[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.

[Fibrin glue injection therapy with diluted thrombin for complicated postoperative fistulas following digestive surgery].

Fibrin glue injection is used for treating postoperative digestive fistulas; however, this method is not always successful, especially in cases of complicated fistulas. Generally, the fibrin glue coagulates immediately after application before it reaches the end of the fistulas. Based on the results of an in vitro study of tensile strength and coagulation time, we utilized fibrin glue injection therapy with diluted thrombin solution (× 30) for treating refractory postoperative complicated fistulas in 23 cancer patients. In 20 of these patients, the fistulas were successfully closed after an average of 2.0 treatment cycles. This simple method of fibrin glue injection with diluted thrombin is useful for treating complicated postoperative digestive fistulas.

[Adjuvant therapy with WT1 peptide-pulsed dendritic cell therapy in combination with TS-1 for pancreatic cancer with positive peritoneal cytology after curative operation].

A 66-year-old woman was diagnosed with pancreatic tail cancer, and she was referred to our hospital. Abdominal computed tomography(CT)revealed a tumor(2.5 cm in diameter)in the pancreatic tail, with invasion to the spleen and splenic vein. In February 2013, we performed distal pancreatectomy with splenectomy, left adrenal gland resection, and D2 lymph node dissection. Diagnostic peritoneal lavage cytology during surgery was positive; however, we performed curative resection because there were no signs of peritoneal dissemination and distant metastasis. The patient was discharged from the hospital 23 days after the operation, with good postoperative course. Histological diagnosis was pancreatic tail cancer, pT4N0H0P0M(-) fStage IVa. Subsequently, the patient received postoperative adjuvant chemotherapy(TS-1: 100mg/day, 4 courses)combined with Wilms'tumor 1(WT1)peptide-pulsed dendritic cell therapy. No serious adverse events occurred during the postoperative adjuvant therapy. The patient remains alive without recurrence 16 months after the operation.

[A case of curatively resected advanced intrahepatic cholangiocellular carcinoma through effective response to neoadjuvant chemotherapy].

A 67-year-old-man came to our hospital for further evaluation of a liver tumor detected by abdominal ultrasonography at another hospital. Abdominal computed tomography showed a tumor (8 cm in diameter)in the left lobe of the liver, with invasion of the left and middle hepatic veins, and multiple lymph node metastases. Liver biopsy examination revealed intrahepatic cholangiocellular carcinoma (cStage IVB). Therefore, chemotherapy with gemcitabine(GEM)was administered. The hepatic tumor and multiple lymph nodes were reduced in size after eight courses of GEM chemotherapy. In May 2013, we performed an extended left hepatectomy with biliary tract reconstruction and extended lymph node dissection. The histological diagnosis was intrahepatic cholangiocellular carcinoma, pT3N0H0P0M (-), fStage III. The patient's postoperative recovery was good, and 1 month after surgery, the patient received 6 course of postoperative adjuvant GEM chemotherapy. No serious adverse events occurred during the postoperative adjuvant therapy period. The patient is alive without recurrence 14 months after surgery and 23 months after diagnosis.

[A case of curative resected pancreatic cancer coincident with a retroperitoneal abscess].

A 64-year-old man presented with a chief complaint of abdominal pain. An abdominal computed tomography (CT) scan showed a mass 30-mm in diameter at the splenic flexure, and we diagnosed a retroperitoneal abscess. Conservative therapy was successful, and the patient was discharged. However, 1 month later, he again experienced abdominal pain. To reassess the abscess, contrast-enhanced abdominal CT was performed. In addition to the retroperitoneal abscess, the CT scan showed an approximate 30-mm mass in the head of the pancreas with no contrast uptake. The abscess was also detected by endoscopic retrograde pancreatography. We suspected but could not confirm pancreatic cancer. Two months later, the patient developed obstructive jaundice. At this time, we diagnosed pancreatic cancer, and subtotal stomach-preserving pancreaticoduodenectomy was performed. The histopathologic diagnosis was pancreatic cancer, T4, N0, M0, Stage IVa. The postoperative course was favorable, and the patient received postoperative adjuvant chemotherapy. He remains alive without recurrence 15 months after surgery.

[HER2 testing for advanced recurrent gastric cancer in a general hospital].

The Japanese gastric cancer treatment guidelines(published as a web supplement for version 3)recommend the implementation of HER2 testing prior to the selection of chemotherapy. Since we had not yet implemented HER2 immunohistochemistry(IHC)methods for gastric cancer, we tried to compare the HER2 testing results from a reference laboratory(ref lab) and our hospital(in-house). The HER2 concordance rates were calculated between the results from in-house and ref lab using 26 cases(31 samples)which were from patients with advanced, metastatic unresectable, or Stage IV resectable gastric cancer. The HER2 expression(in-house/ref lab)was distributed as follows: negative/negative, 18 cases; negative/equivocal, 2 cases; negative/positive, 1 case;equivocal/equivocal, 2 cases; and positive/positive, 3 cases. The concordance rate was 88. 4%(23/26), and the mismatch rate was 11. 6%(3/26)between in-house and ref lab. Although IHC test results with in-house and ref lab had been generally consistent, it is still necessary to improve and standardize diagnostic accuracy in the near future.

[Efficacy of endoscopic gastroduodenal stenting for gastric outlet obstruction caused by unresectable gastric cancer].

BACKGROUND: In this retrospective study, we investigated the clinical outcomes of endoscopic gastroduodenal stenting (EGDS) for gastric outlet obstruction( GOO) caused by unresectable gastric cancer( UGC). METHODS: A retrospective study was performed on 20 UGC patients with GOO between 2007 and 2012. We compared the clinical outcomes of EGDS using the WallFlex stent( GDS group, n=8) and palliative Roux-en-Y gastrojejunostomy( RYGJ group, n=12). RESULTS: The numbers of patients with a poor performance status and prior use of chemotherapy were higher in the GDS group than in the RYGJ group. No postoperative complications were observed, and the GOO score improved in both groups. The median days taken to resume oral food intake, the median duration of oral food intake, and the median survival time in the RYGJ and GDS groups were 4 and 3 days( p=0.0008), 301 and 151 days( p=0.0698), and 345 and 161 days (p=0.0070), respectively. CONCLUSIONS: EGDS for GOO caused by UGC can be performed safely even after chemotherapy and is beneficial in terms of improvement of oral food intake.

[Efficacy of stereotactic radiotherapy for primary and metastatic liver cancer].

Twenty patients( 30 nodules) with metastatic liver cancer( MLC) and 10 cases with hepatocellular carcinoma( HCC) treated by stereotactic radiotherapy (SRT) were analyzed. SRT was administered at 48.0 or 52.8 Gy/4 Fr/1 wk. The response rate (RR) in MLC patients was 78%, and 11 patients survived longer than 1 year and 9 patients survived as long as 2 years. Clinical analysis suggests that the ideal indications for SRT in MLC are solitary nodules in patients without extrahepatic disease who have undergone systemic chemotherapy. Although RR of SRT for HCC was as high as 85%, intrahepatic recurrence was observed in all patients and 6 patients died within 1 year. Further analysis is needed to determine the indication for SRT in HCC patients.

[Stereotactic radiotherapy for metastatic liver cancer].

Twenty cases (27 therapeutic sites/30 nodules) of metastatic liver cancer treated with stereotactic radiotherapy (SRT)were analyzed. The original sites of cancer were colorectal(8 cases), breast(4 cases), stomach(3 cases), esophagus(2 cases), and other organs (3 cases). SRT was performed with 52.8 Gy·4 fr·-1·wk-1. The response rate was 78%, including complete response (CR) at 8 sites, partial response (PR) at 10 sites, stable disease (SD) at 2 sites, progressive disease(PD) at 3 sites, and not detected(ND) at 4 sites, thus demonstrating a potent local therapeutic effect. Ten patients survived for more than 1 year, 8 patients survived for 2 years, and 4 died before 6 months. Clinical analysis suggests that the ideal indications for SRT are patients with a solitary nodule and without extrahepatic disease who have undergone systemic chemotherapy.

[A case of paraaortic lymph node metastasis of gastric cancer resistant to chemotherapy successfully treated with chemoradiation therapy].

We report a case of recurrent gastric cancer with paraaortic lymph nodes (No.16LNs) that was effectively controlled with chemoradiation therapy. A 63-year-old man underwent distal gastrectomy, cholecystectomy, and D2 dissection in July 2004 for advanced gastric cancer in the lower third area that was diagnosed as moderately differentiated stage II adenocarcinoma [T1(SM), N2, H0, P0, CY0, M0]. He suffered from No.16LNs metastasis with serum CEA elevation in October 2007, and therefore, 4 courses of S-1, followed by 3 courses of CPT-11 as second-line treatment, 14 courses of docetaxel as third-line treatment, and 15 courses of paclitaxel+cisplatin as fourth-line chemotherapy, were administrated. Enlargement of No.16LNs with serum CEA elevation was observed in October 2010. Other metastases were not observed, and hence, chemoradiotherapy (CRT; S-1: 80 mg/body+total of 65 Gy per 26 Fr) for No.16LNs was performed. A partial response and reduction of serum CEA level were noted, and the patient is alive with no sign of progression 18 months after CRT. Grade 1 adverse events including anemia, fatigue, and anorexia were recognized. It is thought that chemoradiation therapy is an effective treatment for localized LN metastasis originating from gastric cancer resistant to chemotherapy.

[Complications associated with the placement of subcutaneous central venous access port devices: reasons for removal and complications observed].

OBJECTIVE: To clarify the complications associated with subcutaneous central venous access port devices, we investigated the patients who underwent placement of central venous access port devices in our hospital. METHODS: Overall, 171 cancer patients who underwent placement of subcutaneous central venous access port devices (119 for chemotherapy and 52 for home parenteral nutrition) between February 2006 and December 2011 and who were followed up for 1 month, were retrospectively analyzed in this study. Univariate analysis was performed on complications related to clinical factors, including age, gender, insertion sites, intended purposes, duration of catheterization, surgeons, catheter materials, and use of bevacizumab. RESULTS: The mean follow-up time was 213 days (range, 31-1,873), and 35 patients (20.5%) required the port device to be extracted due to complications, including infection in 24(14.0%), wound dehiscence at the port site in 2 (1.2%), obstruction of the catheter in 6 (3.5%), catheter-induced venous thrombosis in 1 (0.6%), and catheter fracture in 2(1.2%). No statistically significant differences were observed between the frequency of complications and age, gender, insertion sites, intended purposes, duration of catheterization, surgeons, catheter materials, or use of bevacizumab. CONCLUSION: The incidences of complications related to implantation and management of these devices are relatively high and early. Patients should be followed carefully by chest radiography at regular intervals.

A phase I study of bi-weekly docetaxel for recurrent or advanced gastric cancer patients whose disease progressed by prior chemotherapy.

OBJECTIVE: Although docetaxel is active against gastric cancer, Grade 3 or 4 neutropenia occurs in the majority of patients in Japan when administered at 60 mg/m(2) every 3 weeks. To determine a more convenient and tolerable schedule than the tri-weekly schedule, we conducted a dose-escalation study of bi-weekly docetaxel. In this study, we investigated the maximum-tolerated dose and recommended dose. METHODS: Patients with advanced gastric cancer who had received prior chemotherapy were enrolled between April 2004 and March 2007. This study was designed to evaluate the escalated dose of docetaxel starting at 35 mg/m(2) (Level 1) given every 2 weeks. The dose was escalated in a stepwise fashion to 40 mg/m(2) (Level 2), 45 mg/m(2) (Level 3) and 50 mg/m(2) (Level 4). RESULTS: Fifteen patients completed at least two cycles of the therapy. Three episodes of Grade 3 neutropenia occurred in all patients and Grade 4 neutropenia was observed at Level 4 in six patients. Grade 3 or 4 thrombocytopenia and anemia were not observed. Grade 3 aspartate aminotransferase/alanine aminotransferase elevation (n= 1) and Grade 3 stomatitis (n = 1) were noted at Level 4. There was no other Grade 3 or 4 non-hematologic toxicity. The definition of dose-limiting toxicities of this docetaxel schedule at Level 4 are Grade 4 neutropenia, Grade 3 aspartate aminotransferase/alanine aminotransferase elevation and Grade 3 stomatitis. CONCLUSIONS: The maximum-tolerated dose of docetaxel when administrated following the bi-weekly schedule was 50 mg/m(2) and the recommended dose was 45 mg/m(2). Bi-weekly administration of docetaxel may provide a better tolerated and efficacious use in gastric cancer.

[S-1 treatment for elderly patients over 75 years with gastric cancer].

BACKGROUND: In our hospital, the starting dose of S-1 for patients over 75 years of age with advanced gastric cancer was determined by body surface of area, creatinine clearance, performance status(PS)and the presence of complications. The objective of this retrospective study was to investigate the proper administration of S-1 in elderly patients by comparing patients given a standard dose of S-1 to those given a reduced dose. METHODS: Twenty patients participated. Six patients were administered S-1 at a standard dose(standard group)and fourteen patients with at a reduced dose(reduced group). Safety, feasibility and anti-tumor effects were assessed. RESULTS: Three cases of grade 3 adverse events were found in the standard group, and one case was found in the reduced group. Time to treatment failure was 4. 4 months for the standard group and 8. 2 months for the reduced group. The overall response rate was 25% in the standard group and 30% in the reduced group. CONCLUSIONS: It is important to reduce S-1 administration to patients over 75 years of age with caution, and take into account the patient's renal function, PS and Ccr complications.

Paclitaxel-resistant recurrent gastric cancer responsive to docetaxel: a case report.

We present the case of a 58-year-old man who underwent distal gastrectomy for Stage III A advanced gastric cancer, identified as poorly-differentiated adenocarcinoma. He was diagnosed with recurrent peritoneal metastasis 11 months after surgery. S-1(80mg/m / 2)was administered as first-line chemotherapy, followed by weekly paclitaxel(80mg/m2)as secondline chemotherapy. Although a partial response was obtained, a peritoneal tumor in the upper abdomen, ascites, and an elevation in the serum carcinoembryonic antigen(CEA)level were observed. As the tumor proved resistant to paclitaxel, making the treatment ineffective, bi-weekly docetaxel(45mg/m2)was initiated. The tumor showed a partial response, the ascites disappeared, and the serum CEA level decreased. The time to progression was seven months until the appearance of ileus and ascites due to tumor re-growth. This paclitaxel-resistant gastric cancer with peritoneal recurrence proved responsive to docetaxel as third-line chemotherapy. Docetaxel may be active against gastric cancer that is resistant to paclitaxel because of the different effects of these two agents. Further clinical studies on the efficacy of docetaxel against paclitaxel-resistant gastric cancer are needed.

[A case of recurrent gastric cancer with lymph node metastasis successfully treated by CPT-11/CDDP therapy].

We report a case ofa 76-year-old man suffering from advanced gastric cancer with lymph node recurrence. Distal gastrectomy was performed for gastric cancer with pylorus stenosis in April 2001. Pathological staging was III A(T3, N1, M0, Cur B). He underwent outpatient treatment with oral administration of UFT 400mg/day as postoperative adjuvant chemotherapy, but stopped after two months because of loss of appetite and general fatigue. Partial liver resection(S4/5)was performed for liver metastasis(S4)in June 2002, and S-1 was administered 80mg/day as adjuvant chemotherapy. However, obstructive jaundice was detected for lymph node recurrence in March 2003, and conducted bile duct stent after PTCD. He started to undergo a biweekly combination chemotherapy of irinotecan (CPT-11)60mg/m / 2 and cisplatin(CDDP)30mg/m2. Three months later, the lymph node had decreased in size. We reduced this therapy, extended the interval, and discontinued it after 24 courses due to adverse reactions, such as leucopenia(grade 3)and general fatigue(grade 2). Afterward, he had no recurrence for over 5 years.