A Multicenter, Phase II Trial of Schedule Modification for Nab-Paclitaxel in Combination with Ramucirumab for Patients with Previously Treated Advanced Gastric or Gastroesophageal Junction Cancer: The B-RAX Trial (JACCRO GC-09).

BACKGROUND: This study investigated whether schedule modification of bi-weekly nanoparticle albumin-bound paclitaxel (nab-PTX) plus ramucirumab (RAM) is efficacious against gastric cancer (GC) or gastroesophageal junction cancer (GJC). PATIENTS AND METHODS: Patients with unresectable GC or GJC who were previously treated with fluoropyrimidine-containing regimens received nab-PTX (100 mg/m2) on days 1, 8, and 15 and RAM (8 mg/kg) on days 1 and 15 of a 28-day cycle. Based on the incidence of severe adverse events (AEs) during the first cycle, patients were modified to bi-weekly therapy from the second cycle. The primary endpoint was progression-free survival (PFS) in the bi-weekly therapy population. Based on the hypothesis that bi-weekly nab-PTX plus RAM would improve PFS from 4.5 to 7.0 months, 40 patients were required for power of 0.8 with a one-sided α of 0.05. RESULTS: Of the 81 patients enrolled, 47 patients (58%) were assigned to bi-weekly therapy. Patient characteristics were Eastern Cooperative Oncology Group performance status of 1 (19%) and diffuse type (45%). Median PFS was 4.7 months (95% confidence interval [CI] 3.7-5.6 months) and overall response rate was 25% (95% CI 11-39%). Severe AEs of grade 3 or worse were mainly neutropenia (83%) and hypertension (23%). EQ-5D scores were maintained during the treatment. In patients who continued standard-schedule therapy, median PFS was 2.7 months (95% CI 1.8-4.0 months). CONCLUSIONS: The primary endpoint for PFS was statistically not met, but modification of nab-PTX plus RAM to a bi-weekly schedule might be a feasible treatment option as second-line treatment for advanced GC/GJC patients, especially elderly patients, with severe AEs during the first cycle.

Is frequent measurement of tumor markers beneficial for postoperative surveillance of colorectal cancer?

PURPOSE: To determine whether frequent measurement of tumor markers triggers early detection of colorectal cancer recurrence. METHODS: Of 1,651 consecutive patients undergoing colorectal cancer surgery between 2010 and 2016, 1,050 were included. CEA and CA 19-9 were considered to be postoperative tumor markers and were measured every 3 months for 3 years, and then every 6 months for 2 years. Sensitivity analysis of elevated CEA and CA19-9 levels and multivariate analysis of factors associated with elevated CEA and CA19-9 levels were performed. The proportion of triggers for detecting recurrence was determined. RESULTS: The median follow-up period was 5.3 years. After applying the exclusion criteria, 1,050 patients were analyzed, 176 (16.8%) of whom were found to have recurrence. After excluding patients with persistently elevated CEA and CA19-9 levels before and after surgery from the 176 patients, 71 (43.6%) of 163 patients had elevated CEA levels and 35 (20.2%) of 173 patients had elevated CA19-9 levels. Sensitivity/positive predictive values for elevated CEA and CA19-9 levels at recurrence were 43.6%/32.3% and 20.2%/32.4%, respectively. Lymph node metastasis was a factor associated with both elevated CEA and CA19-9 levels at recurrence. Of the 176 patients, computed tomography triggered the detection of recurrence in 137 (78%) and elevated tumor marker levels in 13 (7%); the diagnostic lead interval in the latter 13 patients was 1.7 months. CONCLUSION: Tumor marker measurements in surveillance after radical colorectal cancer resection contribute little to early detection, and frequent measurements are unnecessary for stage I patients with low risk of recurrence.

Evaluation of 4-hand reduction for obturator hernia with the guidance of sonography as a new treatment strategy: A retrospective study.

To evaluate the effectiveness of 4-hand reduction for obturator hernia with the guidance of sonography (FROGS) as a new treatment strategy for obturator hernia. Since November 2019, FROGS was performed for all patients with obturator hernia at our emergency department. We retrospectively compared the clinical data of 20 patients who underwent FROGS (after FROGS group) to those of 23 patients who did not (before FROGS group). All patients except one were female. The male-to-female ratio, age, duration of symptoms, lesion site, and predisposing factors did not significantly differ between groups. However, the diameter of the prolapsed bowel and the body mass index of the after FROGS group were significantly larger and lower, respectively. Manual reduction was successfully performed for all 20 patients in the after FROGS group, and bowel resection was avoided for all 20 cases. However, 14 patients in the before FROGS group underwent manual reduction; of these, only one was successfully treated using a method other than FROGS, and 8 patients underwent bowel resection. There were no significant differences between groups in terms of postprocedural complications or mortality within 30 days of hernia presentation. The FROGS technique was safe and reproducible and could be used as the first choice of treatment for patients with obturator hernia.

Post-Partum Diastasis Recti Abdominis Treatment Using the Extended-View Totally Extraperitoneal Approach, Rives-Stoppa Technique, and Transversus Abdominis Release Procedure.

Introduction: Diastasis recti abdominis usually occurs during pregnancy and delivery in young women with no surgical history, and can induce a severely negative body image, urogynecological symptoms, and musculoskeletal pain. However, the optimal surgical procedure for diastasis recti abdominis is undetermined, and minimally invasive surgery has not been adopted. Additionally, open repair causes scarring that is unlikely to improve negative body image and may even worsen it. We present a case of diastasis recti abdominis surgically treated using an extended-view totally extraperitoneal approach, Rives-Stoppa technique, and transversus abdominis release procedure. Case Description: The patient was a 29-year-old woman who delivered transvaginally two weeks before presenting with bulging of the abdominal wall. Computed tomography revealed separation of the rectus. A three-month course of conservative therapy comprising exercises to strengthen the transversus abdominis was ineffective, and the patient had newly developed abdominal pain. Therefore, we performed surgical repair using the Rives-Stoppa technique and transversus abdominis release via the extended-view totally extraperitoneal approach. The postoperative course was uneventful, with no recurrence. This procedure may be superior to other methods in terms of cosmetic appearance, preventing infection, bowel adhesion, and recurrence. Discussion: In the case study, the Rives-Stoppa technique and transversus abdominis release via the extended-view totally extraperitoneal approach achieved a good therapeutic outcome for diastasis recti abdominis.

The necessity of intensive surveillance colonoscopy for patients with a remaining right colon after resection of colorectal cancer: a retrospective cohort study.

PURPOSE: To clarify how often postoperative surveillance colonoscopy should be undertaken based on the risk factors for the development of metachronous cancer (MC) and advanced adenoma (AA) after surgery for colorectal cancer. METHODS: We collected data of consecutive patients who underwent curative resection for primary colorectal cancer between 2005 and 2012, with preoperative colonoscopy and surveillance colonoscopy at 1 year after surgery (406 patients, mean age: 69 years, 59% male). The detection rates of AA (with villous features, > 10 mm or high-grade dysplasia) and MC by surveillance colonoscopy were the primary outcomes. RESULTS: At 5 years, colonoscopy was performed as postoperative surveillance an average of 3.2 times. AA and MC were detected in 57 (14.0%) and 18 patients (4.4%), respectively. Both lesions were more common in the right colon (n = 43) than in the left colon (n = 28). The detection rate did not differ to a statistically significant extent according to the number of colonoscopies performed for surveillance (p = 0.21). However, after left-sided colectomy, both types of lesions were more commonly detected in those who received ≥ 3 colonoscopies than in those with one or two colonoscopies (p = 0.04). CONCLUSION: A remaining right colon after left-sided colectomy was associated with a higher risk of developing AA and MC. Physicians should consider performing surveillance colonoscopy more frequently if the right colon remains after surgery.

[Appendiceal Goblet Cell Carcinoid Successfully Treated with Bevacizumab plus mFOLFOX6 Regimen-A Case Report].

A 67-year-old man presented with abdominal distention and vomiting.Computed tomography revealed bowel obstruction due to a cecal tumor.We performed laparoscopic ileocecal resection after decompression with an ileus tube. Intraoperative findings included multiple disseminated nodules on the mesenterium surrounding the cecal tumor.The histopathologic diagnosis was poorly differentiated adenocarcinoma, which consisted of glandular proliferation of atypical epithelial cells and dispersed infiltration of goblet cells. Immunohistochemistry showed positively stained neuroendocrine markers, such as CD56, chromogranin, and synaptophysin.The patient was diagnosed with goblet cell carcinoid of the appendix and treated with combination chemotherapy of bevacizumab, fluorouracil, folinic acid, and oxaliplatin.He remained free from progression for over 1 and half years with this treatment.Subsequent chemotherapy was ineffective, and he passed away.There is no established chemotherapy regimen for goblet cell carcinoid, which has the aspects of both adenocarcinoma and neuroendocrine tumors.However, the present case suggested the efficacy of the mFOLFOX6 regimen in combination with bevacizumab for appendiceal goblet cell carcinoid.

[Sigmoid Colon Cancer with Lateral Lymph Node Metastasis That Presented with Gastric Perforation].

A 74-year-old man visited his local clinic complaining of abdominal pain that persisted for three days. He was diagnosed with diffuse peritonitis and was transported to our hospital. Contrast computed tomography(CT)showed gastric perforation and a tumor in the sigmoid colon with left obturator lymph node metastasis. He was diagnosed with diffuse peritonitis resulting from gastric perforation and performed emergent surgery. As the size of the gastric perforation was large, we performed distal gastrectomy and transverse colostomy. He was discharged without any complications, and a total of 6 courses of SOX with a bevacizumab regimen were administered postoperatively. CT following chemotherapy showed shrinkage of the lesion. He was admitted again for sigmoidectomy with left lateral lymph node resection and discharged from the hospital on postoperative day 8. We administered 2 courses of SOX regimen after the surgery. He remains alive with no recurrence 27months after the first surgery.

The safety and efficacy of laparoscopic hepatectomy in obese patients.

BACKGROUND: Obesity is generally reported to increase the risk of surgical complications. There have been few reports of laparoscopic hepatectomy (LH) in obese patients. The purpose of this study was to compare the safety and efficacy of (1) LH versus open hepatectomy (OH) in obese patients and (2) LH in obese patients versus LH in non-obese patients. METHODS: We introduced LH at our institution in April 2014. LH was performed in 63 obese patients and 108 non-obese patients from April 2014 to May 2017. OH was performed in 79 obese patients from January 2010 to May 2017. This study retrospectively compared the short-term outcomes of the LH obese group with those of the OH obese group and the LH non-obese group. RESULTS: In patient characteristics, the LH obese group included a significantly higher percentage of patients with liver cirrhosis than the OH obese group. The LH obese group had fewer patients with a history of abdominal surgery but more with liver cirrhosis than the LH non-obese group. For short-term outcomes, the LH obese group had significantly less blood loss, fewer intraoperative transfusions, fewer positive surgical margins, and shorter postoperative hospital stays than the OH obese group. In contrast, only operation time was significantly different (longer) in the LH obese group than in the LH non-obese group. There were no significant differences in morbidity or mortality between the LH obese group and either the OH obese or the LH non-obese groups. CONCLUSION: LH in obese patients is safe and effective.

Strangulated Hernia Can Be a Risk Factor of Seroma following Laparoscopic Transabdominal Preperitoneal Repair.

PURPOSES: Seroma is a postoperative complication following laparoscopic transabdominal preperitoneal repair (TAPP) for inguinal hernioplasty. Seroma naturally resolves in most cases, but it can lead to an increased amount of visits to the outpatient clinic and can result in anxiety of the patient. Local inflammation of the inguinal area is etiology of seroma formation. Strangulated hernia involves severe inguinal pain and can lead to severe inflammation and subsequent seroma. There have been no reports demonstrating the links of seroma and strangulated hernia. This study aimed to retrospectively evaluate the risk of seroma after TAPP and to identify the association between strangulated hernia and seroma. METHODS: We treated 300 inguinal hernias by TAPP between 2013 and 2016 at Kurashiki Central Hospital. We used the Chi-square test. Factors significant in each association were further examined using multiple subsequent logistic regressions. RESULTS: A total of 222 hernias were eligible for analysis. The incidence of seroma was 11% (n=25). There were nine cases of strangulated hernias, and three (33%) resulted in seroma. The ratio of strangulated hernia of seroma group is significantly high (p<0.03). Multiple subsequent logistic regressions showed that strangulated hernia was associated with a significantly increased risk for seroma formation (p = 0.023; OR 6.564; 95% CI 1.29-33.3). CONCLUSION: This study shows that strangulated hernia can be a risk factor in seroma formation. This risk should be incorporated into a management plan of TAPP for strangulated hernia, with careful consideration of patients' concerns.

[A Case of HER2-Positive Breast Cancer with Liver Metastases Showing Three Years of Complete Response to Combination Therapy with Trastuzumabplus Pertuzumab].

A 48-year-old woman with severe interstitial pneumonitis was diagnosed with right breast cancer(invasive ductal carcinoma, T1aN1M0, ER+, PgR-, HER2 3+)and underwent modified radical mastectomy.The patient was administered tamoxifen as adjuvant therapy.However, 1 year after the mastectomy, multiple liver metastases were found and the patient received 2 anti-HER2 agents, trastuzumab and pertuzumab.A complete response(CR)was observed with the disappearance of the liver metastases in 7 months.CR was maintained for 2 years after the initiation of treatment, and then, we started trastuzumab monotherapy, which has resulted in long-term disease control.

Feasibility of a novel tacking method of securing mesh in transabdominal preperitoneal inguinal hernia repair: Secure tacking against recurrence.

INTRODUCTION: Postoperative chronic pain is an important outcome of hernia surgery. In laparoscopic hernia surgery, either fixation outside the trapezoid of disaster or no fixation is recommended to avoid postoperative pain. To avoid recurrence are transabdominal preperitoneal (TAPP) hernia repair, the myopectineal orifice must be covered with mesh during TAPP, but lifting or shrinking of the mesh can lead to recurrence. The aim of this study was to evaluate the feasibility of a novel technique for mesh fixation to prevent the mesh from lifting off. METHODS: After the preperitoneal space was created during TAPP, the anatomy of the lateral cutaneous nerve of the thigh or the femoral branch of the genitofemoral nerve within the trapezoid of disaster was checked. The mesh was tacked at the trapezoid of disaster without nerve injury, and the mesh was fixed with circumferential tacking. We call this procedure secure tacking against recurrence (STAR). We treated 391 adult patients (478 hernias) with TAPP repair; novel tacking was used in some patients (STAR group, 236 hernias). The results of the STAR group were retrospectively compared with those of patients in whom we did not use this novel tacking (conventional group, 242 hernias). RESULTS: There was no postoperative chronic pain in either group. There were no cases of hernia recurrence in the STAR group, but there were four cases of hernia recurrence in the conventional group (0% vs 1.7%, P = 0.047). These four recurrences consisted of indirect hernia and mesh lifting on the lateral side. CONCLUSION: The STAR procedure is feasible and safety as a standard procedure for securing the mesh during TAPP.

The feasibility and efficacy of pure laparoscopic repeat hepatectomy.

BACKGROUND: Repeat hepatectomy is often required for hepatocellular carcinoma and metastatic tumors. However, this procedure is technically challenging, so laparoscopic repeat hepatectomy (LRH) has not been widely adopted. The aim of this study was to evaluate the feasibility and efficacy of LRH compared with open repeat hepatectomy (ORH) and laparoscopic primary hepatectomy (LPH). METHODS: We introduced laparoscopic hepatectomy at our institution in April 2014. We performed 127 LPH (LPH group) and 33 LRH procedures (LRH group) from April 2014 to April 2017; 37 patients underwent ORH from January 2010 to April 2017 (ORH group). This study retrospectively compared the patient characteristics and short-term outcomes of the LRH and ORH groups as well as the LRH and LPH groups. RESULTS: There were no conversions to open surgery in the LRH group. In comparing the LRH and ORH groups, there were no significant differences in patient characteristics except for the type of approach to the previous hepatectomy (p = 0.004) and indocyanine green retention rate at 15 min (median 12.5 vs. 8.75%, p = 0.026). The LRH group had less blood loss (median 30 mL vs. 652 mL; p < 0.001), less intraoperative transfusion (6.1 vs. 32.4%; p = 0.006), and shorter postoperative hospital stays (median 6.5 days vs. 9.0 days; p < 0.001). There were no differences with regard to operation time, severe postoperative complications, and mortality. In comparing the LRH and LPH groups, there was a significant difference only in past history of abdominal surgery (100 vs. 61.4%; p < 0.001). In the short-term outcomes, the postoperative hospital stay was significantly shorter in the LRH group (median 6.5 days vs. 7 days; p = 0.033), and the other results were comparable between the two groups. CONCLUSIONS: LRH is feasible and useful for repeat hepatectomy, achieving good short-term outcomes.

Feasibility of Endo GIA™ Reinforced Reload with Tri-Staple™ Technology for delta-shaped anastomosis.

BACKGROUND: We report the short-term clinical outcomes of a delta-shaped (DS) anastomosis in laparoscopic distal gastrectomy (LDG), comparing Endo GIA™ Reinforced Reload (Reinforced GIA) with Endo GIA™ (GIA) staplers. METHODS: This was a retrospective analysis of 40 patients who underwent totally LDG with DS anastomosis with Reinforced GIA (group A) and 90 patients who underwent the same procedure with GIA (group B) for clinical T1-T3 gastric cancer from May 2013 to December 2016. Operation time, intraoperative blood loss, hospital length of stay, reconstruction time, and complications were compared. RESULTS: No patients required conversion to open surgery, and no patients died. There was no significant difference between the groups regarding patient background, postoperative hospital stay, and operation time. Bleeding from the V-shaped anastomosis was significantly less frequent in group A compared with group B (0% vs 11.2%, p = 0.021). Anastomosis-related complications were less frequent in group A, but there was no statistically significant difference between the groups. The fasting period in group A was significantly shorter than that of group B (2.81 vs 3.39 days, p = 0.034). CONCLUSION: DS anastomosis using Reinforced GIA can prevent minor postoperative anastomosis leakage. Based on our findings and experience, we recommend DS anastomosis with Reinforced GIA after LDG for gastric cancer as an effective procedure with good short-term outcomes.

Laparoscopic approach to suspected T1 and T2 gallbladder carcinoma.

AIM: To evaluate a laparoscopic approach to gallbladder lesions including polyps, wall-thickening lesions, and suspected T1 and T2 gallbladder cancer (GBC). METHODS: We performed 50 cases of laparoscopic whole-layer cholecystectomy (LCWL) and 13 cases of laparoscopic gallbladder bed resection (LCGB) for those gallbladder lesions from April 2010 to November 2016. We analyzed the short-term and long-term results of our laparoscopic approach. RESULTS: The median operation time was 108 min for LCWL and 211 min for LCGB. The median blood loss was minimal for LCWL and 28 ml for LCGB. No severe morbidity occurred in either procedure. Nine patients who underwent LCWL and 7 who underwent LCGB were postoperatively diagnosed with GBC. One of these patients had undergone LCGB for pathologically diagnosed T2 GBC after LCWL. All of the final surgical margins were negative. Three of these 15 patients underwent additional open surgery. The mean follow-up period was 26 mo, and only one patient developed recurrence. CONCLUSION: LCWL and LCGB are safe and useful procedures that allow complete resection of highly suspected or early-stage cancer and achieve good short-term and long-term results.

Laparoscopic radical antegrade modular pancreatosplenectomy for left-sided pancreatic cancer using the ligament of Treitz approach.

BACKGROUND: Laparoscopic distal pancreatectomy (Lap-DP) for benign lesions or those with low malignant potential has been proven safe and effective, and its performance is now widespread [1-3]. Lap-DP for left-sided pancreatic cancer (PC) is also being increasingly performed. According to some reports, Lap-DP has superior short-term outcomes (blood loss, postoperative hospital stay) and comparable oncological outcomes and overall survival with those of open distal pancreatectomy (Op-DP) [4-6]. PC has highly malignant potential; thus, complete resection and sufficient regional lymphadenectomy with tumor-free margins are very important. Radical antegrade modular pancreatosplenectomy (RAMPS) is an accepted standard Op-DP technique for PC and is reportedly useful for achieving R0 resection and radical lymphadenectomy [7-10]. However, laparoscopic RAMPS (Lap-RAMPS) is not yet popular because of its technical difficulty and lack of adequate evidence. Few reports have described the detailed surgical technique of Lap-RAMPS [11-13]. We employ Lap-RAMPS using the ligament of Treitz approach with the benefit of a laparoscopic view and herein describe the usability of this laparoscopic procedure with a video. METHODS: Our indication for Lap-RAMPS is left-sided PC located ≥1 cm away from the origin of the splenic artery (SPA) without invasion of the superior mesenteric artery (SMA), celiac artery (CA), common hepatic artery (CHA), or portal vein (PV). We apply either anterior or posterior RAMPS to achieve tumor-free margins. Therefore, the left adrenal gland and the nerve plexus around the SMA and CA are resected depending on the extent of the cancer. Three patients underwent Lap-RAMPS for left-sided PC using the ligament of Treitz approach from April to December 2016. This video shows our Lap-RAMPS procedure performed in a 67-year-old man with pancreatic body cancer who was being followed up for autoimmune pancreatitis. The tumor was suspected to have invaded the SPA, splenic vein, and retroperitoneum but was not close to the SMA, CA, CHA, or PV. The patient was put in the supine position with his legs opened, and the operation was performed using five trocars. Early in the operation, we incised the retroperitoneum just beside the ligament of Treitz, and the inferior vena cava and left renal vein (LRV) were exposed with resection of Gerota's fascia under a good laparoscopic view. The left adrenal gland was resected in this case to obtain sufficient tumor-free margins. The origin of the SMA was easily identified above the LRV. The most posterior dissection was carried out early in the operation, making it easy and safe to determine the resected margin and enabling curative resection with sufficient regional lymphadenectomy. After division of the pancreas with a linear stapler, the lymph nodes around the SMA and CA were safely removed. RESULTS: The operative time was 358 min, and the estimated blood loss was 1 ml. The postoperative course was uneventful, and the patient was discharged on postoperative day 10. Pathological examination revealed invasive ductal carcinoma (stage III, T3N1M0 according to the 7th edition of the Union for International Cancer Control system) with tumor-free margins. In all three patients, the median operative time and blood loss were 358 (328-451) min and minimal (minimal to 1 ml). One patient underwent anterior RAMPS and the other two patients, including the case mentioned above, underwent posterior RAMPS. One patient developed a grade B pancreatic fistula according to the International Study Group for Pancreatic Fistula (ISGPF) classification, but he recovered promptly with conservative treatment. No life-threatening complications occurred. The median postoperative hospital stay was 14 (10-16) days. CONCLUSIONS: Lap-RAMPS using the ligament of Treitz approach is feasible and extremely helpful in performing minimally invasive, curative resection for well-selected left-sided PC.

Feasibility of a new approach for creating a preperitoneal space in transabdominal preperitoneal repair inguinal hernia repair: using a sandwich approach.

PURPOSE: In Japan, transabdominal preperitoneal (TAPP) inguinal hernia repair is performed by firmly pulling the peritoneum inwards to lift it from the underlying deep layer of subperitoneal fascia. It decreases the postoperative pain and discomfort in the inguinal area. The aim of this study was to evaluate the feasibility of the sandwich approach, which is a new technique for creating a preperitoneal space. METHODS: The operation was performed via the sandwich approach. We made sure to protect the preperitoneal fascia areolar layer when making the preperitoneal space. RESULTS: We performed TAPP in 745 patients (876 hernias) treated between October 2006 and April 2015 at Himeji Medical Center and Kurashiki Central Hospital. Before October 2010, we did not use the sandwich approach, and recurrence was observed in three patients. From October 2010, we always used the sandwich approach and never experienced any cases of recurrence. Clavien-Dindo classification Grade 3 or higher postoperative complications occurred in 6 patients (0.8%) between October 2006 and April 2015. Mesh-related ileus was the most frequently observed morbidity. There were no cases of vas differentia or spermatic vessel injury, postoperative chronic pain, or urinary retention. CONCLUSION: The sandwich approach is feasible as another standard dissective procedure for TAPP.

Laparoscopic and Endoscopic Cooperative Surgery for Plexiform Angiomyxoid Myofibroblastic Tumor.

Plexiform angiomyxoid myofibroblastic tumor (PAMT) is a recently described distinctive gastric mesenchymal entity with a peculiar plexiform pattern, bland spindle cells and a myxoid stroma rich in arborizing blood vessels. In this study, we report a new case of this rare gastric tumor resected by laparoscopic and endoscopic cooperative surgery (LECS). A 39-year-old Japanese man was admitted with a gastric mass. Gastroscopy showed an elevated mass in the anterior wall of the gastric antrum. Endoscopic ultrasound examination revealed a focal hypoechoic lesion protruding into the lumen. A partial gastrectomy by LECS was performed, and the patient made an uneventful recovery and remains well 9 months later. The tumor in this case depicted all the typical histopathologic and immunochemical features of gastric PAMT (c-kit negative and smooth muscle actin-positive). Especially, it was characterized by multiple nodules protruding outward within the serosa. Therefore, it is important that the resection line is determined on the serosa to ensure the complete resection of these nodules together.

Inflammatory polyp in the common bile duct with pancreaticobiliary maljunction.

A 63-year-old woman was admitted because of epigastric pain and obstructive jaundice. Endoscopic retrograde cholangiopancreatography and intraductal ultrasonography revealed a 25-mm papillary nodule in the middle to inferior portion of the common bile duct (CBD). Pancreaticobiliary maljunction (PBM) was also identified. Contrast-enhanced computed tomography also showed an enhanced nodule in the CBD, and we suspected intraductal papillary neoplasm of the bile duct. We performed pylorus-preserving pancreatoduodenectomy. Postoperative pathological examination revealed an inflammatory polyp in the middle CBD. Inflammatory polyp in the bile duct is rare and there are no previous reports accompanied by PBM. PBM is a major risk factor for biliary tract cancer. Preoperative diagnosis of a benign disorder was difficult in this case.

[A Case of Signet-Ring Cell Carcinoma of the Sigmoid Colon with Disseminated Carcinomatosis Successfully Treated with CPT-11/Panitumumab].

A 70-year-old man, who had undergone S-1/oxaliplatin/bevacizumab combination chemotherapy for LNs metastasis of signet-ring cell carcinoma of the sigmoid colon, complained of back pain and lumbago.He was diagnosed with disseminated carcinomatosis of the bone marrow and disseminated intravascular coagulation (DIC). He was treated with systemic chemotherapy consisting of CPT-11/panitumumab. After 2 courses of the treatment, the DIC resolved and the back pain and lumbago improved.