[GEM plus CDDP Combination Therapy for Unresectable Biliary Tract Cancer-A Single Institution Experience].

BACKGROUND: Since a randomized phase Ⅲ trial conducted in the UK in 2009 showed the superiority of gemcitabine (GEM)plus cisplatin(CDDP)combination therapy over GEM monotherapy, GEM plus CDDP combination therapy has been first-line chemotherapy for unresectable biliary tract cancer. METHODS: GEM plus CDDP combination therapy was administered to 29 patients with unresectable biliary tract cancer from 2016 to 2021. RESULTS: The mean age was 71.9 years, male/ female 19/10. The target of chemotherapy was below, local progression was 3 cases, first distant metastasis 7 cases, metastatic recurrence 19 cases. The type of cancer was below, intrahepatic bile duct carcinoma was 8 cases, hepatic hilar bile duct carcinoma 6 cases, gallbladder carcinoma 5 cases, cystic duct carcinoma 1 case, distal bile duct carcinoma 6 cases, and papilla Vater's cancer 3 cases. The dosing period was 23.1 weeks(range 2-52 weeks). The relative dose intensities of GEM and CDDP were 73.7% and 75.1%. The adverse events were below, the hematological toxicities of Grade 3 or higher were neutropenia(65.5%), leukopenia(3.4%), and thrombocytopenia(10.3%). Non-hematological toxicities of Grade 2 or higher were fatigue(13.7%)and skin rash(6.9%). There was no interstitial pneumonia. The disease control rate was 66.7 %(complete response, n=0; partial response, n=6; stable disease, n=10; progressive disease, n=8). CONCLUSION: GEM plus CDDP combination therapy was safe to perform and was an effective treatment for unresectable biliary tract cancer.

[A Case of Epithelial Cyst Occurring in Intrapancreatic Accessory Spleen].

Although accessory spleens are often found in clinical practice, it is rare to identify cystic disease in an intrapancreatic accessory spleen. Here, we report a case of an epithelial cyst that occurred in the intrapancreatic accessory spleen. The patient was a 54-year-old male. Liver dysfunction was identified by the primary care doctor, and abdominal CT showed a tumorous lesion in the pancreatic tail. The patient was then referred to our hospital. Contrast-enhanced CT revealed a multilocular cystic lesion in the pancreatic tail. In endoscopic ultrasound, there was no obvious solid tumor in the cyst. A cystic disease such as serous cystic neoplasm(SCN)or mucinous cystic neoplasm(MCN)was suspected, and we performed a laparoscopic distal pancreatectomy. Postoperative pathological examination revealed an accessory spleen in the tail of the pancreas. The identified epithelial cyst was present in this accessory spleen. An epithelial cyst that occurs in the intrasplenic accessory spleen is a rare disease, but it is necessary to keep in mind as a possible differential diagnosis.

[A Case of Disease Control Achieved with TACE Using Cisplatin for Liver-Limited Metastases of Colorectal Cancer].

A 54-year-old woman with unresectable multiple liver-limited metastases of rectal cancer was treated with cisplatin-based transcatheter arterial chemoembolization(TACE). Before initiating TACE, we performed abdominoperineal resection for advanced rectal cancer, resection of the bilateral ovaries for metastasis, liver resection for metastasis, and oxaliplatin/irinote- can/anti-EGFR chemotherapy for the unresectable liver metastases. For the liver-limited metastases that did not respond to systemic chemotherapy, we successfully controlled the disease in 26 months with TACE every 4 or 5months. A combination of 50mg cisplatin and 4 mL lipiodol was injected into the liver through the left or middle hepatic artery with a microcatheter via the femoral artery. The hepatic arteries were mildly embolized with Embosphere. Immediately after TACE, non-contrastenhanced CT was performed to confirm the distribution of the cisplatin powder and embolization. Tumor response was assessed by enhanced CT 3 months after the treatment. We report a case of liver metastasis of colorectal cancer successfully controlled with cisplatin-based TACE over 2 years.

[Sustained Complete Response of Hepatocellular Carcinoma with Multiple Intrahepatic Metastases following the Discontinuation of Sorafenib].

Sorafenib is an oral multi-targeted tyrosine kinase inhibitor used in cases of unresectable advanced HCC that significantly improves progression-free and overall survival. Complete response(CR)is uncommon; however, if major or complete radiological response are obtained, the issue of the discontinuation of sorafenib remains unresolved. The present study reported a case of a 75-year-old man with non-hepatitis B and C virus-related cirrhosis and multiple recurrent HCCs followingresection. In December 2010, a CT scan revealed multiple intrahepatic recurrence after TACE. Laboratory testingshowed Child-Pugh class A cirrhosis and an alpha-fetoprotein level of over 20,000 ng/mL. Sorafenib(800mg/day)was started in December 2010. The subsequent dynamic CT performed at the 6th month of therapy showed a partial response accordingto RECIST criteria and a complete response accordingto mRECIST. The AFP had decreased to within normal levels. In May 2012, the sorafenib dose was reduced(200 mgtwice daily)due to side effects(skin reaction). In December 2013, treatment was stopped after confirmation of a CR associated with shrinkage of the HCC. The patient maintained this remission until June 2018, more than 54 months after the discontinuation of sorafenib therapy. The adverse events of sorafenib were reversible. Further reportingof similar cases should help in the design of treatment strategies after CR to sorafenib therapy.

[A Case of Liver Metastases of Ampullary Carcinoma with Clinical Complete Response Treated with Gemcitabine plus Cisplatin].

We report a case of liver metastases of ampullary carcinoma that achieved clinical complete response after gemcitabine plus cisplatin(GC)combination chemotherapy. A 69-year-old man with obstructive jaundice was diagnosed with ampullary carcinoma and underwent laparoscopic pancreaticoduodenectomy. Postoperative histopathological examination revealed pT3aN0M0, Stage ⅡA adenocarcinoma of the papilla of Vater. Five months after surgery, multiple liver metastases were identified by CT and MRI. The patient received GC chemotherapy intravenously at doses of 1,000 and 25mg/m2 on days 1 and 8, respectively, every 3 weeks. After 3 courses of GC chemotherapy, a CT scan revealed that the liver metastases reduced in size, and PR was achieved based on the RECIST standard. However, Grade 3 neutropenia appeared. After 7 courses, the liver metastases disappeared, and the patient had achieved CR. After 9 courses, the clinical CR continued. Approximately 14 months have passed since the recurrence, and the patient is currently alive.

[Treatment Outcomes of Gemcitabine and Cisplatin Combination Therapy for Unresectable and Recurrent Biliary Tract Cancer].

Gemcitabine and cisplatin combination therapy(GC therapy)is now considered a highly effective regimen for patients with unresectable and metastatic biliary tract cancer. We performed GC therapy for 18 patients between January 2014 and April 2018. The median age of the patients was 67.5 years, and 13 patients were men. Fifteen patients had a performance status (PS)score of 0, and 3 patients had a PS score of 1. Nine patients had distal cholangiocarcinoma, 3 had intrahepatic cholangiocarcinoma, 3 had duodenum papilla cancer, and 3 had gallbladder cancer. Fourteen patients showed recurrence after the radical resection, and 9 had liver metastasis. Sixteen patients had over Grade 3 hematological or non-hematological toxicities. The most-common adverse event was neutropenia. None of the patients had Grade 5 adverse events. The response rate was 11.1%, and the disease-control ratio was 66.7%. GC therapy was effective for patients with unresectable and recurrent biliary tract cancer. However, it is necessary to examine the eligibility of patients before treatment.

[A Case of Laparoscopy Assisted Ileocecal Resection for Large Appendiceal Mucinous Adenocarcinoma].

Appendiceal mucinous adenocarcinoma accompanied by cysts ruptures by surgical operation and leakage of mucus into the peritoneal cavity results in deterioration of prognosis.We report a case where the appendix mucinous adenocarcinoma was safely excised by laparoscopically preceding vascular treatment, lymph node dissection and intestinal dissection.The case was a woman in her forty-age suffering from the right lower quadrant and fever; no improvement was observed even when antibiotics were administered.A cystic lesion with a maximum diameter of 75mm was found on the right side of the pelvis with CT, and numerous lymph adenopathy was observed along the iliac artery.Preoperative diagnosis was diagnosed as appendiceal mucinous adenocarcinoma suspected and laparoscopic resection of the cecum was performed with the above procedure without breaking the cyst.Pathological diagnosis was findings of appendicular mucinous adenocarcinoma.She was discharged on the 7th postoperative day after surgery, 6 months after surgery without relapse survival.In order to resect a cystic tumor by laparoscopic surgery, it is considered to be useful to take care to prevent the forceps from touching the tumor, and perform a procedure that precedes vascular dissection and intestinal dissection.

[The Treatment Outcomes of FOLFIRINOX for Unresectable and Recurrent Pancreatic Cancer].

FOLFIRINOX is now considered to be a highly effective regimen for patients with metastatic pancreatic cancer. We administered FOLFIRINOX therapy in 18 patients between October 2014 and April 2017 as follows: 2-hour infusion of L-OHP at a dose of 85mg/m2, 2-hour infusion of LV at a dose of 200 mg/m2, infusion of CPT-11 for over 90 minutes at a dose of 150 mg/m2, followed by continuous infusion of 5-FU over 46 hours at a dose of 2,400mg/m2. The median age of the patients was 66.5 years. There were 15 patients with performance status(PS)0, and 3 with PS 1. Two patients were Stage III and 16 patients were Stage IV . More than half of the patients had over Grade 3 hematological or non-hematological toxicities. The most common adverse event was neutropenia. Two patients had Grade 5 adverse events: severe cholangitis occurred in the patient with a biliary stent and overwhelmingpost -splenectomy infection occurred in the patient who underwent distal pancreatectomy. The response rate was 11.1%, and the disease control rate was 77.8%. FOLFIRINOX was effective in the patients with unresectable and recurrent pancreatic cancer. However, it is necessary to examine the eligibility of the patients.

[A Case of Recurrent Colon Cancer Successfully Treated with Capecitabine plus Bevacizumab].

A 76-year-old woman had undergone a laparoscopic low anterior resection for rectal cancer. After 12 months, CT showed 2 tumors measuring 25mm in diameter in the pelvis and hydronephrosis. The patient was treated with CapeOX plus bevacizumab( Bmab). After 3 courses of chemotherapy, the size of the tumors was remarkably reduced. After 6 courses, the chemotherapy was withdrawn because of cystitis. Anaphylactic shock occurred after the 7th course after resumption of treatment. After 42 days, the chemotherapy(Cape plus Bmab)was resumed. The patient is recurrence free 13 months after achieving a complete response(CR).

[A Case of a Two-Stage Hepatectomy for Irresectable Colorectal Cancer Liver Metastases].

A 60-year-oldman was diagnosedwith ascending colon cancer with multiple bilobar metastases. He then received7 courses of tegafur-gimeracil-oteracil andoxaliplatin (SOX)plus panitumumab as downstaging chemotherapy. This treatment significantly reducedthe size of the metastatic tumor, andwe subsequently triedto perform a curative resection. A twostage hepatectomy was plannedto avoidthe risk of hepatic failure from small future liver remnant. First, the anterior segmentectomy andthe left portal vein ligation were performed. Then, a curative resection consisting of a left lobectomy andextend - edright hemicolectomy were performed2 0 days after the first surgery. No recurrence was observed1 5 months after the operation. Two-stage hepatectomy as well as a combination of induction chemotherapy and portal vein ligation may have contributedto the improvedprognosis of the initially unresectable multiple bilobar liver metastases.

[Pancreatic Cancer with Liver Metastasis Treated with Radical Surgery after Chemotherapy].

Pancreatic ductal carcinoma is a highly aggressive cancer, and chemotherapy is the standard therapy for pancreatic adenocarcinoma. We report curative resection for a case of pancreatic cancer with liver metastasis after chemotherapy. A 67-yearold woman presented with vomiting and weight loss, and was admitted to our hospital for an evaluation of pancreatic lesions. Computed tomography revealed a hypoattenuating tumor in the head of the pancreas. We would usually perform pancreatoduodenectomy based on a diagnosis of cStage III . However, this case was inoperable because we found 4 liver metastases during surgery, which we resected. Sixteen days after surgery, we administered FOLFIRINOX chemotherapy. The grade 2 toxicities were nausea, anorexia, diarrhea, and fatigue, but serious adverse events did not occur. After 7 courses of chemotherapy, no new metastases were noted. Therefore, radical subtotal stomach-preserving pancreatoduodenectomy was performed. The patient has survived without any recurrence for more than 17 months after hepatectomy.

[A Case of a Patient with Metastatic Rectal-Uterine Cancer from the Ascending Colon Who Underwent NOSE].

An 80-year-old woman had undergone a right hemicolectomy for ascending colon cancer 9 months prior to the current presentation. CT and PET-CT showed a solitary tumor measuring 55mm in diameter at the uterus and rectum. Three 5mm ports and two 12mm two ports were placed. The sigmoid colon was mobilized using a medial approach as usual in laparoscopic surgery. The rectum and uterus were mobilized and were resected. We inserted the End-catchTM in from the vagina and removed the specimen. The patient had no abdominal pain and was discharged from the hospital 9 days after the operation.

[Nab-Paclitaxel plus Gemcitabine Hydrochloride in Patients with Metastatic or Recurrent Pancreatic Cancer - A Single Institution Experience].

BACKGROUND: Pancreatic adenocarcinoma is one of the leading causes of cancer deaths in Japan.Albumin -bound paclitaxel (nab-paclitaxel)plus gemcitabine hydrochloride(GEM)combination chemotherapy provided significant improvements in the overall and progression-free survival in a phase III trial in Europe and America and a phase II trial in Japan.As a result, this combination therapy was approved for use in Japan. METHODS: We evaluated the efficacy of nab-paclitaxel plus GEM with metastatic or recurrent pancreatic cancer.Between December 2014 and March 2016, 11 patients received nab-paclitaxel plus GEM as follows: nab-paclitaxel(125mg/m2 of body-surface area)followed by GEM(1,000mg/m2)on days 1, 8, and 15 every 4 weeks.The treatment was continued until disease progression, unacceptable adverse events, discontinuation as decided by the investigators, or patient refusal. RESULTS: The mean age was 65.6 years(range, 48-75 years), and 8 out of 11 patients were men.Ten patients had an Eastern Cooperative Oncology Group(ECOG)performance status(PS)of 0.Ten patients had metastatic disease.Only 4 patients had no prior therapy.The mean duration of treatment was 10.2 weeks(range, 2-41 weeks).The relative dose intensities of nab-paclitaxel and GEM were 90.6%(66.7-100%)and 87.5%(62.9-100%), respectively.The major Grade 3 or 4 hematological toxicities were leucopenia(54.5%), neutropenia(36.4%), anemia (27.3%), and thrombocytopenia(18.2%).The major grade 2 or 3 non-hematological toxicities were fatigue(45.6%), skin rash(27.3%), peripheral sensory neuropathy(9.1%), anorexia(9.1%), and stomatitis(9.1%).There were no treatmentrelated deaths.Interstitial lung disease was not observed.The 6 month progression-free and overall survival rate were 25.7% and 66.7%, respectively. The disease control rate was 90.9%(complete response, n=0; partial response, n=1; stable disease, n=9; progressive disease, n=1). CONCLUSIONS: Nab-paclitaxel plus GEM is well tolerated and associated with efficacy and improved survival outcomes.Nab -paclitaxel plus GEM can be the standard treatment for patients with metastatic pancreatic adenocarcinoma.

[A Case of Malignant Anorectal Melanoma with Laparoscopic Abdominoperineal Resection].

A 69-year-old man with anemia underwent colonoscopy. Colonoscopy showed a black tumor, 2 cm from the anal verge. The biopsy specimen revealed malignant melanoma, which was preoperatively diagnosed as T1(SM), N0, M0, Stage I . We performed laparoscopic abdominoperineal resection. The tissue type and diagnosis were malignant melanoma, pT1b(10 mm), pN0, pM0, ly0, v0, pDM0, pPM0, pRM0, pStage I b, according to the Colon Cancer Handling Terms, 8th edition). The patient did not receive adjuvant chemotherapy. However, he survived postoperatively for 9 months, with no sign of recurrence.

[Multiple Metachronal Liver Metastases from a Rectal Neuroendocrine Tumor Controlled by Repeated Transcatheter Arterial Chemoembolization].

A 60-year-old woman was diagnosed with a rectal neuroendocrine tumor(NET)with SM invasion.We performed laparoscopic low anterior resection with D3 lymph node dissection.Pathological findings were rectal NET, G1, pSM(9,000 mm), ly0, v0, pN0, PM0, DM0, pR0, pStage I .Four years and 6 months later, contrast enhanced abdominal computed tomography (CECT)and contrast enhanced magnetic resonance imaging revealed multiple liver metastases.The tumors were unresectable because they were bilobar; therefore, we performed transcatheter arterial chemoembolizaion(TACE).One month later, CECT showed the lesions had shrunk.The metastases were well controlled via repeated TACE.For unresectable liver metastases from rectal NET, TACE can be an effective treatment.

[Nab-Paclitaxel plus Gemcitabine for Metastatic Pancreatic Cancer].

Pancreatic ductal carcinoma is a highly aggressive cancer, with one of the highest mortality rates among gastrointestinal cancers. Nab-paclitaxel plus gemcitabine (GEM) significantly improved overall survival, progression-free survival, and response rate in a phase Ⅲ trial in 151 community and academic centers in 11 countries. As a result, nab-paclitaxel plus GEM was approved for use in December 2014 in Japan. We report a case of a patient with pancreatic cancer who underwent this chemotherapy. A 47-year-old man was admitted to our hospital for evaluation of pancreatic lesions. Computed tomography revealed a hypoattenuating tumor in the body of the pancreas. After the patient underwent preoperative chemoradiotherapy under the diagnosis of cStage Ⅳa cancer, we planned to perform distal pancreatectomy. However, this case was inoperable because we found 3 liver metastases during surgery. On postoperative day 14, we treated the patient with nab-paclitaxel plus GEM. Grade 2 toxicities included neutropenia, diarrhea, and peripheral neuropathy, but serious adverse events did not occur. The progression-free survival was 5 months. He remained alive for 7 months after the chemotherapy. In patients with metastatic pancreatic adenocarcinoma, nab-paclitaxel plus GEM can be considered as the standard treatment.

[A bridge to surgery for colon cancer obstruction in a very elderly patient - a case report].

A 94-year-old woman with a distended abdomen was transferred to our hospital.Based on the enhanced abdominal computed tomographic (CT) finding, she was diagnosed with colonic obstruction due to sigmoid cancer. Colonoscopy was performed to make definitive and qualitative diagnoses, and to release the stenosis using a self-expanding metallic stent (SEMS). The SEMS was inserted without complication.On the fifth day after the decompression, the patient underwent laparoscope-assisted sigmoidectomy with lymph node resection.Despite the colon obstruction, a primary anastomosis was performed.The operation time was 163 min, and 3 mL of blood was lost.The patient was discharged without complications. We describe the case of a bridge to surgery in a very elderly patient. A bridge to surgery can be an effective option for the treatment of colon obstruction in non-elderly and very elderly patients.

[Evaluation of laparoscopic hepatectomy for hepatocellular carcinoma with cirrhosis].

Laparoscopic hepatectomy has been reported as a safe and effective approach for the treatment of hepatocellular carcinoma ( HCC). However, few studies have reported survival outcomes after laparoscopic hepatectomy in HCC patients with cirrhosis. In the present study, we evaluated the surgical outcomes and disease-free survival in these cases. Between June 2010 and March 2013, 35 HCC patients with cirrhosis underwent laparoscopic hepatectomy. Operative variables for laparoscopic vs open hepatectomy were as follows: operative times, 268.3 vs 183.3 minutes (p=0.0043); blood loss volume, 151.0 vs 1,106.1 g (p<.001); 1-year disease-free survival rate, 73.1 vs 71.6%; and 2-year disease-free survival rate, 39.9% vs 28.6% (p=0.568), respectively. Laparoscopic hepatectomy is feasible and safe in selected patients with liver cirrhosis, with similar outcomes in disease-free survival when compared with open hepatectomy.

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

METHODS: We performed endoscopic gastroduodenal stenting for gastric outlet obstruction (GOO) caused by unresectable gastric cancer in 15 patients. We compared the clinical outcomes of the stent placement procedure with those of a gastrojejunostomy performed in 32 patients. RESULTS: Stent placement was performed safely without complications, and the median number of days until oral food intake could be resumed and the median number of days spent in the hospital was 2 and 15 days, respectively. The GOO score improved in 13 patients (87%); however, re-interventions were necessary for 7 patients due to stent obstruction caused by tumor growth. No differences between the stenting and gastrojejunostomy groups were found for the rate of improvement in GOO score, the duration until oral food intake could be resumed, or the overall survival rate. Patients in the stenting group had significantly fewer complications and shorter hospital stay. However, more re-interventions were required for patients of the stenting group compared to patients of the gastrojejunostomy group. CONCLUSION: Endoscopic gastroduodenal stenting can be performed safely and is beneficial for the improvement of oral food intake.