. Global determination of metabolite concentrations in body fluid and tissues provides novel anatomical aspects of pathological conditions that cannot be obtained from target-specific measurements. Here, we characterised metabolic imbalance in Watanabe heritable hyperlipidaemic rabbits as a model of hypercholesterolaemia. Using a mass spectrometry-based system, we measured a total of 335 metabolites in plasma and tissues (liver, aorta, cardiac muscle, and brain) from WHHL and healthy control rabbits. From the comparison between two metabolomic profiles, pathophysiological features including glutathione and phosphatidylcholine metabolism indicated the occurrence of oxidative stress in several tissues. Especially for the liver, imbalanced purine catabolism shed light on the transcriptional activation of xanthine oxidase, which is thought to act in absorbing or possibly triggering oxidative stress. We also applied this system to assess the therapeutic effects of simvastatin administration. After the treatment, a portion of the metabolomic features in pathological conditions showed alterations suggesting restoration of metabolism to the healthy condition. These changes were considered to be due to the pleiotropic action of statin, including antioxidant effects, rather than its main inhibitory action on cholesterol biosynthesis.

[A case of cholangiocellular carcinoma accompanied with peripheral blood eosinophilia which improved by removal of the hepatic tumor]

We present a case of cholangiocellular carcinoma accompanied with moderate blood eosinophilia. A 65-year-old man was admitted to our hospital because of widely spread skin eruption like urticaria with severe itching. Laboratory findings on admission showed leukocytosis (WBC 10,600/mm3) with moderate eosinophilia (eosinophils 3,678/mm3). Stool examination for ova and parasites was negative. Bone marrow aspiration revealed almost normal appearance. Chest X-ray was normal. Abdominal CT scan revealed a hepatic tumor (6.8 cm in diameter) in the left hepatic lobe. Needle biopsy of the hepatic tumor revealed an adenocarcinoma. We performed left hepatectomy with lymph node dissection without a bile duct reconstruction. The tumor was mass forming type accompanied with intra bile ductal growth in macroscopically. Pathological diagnosis was cholangiocellular carcinoma. After removal of the hepatic tumor, peripheral blood eosinophil counts fell down and cutaneous lesion disappeared immediately. Since the surgery, the patient had no sign of recurrence for 4 years.

[A case of duodenal invasion due to recurrent gastric cancer with obstructive jaundice treated by chemotherapy]

A 64-year-old man was admitted to our hospital with complaints of jaundice, upper abdominal distension and pain. He had a history of laparoscopic-assisted distal gastrectomy for gastric cancer about 11 months ago. The stage was IB and pathological examination was poorly differentiated adenocarcinoma. The upper gastrointestinal fiberscope showed a continuous duodenal stenosis between an anastomotic region and the third portion. The pathological diagnosis was recurrent of gastric cancer. The abdominal CT scan showed a dilatation of bile duct due to duodenal invasion. After percutaneous transhepatic cholangio drainage (PTCD) and jejunotomy, the chemotherapy with low-dose CDDP and 5-FU followed by weekly paclitaxel was performed. The stenosis of duodenum and dilatation of bile duct were improved. The patient lived for 8 months after chemotherapy. It is important to understand that gastric cancer diagnosed poorly differentiated adenocarcinoma pathologically sometimes occurs duodenal invasion and obstructive jaundice.

[Highly advanced gastric cancer that responded to neoadjuvant combination chemotherapy with docetaxel/CDDP/S-1 (DCS)]

A 60-year-old male was found to have advanced gastric cancer and multiple lymph node metastases. Since curative surgery was concluded to be unfeasible, we tried neoadjuvant chemotherapy with the aim of controlling the lymph node metastasis. S-1 (80 mg/m2) was administered orally for two weeks then followed by 2-week rest period. CDDP (60 mg/ m2) and docetaxel (40 mg/m2) were simultaneously administered on day 1. Two courses of treatment resulted in marked shrinkage of the primary lesion and a reduction in size of the lymph nodes. The results were evaluated as a clinical PR based on RECIST, and radical resection was considered possible. The patient experienced a grade 3 leukocytopenia and neutropenia as adverse events of the chemotherapy. Total gastrectomy, splenectomy, and D2 lymph node dissection were performed with curative intent, and the postoperative course was uneventful. Histological examination of the surgical specimens revealed almost complete disappearance of cancer cells in the primary lesion in the stomach and complete disappearance in the lymph nodes. Pathological efficacy was Grade 2. The patient experienced a grade 3 appetite loss, and the adjuvant chemotherapy (S-1 regimen) was discontinued. The patient died of peritoneal dissemination eight months after the operation. We concluded that DCS as neoadjuvant chemotherapy was a promising strategy for patients with highly advanced gastric cancer because of its rapid antitumor effect.