[A Case of Lymphoepithelial Cyst of the Pancreas for Which Malignancy Could Not Be Ruled Out Difficult Preoperative Diagnosis]

Lymphoepithelial cyst(LEC)of the pancreas is a relatively rare benign cystic disease of the pancreas. In this report, we describe a case of LEC in which a malignant tumor could not be ruled out by preoperative diagnosis and surgery was performed. The patient was a 72-year-old man. A simple CT scan of the chest and abdomen performed as a follow-up for another disease incidentally revealed a mass in the pancreatic tail. Enhanced CT of the abdomen showed a tumor approximately 3 cm in size at the pancreatic tail with no contrast effect. MRCP showed moderate signal on T2WI, high signal on T1WI, and high signal on T2WI on some cysts inside the pancreas. PET-CT showed slight uptake of FDG. Both tumor markers CEA and CA19-9 were normal. Therefore, malignant disease such as pancreatic IPMC could not be ruled out, and laparoscopic distal pancreatectomy plus splenectomy was performed. The pathology results showed a diagnosis of pancreatic lymphoepithelial cyst with slight differentiation into sebaceous gland.

[Peritoneal Recurrence of Gastric Cancer Treated with Chemoradiotherapy-A Case Report]

A 76-year-old male patient underwent a distal gastrectomy for advanced gastric cancer. As the postoperative serum CA19-9 level was elevated, chemotherapy was initiated. Computed tomography(CT)detected a solitary peritoneal recurrence in the left subhepatic space 17 months later. Consequently, chemoradiotherapy(CRT)at a total dose of 60 Gy, combined with S-1 therapy, was administered for local tumor control. After CRT, CT scans revealed a remarkable reduction in the peritoneal recurrence. Presently, 8 months after CRT, the patient remains alive with no indications of regrowth. CRT could prove efficacious as a treatment for gastric cancer patients with localized peritoneal recurrences.

[A Case of Pathologic Complete Response Achieved with Preoperative Pembrolizumab Therapy for Transverse Colon Cancer]

A 77-year-old female patient presented with a medical history of 4 cancerous lesions, each with a surgical history. She was referred to our hospital due to anemia. Upon examination, she was diagnosed with transverse colon cancer. Duodenal invasion was suspected, which made performing R0 surgery difficult; therefore, the NAC approach was chosen. Three courses of CAPOX were administered, resulting in tumor obstruction, leading to the formation of an ileum stoma. MSI testing revealed MSI-H, and pembrolizumab treatment was initiated. CT scans showed tumor shrinkage, and PET scans indicated no accumulation, resulting in a cCR. Colon resection including the lesion suspected of stenosis was performed with a strong desire for stoma closure and the determination of potential curative resection. Additionally, a partial resection of the duodenum was performed. Pathological examination did not reveal any evident tumor cells, leading to the determination for a pCR. The patient has been under postoperative surveillance for 1 year without any recurrence.

Prognostic Value of C-reactive Protein-to-albumin Ratio after Curative Resection in Patients with Colorectal Cancer

Objectives

The current retrospective study aimed to evaluate the association between combined preoperative and postoperative C-reactive protein-to-albumin ratio, which is correlated with prognosis in different types of malignancies, and prognosis after curative resection in patients with colorectal cancer.

Methods

This study enrolled 263 patients who underwent curative resection for stage II/III colorectal cancer. C-reactive protein-to-albumin ratio was calculated within 30 days before and 7 days after surgery. Receiver operating characteristic curve analyses were performed to determine the optimal cutoff values of preoperative and postoperative C-reactive protein-to-albumin ratio. The correlations between combined preoperative and postoperative C-reactive protein-to-albumin ratio and prognosis were analyzed.

Results

The cutoff values of preoperative and postoperative C-reactive protein-to-albumin ratio were 0.223 and 0.813, respectively; higher ratios were significantly associated with poor overall survival, based on the Kaplan-Meier curves (p < 0.001, p = 0.003, respectively). Further, preoperative and postoperative C-reactive protein-to-albumin ratios were correlated with poor progression-free survival (p < 0.001, p = 0.064, respectively). In the multivariate analysis, combined preoperative and postoperative C-reactive protein-to-albumin ratio was an independent predictor of overall survival and progression-free survival (p = 0.012, p = 0.044, respectively). Compared with low preoperative and postoperative C-reactive protein-to-albumin ratio, high ratios of that were significantly associated with poor overall survival (hazard ratio = 3.897, p = 0.006) and progression-free survival (hazard ratio = 2.130, p = 0.029).

Conclusions

Combined preoperative and postoperative C-reactive protein-to-albumin ratio, useful for prognostic prediction, can be a promising prognostic marker after curative resection in patients with colorectal cancer.

[A Case of Schwannoma in the Ascending Colon]

A 69-year-old man who was diagnosed with a submucosal tumor in the ascending colon by colonoscopy in X-7 year was presented. The endoscopic biopsy showed normal mucosa, and he had been followed up. During follow-up, computed tomography and colonoscopy performed in X year showed an enlargement of the tumor. Positron emission tomography-computed tomography showed intense FDG uptake. Malignant tumor was suspected, and laparoscopic-assisted right hemicolectomy was performed. The histopathological diagnosis showed spindle-shaped tumor cells proliferating in a fascicular manner. Immunohistochemical staining was positive for S-100 protein and negative for CD34, c-kit, and desmin, and schwannoma was diagnosed. Schwannomas are tumors derived from Schwann cells and therefore rarely develop in the gastrointestinal tract. Careful preoperative diagnosis is important because they do not normally metastasize or undergo malignant transformation.

[A Case of Retroperitoneal Leiomyosarcoma Treated with Repeated Surgical Resection]

A 55-year-old male revealed with a 5 cm-diameter mass in the lower abdomen on ultrasonography incidentally. Computed tomography showed a mass of 7 cm in size on the left side of the bladder. A malignant tumor was suspected, and surgically excised for purpose of diagnosis and treatment. Pathological examination confirmed retroperitoneal leiomyosarcoma, and the resection margins were negative. Follow-up computed tomography scan was performed every 3 months. Repeated resections were performed for twice recurrences within a year after surgery. A year after the first surgery, lung metastasis was detected and chemotherapy was started. Although retroperitoneal leiomyosarcoma is considered to have a poor prognosis, the present case had relatively good prognosis. This may be due to early detection and repeated surgical resection.

C-reactive protein/albumin ratio predicts survival after curative surgery in elderly patients with colorectal cancer

Inflammation-based markers, including the C-reactive protein/albumin ratio (CAR), lymphocyte/monocyte ratio (LMR), neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), Onodera's prognostic nutritional index (PNI), and Glasgow Prognostic Score (GPS), have been demonstrated to serve as prognostic indicators in various malignancies. This study aimed to evaluate their potential predictive value for colorectal cancer (CRC) in the elderly. We retrospectively evaluated 163 patients with CRC, aged 80 years and older, who had undergone curative surgery. The receiver operating characteristic curve analyses and the corresponding areas under the curve (AUCs) were used to determine and compare the discriminatory ability of the inflammation-based markers. Besides, the associations of inflammatory markers and clinical characteristics with overall survival (OS), relapse-free survival (RFS), and cancer-specific survival (CSS) were analyzed. The CAR had a significantly larger AUC than the GPS, PLR, NLR, and LMR (p = 0.006, 0.012, 0.018, and 0.002, respectively), except for the PNI (p = 0.052). The optimal cut-off value was 0.106 for the CAR and 44.894 for the PNI. Moreover, a CAR ≥ 0.106 turned out to be significantly associated with worse 5-year OS, RFS, and CSS compared with a CAR < 0.106. The multivariate analysis indicated that the CAR ≥ 0.106 was an independent prognostic factor for poor OS (HR = 3.596, p = 0.0006), RFS (HR = 2.945, p = 0.003), and CSS (HR = 4.411, p = 0.02). CAR is a useful and promising prognostic marker in elderly patients undergoing curative surgery for CRC.

Multicenter prospective trial of total gastrectomy versus proximal gastrectomy for upper third cT1 gastric cancer

BACKGROUND

The appropriate surgical procedure for patients with upper third early gastric cancer is controversial. We compared total gastrectomy (TG) with proximal gastrectomy (PG) in this patient population.

METHODS

A multicenter, non-randomized trial was conducted, with patients treated with PG or TG. We compared short- and long-term outcomes between these procedures.

RESULTS

Between 2009 and 2014, we enrolled 254 patients from 22 institutions; data from 252 were included in the analysis. These 252 patients were assigned to either the PG (n = 159) or TG (n = 93) group. Percentage of body weight loss (%BWL) at 1 year after surgery, i.e., the primary endpoint, in the PG group was significantly less than that of the TG group (- 12.8% versus - 16.9%; p = 0.0001). For short-term outcomes, operation time was significantly shorter for PG than TG (252 min versus 303 min; p < 0.0001), but there were no group-dependent differences in blood loss and postoperative complications. For long-term outcomes, incidence of reflux esophagitis in the PG group was significantly higher than that of the TG group (14.5% versus 5.4%; p = 0.02), while there were no differences in the incidence of anastomotic stenosis between the two (5.7% versus 5.4%; p = 0.92). Overall patient survival rates were similar between the two groups (3-year survival rates: 96% versus 92% in the PG and TG groups, respectively; p = 0.49).

CONCLUSIONS

Patients who underwent PG were better able to control weight loss without worsening the prognosis, relative to those in the TG group. Optimization of a reconstruction method to reduce reflux in PG patients will be important.

[A Case of Medullary Carcinoma of the Colon with Poor Prognosis]

An 87-year-oldwoman was referredowing to lightheadedness. Severe anemia(Hb 3.9 g/dL)was detected, and colonoscopy revealeda circumferential elevatedlesion at the transverse colon(Group 5, por). The patient was diagnosed with colon cancer(cT4a, N0, M0, Stage Ⅱ), andright hemicolectomy was performed. Immunochemical analysis showedthat the lesion was MLH1- andPMS2- and confirmed a diagnosis of medullary carcinoma. Although the patient was discharged 48 days after surgery without any incident, she was readmitted because of lower leg edema. Liver metastasis and peritoneal dissemination were suspectedon performing computedtomography, andthe patient died3 5 days after readmission. Medullary carcinoma has molecular pathological features such as methylation of the promoter region andassociatedattenuation of MLH1 protein expression, as well as microsatellite instability. The prognosis for medullary carcinoma is relatively good comparedto that for poorly differentiatedad enocarcinoma, though the present case hada poor prognosis. Herein, we report a literature review.

[Analysis of Post-Recurrence Survival of Resected Lung Cancer with Brain Metastasis]

METHODS

We retrospectively evaluated the post-recurrence survival of 37 cases with brain metastases out of 439 consecutive resected cases of primary lung cancer between 2001 and 2017.

FINDINGS

There was no difference in survival according to tumor size but survival was significantly shorter in patients with larger numbers of tumors. Patients initially treated with stereotactic radiosurgery(SRS)or surgical resection survived longer than those with whole-brain irradiation(WBI)(median survival: 23 months for SRS, 17 months for surgical resection, and 4 months for WBI: p<0.001 between SRS and WBI).

CONCLUSIONS

As SRS is recommended for 1-4 tumors with maximum diameters ofC3 cm and surgical resection is recommended for tumors larger than 3 cm, these effective locoregional therapies should be aggressively adopted for local control of brain metastases with the aim of improved QOL and prolonged survival. Due to the deterioration of neurocognitive function, WBI should be avoided as initial treatment for brain metastases when effective locoregional therapy or systemic chemotherapy is available and reserved for leptomeningeal dissemination or miliary metastases.

[Curative Resection for Liver Metastasis Ten Years after Surgery for Rectosigmoid Cancer-A Case Report]

Here, we report the case of a 73-year-oldfemale patient, who previously underwent high anterior resection for rectosigmoidcancer at the age of 63. Her scheduled5 years of follow-up after colorectal surgery hadbeen finished, but she kept undergoing endoscopic mucosal resection for colorectal polyps every 1 or 2 years since then. Blood examination 10 years 6 months after surgery for rectosigmoidcancer revealedthat the value of her serum CEA was 5.5 ng/mL, which was slightly higher than the normal range. Contrast-enhancedCT showedan irregular-shapedtumor with a diameter of 3 cm in which the contrast of the peripheral area was mainly emphasized. When combining the results of MRI and PET-CT examinations, the liver tumor was clinically diagnosed as either intrahepatic cholangiocarcinoma or metastatic liver cancer. Since the first choice of therapy was tumor resection for both diagnoses, S8 subsegmental hepatectomy was performed 10 years 8 months after surgery for rectosigmoidcancer. HE staining of the resectedspecimen showedwell or moderately differentiatedad enocarcinoma, andits immunostaining findings were as follows: CDX-2: positive, CK20: positive, CK7: negative. It was pathologically diagnosed as liver metastasis from rectal cancer. It is rare for colorectal cancer to have metachronous liver metastasis more than 10 years after surgery. However, in any case where a tumor marker for colorectal cancer increases, it is necessary to examine carefully with the possibility of any metastasis in mind.

[Pregnancy-Associated Stage Ⅳ Gastric Cancer with No Recurrence for a Long Time-A Case Report]

A 28-year-oldwoman visiteda clinic with a complaint of epigastralgia 3 months after delivery. She was diagnosedwith gastritis andtreatedwith medication. Two months later, in January 2006, she was admittedto our hospital with a complaint of dysphagia. Upper gastrointestinal endoscopy revealed type 3 gastric cancer in the lesser curvature of the cardia, and abdominal CT scan showed wall thickening of the upper gastric body. No apparent distant metastases were found. The patient underwent total gastrectomy with D2 lymph node dissection in February 2006. Although there was no peritoneal dissemination, the patient testedpositive in peritoneal lavage cytology. The postoperative pathological diagnosis was gastric cancer pT4aN2M1(P0CY1H0), Stage Ⅳ. She was discharged on postoperative day 22. S-1 monotherapy(100mg/day, day 1- 28q6wks)was performedfor 1 year on an outpatient basis. For 13 years and1 0 months after the surgery, no apparent recurrences of gastric cancer have been observed. In gastric cancers associated with pregnancy, it is difficult to distinguish between perinatal symptoms andsymptoms of gastric disease. Therefore, endoscopic examination shouldbe performedfor perinatal patients presenting with persistent gastrointestinal symptoms.

Laparoscopic colectomy after transcatheter aortic valve implantation in an elderly patient with obstructive descending colon cancer and severe aortic stenosis: a case report

BACKGROUND

The demand for laparoscopic colectomy is increasing due to greater number of elderly colon cancer patients, and it is important to evaluate existing comorbidities to ensure perioperative safety. Aortic stenosis (AS) is one of the most common heart diseases in the elderly, and elderly cancer patients with severe AS may be considered ineligible for optimal cancer treatment if they cannot endure surgical aortic valve replacement (SAVR). Recently, transcatheter aortic valve implantation (TAVI) has become a valid option in patients who are high risk for SAVR. We herein present the first case of an elderly cancer patient with severe AS who underwent laparoscopic colectomy after TAVI.

CASE PRESENTATION

An 87-year-old woman with a history of multiple cardiovascular diseases was diagnosed with obstructive descending colon cancer and initially underwent colonic stenting. However, as preoperative echocardiography revealed severe AS, she underwent TAVI prior to the colectomy to reduce perioperative risk. TAVI was chosen instead of SAVR due to high SAVR mortality risk, and laparoscopic colectomy was performed 22 days after TAVI. Her postoperative course was uneventful, and she was discharged 14 days later without any deterioration in general condition. No recurrence was observed at more than 1 year, even without adjuvant therapy.

CONCLUSION

TAVI facilitated subsequent laparoscopic colectomy in an elderly cancer patient with severe AS. Our case report shows that TAVI may enable further cancer treatment even in patients with severe AS, who may otherwise be considered not suitable for such treatments.

[Role of Palliative Chemotherapy for Peritonitis Carcinomatosa of Inoperable Advanced Gastric Cancer]

We report a case of peritoneal dissemination of gastric cancer in which the QOL was maintained with a less-than-optimum dose of anticancer agent. A 64-year-old man underwent total gastrectomy for corpus gastric cancer without distant metastasis performedas an open-laparotomy. Peritoneum disseminations were observed in the left sub-diaphragmatic space and back side of the mesocolon, andthe tumor passedd irectly to the superior mesenteric vein of transverse mesocolon. As a first- line chemotherapy, G-SOX therapy(S-1 80mg/day/body and oxaliplatin 100mg/m2)was administered for 15 courses. After these courses, the disease was categorized as PD. Next, RAM/PTX(ramucirumab 8mg/kg andpaclitaxel 80mg/m2) were administered as second-line chemotherapy. However, the PTX, especially causedprolongedad verse effects such as G4- leveledbloodtoxicity andsevere general fatigue. Therefore, we administereda lower dose of PTX than the original optimal minimum dose. This lower dose chemotherapy resulted in effective changes such as decreased pain and general fatigue and resolution of the bloodtoxicity. As a result, the patient's QOL improved, and his condition has been maintained as SD for 2 years after the operation. For these reasons, this ordinary chemotherapy may be used as a palliative chemotherapy.

[A Case of Hepatocellular Carcinoma Complicated with Idiopathic Thrombocytopenic Purpura]

The patient was a 72-year-oldwoman. She had been diagnosed with idiopathic thrombocytopenic purpura(ITP), hepatitis B, and diabetes mellitus. She was admitted to our hospital because of anemia andvomiting of blood vomiting and was diagnosed with hepatocellular carcinoma at S6. A splenectomy was performed, with a temporary improvement of her platelet count. We tried to control the platelet count with medication and performed transcatheter arterial embolization(TACE)3 times. However, the tumor size decreased only slightly anda new tumor was observed on S2. Therefore, we increased the patient's platelet count to 109×10 4/mL and performed a partial hepatectomy of 4 lesions. The postoperative complications included intraabdominal abscess, but there was no bleeding and the patient was discharged on POD 114. Platelet count is often difficult to maintain in patients diagnosed with ITP. We report our experiences and also provide a discussion of a case of operated hepatocellular carcinoma complicated with refractory ITP.

[A Case of a Duodenal GIST Observed as a Non-Functional Pancreatic Neuroendocrine Tumor]

A 67-year-oldman was referredto our hospital because his CEA level was increasing. In March 2007, abdominal computed tomography(CT)showedthe presence of a tumor(30mm in diameter)in the pancreatic head. Upon close inspection, the patient was diagnosed with a non-functional pancreatic neuroendocrine tumor and was observed. In September 2016, the patient showedhyperglycemia, liver dysfunction, andelevation of tumor markers. CT revealeda tumor(42mm in diameter) in the pancreatic head. It hadincreasedmore than before. We diagnosedhim with a gastrointestinal stromal tumor(GIST)of the duodenum based on endoscopic ultrasound-guided fine-needle aspiration biopsy and performed pancreaticoduodenectomy. Immunohistochemical staining showedpositive c-kit, andmore than 10%positive MIB-1. Currently, the patient is alive after the surgery.

[A Case of Extramedullary Plasmacytoma of the Stomach Detected Due to Severe Anemia]

A 78-year-oldwoman was referredfor exertional dyspnea. Severe anemia(Hb 4.2 g/dL)was detected, and upper endoscopy revealeda giant ulcer at the posterior wall of the gastric body. Computedtomography showeda mass protruding from the gastric wall, suggestive of a submucosal tumor. Although biopsy did not confirm a diagnosis, we performed distal gastrectomy to control the bleeding. The pathological findings and systemic examination confirmed a diagnosis of extramedullary plasmacytoma of the stomach. Plasmacytoma is a tumor of the bone marrow derived from plasma cells that mature from B cells. The frequency of extramedullary plasmacytoma for all plasmacytoma is about 5% and plasmacytoma derived from the stomach occurs in approximately 2%of these cases. Complete resection with lymph node dissection according to the surgical treatment of gastric cancer is recommended. Large tumors, such as that in the present case, may have a poor prognosis; thus, careful follow-up is required for the early detection of recurrence. We report a case of extramedullary plasmacytoma of the stomach with a literature review.

[A Case of Long-Term Control of Stage Ⅳ Gastric Cancer by Multimodal Therapy]

An 82-year-oldwoman was admittedto our hospital because of appetite loss andwas diagnosedwith a Type 3 tumor in the lower gastric body. Pathological examination suggested moderately differentiated adenocarcinoma with negative staining for HER2 by immunohistochemistry. An abdominal CT revealedthickening of the gastric wall andparaaortic lymph node metastases. The clinical findings suggested Stage Ⅳ disease(T4aN3M1). Chemotherapy was administered with a combination of S-1 plus oxaliplatin(SOX). After 2 courses of the SOX regimen, an abdominal CT showed a reduction of the paraaor- tic lymph node metastases, and the CEA level hadd ecreasedto 6.2 ng/mL. After 7 courses of the SOX regimen, the CEA level hadincreasedto 10.1 ng/mL, and the treatment schedule was changed to a regimen of paclitaxel plus ramucirumab(PTX/ RAM). However, grade 4 neutropenia was observed after the first treatment. Distal gastrectomy with D1+lymph node dissection was performedfor local control in September 2016. The post-operative pathological findings were ypT1b2ypN2M1, ypStage Ⅳ and the chemotherapeutic effect was grade 1a. A CT scan revealedregrowth of the paraaortic lymph node 3 months after the operation. Chemotherapy was administered with a combination of capecitabine plus oxaliplatin(CapeOX). At present, the patient is being treatedwith capecitabine monotherapy in the outpatient department with no signs of tumor regrowth.

[A Case of Multiple Pulmonary Metastases of Rectal Cancer Controlled with Pulmonary Resection and Stereotactic Body Radiotherapy for Four Years]

A female in her 40s underwent surgical resection for rectal cancer, and metastases in the liver, ovaries, and peritoneum in 2 stages. Multiple pulmonary metastases appeared after the second operation, and right lung middle lobectomy and left lung S8 wedge resection were performed sequentially. Because another metastatic lesion in the right lung S7 was located deep in the parenchyma, stereotactic body radiotherapy(SBRT), instead of surgery, was selected for this lesion and a right lung S8 nodule. SBRT was also performed for a new metastatic lesion in the right lung S6. Local relapse of resected or irradiated lesions was not recognized for 53 months after the first pulmonary resection, and no new lesions appeared for 20 months after the last SBRT. SBRT for pulmonary metastases of colorectal cancer can achieve good survival and local control comparable to surgery and has the advantage of safety and respiratory reserve over surgery. The combination of surgical resection and SBRT for multiple pulmonary metastases is especially beneficial for relatively young patients with jobs and/or children, because it enables patients to maintain good quality of life by avoiding systemic chemotherapy accompanied with adverse events.

[Resection of a Desmoid Tumor Originating from the Greater Omentum after Surgery for Colon Cancer and Liver Metastasis-A Case Report]

Here, we report the case of a 66-year-old male patient who previously underwent resection of sigmoid colon cancer and its liver metastasis. His follow-up contrast-enhanced CT scan revealed a mass shadow at around the gastrosplenic ligament, which gradually increased in size. Because it could not be pathologically diagnosed by transgastric EUS-FNA, en bloc resection wasperformed surgically for the tumor in the greater omentum. Hematoxylin-eosin staining of the resected specimen showed fibroblast-like cellswith hyperplasia of bold collagen fibersand spindle-shaped nucleus. While the immunostaining findings denied a diagnosis of mesenchymal neoplasm such as GIST, leiomyosarcoma, or schwannoma, it was pathologically diagnosed as a desmoid tumor. He has been followed up without any recurrence for 2-and-a-half years after the surgical resection. Desmoid tumors tend to be locally invasive; thus, there is the potential for local recurrence, although the frequency of distant metastasis is very low. In cases in which the tumor increases in size, en bloc resection with sufficient surgical margin should be performed. Cases of desmoid tumors originating from the greater omentum are reportedly rare; however, en bloc resection may be useful for both diagnosis and treatment of tumors of the greater omentum showing increased size that are also surgically resectable.

[A Case of Locally Advanced and Metastatic Breast Cancer Treated with Preoperative Bevacizumab Combination Chemotherapy That Attained Local Control]

We report a case of a 74-year-old woman with a left breast tumor with skin infiltration. Luminal type breast cancer with lung, bone, and parasternal lymph node metastases was diagnosed. She received paclitaxel and bevacizumab treatment. After chemotherapy, the lung metastasis and parasternal lymph node metastasis had disappeared, and the breast tumor had shrunk. Mastectomy and axillary lymph node dissection were performed. She has been receiving post-operative endocrine therapy. Paclitaxel and bevacizumab combination therapy is one of the useful treatments for metastatic breast cancer with skin infiltration.

[Four Cases of Resected cN2 Stage III A Non-Small-Cell Lung Cancer after Induction Chemotherapy]

Four patients with non-small-cell lung cancer(NSCLC), diagnosed with cN2 stage III A disease, by using CT and FDG-PET/ CT imaging, received 2 or 3 courses of platinum-based combination chemotherapy.The patients achieved partial response after chemotherapy and underwent surgery.Complete tumor resection was performed via upper lobectomy for 3 patients, but in 1 patient, interlobar metastatic lymph nodes remained after middle and lower bilobectomy.Two courses of postoperative chemotherapy were administered to 3 patients, but 1 patient could not receive postoperative chemotherapy due to complications.One patient, in whom lymph node metastasis completely disappeared after induction chemotherapy, is still alive and without disease recurrence for 7 years.Another patient, with the presence of only one intralobar metastatic lymph node after chemotherapy, died of brain and meningeal metastases, 3 years after surgery.Two other patients, with multiple pN2 lymph nodes after chemotherapy, died of early intrathoracic local relapse, indicating that prognosis is influenced by response to chemotherapy, especially in patients with poor N-downstaging.Improvements in response to induction therapy by using intensive chemotherapeutic regimens, concurrent radiotherapy, and strict patient selection, limited to N-downstaged cases, are needed for successful surgery outcomes in patients with cN2 stage III A NSCLC who have received induction therapy.

[Curative Resection for Metastatic Lower Rectal Tumor from Ovarian Cancer - Report of a Case]

We here report the case of a 56-year-old female patient who underwent curative resection for right ovarian cancer with intraperitoneal dissemination and liver metastases. She received following adjuvant chemotherapy, and had been visited hospital for regular follow-up since then. One and half a year after surgery, blood examination showed increasing value of CA125. Contrast-enhanced CT scan revealed a tumor whose long diameter was 5 cm at front side of lower rectum. Following MRI and PET-CT examinations indicated the pelvic tumor as recurrence of ovarian cancer, so that laparotomy was carried out. As the tumor was palped through Douglas cavum, we performed low-anterior rectal resection for en bloc tumor extirpation. Tumor cells mainly developed at peri-rectal wall and proper muscle by HE staining of pathological findings, and ER(positive), vimentin(positive), CD56(positive), synaptophysin(negative)and chromogranin A(negative)by immunostaining indicated the tumor as metastasis of ovarian cancer. Though rectal metastasis from ovarian cancer is basically rare, it might be necessary to rule out possibility of metastatic colon tumor from ovarian cancer when treating patient with rectal tumor who had underwent surgery for ovarian cancer before.

[A Case of Advanced Gastric Cancer with Synchronous Liver Metastases Responding to Preoperative Combination Chemotherapy with S-1 plus Oxaliplatin(SOX)]

A 67-year-old man was admitted to our hospital because of anemia and weight loss, and diagnosed with a type 3 tumor in the upper gastric body. Pathological examination suggested moderately differentiated adenocarcinoma with immunohistochemically negative staining for HER2. Abdominal CT revealed thickening of the gastric wall and multiple liver metastases. The clinical findings suggested Stage IV disease(T4aN0M1). Chemotherapy was administered with a combination of S-1 plus CDDP(SP). However, the level of CEA(ng/mL)increased from 49.2 to 634.6, and the treatment schedule was changed to a combination of S-1 plus oxaliplatin(SOX). After 3 courses of the SOX regimen, abdominal CT showed a reduction of liver metastases and the level of CEA decreased to 8.4 ng/mL. We performed total gastrectomy with D1 lymph node dissection in September 2016. Post-operative pathological findings were ypStage IV (T3N0M1)and chemotherapeutic effect was grade 2. CT scan revealed regrowth of the tumor in S2 3 months after the operation. The patient underwent transcatheter arterial chemoembolization(TACE)followed by a regimen of paclitaxel plus ramucirumab(PTX/RAM). At present, he is being treated with the PTX/RAM regimen in the outpatient department with no signs of tumor growth. Although the prognosis of gastric cancer with synchronous liver metastases is very poor, it is possible for survival to be prolonged with multimodality therapy.

[A Case of Successful Repeated Metastectomy for Peritoneal Recurrence of over 90 Years Old Colon Cancer Patient]

Treatment for cancer recurrence in elderly people over 90 years old is usually less advantageous in chemotherapy, and surgical resection is considered rather invasive if cure can be expected. We experienced a case of colon cancer in which recurrence of peritoneal dissemination was discovered and resected at the age of 90 years and at 92 years twice. Laparoscopic surgery for colon cancer at the age of 89 years was performed. At 13 months after primary surgery, CT revealed a nodule of 10mm in diameter in the abdominal cavity, and it was also positive in PET-CT. Because there was no other recurrent foci, radical resection was performed. After 14 months(2 years and 4 months after primary surgery), a 17mm large nodule was pointed out and radical resection was done again. Three years later(5 years and 6 months from primary surgery)have passed, she survives without recurrence at 95-years-old and 4 months without any decline in QOL. When recurrence of peritoneal dissemination can obtain radicality in resection, even for elderly persons, surgery should be considered if invasion is minor.

[An 85-Year-Old Man with Lymph Node Metastasis of Recurrent Rectal Cancer Treated UsingProton Beam Therapy]

There are few reports that describe the efficacy of proton beam therapy for lymph node metastasis of recurrent rectal cancer, and carbon ion radiotherapy yields higher local tumor control rates. Proton beam therapy needs a longer treatment period but is less toxic to adjacent healthy organs compared to carbon ion radiotherapy. Here we report an 85-year-old man who underwent curative surgery for rectal and sigmoid cancer at the age of 76 years. After 4 years and 2 months, he had liver metastases at S3 and S8, both of which were resected. Eight years and 6 months after primary resection, CT imaging revealed a solitary lymph node metastasis of 28mm in the minor axis, adjacent to the portal vein and IVC. Because of the location and patient's age, proton beam therapy was selected as the treatment strategy, rather than surgery or chemotherapy. A total of 67.5 GyE/25 fx proton beam therapy was applied. CT imaging 4months after irradiation revealed a partial response(PR)and the tumor had shrunk to 8mm. PR continued for 2 years and 1 month. Although the tumor relapsed after 3 years of irradiation and had grown to 16 mm, the patient had no adverse events or symptoms throughout this period. Proton beam therapy may be one of the options for tumors at difficult locations in fragile patients because of its reduced toxicity.

[A Case of T1a Early Gastric Cancer That Metastasized to the Right Femoral Muscles Six Years and Seven Months after Radical Surgery]

A 49-year-old woman presented to our hospital complaining of abdominal distension and right thigh edema 6 years and 7 months after undergoing total gastrectomy for early gastric cancer in December 2008. The histopathological type of the tumor was poorly differentiated adenocarcinoma. The pathological findings led to a diagnosis of T1aN2M0, Stage II A disease. In August 2015, abdominal CT and MRI revealed para-aortic lymph node swelling, ascites, and a tumor on the right femoral muscles. We performed a needle biopsy of the femoral muscle, and the final diagnosis was intramuscular metastasis from the primary gastric cancer. We initiated chemotherapy using TS-1 plus docetaxel. TS-1(80mg/m2/day)was orally administered for 2 weeks followed by a 1-week drug-free period, and 1 course of docetaxel(40mg/m2)was administered intravenously on day 1. After 2 courses of this regimen, the tumor on the right femoral muscles was reduced in size. However, diarrhea and leukopenia were observed, and the treatment schedule was changed to several other chemotherapy regimens. The patient died of progressive disease 6 months after the diagnosis of muscle metastasis. We report a rare case of late recurrence after curative resection in a patient treated for T1a early gastric cancer.

[Right Hemi-Colectomy for a Metastatic Transverse Colon Tumor from Breast Cancer Following Bilateral Breast Cancer Resection - A Case Report]

We herein report the case of a 75-year-old female patient who underwent 4 surgeries for bilateral breast cancer and its recurrence. When she presented at a clinic with an irritable colon, a fist-sized tumor was palpated in the right upper abdomen at her first medical examination. Abdominal CT scan at the clinic revealed a tumor with a maximum diameter of 10 cm on the right side of the transverse colon and multiple swollen mesenteric lymph nodes. Therefore, the patient was referred to our hospital for surgery. Colonoscopy revealed stenosis of the same lesion with an edematous mucosa and sclerosis. Using immunohistochemistry, a biopsy specimen from the lesion tested positive for CK AE1+AE3, and negative for CD20(-)and CD3 (-). As a result, the tumor was diagnosed as a poorly differentiated adenocarcinoma. We performed right hemicolectomy to avoid her intestinal obstruction. Tumor cells were mainly present at the subserosa, according to HEstaining. Using immunostaining, the cells were tested for the following markers: CDX2(-), GCDFP15(weakly positive), CK7(strongly positive), CD20(partially positive), E R(+), PgR(-), and HER2(1+), characterizing the tumor as metastasis of breast cancer. Although gastro-intestinal metastasis from breast cancer is rare, and colon metastasis is even rarer, it might be necessary to rule out the possibility of a metastatic colon tumor from breast cancer when treating patients with a colon tumor who have undergone surgery for breast cancer.

[A Case of Advanced Rectal Cancer Resulting in a Pathologically Complete Response after Neoadjuvant Chemotherapy]

A 61-years-old man was admitted to our hospital because of abdominal pain. Colonoscopy revealed a type 2 tumor in the rectum, which was diagnosed as low differentiated adenocarcinoma. At least 8 abdominal lymph adenopathies were enhanced on contrast-enhanced CT. We diagnosed stage cT3N2H0M0P0, cStage III b. Because of the risk of a poor prognosis, we tried neoadjuvant chemotherapy for the purpose of down staging. A CRT was prevented by Clostridium difficile enteritis, but we completed 80% of the regimen. Laparoscopic abdominoperineal resection was performed after 4 months of chemotherapy. The specimen contained no tumor lesion, and the pathology results were no residue of adenocarcinoma, status postchemoradiation therapy, Grade 3.

[A Case of Lymph Node Metastases from Esophageal Cancer Successfully Treated with Weekly Paclitaxel Chemotherapy]

A 61-year-old man underwent a curative operation for advanced esophageal cancer (CT-pT3N2M0, pStage Ⅲ), which had been downstaged with docetaxel, CDDP, 5-FU (DCF) neoadjuvant chemotherapy. Five months after the operation, we diagnosed the patient with recurrence of esophageal cancer with para-aortic lymph node (PALN) metastasis. Systemic chemotherapy was initiated using a regimen of weekly paclitaxel (PTX) administration. After 2 courses, abdominal computed tomography examination indicated regression of the PALN swelling. Eighteen months have passed since the curative operation, and the patient has been doing well with no signs of recurrence. In summary, we successfully treated a case of lymph node metastases from esophageal cancer with weekly PTX chemotherapy.

[A Case of Advanced Gastric Cancer with Synchronous Liver Metastases Treated with Combination Therapy]

A 66-year-old woman was admitted to our hospital because of epigastralgia, and she was diagnosed with a type 2 tumor at the antrum of the stomach. Pathological examination suggested a moderately differentiated adenocarcinoma with negative staining for HER2 on immunohistochemistry. Abdominal CT showed gastric wall thickening and enlarged lymph nodes. Although the clinical finding was Stage ⅢB(T4aN2M0), a liver metastasis (S2) was found during the operation. We performed distal gastrectomy with D2 lymph node dissection and partial hepatic resection in December 2010. A post-operative pathological diagnosis of gastric cancer, pT4aN2M1, pStage Ⅳ, was made. Although adjuvant chemotherapy of S-1 was administered, CT revealed a liver metastasis in S3 5 months after the operation, and the patient underwent transcatheter arterial chemoembolization (TACE) followed by a regimen of S-1 plus CPT-11. After 3 courses of this regimen, grade 2 anorexia was observed, and the treatment schedule was changed to a regimen of capecitabine plus cisplatin (XP). After 7 courses of this regimen, CT revealed multiple liver metastases in S2, S3, and S8, and the treatment schedule was changed to several other chemotherapy regimens. However, liver metastases continued to grow, and the patient died 51 months after surgery. Although the prognosis of gastric cancer with synchronous liver metastases is very poor, it is possible to prolong survival with multimodal therapy.

[Long-Term Multidisciplinary Therapy for Multiple Liver Metastases from Colorectal Cancer with Biliary Drainage for Occlusive Jaundice--A Case Report]

Here, we report the case of a 43-year-old man who was diagnosed with sigmoid colon cancer with synchronous multiple liver metastases following resection of a primary lesion. Subsequent mFOLFOX+BV therapy elicited a marked response in the liver metastases, which led to the patient undergoing hepatic (S7) radiofrequency ablation (RFA), hepatic resection (lateral segmentectomy and partial [S5] resection), and cholecystectomy. Six months later, transluminal RFA was repeated because liver (S7) metastasis recurred, and 8 courses of XELOX plus BV therapy were administered. As obstructive jaundice due to recurrence of the liver metastases developed after a 6 months hiatus in chemotherapy, we endoscopically inserted a biliary stent. Despite reducing IRIS plus BV therapy, obstructive jaundice developed again, and 3 intrahepatic biliary stents were inserted with percutaneous transhepatic biliary drainage. To date, the patient has been alive for 4 years since the initial resection of the primary lesion after undergoing consecutive systemic chemotherapy with different regimens. Some studies have shown that in cases of obstructive jaundice caused by advanced gastrointestinal cancer, longer survival could be expected by reducing the severity of jaundice, suggesting that resuming chemotherapy as well as improving the severity of jaundice could contribute to better outcomes. The patient in the present case was successfully treated twice with biliary drainage for occlusive jaundice and chemotherapy, suggesting that a combination of multidisciplinary therapy and adequate local therapy such as biliary drainage could be important for the treatment of metastatic liver cancer.

[Laparoscopic Surgery for T4b Colorectal Cancer]

BACKGROUND

It is considered difficult to perform laparoscopic surgery for colorectal cancer with T4b that is directly invades to adjacent organs. This retrospective study evaluated pT4b colorectal cancer in terms of the efficacy of laparoscopic surgery.

METHODS AND RESULTS

Forty-six cases with pT4b colorectal cancer that occurred between 2006 and 2014 were investigated. Laparoscopic surgery (LAC) was performed in 20 cases, of which 5 were conversions, and open surgery (OC) was performed in 26 cases. Pathologically-proven invaded organs resected by LAC were the abdominal wall (n=6), greater omentum (n=5), small intestine or colon (n=3), bladder, appendix, or ovary (n=1). Organs resected by OC were the abdominal wall (n=8), bladder (n=5), colon, greater omentum, or small intestine (n=3), stomach, ovary, spermatic duct (concurrent with bladder), prostate, or sacrum (n=1). Operation time (median) was 275 min for LAC and 260 min for OC. Blood loss (median) was 100 mL for LAC and 410 mL for OC. The duration of hospital stay (median) was 15 days after LAC and 18 days after OC. There were 2 cases with morbidities greater than Grade 3 after LAC and 1 case after OC. There was 1 hospital death in the OC group.

CONCLUSION

Laparoscopic surgery for T4b colorectal cancer can be feasible in select cases.

[A Case of RFA for Liver Metastasis after Resection for Rectal Cancer in a 102-Year-Old Man]

A 100-year-old man was admitted to our hospital because of bloody stool. Colonoscopy revealed a type-2 tumor in the rectum, which was diagnosed as moderately differentiated adenocarcinoma. There was no distant metastasis on CT. After meticulous preoperative evaluation of surgical risks considering his age, laparoscopic high anterior resection was performed. During surgery, the edge of the descending colon showed ischemia; therefore, we performed conversion to open surgery and transverse colon resection. However, the edge of the transverse colon showed ischemia; therefore, ascending colon resection and ascending colon-rectum anastomosis were performed. On day 5 after surgery, the patient developed aspiration pneumonia, for which respirator management was conducted. As his condition improved, he was discharged on postoperative day 32. The pathology results were tub2, pT3, ly0, v2, PM0, DM0, RM0, pN1, Stage Ⅲa. One year 6 months after the surgery, when the patient was 102 years old, CT revealed liver metastasis. RFA was performed for the liver lesion. In people aged 100 years or older, few reports are available on colectomy, and there is no report of treatment for metastasis.

[A case of long-term survival of advanced gastric cancer with schnitzler metastasis effectively treated with combination chemotherapy]

A 66-year-old woman was diagnosed with unresectable advanced gastric cancer with Schnitzler metastasis in January 2012. She was treated with combination chemotherapy comprising S-1 and docetaxel (DTX). However, in January 2013, after 13 courses of treatment, a computed tomography (CT) indicated peritoneal dissemination growth. The chemotherapy regimen was changed to a combination of S-1 and irinotecan (CPT-11), but after a single course of treatment the patient complained of stomachaches and vomiting. The patient developed ileus from the stenosis of the rectum, and a transanal ileus tube was used to decompress the bowel tract. Due to the patient's poor general condition, a metallic stent was inserted, and she could resume eating. Thereafter, we changed the chemotherapy regimen to weekly paclitaxel (PTX). However, 1 year and 4 months after starting treatment she died of regrowth of the peritoneal disseminating lesions. We recommend a combination of chemotherapy and metallic stent placement to improve quality of life and long-term survival.

[Laparoscopic surgery for primary resection of StageIV colorectal cancer]

BACKGROUND

The outcomes of laparoscopic surgery for primary tumors of symptomatic Stage IV colorectal cancer have not been clarified.This study aimed to review the outcomes of colorectal resection in patients with symptomatic StageIV colorectal cancer, treated either by laparoscopic colorectal resection (LAC), or by open colorectal resection (OC).

METHODS AND RESULTS

A total of 69 patients were included, of which 55 patients underwent LAC.The proportion of patients with ileus was higher in the OC group than in the LAC group.The conversion rate of patients receiving LAC was 13% (7 cases).No operative mortality was observed in either group.The operation time was shorter, postoperative complication rate was lower, and postoperative hospital stay was significantly shorter in the LAC group.Median survival times in the LAC and OC groups were 26.3 months and 26.8 months, respectively.

CONCLUSION

Although the short-term outcome of LAC for symptomatic Stage IV colorectal cancer was favorable, the long-term outcomes were similar in both groups.A safe and minimally invasive surgical procedure is needed for the treatment of Stage IV colorectal patients.

[A case of advanced gastric cancer with portal vein thrombus leading to liver metastases]

A 68-year-old man presenting with anorexia was admitted to our hospital; he was diagnosed with pyloric stenosis arising from a type 3 tumor in the antrum of the stomach. Pathological examination revealed a poorly differentiated adenocarcinoma; immunohistochemical staining tested positive for alpha fetoprotein(AFP), and negative for human epidermal growth factor receptor 2(HER2). Abdominal computed tomography (CT) showed a portal vein thrombus and enlarged lymph nodes. Since the clinical finding was Stage IV(T4aN3M1), curative surgery was ruled out. Following stent placement for food intake, TS-1 plus cisplatin (CDDP) neoadjuvant chemotherapy was initiated. TS-1(80 mg/m² / day) was administered orally for 2 weeks followed by a drug-free 1-week period, and CDDP (60 mg/m²) was administered intravenously on day-1 as 1 course. After 5 courses of this regimen, lymph nodes were reduced in size and the portal vein thrombus disappeared. However, grade 4 thrombocytopenia was observed, and the treatment schedule was modified to include several other chemotherapies. Two years after the initiation of chemotherapy, liver metastasis was detected via elevated AFP. The patient died 27 months after initial treatment. Although the prognosis for gastric cancer with portal vein thrombus is very poor, it is possible to prolong survival with multimodality therapy.

[Post-recurrence survival after surgical resection of non-small cell lung cancer with local recurrence]

We retrospectively evaluated the clinical outcomes of 192 consecutive patients with local recurrence after complete resection of non-small cell lung cancer NSCLC). The initial local recurrent site was the resection stump in 5 patients the chest wall in 3 patients, mediastinum in 1 patient, and diaphragm in 1 patient), and the hilar and/or mediastinal lymph node (HMLN) in 17 patients. The sites of distant metastasis were the lungs in 10 patients, pleura in 4 patients, brain in 7 patients, liver in 5 patients, bone in 4 patients, and other sites in 4 patients. Treatments after initial recurrence included surgery in 2 patients, radiotherapy in 5 patients, chemotherapy in 9 patients, and chemo-radiotherapy in 5 patients. Only 1 patient received supportive care. The response to radiotherapy was a complete response (R) in 1 patient, partial response (PR) in 5 patients, stable disease (SD )in 3 patients, and progressive disease (PD )in 1 patient. The best response of all lines of chemotherapy was CR in 3 patients, PR in 4 patients, SD in 3 patients, and PD in 4 patients. The median post-recurrence survival (PRS) time with local recurrence was better than that with distant metastasis (23 vs 14 months); however, the best PRS was obtained in patients with recurrence in the lungs (29 months). A CR for more than 2 years was obtained in 1 patient after surgery, in 1 patient after radiotherapy, and in 2 patients after chemotherapy. Although local recurrence of resected NSCLC can be potentially controlled by using local treatments - such as surgery and radiotherapy - or systemic chemotherapy, curative aggressive treatment should be considered when required.

[A case of successful treatment of peritoneal dissemination from gastric cancer with S-1/DOC chemotherapy]

A 66-year-old man underwent a curative operation for advanced gastric cancer (T4aN0M0, Stage IIB). A gastric cancer recurrence with paraaortic lymph node (PALN) metastasis was diagnosed fifteen months after the operation. Systemic chemotherapy was initiated, using a regimen of S-1/CDDP. After 7 courses, abdominal computed tomography (CT) examination indicated the regression of PALN swelling. However, peritoneal dissemination was detected in the neighborhood of the right kidney. S-1/docetaxel (S-1/DOC) was selected as the second-line chemotherapy. After 3 courses, the peritoneal dissemination could not be detected. Five years since the curative operation, the patient has been doing well, with no signs of recurrence. In summary, we successfully treated a case of peritoneal dissemination from gastric cancer with S-1/DOC chemo- therapy.

Randomized controlled trial of the LigaSure vessel sealing system versus conventional open gastrectomy for gastric cancer

PURPOSE

LigaSure, a bipolar electronic vessel sealing system, has become popular in abdominal surgery but few clinical studies have been conducted to evaluate its effectiveness in radical gastrectomy for gastric cancer.

METHODS

In this multicenter, prospective, randomized controlled trial, patients with curative gastric cancer were randomly assigned to undergo gastrectomy either with LigaSure or a conventional technique.

RESULTS

Of the 160 patients enrolled, 80 were randomized to the LigaSure group and 78 to the conventional group. Patient characteristics were well balanced in the two groups. There were no significant differences between the LigaSure and conventional groups in blood loss (288 vs. 260 ml, respectively; P = 0.748) or operative time (223 and 225 min, respectively; P = 0.368); nor in the incidence of surgical complications or duration of postoperative hospital stay. In a subgroup analysis of patients who underwent gastrectomy that preserved the distal part of the greater omentum, the use of LigaSure significantly reduced blood loss (179 vs. 245 ml; P = 0.033), and the duration of the operation (195 vs. 221 min; P = 0.039).

CONCLUSIONS

LigaSure did not contribute to reducing intraoperative blood loss, operative time, or other adverse surgical outcomes. The usefulness of the device may be limited to a specific part of the surgical procedure in open gastrectomy.

Prognostic impact of major receptor tyrosine kinase expression in gastric cancer

BACKGROUND

Various kinds of molecular targeted drugs to inhibit receptor tyrosine kinases (RTKs) have been recently developed. The relationship between the expression status of major RTKs and prognosis in gastric cancer remains unclear. We conducted a multicenter study to evaluate the prognostic impact of the expression of epidermal growth factor receptor (EGFR), c-Met, platelet-derived growth factor receptor (PDGFR), and c-Kit in gastric cancer.

METHODS

This study included 153 gastric cancer patients who underwent gastrectomy at 9 institutions between 2000 and 2006. Expression status of EGFR, c-Met, PDGFR, and c-Kit were evaluated with immunohistochemistry (IHC) centrally. Overall survival based on RTK expression status was statistically compared. Cox multivariate analysis was conducted to adjust for potentially confounding factors.

RESULTS

The positive rates for EGFR, c-Met, PDGFR, and c-Kit were 14.4, 24.8, 41.2, and 11.1 %, respectively. Significant interactions with expression status were observed for pathological N stage with EGFR; HER2-status with c-Met; tumor location, histology, and pathological N stage with PDGFR; and no examined variables with c-Kit. Concomitant HER2 positivity was observed for 0.7 % of tumors positive for EGFR, 3.9 % for c-Met, 4.6 % for PDGFR, and 1.3 % for c-Kit. There were some differences in overall survival between patients with or without RTK expression, but only c-Kit expression showed a significant survival difference in Cox multivariate analysis (P = 0.046).

CONCLUSIONS

Our multicenter study indicated that IHC expression of 4 RTKs had some prognostic impact and that c-Kit-positive status may be a significant indicator of good prognosis in gastric cancer patients.

[A case of liver and bone metastasis from gastrointestinal stromal tumor treated using imatinib]

A 71-year-old man with an unspecified gastric tumor had undergone gastrectomy 15 years previously, and in 2012, positron emission tomography-computed tomography(PET-CT)showed the presence of a bulky tumor located in the right hepatic liver and multiple bone metastases. Although it was unclear whether the tumor was primary or metastatic, liver biopsy was performed. Immunostaining revealed that the lesions were positive for c-kit, and therefore, these lesions were diagnosed as liver and bone metastases from gastric gastrointestinal stromal tumor(GIST). Chemotherapy with imatinib was initiated. PET-CT performed after 3 months revealed a marked decrease in fluorodeoxyglucose(FDG)accumulation. The patient is alive at present with no recurrence.

[A case of jejunum cancer diagnosed by anemia]

The patient was an 85-year-old woman who was referred to a nearby clinic complaining of shortness of breath. Blood test showed anemia, and she was referred to our hospital for identification of the source of bleeding. Upper and lower endoscopy were performed and revealed no abnormalities. Computed tomography (CT) was performed and showed a >7- cm thickening in the wall of her small intestine. The presence of small bowel cancer was suspected. Oral double-balloon endoscopy was performed and showed a near-circumferential ulcerative lesion in the jejunum that was causing small bowel stenosis. A biopsy yielded a diagnosis of signet-ring cell carcinoma. We performed a partial resection of the patient's jejunum. The histopathological diagnosis of the resected specimen (according to the Union for International Cancer Control [UICC]TNM Classification of Malignant Tumours, seventh edition) was poorly differentiated adenocarcinoma, signet-ring cell carcinoma, mucinous carcinoma, T2 (MP), N0, H0, P0, stage I. 7 months after surgery, the patient is alive without recurrence. The incidence of small intestinal cancer is generally reported to be 1% to 2% of all gastrointestinal malignancies. We report a rare case in which cancer of the small intestine was identified during investigation of anemia.

[A case of advanced gastric cancer with peritoneal dissemination recurrence after gastrectomy effectively treated with combination chemotherapy of S-1 and docetaxel]

A 66-year-old man underwent distal gastrectomy with Roux-en-Y anastomosis and D2 dissection for the treatment of advanced gastric cancer (pT4a, N0, M0, stage IIB) in June 2009. He was treated with adjuvant postoperative chemotherapy consisting of S-1. However, in September 2010, computed tomography (CT) showed #16a2 lymph node recurrence, which was treated with combination chemotherapy of S-1 and cisplatin. After 7 courses of this combination chemotherapy, CT revealed a significant reduction in the size of the metastatic lesion as well as a new peritoneal dissemination recurrence around the right kidney. We therefore changed the regimen to combination chemotherapy of S-1 and docetaxel. After 3 courses of this treatment, the dissemination lesion was no longer evident by CT. After 6 more courses of treatment, the lymph node and peritoneal dissemination recurrence showed no regrowth. In response to the patient's wish, we changed the chemotherapy to S-1 alone beginning in June 2012. He survived without recurrence for approximately 2 years after gastrectomy. We suggest that the taxane drug was effective as second-line chemotherapy for the treatment of patients with peritoneal dissemination recurrence.

[A case of unresectable gastric cancer in a patient who maintained a good quality of life with multidisciplinary treatment]

Herein, we report the case of 57-year-old woman who visited our hospital for abdominal distention, difficulty in walking, and edema of the legs in January 2012. She underwent gastroendoscopy, resulting in a diagnosis of advanced gastric cancer of the pyloric antrum. A diagnosis of unresectable advanced gastric cancer was made because computed tomography (CT) showed the presence of ascites (suspected to indicate peritoneal dissemination), para-aortic lymph node metastases, and brain metastases. Stenting was performed for pyloric stenosis and cell-free and concentrated ascites reinfusion therapy (CART) was administered to facilitate oral intake. We administered two courses of chemotherapy with weekly paclitaxel. However, CT showed the presence of ascites and growth of the main tumor in the first month after the initiation of chemotherapy. We performed CART, and treatment was changed to S-1/paclitaxe(l 5 courses). Ascites decreased markedly and activities of daily living improved. However, 11 months after the initiation of therapy, the patient died.

[Neoadjuvant chemoradiotherapy with capecitabine and oxaliplatin for the treatment of locally advanced lower rectal cancer]

Chemoradiotherapy before surgical treatment of locally advanced lower rectal cancer is currently uncommon in Japan. We have treated 5 patients with T3 and/or N1 and 2 patients with rectal cancer using chemoradiotherapy including capecitabine and oxaliplatin( XELOX). The treatment consisted of concomitant administration of radiotherapy( 45 Gy/25 Fr), capecitabine (2,000 mg/m2/day; 2 weeks followed by 1 week off), and XELOX (2 courses). Surgery was performed 1 month after the final dose of chemotherapy was administered. The adverse events of Grade greater than 2 observed were radiation dermatitis (n=3), peripheral neuropathy (n=1), and rash (n=1). Either laparoscopic abdominoperineal resection( n=4) or open low anterior resection( n=1) was performed for surgical treatment. Histopathological regression grading revealed Grade 1a (n=1) and Grade 2 (n=4). The combined therapy resulted in downstaging in all patients. Preoperative chemoradiotherapy followed by XELOX might be effective for the treatment of locally advanced lower rectal cancer.

[A case of carcinoma associated with anal fistula effectively treated with preoperative chemoradiotherapy]

A 60-year-old man presented with anal pain. He was diagnosed as having perianal abscess and carcinoma associated with anal fistula. We performed chemoradiotherapy (radiation, total 50.4 Gy; capecitabine 2,000 mg/m2) followed by chemotherapy( XELOX, 2 courses: capecitabine 2,000 mg/m2, oxaliplatin 130 mg/m2). After chemoradiotherapy, the tumor significantly reduced in size. Laparoscopic abdominoperineal resection of the rectum, extended resection of the perianal region, and reconstruction of the perianal skin defect using a rectus abdominis musculocutaneous flap were performed. Histopathologically, the tumor was classified as tub2, pMP, ly0, v0, pN0 (0/3), pStage I, and the therapeutic efficacy was classified as Grade 2. Chemoradiation appears to be effective for the treatment of carcinomas associated with anal fistula.

[Radiofrequency ablation for liver metastases from colorectal cancer after systemic chemotherapy]

PURPOSE

To evaluate the effectiveness and safety of radiofrequency ablation(RFA)for liver metastases from colorectal cancer after chemotherapy.

PATIENTS

From January 2006 to June 2012, 27 tumors in 17 patients with liver metastases from colorectal cancer were treated using RFA after systemic chemotherapy.

RESULTS

The median tumor diameter after chemotherapy was 12(range: 3-35)mm, and the mean number of tumors was 1.6(range: 1-4).The median time without local recurrence was 21.3(range: 2.2-61.9)months, and the median overall survival time was 38.0(range: 5.9-66.3)months. One patient had a complication(liver abscess).Of the 27 tumors, 9 were larger than 20 mm in diameter, and 4 of these 9 tumors showed local recurrence after RFA. In tumors smaller than 20 mm in diameter, only 1 showed local recurrence. The local recurrence rate was significantly higher for tumors larger than 20 mm than for tumors smaller than 20 mm(44.4% vs 5.6%,p=0.030).

CONCLUSION

RFA was an effective and safe method for treating liver metastases from colorectal cancer, especially for tumors smaller than 20 mm and in cases of less than 3 tumors after systemic chemotherapy.

[A case of small-sized lung cancer complicated by sarcoidosis]

A woman in her seventies presented with bilateral hilar and mediastinal lymphadenopathy with high fluorodeoxyglucose (FDG) uptake by positron emission tomography (PET)-computed tomography (CT), small lung nodules, and uveitis. Mediastinoscopic biopsy yielded a histological finding of epithelioid granuloma and a diagnosis of sarcoidosis. A nodule, 1 cm in diameter, in the right middle lobe with moderate FDG uptake was deemed to be a sarcoidosis lesion. Steroid therapy for uveitis resulted in shrinkage of the hilar and mediastinal lymph nodes; however, 1 year later the nodule in the right middle lobe had enlarged to 2 cm in diameter. Right middle lobectomy was performed, and a histological diagnosis of lung squamous cell carcinoma was made. Six months later, right pretracheal lymphadenopathy with high FDG uptake was noted and was proved to be a metastatic squamous cell carcinoma by endobronchial ultrasound-guided transbronchial needle aspiration( EBUS-TBNA). After 7 courses of chemotherapy with docetaxel, the target lesion shrank and its abnormal FDG uptake disappeared. Small-sized lung cancer could be missed when complicated by sarcoidosis because the latter produces a background of multiple lesions, so careful diagnostic imaging and follow-up should be performed in patients diagnosed as having sarcoidosis.

[Safety and validity of port-less forceps in reduced-port surgery for laparoscopic resection of colorectal cancer]

The purpose of this study was to examine the safety and validity of reduced-port surgery( RPS) in comparison with conventional laparoscopic surgery for colorectal cancer. We investigated 64 cases of colorectal cancer( CRC) resected by laparoscopic surgery at our hospital in 2012, including 22 cases resected by RPS using 1 or more port-less forceps( Endo Relief, Hope Electronics, Japan). With regard to safety, Endo Relief yielded satisfactory outcomes in terms of the limitations of other needlescopic devices, such as lack of strength and risk of tissue injury, while maintaining countertraction. In addition to the original reasons for introducing RPS, such as lessening wound pain and improving the cosmetic outcome after surgery, the advantages of RPS for CRC are high cost efficiency and the possibility of using additional forceps to maintain triangulation or countertraction during laparoscopic surgery. Because it involves a port-less system, RPS facilitates the frequent reuse of forceps, thereby contributing to its high cost efficiency. In the introduction of RPS for laparoscopic colorectal resection, the use of port-less forceps for countertraction could be safe and effective.