Tolerability and Safety Assessment of Adjuvant Chemoradiotherapy with S-1 after Limited Surgery for T1 or T2 Lower Rectal Cancer.

BACKGROUND: The short-term outcomes of chemoradiotherapy (CRT) with S-1 (a combination of tegafur, gimeracil, and oteracil) following limited surgery for patients with T1 or T2 lower rectal cancer have shown encouraging results. OBJECTIVES: This study was designed to delve deeper into the long-term outcomes of CRT with S-1 after limited surgery, with the goal of evaluating both the long-term efficacy and potential risks associated with this treatment approach in patients diagnosed with T1 or T2 lower rectal cancer. METHODS: This was conducted as a multicenter, single-arm, prospective phase II trial. The patient population consisted of individuals clinically diagnosed with either T1 or T2 lower rectal or anal canal cancer, with a maximum tumor diameter of 30 mm and classified as N0 or M0. Patients underwent local excision or endoscopic resection. After surgery, CRT with S-1 was administered to patients meeting several criteria, including the confirmation of well-differentiated or moderately differentiated adenocarcinoma, negative surgical margins, submucosal invasion depth of ≥1000 µm, and high tumor-budding grade (2/3). The primary endpoint of this study was relapse-free survival, while secondary endpoints included local recurrence-free survival, overall survival, anal sphincter preservation rate, and safety. RESULTS: A total of 52 patients were included, with pathological diagnoses revealing T1 in 36 patients and T2 in 16 patients. The 3-year and 5-year relapse-free survival rates were 90.17% and 85.87%, respectively. The 3-year and 5-year local recurrence-free survival rates were 90.17% and 88.07%, respectively, while the 3-year and 5-year overall survival rates were 94.03% and 91.94%, respectively. CONCLUSIONS: CRT with S-1 after limited surgery for T1 lower rectal cancer demonstrated favorable outcomes in terms of recurrence, survival, and local control rates while effectively maintaining anal function in patients. However, further treatment approaches may be necessary to improve outcomes for patients diagnosed with stage T2 lower rectal cancer.

Robotic purse-string suture technique for intracorporeal anastomosis using double-stapling technique in robotic resection of rectal and sigmoid colon cancer: a propensity score-matched analysis.

BACKGROUND: Robotic three-dimensional magnified visual effects and field of view stabilization have enabled precise surgical operations. Intracorporeal anastomosis in right-sided colorectal cancer surgery is expected to shorten operation times, avoid paralytic ileus, and shorten wound lengths; however, there are few reports of intracorporeal anvil fixation for intestinal anastomosis in left-sided colorectal cancer surgery. Herein, we introduce a simple, novel procedure for using robotic purse-string suture (RPSS) in intracorporeal anastomosis with the double-stapling technique in rectal and sigmoid cancer surgery and report short-term outcomes. METHODS: From September 2022 to April 2024, 105 consecutive patients underwent robotic surgery with double-stapling technique anastomosis for rectal or sigmoid colon cancer at our institution. Their data were retrospectively analyzed. Intracorporeal anastomosis with the double-stapling technique using RPSS was performed in 26 patients (the RPSS group), while the double-stapling technique anastomosis with extracorporeal anvil fixation was performed in 79 patients (the EC group). A 1:1 propensity score-matched analysis was performed (matching criteria: sex, age, body mass index (BMI), tumor location and tumor size) using a caliper 0.3. In the RPSS group, after tumor-specific or total mesorectal excision, specimens were extracted from the umbilical wound with simultaneous anvil placement in the body cavity. The oral colonic stump was robotically excised and robotically circumferentially stitched with 3-0 Prolene in all layers. After anvil insertion into the stump, the bowel wall of the colon was completely sewn onto the central rod of the anvil. Reconstructions were anastomosed using the double-stapling technique. RESULTS: The matched cohort contained 23 patients in each group. The RPSS group had significantly less bleeding than the EC group (p = 0.038). Super-low anterior resection (SLAR) in the RPSS group had shorter total operative times than those in the EC group (p = 0.045). The RPSS group experienced no perioperative complications greater than Clavien-Dindo grade III or any anastomosis-related complications. CONCLUSIONS: The RPSS technique can be performed safely without any anastomosis-related complications and reduces the total operative times in SLAR and blood loss through total robotic surgery. This may be a useful modality for robotic colorectal surgery.

Safety and feasibility of minimally invasive distal pancreatectomy for pancreatic cancer in elderly patients: A retrospective study.

INTRODUCTION: Previous studies have not evaluated the surgical difficulty of minimally invasive distal pancreatectomy for pancreatic cancer in elderly patients. Therefore, we aimed to investigate the effect of elderly age on the perioperative outcomes of minimally invasive distal pancreatectomy, focusing on surgical difficulty. METHODS: This single-center retrospective study included patients who underwent minimally invasive distal pancreatectomy for pancreatic cancer at Kansai Rosai Hospital between September 2012 and December 2023. Perioperative outcomes were investigated between the elderly (>75 years) and non-elderly (≤75 years) groups. RESULTS: Fifty-six patients were included: 26 and 30 in the elderly and non-elderly groups, respectively. The median operative time was significantly shorter in the elderly group than in the non-elderly group (324 vs. 414 min, p = .022), but other surgical outcomes were not significantly different including oncological factors. The median difficulty score was similar between the elderly and non-elderly groups (6 vs. 7, respectively; p = .699). The incidences of postoperative complications and pancreatic fistulas were not significantly different in the elderly and non-elderly groups (23% vs. 43%, p = .159, and 19% vs. 36%, p = .236, respectively), even though analyzed in subgroups with low-to-intermediate or high difficulty score. CONCLUSIONS: The safety and feasibility of minimally invasive distal pancreatectomy for pancreatic cancer were not significantly different between elderly and non-elderly patients, even when surgical difficulty was considered. This surgical procedure can be safe and feasible for elderly patients.

Robotic versus open and laparoscopic pelvic exenterations for pelvic cancer: a multicenter propensity-matched analysis in Japan.

BACKGROUND: Pelvic exenteration (PE) is the last resort for achieving a complete cure for pelvic cancer; however, it is burdensome for patients. Minimally invasive surgeries, including robot-assisted surgery, have been widely used to treat malignant tumors and have also recently been used in PE. This study aimed to evaluate the safety and efficacy of robot-assisted PE (RPE) by comparing the outcomes of open PE (OPE) with those of conventional laparoscopic PE (LPE) for treating pelvic tumors. METHODS: Following the ethics committee approval, a multicenter retrospective analysis of patients who underwent pelvic exenteration between January 2012 and October 2022 was conducted. Data on patient demographics, tumor characteristics, and perioperative outcomes were collected. A 1:1 propensity score-matched analysis was performed to minimize group selection bias. RESULTS: In total, 261 patients met the study criteria, of whom 61 underwent RPE, 90 underwent OPE, and 110 underwent LPE. After propensity score matching, 50 pairs were created for RPE and OPE and 59 for RPE and LPE. RPE was associated with significantly less blood loss (RPE vs. OPE: 408 mL vs. 2385 ml, p < 0.001), lower transfusion rate (RPE vs. OPE: 32% vs. 82%, p < 0.001), and lower rate of complications over Clavien-Dindo grade II (RPE vs. OPE: 48% vs. 74%, p = 0.013; RPE vs. LPE: 48% vs. 76%, p = 0.002). CONCLUSION: This multicenter study suggests that RPE reduces blood loss and transfusion compared with OPE and has a lower rate of complications compared with OPE and LPE in patients with locally advanced and recurrent pelvic tumors.

Monitoring ctDNA RAS Mutational Status in Metastatic Colorectal Cancer: A Trial Protocol of RAS-trace and RAS-trace-2 Studies.

Background: Spatial and temporal heterogeneities of RAS and other molecular genes should be considered in the treatment of metastatic colorectal cancer (mCRC) treated with anti-epidermal growth factor receptor (EGFR) monoclonal antibodies (mAbs); acquired RAS mutation is sometimes observed at disease progression of treatment with the anti-EGFR mAb. At the same time, discrepancy of RAS status from tissues and circulating tumor DNA (ctDNA) in the same patient is sometimes observed. Based on this, we commenced two observational studies to clarify these heterogeneities of RAS and BRAF in mCRC, using next generation sequencing from liquid biopsy. Methods/Design: RAS-trace study is an observational study to monitor ctDNA RAS/BRAF/PIK3CA status every 4-12 weeks using the Plasma-SeqSensei™ CRC RUO Kit (Sysmex Inostics GmbH) in mCRC with RAS/BRAF wild-type (wt) on tumor tissue. The primary endpoint was the time to the acquired RAS mutations. A total of 42 patients has been accrued. RAS-trace-2 study is also an observational study aimed at comparing the efficacy of the anti-EGFR mAb in ctDNA RAS/BRAF wt with ctDNA RAS or BRAF mutant mCRC patients, whose RAS/BRAF are wt in tumor tissue. The primary endpoint was progression-free survival in patients with ctDNA RAS/BRAF wt and RAS or BRAF mutant. A total of 240 patients will be accrued over 2 years. Discussion: These trials will help us understanding the clinical significance of spatial and temporal heterogeneities of RAS, BRAF and other genes, while optimizing the anti-EGFR mAb treatment strategies in mCRC.

[A Case of Hilar Cholangiocarcinoma Arising during Long-Term Follow-Up of Hepatolithiasis].

A 91-year-old man had a history of cholecystectomy and choledochostomy for cholecystolithiasis and choledocholithiasis. Eleven years earlier, intrahepatic stones were found in the posterior bile duct, and he did not wish to undergo treatment. Over time, worsening of the intrahepatic stones and dilation of the intrahepatic bile duct were observed. At 91 years old, enhanced abdominal CT revealed wall thickening of the hilar bile duct, and MRCP showed stenosis of the hilar bile duct. Endoscopic retrograde cholangiography showed no contrast in the right intrahepatic bile duct and marked dilation of the left intrahepatic bile duct. Brush cytology confirmed adenocarcinoma, leading to a diagnosis of hilar cholangiocarcinoma. He underwent open right and caudal lobectomy with biliary reconstruction. Histopathological examination revealed a hilar cholangiocarcinoma, T3N1M0, Stage Ⅲc, mainly located at the confluence of the right and left hepatic ducts. This case suggests a potential association between hepatolithiasis and hilar cholangiocarcinoma, emphasizing the importance of regular imaging examinations for timely surgical resection. Early intervention, including liver resection, is recommended for the management of hepatolithiasis.

[Long-Term Complete Response by CapeOX plus Nivolumab Chemotherapy for Postoperative Recurrence of Gastric Cancer-A Case Report].

A 73-year-old man underwent upper gastrointestinal endoscopy during a medical check-up that revealed a Type 2 lesion in the anterior wall of the gastric body. The biopsy confirmed tub2. A contrast-enhanced CT scan revealed focal wall thickening and lymphadenopathy in the gastric body. The patient was diagnosed with gastric cancer(M, ante, Type 2, T4aN1M0, Stage ⅢA). Laparotomy total gastrectomy D2 dissection and Roux-en-Y reconstruction were performed. Pathological results were tub1, int, INF b, ly0, v1, pT4aN0M0, pStage ⅡB. S-1(100 mg/day)was started as adjuvant chemotherapy but discontinued after 3 courses due to anorexia(Grade 2). Multiple pulmonary metastases(both lungs, 5)were confirmed by CT examination 9 months after the operation. A diagnosis of gastric cancer recurrence was made, and CapeOX plus nivolumab was started as first-line therapy. After 2 courses, lung metastases tended to shrink. The lesion developed a complete response(CR)after 3 months. After that, CapeOX plus nivolumab was continued, but peripheral neuropathy(Grade 2)was observed in the 15th course. With continued capecitabine monotherapy and nivolumab(impaired liver function [Grade 3]for irAE), despite the maintenance of CR, hepatic function increased repeatedly(Grade 3)and led to the discontinuation of chemotherapy upon patient's request. Currently, CR has been maintained for 5 years and 6 months after recurrence.

[A Case of Repeat Pancreatectomy-Robotic Spleen-Preserving Distal Pancreatectomy after Robotic Pancreaticoduodenectomy].

Laparoscopic pancreaticoduodenectomy has been covered by insurance since 2016 in Japan, and advance laparoscopic and robotic pancreaticoduodenectomy has been also covered by insurance since 2020 in Japan. It has been reported that laparoscopic pancreatectomy causes few postoperative adhesions in the abdominal cavity and that repeat laparoscopic surgery could be performed. However, in robotic pancreatectomy, there have been no such reports yet. We reported that even after robotic pancreaticoduodenectomy, there were few adhesions in the abdominal cavity, and we were able to perform the robotic distal pancreatectomy with preservation of the splenic artery and vein. This suggested that robotic surgery was an effective treatment method for repeat pancreatectomy, given its low invasiveness and minimal adhesion.

[A Case of Conversion Surgery for Stage â £ ATP-Producing Gastric Cancer with Distant Metastasis].

We report a case in which a patient with advanced gastric cancer with liver metastasis and bulky N showed marked tumor shrinkage with chemotherapy, and underwent conversion surgery. A 77-year-old male. Patient was referred to our department because of advanced gastric cancer. Upper gastrointestinal endoscopy revealed type 2 advanced cancer in the posterior wall of the gastric antrum. Abdominal CT showed thickening of the gastric wall in the same region and bulky lymph node enlargement and para-aortic lymphadenopathy behind the stomach. Staging laparoscopy showed the primary tumor and bulky lymph nodes forming a single mass, invading the pancreas, jejunum, and mesentery, and a solitary mass in the hepatic S3. Biopsy pathology revealed adenocarcinoma. We diagnosed the advanced gastric cancer cT4b(pancreas, jejunum), N2M1 (LYM, HEP), P0CY0, Stage ⅣB. After 2 courses of systemic chemotherapy FOLFOX/nivolumab, total gastrectomy, D2 node dissection, splenectomy pancreas tail resection, cholecystectomy, hepatic resection, partial transverse colon resection, partial jejunum resection, Roux-en-Y reconstruction. R0 resection was performed. The operative time was 620 minutes and blood loss was 1,025 mL. Pathologically, the patient was diagnosed with hepatoid adenocarcinoma, ypT4bN1M1(LYM, HEP), ypStage Ⅳ. The pathological efficacy evaluation was Grade 1a in the primary tumor. The patient has been recurrence-free for 9 months since the initial diagnosis.

Successful treatment of an anastomotic leakage after total gastrectomy using a fully covered self-expandable metal stent with an anchoring thread: A case report.

INTORODUCTION AND IMPORTANCE: The incidence of anastomotic leakage in the esophagojejunostomy after total gastrectomy is a serious complication of this procedure. Here, we report a case in which a fully covered stent was endoscopically placed into a fistula caused by anastomotic leakage after total gastrectomy. CASE PRESENTATION: An 88-year-old man diagnosed with advanced gastric cancer had tumor invasion close to the esophagogastric junction. We performed a laparoscopic total gastrectomy and Roux-en-Y reconstruction. On postoperative day (POD) 3, the patient experienced septic shock due to anastomotic leakage and subsequent mediastinitis. Mediastinal irrigation and drainage under laparotomy were performed. Sepsis improved with drainage, but the fistula persisted due to anastomotic leakage. CLINICAL DISCUSSION: Based on a diagnosis of refractory fistula, a fully covered self-expandable metal stent (HANAROSTENT® Esophagus) was inserted POD 21 using esophagoscopy. To prevent stent migration, a 3-0 silk thread was attached to the ostial side of the stent and fixed at the nose. The stent was endoscopically removed 36 days. Esophagoscopy after stent removal revealed that the fistula had resolved and that the anastomotic leakage had healed. The patient started oral intake and was discharged home. CONCLUSION: This case demonstrates the potential for use of a fully covered self-expandable metal stent with an anchoring thread for anastomotic leakage after total gastrectomy for gastric cancer.

Minimally invasive liver resection for cholangiolocellular carcinoma: A single-institution experience.

INTRODUCTION: Cholangiolocellular carcinoma (CoCC) resembles cholangiocellular carcinoma (CCC) and presents a variety of imaging findings; thus, preoperative diagnosis is often difficult. METHODS: We retrospectively studied patients who were diagnosed with CoCC at the Kansai Rosai Hospital from 2006 to 2021 and treated by laparoscopic liver resection (LLR) or open liver resection (OLR). RESULT: Among 918 liver resections, 15 patients were diagnosed with CoCC: 11 underwent LLR and 4 OLR. For LLR and OLR, respectively, patient age was 69.9 ± 6.8 and 72.8 ± 10.6, sex was M/F: 10/1 and 2/2, Child-Pugh was A/B/C: 10/1/0 and 4/0/0, liver damage was A/B/C: 8/3/0 and 4/0/0, preoperative diagnosis was CoCC/CCC/HCC: 1/2/8 and 2/2/0, pathological stage of Union for International Cancer Control (UICC) was IA/IB/II/IIIA/IIIB/IV: 8/0/2/1/0/0 and 0/0/3/0/1/0 (p = .0312), and extent of liver resection was Hr0/HrS/Hr1/Hr2/: 3/0/5/3 and 1/1/0/2. In LLR and OLR, respectively, operation time was 417.5 ± 191.0 and 407.5 ± 187.9 min, blood loss was 123.3 ± 217.4 and 1385.0 ± 1038.7 mL, and postoperative hospital stay was 12.2 ± 13.7 and 15.0 ± 6.6 days. For stages I and II/III, respectively, the 5-year disease-free survival rates were 100.0% and 34.3%, and the 5-year overall survival rates were 100.0% and 55.6%. For stage II/III LLR and OLR, respectively, the 3-year disease-free survival rates were 33.3% and 37.5% (p = .8418), and the 5-year overall survival rates were 66.7% and 50.0% (p = .8084). CONCLUSION: Although further studies are still needed to confirm, minimally invasive liver resection without lymph node dissection is one of a safe and effective approach to the management of CoCC.

Usefulness of blood flow evaluation by indocyanine green fluorescence in laparoscopic or robot-assisted surgery for colorectal cancer with persistent descending mesocolon.

A persistent descending mesocolon is defined as a congenital fixation anomaly caused by the defective membrane fusion of the descending colon and the lateral abdominal wall. Anatomically, in persistent descending mesocolon, the left colonic artery is often shortened, and joins the marginal artery soon after its bifurcation from the inferior mesenteric artery, while the colonic mesentery often adheres firmly to the mesentery of the small intestine. As a result of these characteristics, anatomical knowledge of the persistent descending mesocolon and preservation of bowel blood flow are important during surgery for left-sided colorectal cancer to avoid adverse events. Moreover, indocyanine green based blood flow assessment is useful for the detailed evaluation of bowel ischemia at the anastomotic site. Here we report the usefulness of blood flow evaluation using indocyanine green fluorescence in laparoscopic or robot-assisted surgery for three patients with colorectal cancer and persistent descending mesocolons.

Definitive S-1/mitomycin-C chemoradiotherapy for stage II/III anal canal squamous cell carcinoma: a phase I/II dose-finding and single-arm confirmatory study (JCOG0903).

BACKGROUND: Definitive chemoradiotherapy (CRT) with 5-fluorouracil plus mitomycin-C is a standard treatment for stage II/III squamous cell carcinoma of the anal canal (SCCA). We performed this dose-finding and single-arm confirmatory trial of CRT with S-1 plus mitomycin-C to determine the recommended dose (RD) of S-1 and evaluate its efficacy and safety for locally advanced SCCA. METHODS: Patients with clinical stage II/III SCCA (UICC 6th) received CRT comprising mitomycin-C (10 mg/m2 on days 1 and 29) and S-1 (60 mg/m2/day at level 0 and 80 mg/m2/day at level 1 on days 1-14 and 29-42) with concurrent radiotherapy (59.4 Gy). Dose-finding used a 3 + 3 cohort design. The primary endpoint of the confirmatory trial was 3-year event-free survival. The sample size was 65, with one-sided alpha of 5%, power of 80%, and expected and threshold values of 75% and 60%, respectively. RESULTS: Sixty-nine patients (dose-finding, n = 10; confirmatory, n = 59) were enrolled. The RD of S-1 was determined as 80 mg/m2/day. Three-year event-free survival in 63 eligible patients who received the RD was 65.0% (90% confidence interval 54.1-73.9). Three-year overall, progression-free, and colostomy-free survival rates were 87.3%, 85.7%, and 76.2%, respectively; the complete response rate was 81% on central review. Common grade 3/4 acute toxicities were leukopenia (63.1%), neutropenia (40.0%), diarrhea (20.0%), radiation dermatitis (15.4%), and febrile neutropenia (3.1%). No treatment-related deaths occurred. CONCLUSIONS: Although the primary endpoint was not met, S-1/mitomycin-C chemoradiotherapy had an acceptable toxicity profile and favorable 3-year survival and could be a treatment option for locally advanced SCCA. CLINICAL TRIAL INFORMATION: jRCTs031180002.

Prohaptoglobin is a possible prognostic biomarker for colorectal cancer.

BACKGROUND AND AIMS: Fucosylated haptoglobin is a novel glycan biomarker for colorectal and other cancers, while the significance of its precursor, prohaptoglobin (proHp), remains to be elucidated. In this study, we investigated whether proHp can be a colorectal cancer (CRC) biomarker and the biological functions of proHp in CRC using 10-7G, a monoclonal antibody recently developed in our laboratory. MATERIALS AND METHODS: Serum proHp level in 74 patients with CRC was semi-quantified by western blotting, and 5-year recurrence-free survival and overall survival were analyzed for groups stratified by proHp status (high vs. low). We also performed immunohistochemical analyses of 17 CRC tissue sections using 10-7G mAb. The biological functions of proHp were evaluated by overexpressing proHp in CRC cell lines. RESULTS: Serum proHp correlated with the clinical stage and poorer prognosis of CRC. In the primary CRC sections, immune cells were stained positive for 10-7G in ∼50% of the cases. Overexpression of proHp in HCT116 human CRC cells induced epithelial-mesenchymal transition-like changes and promoted cell migration in CRC cells. CONCLUSION: We provide evidence for the first time that proHp has potential as a prognostic biomarker for CRC and demonstrated specific biological activities of proHp.

Clinical outcomes of neoadjuvant chemotherapy for resectable colorectal liver metastasis with intermediate risk of postoperative recurrence: A multi-institutional retrospective study.

Aims: Risk-scoring systems for colorectal liver metastasis (CRLM) after hepatectomy allow prognoses to be predicted preoperatively. We investigated the clinical outcomes of neoadjuvant chemotherapy for resectable CRLM according to patient risk status, aiming to determine the subgroup of patients who could benefit from neoadjuvant chemotherapy. Methods: In this multi-institutional retrospective analysis, the preoperative risk score was calculated from six previously reported factors: synchronous metastases, primary lymph node positivity, tumor number, largest tumor diameter, extrahepatic metastasis, and the preoperative carbohydrate antigen 19-9 level. Patients were divided into three groups according to their risk scores: low risk (score = 0), intermediate risk (score 1-10), and high risk (score ≥11). Overall and recurrence-free survival curves were calculated using the Kaplan-Meier method. After propensity-score matching in the intermediate-risk group, we compared clinicopathological features and outcomes. Results: There were 318 cases, from 20 institutions. The preoperative risk score could be calculated in 277 cases. There were 34, 192, and 51 patients in the low-, intermediate-, and high-risk groups, respectively. Intermediate-risk group patients who received neoadjuvant chemotherapy had significantly better recurrence-free survival than that of patients without neoadjuvant chemotherapy (P = .0453). After propensity-score matching in the intermediate-risk group, the recurrence-free survival rate was better in patients who received neoadjuvant chemotherapy (P = .0261). But the overall survival rate was not improved after the matching. Conclusion: Neoadjuvant chemotherapy for resectable CRLM might prolong the recurrence-free survival period for intermediate-risk patients with preoperative risk scores in the range of 1-10, but the overall survival was not improved by neoadjuvant chemotherapy.

Lymph node metastasis in T1 colorectal cancer: Risk factors and prediction model.

Endoscopic resection is typically performed for early T1 stage colorectal cancer (T1 CRC). Additional surgery is subsequently recommended based on pathological findings; however, the current criteria may result in overtreatment. The present study aimed to re-examine the reported risk factors for lymph node (LN) metastasis in T1 CRC and develop a prediction model using a large multi-institutional dataset. In this retrospective study, the medical records of 1,185 patients with T1 CRC who underwent surgery between January 2008 and December 2020 were investigated. Slides pathologically re-assessable for additional risk factors were re-examined. A total of 251 patients with inadequate data were excluded, and 934 patients were randomly assigned at a ratio of 3:1 to the training and validation datasets. In the univariate analysis, left-sided CRC (P=0.003), deep submucosal invasion depth (P=0.005), poor histological grade (P=0.020), lymphatic invasion (P<0.001), venous invasion (P<0.001) and tumor budding grade 2/3 (P<0.001) were significant risk factors for LN metastasis. A nomogram predicting LN metastasis was developed using these variables, with an area under the received operating characteristic curve (AUC) of 0.786. The nomogram was validated using a validation set with an AUC of 0.721, indicating moderate accuracy. No LN metastases were observed in patients with <90 points using the nomogram; therefore, patients with a low nomogram score may avoid undergoing surgical resection. Prediction of LN metastasis using this developed nomogram may help identify patients who are at high-risk who require surgery.

[A Case of Inguinal Hernial Sac Metastasis of Cecal Cancer Resected with TAPP Approach].

Malignant tumor occurring in the inguinal region are relatively infrequent, and metastatic tumor is extremely rare. We report a case of inguinal hernial sac metastasis of cecal cancer resected with TAPP approach. The case is a 80's man. One year and 6 months after cecal cancer surgery, contrast-enhanced computer tomography(CT)examination revealed a solitary tumor in the right inguinal canal. We diagnosed inguinal hernia sac metastasis of cecal cancer and performed surgery. The mass in the hernia sac was resected with the TAPP approach. Histopathological findings were consistent with peritoneal metastasis directly to the inguinal hernia sac. The patient has been alive without 2 years after metastasectomy. It is necessary to treat patients with a history of malignant disease with keeping the possibility of inguinal hernia sac metastasis in mind.

[A Case of Rectal Cancer Suspectedly Recurred Seventeen Years after EMR].

We report a case of a 73-year-old man who underwent endoscopic mucosal resection (EMR) for early rectal cancer(i ntramucosal cancer)at other hospital 17 years ago. Ten years later, he underwent a total colonoscopy, which showed no recurrence of the tumor. Twelve years later, a mass with calcification was incidentally detected in front of the sacrum, which was diagnosed as a benign tumor at that time. Seventeen years later, he presented with constipation and diarrhea, and was detected of a sub-circumferential tumor in the rectum by a total colonoscopy. Biopsy revealed that the tumor was malignancy. CT showed a mass in the left lateral liver lobe. The mass was suspected of metastasis. Laparoscopic super lower anterior resection was performed for rectal cancer, and pathological examination showed that the tumor was pT4a, N3, M1(H), Stage Ⅳa. One month after surgery, laparoscopic hepatectomy was performed for liver metastasis. Six months after surgery, CT showed multiple lung metastases. He continues to undergo chemotherapy. Although this case was treated with EMR for intramucosal carcinoma, clinical history and pathological findings suggested local recurrence.

[A Case of De Novo Stage â £ Breast Cancer with Umbilical Metastasis and Peritoneal Dissemination].

The patient was a 48-year-old woman. At the time of consultation, a hard mass of 30 mm in size was palpated in area A of the right breast, and a firm mass of about 10 mm was seen in the umbilical region. Histological diagnosis of the breast mass was invasive ductal carcinoma. PET-CT scan showed accumulation in the right breast, as well as suspicion of umbilical metastasis and peritoneal dissemination, uterine mass, and left ovarian cancer. Since this is an atypical metastatic site for invasive ductal carcinoma of the breast, and the possibility of peritoneal dissemination due to gynecological cancer complications cannot be ruled out, resection of the umbilical mass and laparoscopy was performed. The review laparoscopy revealed no evidence of primary cancer in the uterine body or left ovary, and a white nodular lesion of suspected seeding in the peritoneum around the left ovary. The histology and immunostaining results of the umbilical mass and left peri-ovarian nodule both showed glandular luminal structures similar to those of the primary breast cancer, and the left peri-ovarian nodule was ER positive, GATA3 positive, and PAX8 negative, leading to the diagnosis of umbilical metastasis and peritoneal seeding derived from breast cancer. Umbilical metastasis is often referred to as Sister Mary Joseph's nodule in the case of visceral malignancies and is often associated with peritoneal dissemination and is often caused by invasive metastasis of peritoneal dissemination lesions on the dorsal side of the umbilical region. In this case, histological examination of the umbilical specimen showed no disseminated lesion on the peritoneal side, so it was not considered to be an invasive metastasis due to peritoneal dissemination.

[The Six Cases of Recurrence of Lung Metastasis after Radical Resection of Pancreatic Cancer Performed at Our Hospital].

Prognosis of pancreatic cancer is extremely poor due to recurrence in the early postoperative period. However, there are some reports that the prognosis for lung recurrence alone is relatively better than that of others. In this study, we report the cases of lung recurrence alone after radical resection of pancreatic cancer performed at our hospital. Among 255 cases of radical resection of pancreatic cancer performed at our hospital between July 2010 and August 2021, 6 cases in which the initial recurrence site of recurrence was lung alone were included in the study. The median age of the patients was 72 years (62-82), and there were 5 males and 1 female. Four patients had undergone pancreaticoduodenectomy and 2 patients underwent distal pancreatectomy. Four patients received adjuvant chemotherapy, 3 with S-1 and 1 with GEM. No patients underwent surgical resection for recurrence of lung metastasis, and all patients were treated with chemotherapy. The median time to recurrence was 351 days. As initial therapy after recurrence, 3 patients received GEM plus nab-PTX combination therapy and 3 patients received S-1. The median overall survival after recurrence was 1,979 days, and the 1-year and 3-year overall survival rates after recurrence were 100% and 100%, respectively. The prognosis of patients with recurrence of lung metastasis after surgery for pancreatic cancer at our hospital was similarly good as the previous reports.