[A Case of Stage IV Gastric Cancer Which Showed Pathological Complete Response after Neo-Adjuvant Chemotherapy]

We report a case of Stage IV gastric cancer showing pathological complete response(pCR)after neo-adjuvant chemotherapy( NAC)using S-1 and oxaliplatin(SOX).A woman 73-year-old was diagnosed as harming type 3 Stage IV gastric cancer with para-aortic lymph node(PAN)metastasis.She underwent 4 courses of NAC with SOX regimen.After the treatment, both the primary tumor and the metastatic PAN decreased in size remarkably.She underwent distal gastrectomy with D2 plus PAN dissection with curative intent.Pathological diagnosis revealed complete disappearance of cancer cells in both the primary lesion of the stomach and all dissected lymph nodes, confirming pCR.She is alive without recurrence 4 months after surgery.

[Clinical Outcomes of Local Therapy for Lymph Node Recurrence after Radical Esophagectomy for Esophageal Cancer]

We analyzed the prognostic factors related to long-term survival in 31 patients, 27 men and 4 women, median age 67 years, who had lymph node recurrence after radical esophagectomy for esophageal cancer. The pathological Stage was Stage I in 2 patients, Stage II in 9 patients, Stage III in 18 patients, and Stage IV a in 2 patients. Seventeen patients were diagnosed with lymph node recurrence in a single area and the other 14 patients were diagnosed with lymph node recurrence in multiple areas(n=3)or lymph node recurrence complicated by hematogenous or disseminated metastases(n=11). Eighteen patients were treated with chemoradiotherapy(CRT), and surgical intervention after CRT was indicated in 5 of them. One patient had surgery alone, 7 were treated with chemotherapy, and 5 were administered best palliative care. The median survival after recurrence was 357 days. The patients with lymph node recurrence in a single area and those treated by CRT or surgery had significantly better prognosis than the others. Although the overall prognosis for patients with tumor recurrence after esophagectomy is poor, lymph node recurrence in a single area or treated with local therapy was associated with better long-term survival.

[Two Resected Cases with Superficial Basaloid Squamous Carcinoma of the Esophagus]

We report 2 resected cases of superficial type basaloid squamous cell carcinoma of the esophagus. Case 1 is a 67-year-old man who underwent endoscopic submucosalresection for superficialel evated type esophagealcancer of the middle thoracic esophagus. Because the pathological diagnosis of the resected specimen was basaloid squamous cell carcinoma invading to the submucosal layer with lymphatic vessel invasion, esophagectomy was indicated. The resected specimens showed no tumor in the esophagus. However, metastasis was diagnosed in the dissected mediastinall ymph nodes. Left cervicall ymph node recurrence was detected 1 years 10 months after surgery, and lymphadenectomy was performed after irradiation therapy. He survived 4 years after the first operation. Case 2 is a 60-year-old man who underwent esophagectomy for superficial elevated type adenosquamous cell carcinoma with submucosal invasion. The pathological diagnosis revealed basaloid squamous cell carcinoma with submucosal invasion. The pathological diagnosis revealed basaloid squamous cell carcinoma invading the submucosal layer with lymphatic and blood vessel invasion. The patient died of recurrent disease in the lungs and liver 3 months after surgery. Although these 2 cases were superficial type esophageal basaloid squamous cell carcinoma, both had severe vessel invasion and lymph node metastasis. In basaloid squamous cell carcinoma, adjuvant therapies are needed after surgery, even if the lesion is diagnosed as superficial type. Multimodality treatment is needed for greater survival benefit.

[Clinical Outcomes and Prognosis of Salvage Thoracoscopic Esophagectomy after Definitive Chemoradiotherapy]

We examined the treatment outcomes and survival rate of patients treated with salvage thoracoscopic esophagectomy after definitive chemoradiotherapy (dCRT). Twenty-seven patients who were indicated for salvage thoracoscopic esophagectomy after dCRT in our department were enrolled through April 2014. Eight patients had tumor regrowth after a complete response, and 19 had residual tumors. Two patients needed conversion to conventional thoracotomy. The operation time was 340 minutes (thoracic procedure: 125 minutes), and the estimated blood loss was 330 mL (thoracic procedure: 100 mL). The mean number of dissected nodes was 18. None of the patients experienced serious perioperative complications, and R0 surgery was performed in 24 patients. Postoperative complications developed in 15 patients (56%), and anastomotic leakage occurred in 11. Pneumonia developed in 3 patients, but none of the patients had tracheal necrosis or hospital mortality. The 5-year survival rate of all the patients was 40.4%, and the patient who underwent R0 surgery had a significantly better outcome than a patient with R1 or R2. Thoracoscopic esophagectomy is a safe option for salvage treatment of patients in an institution that has physicians experienced and skilled in thoracoscopic esophagectomy. However, it is always necessary to prepare for conversion to conventional thoracotomy.

Overexpression of Ephrin A2 receptors in cancer stromal cells is a prognostic factor for the relapse of gastric cancer

BACKGROUND

Microenvironments control cancer growth and progression. We explored the prognostic impact of stromal reaction and cancer stromal cells on relapse risk and survival after curative gastrectomy in gastric cancer patients.

METHODS

Tissue samples were obtained from 107 patients with gastric adenocarcinoma who underwent curative (R0) gastrectomy. Primary stromal cells isolated from gastric cancer tissue (GCSC) and normal gastric tissue (Gastric stromal cell: GSC) in each patient were cultured and subjected to comprehensive proteome (LC-MS/MS) and real-time RT-PCR analysis. Expression of Ephrin A2 receptors (EphA2) in cancers and GCSC was evaluated immunohistochemically. Intermingling of EphA2-positive cancer cells and GCSC (IC/A2+) and overexpression of EphA2 in cancer cells (Ca/A2+) in invasive parts of tumors were assessed, as were relationships of IC/A2+, Ca/A2+, and clinicopathological factors with relapse-free survival and overall survival.

RESULTS

Proteome analysis showed that EphA2 expression was significantly higher in GCSC than GSC. Real-time RT-PCR analysis showed that levels of EphA1/A2/A3/A5 and EphB2/B4 were ≥2.0-fold higher in GCSC than GSC. Ca/A2 and IC/A2 were positive in 65 (60.7 %) and 26 (24.3 %) patients, respectively. Relapse was significantly more frequent in IC/A2-positive than in IC/A2-negative (HR, 2.12; 95 % CI, 1.16-5.41; p = 0.0207) patients. Among the 54 patients who received S-1 adjuvant chemotherapy, relapse-free survival (RFS) was significantly shorter in those who were IC/A2-positive than in those who were IC/A2-negative and Ca/A2-negative (HR, 2.83; 95 % CI, 1.12-12.12; p = 0.0339). Multivariable analysis indicated that pathological stage (p = 0.010) and IC/A2+ (p = 0.008) were independent risk factors for recurrence.

CONCLUSION

IC/A2+ was predictive of relapse after curative (R0) gastrectomy.

[Treatment outcomes of patients with cervical lymph node recurrence after esophagectomy for esophageal cancer]

Herein, we report the treatment outcomes of patients with limited cervical lymph node recurrence after esophagectomy for esophageal cancer. Between April 2010 and December 2013, 8 patients with cervical lymph nodes recurrence were diagnosed and treated in our department. All patients were detected with recurrent disease by using positron emission tomography computed tomography(PET-CT), and among these, 5 patients had solitary node recurrence. Initial treatments were irradiation therapy in 5 patients and lymphadenectomy in 3 patients. Four of 5 patients underwent irradiation therapy and lymphadenectomy. Four of 5 patients with solitary node recurrence are still alive without relapse of disease. In conclusion, PET-CT can be useful for early detection of recurrent disease after esophagectomy. Appropriate therapy for patients with solitary cervical lymph node recurrence is associated with long-term survival after recurrence.

[Clinical outcomes of thoracoscopic esophagectomy after neoadjuvant chemotherapy]

AIM

With recent advances in multimodal therapy for esophageal cancer, neoadjuvant chemotherapy (NAC) followed by surgery has become the standard treatment for advanced resectable esophageal cancer. This study analyzed the feasibility and clinical outcomes of thoracoscopic esophagectomy (TE) after NAC.

PATIENTS AND METHODS

We retrospectively analyzed 129 patients who underwent TE with radical mediastinal lymph node dissection between January 2005 and December 2012. Of these patients, 54 received NAC( NAC+group) and 75 did not( NAC-group).The perioperative clinical outcomes, number of dissected nodes, and postoperative mortality were compared between the 2 groups.

RESULTS

The operation time in the NAC+group was significantly longer than that in the NAC-group( p<0.01).However, the estimated blood loss was significantly less in the NAC+group( p<0.01).There was no significant difference in the number of dissected nodes and the frequency of postoperative complications between the 2 groups.

CONCLUSION

TE can be safely adopted for the treatment of patients with advanced esophageal cancer after NAC.

[Utility and drawbacks of fludeoxyglucose-positron emission tomography in locally advanced esophageal cancer treated by neoadjuvant chemotherapy followed by esophagectomy]

In Japan, neoadjuvant chemotherapy followed by esophagectomy has become the standard treatment for resectable advanced esophageal cancer. However, there are few reports on the utility of fludeoxyglucose( FDG)-positron emission tomography (PET) in such cases so far. In this study, we analyzed the utility and drawbacks of FDG-PET in patients who underwent neoadjuvant chemotherapy followed by surgery. Thirty-seven patients with cStage II or III thoracic esophageal cancer who received 2 courses of combination chemotherapy with 5-fluorouracil and cisplatin followed by surgery were enrolled this study. The maximum standardized uptake value (SUVmax) in the main lesion significantly decreased after chemotherapy (38.6%), and there was a greater decrease in SUVmax in patients with downstaging. Following chemotherapy, the esophageal lesions were not detected by FDG-PET in 6 patients. However, in these patients, the histopathological diagnosis of the resected specimens revealed that the cancer cells persisted. The SUVmax increased after chemotherapy in 5 patients, and in 4 of 5 patients recurrent disease was observed. In conclusion, we should understand the characteristics of FDG-PET in esophageal cancer after neoadjuvant chemotherapy and use it precisely.

[Clinical utility of PET-CT for esophageal cancer]

It is important to diagnose the exact clinical staging according to the improvement of treatment for esophageal cancer. PET examinations for esophageal cancer are now covered by Japanese government health insurance, so the number of PET scans is now gradually increased in many institutions and their utility has been reported. In this report, we reviewed the conventional diagnostic tools for esophageal cancer and evaluated the clinical significance of PET-scans conventionally associated with it. The depth of tumor invasion of a primary tumor is detectable in more than 80% of cases of SM2 or deeper invasion. With lymph node metastasis, the sensitivity was 66. 7% and specificity 93. 5%. With distant metastasis, there is reportedly a high detection rate in bone metastasis and liver metastasis. However, with lung metastasis, reference to CT scans rather than PETscans is important in making a carefull diagnosis. In judging the effect of preoperative chemoradiotherapy, PET-CT was suggested to be an effective diagnostic tool. In addition, PET may be a useful diagnostic tool for postoperative follow-up patients. Finally, further investigation may well be necessary in the future.

Solid-pseudopapillary neoplasm of the pancreas with massive central calcification in an old man

Solid-pseudopapillary neoplasm (SPN) is a rare pancreatic tumor primarily affecting women in their twenties. It is characterized by a well-demarcated or encapsulated mass, indolent behavior and favorable prognosis. Capsular or punctate calcification is occasionally observed. Reported herein is a case of SPN of the pancreas with massive calcification in a 76-year-old Japanese man. Macroscopically, the pancreatic tumor appeared to be a simple calcified nodule, but histological examination revealed that it was an epithelioid tumor with massive calcification. The tumor cells, forming nests and cords, had eosinophilic cytoplasm and small eccentric nuclei. They were immunohistochemically positive for vimentin, CD56 and neuron-specific enolase. Nuclear accumulation of beta-catenin protein and a point mutation of the beta-catenin gene by genomic DNA sequencing confirmed that the tumor was SPN. This is a very rare case of pancreatic SPN with massive calcification in an old man.

Diffuse gastroduodenitis and pouchitis associated with ulcerative colitis

We experienced a very rare case of ulcerative colitis (UC) accompanied with analogous lesions in the stomach, duodenum, and ileal J -pouch. Ileal J-pouch anal anastomosis was performed on a 29-year old woman in 1996. Six years later, she was admitted again to our hospital because of epigastralgia, nausea, watery diarrhea and low fever. Based on the results of endoscopic examination, we diagnosed it as pouchitis. Moreover, on hypotonic duodenography, expansion of the duodenal bulb and the descending portion were poor. Kerckring folds disappeared with typical lead-pipe appearance. The pathogenesis of the gastric and duodenal lesion in this patient was similar to that of the colonic lesions of UC. For the gastroduodenal lesions in this patient, symptomatic remission was obtained following administration of crushed mesalazine tablets (1500 mg/d) for 14 d with continuous administration of omeprazole. Firstly we used ciprofloxacin to treat pouchitis. On the fifth day, she got a fever because of catheter infection. In the catheter culture, methicillin-resistant Staphylococcus aureus (MRSA) was detected. Therefore we changed ciprofloxacin to vancomycin hydrochloride (Vancomycin^®). Vancomycin was very effective, and the stool frequency dramatically improved in three days. Now she continues to take mesalazine, but her condition is stable and there has been no recurrence of pouchitis.