[CA19-9 Producing Gastric Cancer with Early Recurrence of Multiple Colon Metastases Following Gastrectomy-A Case Report].

A 90-year-old male underwent total gastrectomy for gastric cancer 10 months earlier. The cancer was pathologically diagnosed as Stage ⅢA. Preoperative serum CA19-9 level was as high as 1,326 U/mL, but quickly decreased after surgery. Although the serum CA19-9 level gradually re-increased, CT did not reveal recurrence of the disease. Ten months following surgery, the patient visited our hospital due to vomiting, and ileus was suspected because of finding of sigmoid colon tumors in the abdominalCT. Colonoscopy showed a circumferentialtumor with severe stenosis in the sigmoid colon, which was diagnosed as tubular adenocarcinoma by biopsy. After preoperative diagnosis of multiple colon cancers, sigmoidectomy was performed. A total of 4 tumors were revealed in the resected specimen. Pathological findings showed cancer cells with nuclear atypia in all tumors, which was very similar to findings in the previous gastric cancer. Immunohistochemical staining confirmed high expression of CA19-9 in both gastric and colon tumors. We concluded that the tumors were metastases of the CA19-9 producing gastric cancer.

[Long-Term Survival in a Patient with Combined Hepatocellular-Cholangiocarcinoma Treated with Multidisciplinary Therapy - A Case Report].

The patient was a woman in her 50's. She went to the hospitalfor epigastric discomfort. Numerous hypovascular tumors spreading almost to the entire liver were detected via abdominal CT. We diagnosed the tumors as unresectable intrahepatic cholangiocarcinoma(ICC). Chemotherapy with gemcitabine(GEM)and S-1 was given. The tumors shrunk markedly, and stable disease status was maintained for 2 years and 4 months. Thereafter, the regimen was changed to GEM plus cisplatin (CDDP)because of progressive disease, which was then uncontrolled. Although proton beam therapy and radiofrequency ablation were subsequently performed, multiple lesions appeared in the liver, and metastasis was also observed shortly in the left lung. Right hepatic trisegmentectomy and thoracoscopic left lung partial resection were performed in 2 stages. Histopathological findings showed morphological hepatocellular carcinoma(HCC)as well as positive immunostaining with CEA, CK7, and CK19. The final diagnosis was combined hepatocellular-cholangiocarcinoma. The patient is without recurrence for 9 months following operation, and long-term survivalfor 4 years and 6 months has been obtained.

[Gastric Cancer Diagnosed with Metastasis of the Navel(Sister Mary Joseph's Nodule) - A Case Report].

A woman in her 60s was admitted to our hospital with pain and induration of the navel. She was diagnosed with gastric cancer with metastasis to the navel and underwent total gastrectomy and navel extraction. Because disseminated nodules were detected in the Douglas pouch and sigmoid colon, sigmoidectomy was performed to prevent bowel obstruction. The navel tumor was histologically diagnosed as a metastasis of the gastric cancer. One month after surgery, a chest skin tumor, which was also a skin metastasis of the gastric cancer[T4aN3M1(SKI, OTH)H0P1, fStage IV ], was detected, and tumor enucleation was performed. Enucleation was followed by 47 courses of systemic chemotherapy consisting of capecitabine, cisplatin, and trastuzumab. No recurrence or metastasis has been observed via FDG-PET/CT as of 5 years after surgery. Gastric cancer with peritoneal dissemination in addition to navel metastasis has been reported to have an extremely poor prognosis. However, long-term, recurrence-free survival was obtained in this case owing to aggressive surgical resection, followed by persistent systemic chemotherapy.

[Multiple Endocrine Neoplasia Type 1(MEN1)Presenting with Hypoglycemic Attacks - A Case Report].

A woman in her 60s visited our hospital because of frequent hypoglycemia and episodes of unconsciousness over the last 6 years. A 4 cm tumor was detected on the pancreatic tail using abdominal computed tomography and ultrasonography. An insulinoma was strongly suspected from the results of the fasting test and glucagon load test, and a distal pancreatectomy with splenectomy was performed. Pathological examination indicated an insulinoma and neuroendocrine tumor(NET)G2 based on the WHO 2010 classification. The patient's blood sugar and insulin levels returned to normal, and hypoglycemic attacks disappeared postoperatively. Six months later, a total parathyroidectomy was performed because of primary hyperparathyroidism with hypertrophy of the parathyroid glands. Furthermore, pituitary swellingwas also detected usinghead MRI. However, the patient has been under observation because the tumor was non-functional without any associated symptoms. Thus, we diagnosed the patient with multiple endocrine neoplasia type 1(MEN1). In patients with pancreatic NET, it is necessary to consider the possibility of MEN1.

[Successful Placement of Self-Expandable Metallic Stent for Malignant Gastrojejunostomy Obstruction Following Pancreatoduodenectomy - A Case Report].

A man in his 50 s, who had undergone subtotal stomach-preserving pancreatoduodenectomy with modified Child's reconstruction for pancreatic cancer 8 months back, was hospitalized because of vomiting and difficulty in feeding.Radiological and endoscopic studies revealed a malignant obstruction of the gastrojejunostomy site due to peritoneal recurrence of the cancer.Although a self-expandable metallic stent(SEMS)was placed in the anastomotic site, it slipped back into the stomach 3 days later.It was suggested that the migration was caused by antiperistalsis, because the SEMS was placed in the afferent loop.Although the SEMS was required to be placed in concordance with the peristaltic direction, it was impossible to pass a guidewire directly from the stomach into the efferent loop.Therefore, the guidewire was placed antidromically through a narrow site from the distal portion of the efferent loop via Braun anastomosis, and the SEMS was subsequently placed without any complication.This allowed the patient to maintain oral intake throughout his remaining life.Our antidromic approach for SEMS placement could be beneficial if performing a standard procedure is difficult.

[Adjuvant Surgery for Initially Unresectable Locally Advanced Pancreatic Cancer following Gemcitabine and S-1 Chemotherapy--A Case Report].

A man in his 60s was admitted with obstructive jaundice. A hypovascular tumor, 55 mm in diameter, was detected in the pancreas head on imaging. The superior mesenteric vein showed severe stenosis bilaterally and the roots of all branches were invaded by the tumor. The tumor was diagnosed as unresectable pancreatic cancer, and chemotherapy of gemcitabine and S-1 was administered, resulting in a remarkable reduction of the tumor size. Following 7 courses of chemotherapy, a subtotal stomach-preserving pancreatoduodenectomy was carried out. Microscopic examination revealed no residual cancer cells in the resected specimen, indicating that pathological complete remission was obtained. Although some reports suggest that surgical treatment for patients with initially unresectable pancreas cancer who show excellent response to chemotherapy may improve the prognosis, further studies are needed.

[Surgical treatment for gall bladder cancer with a confluence stone-a case report].

The patient was a 71-year-old man. In September 2011, he experienced abdominal pain with high fever. Abdominal computed tomography (CT) diagnosed acute cholecystitis with a confluence stone (corlette classification type II). He underwent total cholecystectomy and placement of a T-tube in the main bile duct through the gall bladder duct. However, pathological investigations revealed gall bladder cancer in the neck and body part of the gall bladder, leading to a diagnosis of gall bladder adenocarcinoma(Gbn, Flat type, tub2, INF ß,pSS, pHinf0, pBinf1, pPV0, pA0, pT3) with a confluence stone. We suspected that the tumor was present in the common bile duct. Therefore, in October 2011, he underwent choledochectomy, resection of the liver bed, lymph node dissection, and choledocho-jejunostomy. Pathological findings revealed that the tumor was present in the common bile duct. He died 8 months after the last surgery because of recurrence of peritoneal metastasis.

[Complete response of primary tumor in a case of advanced gastric cancer with liver metastasis treated by TS-1 plus divided administration of CDDP].

A 62-year-old female patient was hospitalized for general fatigue and appetite loss. Type 3 gastric cancer (moderate differentiated adenocarcinoma) with liver metastasis (S8) and direct invasion to the retro-peritoneal space and duodenal third portion was detected by endoscopic and radiographic examination. This case was judged to be unresectable from these findings. TS-1 plus divided administration of CDDP was performed. TS-1 (100 mg/day) was administrated from day 1 to 21 followed by 14 days rest as one course. CDDP (20 mg/m2) was infused for 2 hours on day 1, 8, and 15. One course was done in the hospital, and the following 2 courses as ambulatory treatment. Grade 2 neutropenia was observed as an adverse reaction. At the completion of 3 courses, partial response in the primary tumor, complete response in the duodenal third portion and no change in the liver metastasis were assessed by examination. Because of this remarkable down-staging, distal gastrectomy and radiofrequency ablation (RFA) for liver metastasis were performed. There was no evidence of direct invasion to the other organs from the primary tumor in intraoperative findings. Pathological examination revealed the disappearance of carcinoma cell in the resected stomach and the surrounding lymphnodes. In conclusion, this chemotherapy regimen has an excellent antitumor effect with low toxicities. Therefore, this regimen was comparatively safe for outpatients and was an effective neo-adjuvant chemotherapy.