[A Case of Simultaneous Laparoscopic Surgery for Intrahepatic Cholangiocarcinoma and Sigmoid Colon Cancer].

The patient was an 83-year-old woman. CT scan showed a 20 mm mass in the surgical anatomy of the medial segment (S4)of the liver, but the patient refused to undergo surgery and continued periodic clinical follow-up. After 1 year and 3 months of initial examination, a CT scan showed an enlargement of 36 mm. Therefore, surgical treatment was adopted. Preoperative lower gastrointestinal endoscopy revealed a type 1 tumor of the sigmoid colon quarter circumference 30 mm from the anal verge, and the biopsy led to a diagnosis of adenocarcinoma equivalent to tub 1. The hepatic mass showed heterogeneous contrast effect centered on the arterial phase margins and prolonged contrast effect in the equilibrium phase. Since the liver tumor was a single S4 mass with a 36 mm diameter, laparoscopic sigmoidectomy and laparoscopic partial hepatic resection were performed subsequently. Pathology results showed that the sigmoid colon tumor and hepatic S4 mass were predominantly well-differentiated and moderately-differentiated adenocarcinomas, respectively. Immunohistochemical results were cytokeratin 7 antibody-positive and cytokeratin 20 antibody-negative, leading to a definitive diagnosis of intrahepatic cholangiocarcinoma. The patient's postoperative course was well and was discharged from the hospital on postoperative day 12. After 1 year postoperatively, the patient remains recurrence-free.

[Questionnaire Survey of Treatment Strategies for Gastric Cancer with Peritoneal Dissemination in Yamaguchi Prefecture].

The questionnaire survey was conducted on treatment strategies for gastric cancer with peritoneal dissemination at 7 institutions, including 5 designated cancer hospitals in Yamaguchi prefecture. Staging laparotomy was performed at 6 out of 7 institutions. Six out of 7 institutions selected the treatment strategy for P0CY1 cases", upfront resection and adjuvant therapy". The doublet chemotherapy was performed by S-1 plus platinum or taxane. Surgical treatment for P1 cases, conversion gastrectomy was considered at all institutions when it was judged that R0 resection was possible after induction chemotherapy. Chemotherapy for P1 cases was treated according to the guidelines at all institutions, and the regimen was not changed depending on the peritoneal dissemination.

[A Case of Tumor Embolization to the Internal Iliac Vein Four Years after the Surgery for Rectal Cancer].

60-year-old man was admitted to our hospital with a chief complaint of melena. Lower gastrointestinal endoscopy revealed a type 2 tumor on the anterior wall of the rectum(Rb). He was referred to our department, and he underwent abdominoperineal rectal resection with D3 dissection and right lateral node dissection for Rb, cT2, N0, M0 intestinal cancer. Pathological diagnosis was a tub2, pT2, N0, Ly0, V0, pDM0(30 mm), pPM0(160 mm), pR0, pStage Ⅰ cancer. Therefore, postoperative adjuvant chemotherapy was not performed. Subsequent follow-up examinations were conducted on a regular basis to confirm no recurrence. However, 4 years after the surgery, high levels of tumor markers, such as CEA(59.2 ng/mL) and CA19-9(75.5 U/mL), were detected. CT showed tumor embolism to the internal iliac vein and multiple lung metastases. After IVC filter placement, chemoradiotherapy was performed. Although the tumor embolism disappeared, multiple lung metastases increased. Additionally, brain metastasis appeared 6 years after the operation. After that, according to the policy of BSC, he died 7 years after the surgery.

[Questionnaire Survey of Third-Line Chemotherapy for Gastric Cancer in Yamaguchi Prefecture].

A questionnaire survey was conducted on third-line chemotherapy of unresectable or recurrent gastric cancer for 23 doctors involved in gastric cancer treatment in Yamaguchi prefecture. Eighty-seven% of doctors replied that third-line chemotherapy transfer rate was less than 60% of patients, and 13% of doctors replied that third-line chemotherapy transfer rate was more than 60% of patients. Nivolumab was the first-choice regimen for third-line chemotherapy, with 87% of doctors, 4% of doctors each for CPT-11, trifluridine/tipiracil hydrochloride, and docetaxel. Timing of switching from the second-line therapy to the third-line therapy, RECIST PD was the highest in 61% of doctors, with other baseline PD in 43% of doctors, clinical PD in 43% of doctors, and tumor marker elevation in 39% of doctors. The timing of regimen switching after using the immune checkpoint inhibitor was PD at the first CT in 43% of doctors, PD at the second CT in 43% of doctors. Nivolumab was used as the first-choice in more than 80% of the regimens for gastric cancer third-line chemotherapy in Yamaguchi prefecture. There was a difference in consciousness among doctors regarding the timing of switching from second- line to third-line chemotherapy and the timing of switching from nivolumab to fourth-line therapy.

[A Case of Laparoscopic Gastric Local Resection for Simultaneous Multiple Gastric GIST Discovered Owing to Gastrointestinal Bleeding].

An 80-year-old woman with anemia presented to our hospital. Upper gastrointestinal endoscopy revealed a 4 cm submucosal tumor(SMT)with a delle and 2 cm SMT in the upper part of the stomach. CT revealed sustained enhancement of both tumors. The posterior tumor was an intraductal growth, and the anterior tumor was an extravascular growth. We performed a laparoscopic gastric local excision for the multiple SMTs. The anterior tumor was resected with an automatic suture instrument. However, the posterior tumor could not be identified from within the abdominal cavity because it was resected while confirming using an endoscope, and all layers were sutured. On histopathological examination, the posterior tumor was 40mm in size, with spindle-shaped atypical cells growing in the submucosal layer. Immunostaining was c-kit(+), CD34(+), S-100(-), and desmin(-). The Ki-67 level was<1%. The anterior wall tumors showed similar findings, but some showed smooth muscle differentiation. From the results, a diagnosis of simultaneous multiple gastric GIST(low risk)was made.

[A Case of Gastric GIST with Pathological Complete Response Achieved by Long-Term Chemotherapy with Imatinib Mesylate].

A 78-year-old woman was diagnosed with a gastrointestinal stromal tumor(GIST)of the stomach, gradually increasing from 5 years prior. The tumor was suspected to invade the pancreatic body tail and spleen, as observed with computed tomography. Because the patient refused to undergo resection, we administered imatinib mesylate for 6 years. Since early rectal cancer was revealed, the patient was referred for resection and underwent laparoscopic low anterior resection and partial gastrectomy. Histopathologically, the tumor was replaced by tissues with myxomatous changes, and no viable tumor cells were detected. This was a rare case of GIST, resected after long-term chemotherapy by imatinib mesylate, and pathological complete response was achieved.

[A Case of Metastasis of Ascending Colon Cancer to the Small Intestine That Was Diagnosed Based on Ileus].

A 69-year-old man was administered an ileus tube for ileus by ascending colon cancer. The next day, he underwent right hemicolectomy with D3 lymph node dissection for perforative peritonitis due to ascending colon cancer. The pathological diagnosis was A, type 2, muc>tub1, pT3, pN0. M0, pStageⅡ. He received 5 courses of UFT/Leucovorin(LV)chemotherapy. Two years later, he was hospitalized for ileus. He underwent surgery. The peritoneal dissemination was absent in the surgical findings. We resected a small intestinal tumor from the oral side of anastomosis. Because the tumor appearance and pathological findings were similar to those of ascending colon cancer, the patient was diagnosed with metastasis of ascending colon cancer to the small intestine. We report our rare encounter with metastases of colorectal cancer to the small intestine.

[A Case of Rectal Neuroendocrine Carcinoma That Showed a Sharp Turning Point after Neoadjuvant Radiochemotherapy and Conversion Surgery].

A 45-year-old man presented with the chief complaint of anal discomfort to a previous doctor. The symptoms remained after undergoing seton surgery following the diagnosis of intermuscular anal fistula. CT showed a tumor that was 3 cm in diameter on the right wall of the rectum, and he received a diagnosis of neuroendocrine carcinoma(NEC)based on a biopsy. Subsequently, he was admitted to our hospital. Liver metastasis accompanied NEC, and chemotherapy was performed for stage Ⅳ diagnosis. We detected tumor disappearance after administering 8 courses of CDDP plus CPT-11. However, after 3 months, a 1 cm nodule appeared at the primary lesion, which was considered as recurrence. We selected reintroduction of CDDP plus CPT-11 treatment, but the tumor progressed. CDDP plus VP-16 plus radiation therapy was introduced, and tumor shrinkage was observed without distant metastasis. We judged that radical resection was possible, and performed Miles' operation, total prostate gland resection, and urethra reconstruction. He was discharged on the 28th day after surgery. The pathological findings indicated neuroendocrine small cell carcinoma, and the CRT effect was judged as Grade 2 and curability A. However, he was admitted to the emergency room following convulsions on the 46th day after surgery was performed. CT revealed multiple cerebral metastasis, meningeal dissemination, and liver metastasis. He underwent cyber knife surgery for brain metastasis. Drainage was required for cerebral hypertension due to meningeal dissemination. He died on the 115th postoperative day.

[Effect of Pegfilgrastim Primary Prophylactic Administration on Relative Dose Intensity(RDI)in Postoperative Adjuvant Chemotherapy(TC Therapy)for Breast Cancer - A Single-Center, Retrospective Study].

This study assessed the effect of pegfilgrastim in patients with early stage breast cancer who were receiving docetaxel and cyclophosphamide(TC)therapy(75mg/m / 2 docetaxel plus 600 mg/m2 cyclophosphamide). In total, 17 patients who were to receive 4 planned cycles of TC therapy every 3 weeks were included in this study. Of the 17 patients, 10 who received pegfilgrastim after January 2016 formed the Peg-G group and 7 who did not receive pegfilgrastim until December 2015 formed the control group. We observed a high successful execution rate and relative dose intensity(RDI)with docetaxel in both groups. The successful execution rates were 100% in the Peg-G group and 42.8% in the control group. The RDI was 86.5%(65.4-100%)in the Peg-G group and 52.5%(48.0-58.0%)in the control group. This study showed that the use of pegfilgrastim results in a high successful execution rate and RDI in patients with early stage breast cancer undergoing TC therapy.

[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.

[A Case of Rectal Villous Tumor Detected with Heart Failure and Electrolyte Imbalance].

A 74-year-old woman presented to our emergency department with a chief complaint of appetite loss, and already diagnosed dehydration and heart failure. After hospitalization, the signs of heart failure were improved with liquid supplementation and electrolyte revision. At admission, computed tomography incidentally detected a rectal tumor. She underwent colonography, which revealed a huge villous tumor in the rectum. Based on the result of the initial biopsy, it was classified as a group 4 tumor, but additional biopsy of specimens obtained from 6 places led to a diagnosis of group 5 tumor. Then, we performed laparoscopic super-low anterior resection and made an ileal stoma. The electrolyte imbalance was improved and did not recur after the operation. In this case, the electrolyte imbalance caused by the huge villous tumor was electrolyte depletion syndrome (EDS).

Characterization of uncultured giant rod-shaped magnetotactic Gammaproteobacteria from a freshwater pond in Kanazawa, Japan.

Magnetotactic bacteria (MTB) are widespread aquatic bacteria, and are a phylogenetically, physiologically and morphologically heterogeneous group, but they all have the ability to orientate and move along the geomagnetic field using intracellular magnetic organelles called magnetosomes. Isolation and cultivation of novel MTB are necessary for a comprehensive understanding of magnetosome formation and function in divergent MTB. In this study, we enriched a giant rod-shaped magnetotactic bacterium (strain GRS-1) from a freshwater pond in Kanazawa, Japan. Cells of strain GRS-1 were unusually large (~13×~8 µm). They swam in a helical trajectory towards the south pole of a bar magnet by means of a polar bundle of flagella. Another striking feature of GRS-1 was the presence of two distinct intracellular biomineralized structures: large electron-dense granules composed of calcium and long chains of magnetosomes that surround the large calcium granules. Phylogenetic analysis based on the 16S rRNA gene sequence revealed that this strain belongs to the Gammaproteobacteria and represents a new genus of MTB.

Early phase II study of robot-assisted distal gastrectomy with nodal dissection for clinical stage IA gastric cancer.

BACKGROUND: Robot-assisted distal gastrectomy (RADG) is increasingly performed in Japan and Korea and is thought to have many advantages over laparoscopic gastrectomy. However, a prospective study investigating the safety of RADG has never been reported. The present study evaluated the safety of RADG with nodal dissection for clinical stage IA gastric cancer. METHODS: This single-center, prospective phase II study included patients with clinical stage IA gastric cancer located within the lower two-thirds of the stomach. The primary endpoint was the incidence of postoperative intraabdominal infectious complications including anastomotic leakage, pancreas-related infection, and intraabdominal abscess. The secondary endpoints included all in-hospital adverse events, RADG completion rate, and survival outcome. RESULTS: From May 2012 to November 2012, 18 eligible patients were enrolled for this study. The incidence of intraabdominal infectious complication was 0 % (90 % CI, 0-12.0 %). The overall incidence of in-hospital adverse events was 22.2 % (90 % CI, 8.0-43.9 %). No patient required conversion to laparoscopic or open gastrectomy; thus, the RADG completion rate was 100 %. CONCLUSIONS: This early phase II study suggested that RADG might be a safe and feasible procedure for stage IA gastric cancer, providing experienced surgeons perform the surgery. This conclusion should be clarified in subsequent late phase II studies with a larger sample size.

[The feasibility of reduced port surgery for sigmoid colon and rectal (Rs) cancer].

Laparoscopic surgery for colorectal cancer has the advantage of being less invasive and delivering better cosmetic appearance. Although single-incision laparoscopic surgery produces excellent cosmetic results, it is considered very difficult to perform. We performed reduced port surgery (single-incision plus one or 2 ports) on 42 patients in our institute. The operation time, number of dissected lymph nodes, morbidity rates, and length of hospital stay after the operation were not inferior to those in conventional laparoscopic surgery. The estimated blood loss in reduced port surgery was less than in conventional laparoscopic surgery. In conclusion, the procedure of reduced port surgery should be further standardized to make it safer and more feasible, and to provide a favorable cosmetic result for selected patients.

[Laparoscopic hemi-double stapling and reduced-port laparoscopic distal gastrectomy for gastric cancer].

INTRODUCTION: The hemi-double stapling method (HDS) is typically used for extracorporeal Billroth-I anastomosis. We used HDS for reduced-port surgery. Laparoscopic HDS is used for intracorporeal Billroth-I anastomosis after laparoscopic distal gastrectomy. We performed reduced-port laparoscopic distal gastrectomy for gastric cancer. METHODS: Reduced-port laparoscopic distal gastrectomy was performed using the multi-trocar method with 5mm and 3mm ports. Laparoscopic HDS was performed using an umbilical incision and a left upper abdominal incision. A total of 17 patients underwent reduced-port laparoscopic distal gastrectomy. A D1+or D1 lymph node dissection was performed, and laparoscopic HDS was used for reconstruction. RESULTS: The patients had no short-term complications. CONCLUSIONS: Laparoscopic HDS and reduced-port laparoscopic distal gastrectomy are safe and feasible procedures.

[A case of an adenocarcinoma in a duplication cyst of the esophagogastric junction].

Duplication cysts of the esophagogastric junction are an extremely rare disease entity. Computed tomography showed a cystic lesion in the wall of the esophagogastric junction ofa 75-year-old man. The cystic tumor gradually increased in size from 40 mm to 60 mm in diameter within 6 months. On the basis of magnetic resonance cholangiopancreatography and positron emission tomography, it was described as a cystic pathological alteration enclosing a solid lesion. The pre-operative diagnosis was a gastrointestinal stromal tumor in the stomach cardia, and we performed proximal gastrectomy under laparotomy. Histological findings showed gastric mucosa in the internal mucosa of the cyst and an adenocarcinoma inside the cyst. We diagnosed the cystic tumor as a duplication cyst of the esophagogastric junction with adenocarcinoma. It is important to carefully choose the procedure to be used for resection of cystic tumors adjacent to the alimentary canal.

[A case of long-term survival of small intestinal adenocarcinoma treated by resection and chemotherapy].

A 60-year-old man had visited our hospital a few times due to vomiting since July 2008. In January 2009, because he was no longer able to eat, he was hospitalized to receive close examination. Single balloon enteroscopy revealed jejunal adenocarcinoma. After examination of the whole body, as there was no distant metastasis, jejunum partial resection was performed in February 2009. One dissemination nodule was recognized on the serosa near the main tumor. We obtained the final pathological diagnosis as Stage IV. From April 2009, adjuvant chemotherapy with combination of oxaliplatin, 5-fluorouracil and Leucovorin (mFOLFOX6) was performed 8 times. In April 2009, a small metastatic lesion appeared in the upper lobe of the right lung. We started administering combination of irinotecan, 5-fluorouracil and Leucovorin (FOLFIRI) from January 2010, but stopped because of side effects after the second cycle. Administration of capecitabine was started in March 2010. The metastatic lesion had diminished for a time but was found to be enlarged in March 2011. Thus, a partial right lung resection was performed in April 2012. After lung resection, systemic chemotherapy was not performed. The patient remains alive without a recurrence 3 years after lung resection and over 5 years after detection of the small intestinal adenocarcinoma.

Effects of Extended Fixation on Advanced Gastric Cancer HER2 Status Assessment Using IHC and FISH.

BACKGROUND/AIM: In gastric cancer, accurate determination of human epidermal growth factor receptor type 2 (HER2) status is crucial for treatment decision-making. However, the optimal formalin fixation time of gastric cancer specimens for HER2 status determination remains unestablished. Here, we investigated real-world data on formalin overfixation and its effect on HER2 status determination in gastric cancer. PATIENTS AND METHODS: We comprehensively analyzed HER2 testing results in 228 gastric cancer specimens, including those subjected to formalin overfixation. Subsequently, we divided 52 resected specimens of advanced gastric cancer into three groups and studied the effects of short-term (6-72 h) and long-term (1 and 2 weeks) fixation on HER2 status determination using immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH). RESULTS: A total of 21.5% (49/228) of the specimens were HER2-positive, whereas 78.5% (179/228) were negative. Among the HER2-negative specimens, no biopsies were overfixed, whereas 12.5% (9/72) of the surgical resection specimens were overfixed. The HER2 status of the 6-72-h group was 82.7% and 76.9% identical to that of the 1- and 2-week groups, when determined using IHC, and 73.1% and 36.5%, when determined using FISH, respectively. However, HER2 determination was not feasible in 26.9% and 63.5% of the specimens in the 1- and 2-week groups, respectively. CONCLUSION: Formalin overfixation may hinder the determination of HER2 status and should be avoided in gastric cancer sample preparation.

[A case of combined resection of multiple adjacent organs in a patient with locally advanced residual gastric cancer].

A 69-year-old man with a history of distal gastrectomy for early gastric cancer consulted our department concerning a possible diagnosis of sigmoid colon cancer. After detailed examination, he was diagnosed with type 3 advanced sigmoid colon cancer with colonic stenosis and large type 3 gastric cancer in the residual stomach with gross infiltration of the adjacent organs. The patient first underwent sigmoidectomy and then received a regimen of neoadjuvant combination chemotherapy with S-1, cisplatin( CDDP), and Lentinan( LNT)( S-1 80 mg/m2, CDDP 60 mg/m2, and LNT 2 mg/body twice weekly for 2 weeks) for gastric cancer( cT4b[ SI, liver, pancreas], N2M0H0, Stage IIIC). After 2 courses of treatment, the gastric tumor had reduced in size but had penetrated the transverse colon. We performed total resection of the gastric remnant, D2 lymph node dissection, and en bloc resection of the transverse colon, partial liver, pancreas body and tail, partial diaphragm, and pericardium. S-1/CDDP (a total of 11 courses) followed by single-agent S-1 therapy was continued as adjuvant chemotherapy. With a follow-up time of 3 years and 10 months, no recurrence was noted following total resection of the gastric remnant.

[A case of locally advanced residual gastric cancer treated with combined resection of multiple adjacent organs].

A 60-year-old man was diagnosed as having type 3 advanced gastric cancer in the gastric antrum and multiple liver metastases( S2, S3, S4, and S7)( cT3[ SS] N0M0H1, Stage IV). The patient received combined neoadjuvant chemotherapy with S-1 and cisplatin( CDDP). S-1( 80 mg/body/day) was administered orally for 3 weeks followed by 2 drug-free weeks as a course, and CDDP (60 mg/m2) was administered by intravenous infusion on day 8. The gastric tumor reduced in size and the liver metastases improved after 5 courses of treatment. Distal gastrectomy, D2 lymph node dissection, and partial liver resection( 4 sites) were performed. S-1 alone was continued as adjuvant chemotherapy; no recurrence was detected in 2 years and 2 months after surgery. Although there is insufficient evidence to support the benefit of surgical resection in patients with advanced gastric cancer with liver metastases, chemotherapy combined with surgical resection would improve the survival time without deterioration of quality of life of these patients. This case suggests that neoadjuvant chemotherapy is effective against advanced gastric cancer even with multiple liver metastases.