Serum NY-ESO-1 antibody as a predictive biomarker for postoperative recurrence of gastric cancer: a multicenter prospective observational study.

BACKGROUND: No reliable marker has been identified to predict postoperative recurrence of gastric cancer. We designed a clinical trial to investigate the utility of serum NY-ESO-1 antibody responses as a predictive marker for postoperative recurrence in gastric cancer. METHODS: A multicenter prospective study was conducted between 2012 and 2021. Patients with resectable cT3-4 gastric cancer were included. Postoperative NY-ESO-1 and p53 antibody responses were serially evaluated every 3 months for 1 year in patients with positive preoperative antibody responses. The recurrence rate was assessed by the positivity of antibody responses at 3 and 12 months postoperatively. RESULTS: Among 1001 patients, preoperative NY-ESO-1 and p53 antibody responses were positive in 12.6% and 18.1% of patients, respectively. NY-ESO-1 antibody responses became negative postoperatively in non-recurrent patients (negativity rates; 45% and 78% at 3 and 12 months, respectively), but remained positive in recurrent patients (negativity rates; 9% and 8%, respectively). p53 antibody responses remained positive in non-recurrent patients. In multivariate analysis, NY-ESO-1 antibody positivity at 3 months (P < 0.03) and 12 months (P < 0.001) were independent prognostic factors for a shorter recurrence-free interval. CONCLUSIONS: Serum NY-ESO-1 antibodies may be a useful predictive marker for postoperative recurrence in gastric cancer. CLINICAL TRIAL REGISTRATION: UMIN000007925.

Comparison of 5-year postoperative outcomes after Billroth I and Roux-en-Y reconstruction following distal gastrectomy for gastric cancer: Results from a multi-institutional randomized controlled trial.

AIM: We previously reported in a randomized controlled trial that Billroth I and Roux-en-Y reconstructions were generally equivalent regarding body weight change and nutritional status 1 year after distal gastrectomy for gastric cancer. We describe the long-term follow-up data 5 years after distal gastrectomy. METHODS: We analyzed consecutive gastric cancer patients who were randomly assigned to undergo Billroth I or Roux-en-Y reconstruction after distal gastrectomy. We evaluated body weight change, nutritional status, late complications, quality of life (QOL) using the European Organization for Research and Treatment of Cancer Core QOL Questionnaire, and dysfunction using the Dysfunction After Upper Gastrointestinal Surgery for Cancer, 5 years after surgery. RESULTS: A total of 228 patients (Billroth I = 105; Roux-en-Y = 123) were eligible for efficacy analyses in this study. Body weight loss 5 years after surgery did not differ significantly between the Billroth I and Roux-en-Y groups (10.0% ± 7.9% and 9.6% ± 8.4%, respectively; P = .70). There were no significant differences in other aspects of nutritional status between the two groups. Reflux esophagitis occurred in 19.0% of the patients in the Billroth I group vs 4.9% in the Roux-en-Y group (P = .002). Regarding QOL, Billroth I was significantly inferior to Roux-en-Y on the diarrhea scale (Billroth I: 28.6, Roux-en-Y: 16.0; P = .047). Regarding dysfunction, no score differed significantly between the two groups. CONCLUSIONS: Billroth I and Roux-en-Y reconstructions were generally equivalent regarding body weight change, nutritional status, and QOL 5 years after distal gastrectomy, although Roux-en-Y more effectively prevented reflux esophagitis and diarrhea.

[A Case of Mesh Infection Due to Transverse Colon Cancer].

A 69-year-old female underwent a mesh repair for an abdominal incisional hernia 4 years previously in our hospital. She visited local hospital for abdominal pain and fever. Abdominal CT showed a localizes abscess formation above the mesh, then she was taken to our hospital. We suspected mesh infection and performed emergent mesh removal. After the operation, we examined for her anemia. Her colonoscopy and CT findings pointed to transverse colon cancer. We performed right hemicolectomy, and final diagnosis was transverse colon cancer pT4aN0M0, pStage Ⅱb. She underwent adjuvant chemotherapy, and 9 months after surgery, no recurrence was found.

[Bilateral Multiple Liver Metastases after Pancreatoduodenectomy for a Duodenal Neuroendocrine Tumor-A Case Report].

The patient was a 79-year-old woman. In January 20XX, upper gastrointestinal endoscopy revealed a duodenal tumor with bleeding and ulceration. This tumor was diagnosed as a duodenal neuroendocrine tumor(NET)based on biopsy findings. In March 20XX, the patient underwent pancreatoduodenectomy with lymph node dissemination. Based on these pathological findings, the tumor was diagnosed as a duodenal NET(G2)with a lymph node metastasis(T2, N1, M0, Stage Ⅲ). Twenty months after the operation, abdominal CT revealed multiple liver metastases(S4, S7, and S8). After this recurrence, she underwent the subcutaneous somatostatin analogue injection therapy every 28 days, and transarterial chemoembolization( TACE)when these recurrent tumors showed remarkable regrowth, once a year, accounting for her age. She has maintained good disease control for 5 years.

[Resection of the Acinar Cell Carcinoma of the Pancreas with Lymph Node Recurrence along the Lesser Curvature of the Stomach-A Case Report].

A 78-year-old woman had undergone subtotal stomach-preserving pancreatoduodenectomy for acinar cell carcinoma (ACC)of the pancreatic head approximately 2 years before presentation, and the pathological diagnosis had been pT2pN0pM0, fStageⅠB(JPS 7th). Adjuvant chemotherapy was discontinued after 3 months because of side effects. Contrast- enhanced CT and PET-CT 2 years postoperatively revealed a tumor measuring 2 cm with a high concentration of FDG in the minor curvature of the stomach. During laparotomy, a 3 cm large lymph node was palpated in the minor curvature of the stomach, and a small lymph node was found adjacently. We diagnosed the patient with multiple lymph node recurrences and performed gastric lymph node dissection of the minor curvature. The pathological diagnosis was a single 2 cm large ACC lymph node metastasis. The patient did not consent to postoperative adjuvant chemotherapy and showed no recurrence for 1 year and 7 months postoperatively. Pancreatic ACC is a rare pancreatic tumor, and its clinicopathologic features are still largely unknown. In recent years, there have been reports of active resection or long-term survival with anti-cancer drug treatment even in recurrent cases, such as the present case. However, the indication and method of anti-cancer treatment are unclear and might need the accumulation of many more cases.

[A Case of Mature Teratoma in the Hepatoduodenal Ligament].

A 60's woman was admitted to our hospital because of palpitations that occurred with exertion. Coronary angiography computed tomography(CT)of suspected angina detected a tumor in the pancreatic head region. Abdominal CT showed a poorly enhanced 40×32 mm solid tumor in the hepatoduodenal ligament that contained a fatty component and calcification. During surgery, the tumor was located in the hepatoduodenal ligament, adhered to the pancreatic head, common hepatic artery, gastroduodenal artery, portal vein and common bile duct. However, the tumor was resected by preserving them. The tumor contained stratified squamous epithelium, a sebaceous gland, nerve, a pancreatic gland, and an adrenal gland. The histological diagnosis was a mature cystic teratoma. The patient showed no recurrence in 2 years and 10 months post-surgery. Mature teratomas in the hepatoduodenal ligament are extremely rare. Some reports showed that combined resection was performed when the tumor was in contact with the common bile duct, portal vein, and arteries. However, in our case, the tumor was removed relatively safely without combined resection.

Our experience of repeat laparoscopic liver resection in patients with recurrent hepatocellular carcinoma.

BACKGROUND: Repeat liver resection is an effective treatment approach for patients with recurrent hepatocellular cell carcinoma (HCC). However, the surgical feasibility and oncological significance of repeat laparoscopic liver resection (r-LLR) remain unproven. This study evaluates and compares the clinical outcomes of non-anatomic r-LLR applied towards recurrent HCC, with those of primary LLR (p-LLR) for primary HCC. METHODS: This retrospective study reports 104 patients with HCC, treated with LLR between 2014 and 2018. Twenty eight of these patients underwent r-LLR for recurrent HCC. The clinical and surgical variables were reviewed for all cases. RESULTS: The analysis was limited to non-anatomic resection across both groups (r-LLR: 89% (25/28) vs. p-LLR: 80% (61/76)). There were no statistically significant differences about patient background between the two groups, with the exception of Child-Pugh classification. r-LLR surgical techniques included single-site laparoscopic adhesiolysis (32%, 8/25), Pringle maneuver (8%, 2/25), and crush-clamp method using BiClamp for hepatic parenchymal transection (72%, 18/25). No severe postoperative complications were observed in the r-LLR group. Postoperative hospital stays and procedure-related postoperative survival were similar for both groups. CONCLUSIONS: Non-anatomical r-LLR renders comparable surgical and oncological outcomes. Our data suggest that non-anatomical r-LLR is a safe and feasible therapeutic approach to recurrent HCC.

Postoperative Long-Term Outcomes in Elderly Patients with Gastric Cancer and Risk Factors for Death from Other Diseases.

BACKGROUND: Elderly patients with gastric cancer are frequently treated surgically in current clinical practice. Although several studies have investigated short-term outcomes after gastrectomy in elderly patients, most did not evaluate long-term outcomes. METHODS: We analyzed 1154 consecutive patients who underwent curative gastrectomy for gastric cancer between 2001 and 2013. We classified them into two groups: the elderly group (n = 241), consisting of patients aged ≥75 years, and the non-elderly group (n = 913), consisting of patients aged <75 years, and compared the short- and long-term outcomes between the two groups. The risk factors for death from other diseases in elderly patients were also examined. RESULTS: Although the incidence of postoperative pneumonia was significantly higher in the elderly group (P < 0.001), the proportion of overall postoperative complications did not differ significantly between the two groups (P = 0.097). The disease-specific survival was similar between the two groups (P = 0.743), whereas the overall survival in the elderly group was significantly shorter than that in the non-elderly group (P < 0.001) because of a higher incidence of death from other diseases throughout all gastric cancer stages. Multivariate analysis revealed that a low preoperative prognostic nutrition index (PNI) and multiple comorbidities were significant risk factors for death from other diseases within 5 years in the elderly group. CONCLUSIONS: Despite acceptable short-term outcomes, long-term outcomes in elderly patients with gastric cancer were poor due to the high incidence of death from other diseases. Indications for surgery in elderly patients with a low PNI or multiple comorbidities should be considered carefully.

Successful management of aberrant right hepatic duct during laparoscopic cholecystectomy: a rare case report.

BACKGROUND: Anatomic variants of the biliary tree present challenges to surgical management during laparoscopic cholecystectomy and affect perioperative outcomes. An aberrant right hepatic duct connecting into the cystic duct is a practically important variation because of the susceptibility to serious postoperative refractory bile leakage. We report a successful case of laparoscopic cholecystectomy in the aberrant right hepatic duct of a patient diagnosed with chronic cystitis. CASE PRESENTATION: A 49-year-old man was referred to our department for treatment of chronic cholecystitis. Magnetic resonance cholangiopancreatography indicated that the cystic duct branched from the common bile duct and an aberrant bile duct connected to the cystic duct. Intraoperative cholangiography revealed that the bile duct was not confluent to the major right branch of the intrahepatic bile duct and drained a narrow area. Preoperative magnetic resonance cholangiopancreatography had diagnostic value. Furthermore, intraoperative cholangiography with the Critical View of Safety method was paramount to achieving safe cholecystectomy based on confirmation of the biliary anatomy and the drainage area of the aberrant right hepatic duct. CONCLUSION: We encountered a rare but clinically significant case of laparoscopic cholecystectomy. This case suggests that precise understanding of the anatomy and drainage area of the aberrant right hepatic duct preoperatively and intraoperatively can lead to safe cholecystectomy.

[Proteinuria in Patients with Gastric Cancer Treated with Ramucirumab].

BACKGROUND: Ramucirumab, an antiangiogenic agent, often causes proteinuria as a characteristic adverse effect. We retro- spectively evaluated proteinuria and clarified the significance of the protein/creatinine ratio by using single urine samples from patients with advanced gastric cancer who were treated with ramucirumab. METHODS: Twenty-three patients who received ramucirumabb etween June 2015 and April 2016 were enrolled. A total of 199 urinalysis specimens were qualitatively analyzed to obtain urine protein levels and the protein/creatinine ratio, and the values were compared. RESULTS: Frequency of proteinu- ria was 43.5%(grade 1: 26.1%, grade 2: 8.7%, and grade 3: 8.7%). The protein/creatinine ratio was less than 2 in -, ±, and 1+ based on the urine protein qualitative examination; 12.5% of 2+ and 71.4% of 3+ or 4+ had a protein/creatinine ratio over 2. CONCLUSIONS: In patients with gastric cancer, treated with ramucirumab, the protein/creatinine ratio should be examined in cases of 2+, 3+ or 4+ via a qualitative examination.

Laparoscopic resection of retroperitoneal paraganglioma behind the Spiegel lobe in a kyphotic patient: A rare case report.

Extra-adrenal paraganglioma is a rare form of neuroendocrine neoplasm capable of catecholamine secretion. The surgical risks associated with the tumor location are compounded in this case of a kyphotic patient. This report presents the successful application of laparoscopy on extra-adrenal paraganglioma located behind the Spiegel lobe in a kyphotic patient. The operation was performed after 1 week of α-blocker administration. The laparoscopic approach, with the patient in the left hemilateral decubitus position on a rotating table, provided optimal access for safe tumor resection after complete hepatic right lobe mobilization. The patient's postoperative course was uneventful. Based on the results, the laparoscopic approach can be a safe and effective method for resecting extra-adrenal paraganglioma in the challenging case of a kyphotic patient.

Prognostic Value of Trefoil Factor 3 Expression in Patients with Gastric Cancer.

BACKGROUND: Trefoil factor 3 (TFF3) is a small molecule secreted by the mammalian gastrointestinal tract and is overexpressed in some human malignant tumors. We investigated the prognostic values of immunohistochemical (IHC) TFF3 expression and serum TFF3 levels in patients with gastric cancer, and whether TFF3 influenced tumor proliferation and invasion in vitro. METHODS: We examined 111 patients who underwent R0 gastrectomy for gastric cancer between April 2012 and April 2015. IHC TFF3 expression and serum TFF3 levels were evaluated regarding their associations with clinicopathological factors and recurrence-free survival (RFS). In vitro cell proliferation and migration assays were used to explore the biological role of TFF3 in human gastric cancer cell lines following transfection with a lentivirus-based shRNA plasmid. RESULTS: IHC TFF3 expression showed significant associations with depth of invasion (p = 0.024), lymph node metastasis (p = 0.008), and RFS (log-rank p = 0.002). Serum TFF3 levels were correlated with IHC TFF3 expression (p = 0.013). RFS was significantly poorer in patients with high (n = 27) compared to low (n = 84) serum TFF3 levels (log-rank p = 0.003). Cox multivariate analysis indicated that serum TFF3 level was an independent prognostic factor for RFS (p = 0.024). In vitro assays, TFF3 downregulation significantly inhibited both proliferation and invasion of gastric cancer cells. CONCLUSIONS: Serum TFF3 levels could be useful prognostic markers in patients with gastric cancer. TFF3 may play various biological roles in proliferation and invasion of gastric cancer cells.

[Improvement of Pain Control after Dealing with Chemical Coping-A Case of Local Recurrence of Rectal Cancer].

A 57-year-old female underwent abdominoperineal resection for rectal cancer. Although she received postoperative adjuvant chemotherapy, she had presacral recurrence with pain 26 months postoperatively. We provided palliative care in parallel with systemic chemotherapy, but she had difficulty controlling pain despite using high-dose opioids at 43 months after surgery. Multimodal therapy contributed to a reduction in opioid use for a brief time. Nevertheless, she required high-dose opioid therapy again at 50 months after the procedure. Since she used a rescue dose for relieving anticipatory anxiety for pain, we estimated that she developed chemical coping. After we tried analgesic adjuvant therapy and psychotherapy, her opioid use was reduced. For 10 months afterward, her disease worsened with time, but her pain was well-controlled. In cases where it is difficult to control pain, protection against exacerbation or opioid dose escalation should be considered. Furthermore, psychological contexts, including chemical coping, should also be considered. It may lead to the use of a proper dose of opioids and improve quality of life for patients.

Risk Factors for Poor Compliance with Adjuvant S-1 Chemotherapy for Gastric Cancer: A Multicenter Retrospective Study.

BACKGROUND: Curative gastrectomy followed by adjuvant S-1 chemotherapy for 12 months is one of the standard treatments for patients with pathological stage (p-stage) II or III gastric cancer. Although some patients have difficulty maintaining compliance with adjuvant S-1, the risk factors for poor compliance are unknown. METHODS: We retrospectively analyzed the data of patients at 21 institutions who underwent curative gastrectomy followed by adjuvant S-1 for p-stage II or III gastric cancer. Patients who had a recurrence within 12 months after surgery were excluded from the analysis. Associations between clinicopathological factors and both 12-month compliance and the cumulative continuation rate of S-1 were analyzed. RESULTS: Of 359 patients, 252 (70.2%) continued adjuvant S-1 until 12 months after surgery. Older age (>65 years) and postoperative infectious complications (Clavien-Dindo grade III or higher) were significantly correlated with low compliance with S-1 for 12 months (p = 0.008 and p = 0.042). These two factors also showed significant associations with low cumulative continuation rate (log-rank p < 0.001 and p = 0.018). Continuation rates at 12 months after surgery in patients aged ≤60 years, 61-65, 66-70, 71-75, and 76-80 years were 81.5, 75.9, 65.4, 58.7, and 62.9%, respectively. Type of gastrectomy or body weight loss at 1 month after surgery did not affect either 12-month compliance or the cumulative continuation rate of S-1. CONCLUSIONS: Older age, especially over 65 years, and postoperative infectious complications were independent risk factors for poor compliance with adjuvant S-1 chemotherapy for gastric cancer.

Amylase concentration in drainage fluid as a predictive factor for severe postoperative pancreatic fistula in patients with gastric cancer.

PURPOSE: Postoperative pancreatic fistula (PPF) sometimes occurs after gastrectomy. We examined the risk factors for severe PPF and evaluated the predictive value of amylase concentration in drainage fluid. METHODS: We retrospectively reviewed 591 patients who underwent curative gastrectomy for gastric cancer. A multivariate analysis was conducted to identify the risk factors for severe PPF. Receiver operating characteristic curves were used to identify the appropriate amylase cut-off value to predict severe PPF. RESULTS: Severe PPF occurred in 23 (3.9%) cases. The multivariate analysis indicated that splenectomy (P = 0.009) was the only significant risk factor. The area under the curve of amylase in drainage fluid for predicting severe PPF on postoperative day (POD) 3 was much greater than that on POD 1 (0.972 vs. 0.894). When the cut-off values for amylase were determined to be 2900 U/L on POD 1 and 2100 U/L on POD 3, the risk ratio for severe PPF on POD 3 was higher than that on POD 1 (99.2 vs. 30.2). CONCLUSIONS: Splenectomy was an independent risk factor for severe PPF. An amylase level of 2100 U/L on POD 3 may be a reliable cut-off value for the early diagnosis of patients at high risk of severe PPF.

Clinical outcomes and prognostic factors for gastric cancer patients with bone metastasis.

BACKGROUND: Bone metastasis due to gastric cancer is rare, and the clinical features have not been fully evaluated. We investigated the clinical features, treatment outcomes, and prognostic factors in gastric cancer patients with bone metastasis. METHODS: We retrospectively collected data on 34 consecutive patients who were diagnosed radiologically with bone metastasis due to gastric cancer. We estimated the overall survival after the diagnosis of bone metastasis using the Kaplan-Meier product-limit method and evaluated which clinicopathological factors were associated with prognostic factors for survival using univariate and multivariate Cox proportional hazards regression models. RESULTS: The treatment for the primary tumor was surgery in 16 patients (47.1%) and chemotherapy in 18 patients (52.9%). The median serum alkaline phosphatase (ALP) and lactate dehydrogenase (LDH) levels at the time of bone metastasis were 375.5 and 249 IU/L, respectively. Ten patients (29.4%) were diagnosed with bone metastasis and gastric cancer at the same time. The 6-month survival rate after the diagnosis of bone metastasis was 63.8%, and the median survival time was 227.5 days. Multivariate analysis revealed that metachronous metastasis (p = 0.035) and extraosseous metastasis (p = 0.028) were significant risk factors for poor survival. CONCLUSIONS: The prognosis of gastric cancer with bone metastasis was poor, and metachronous metastasis and extraosseous metastasis were shown to be poor prognostic factors. Serum ALP, LDH, and tumor markers are not always high, so aggressive diagnosis using appropriate modalities such as bone scan, MRI, or PET-CT may be necessary in routine practice even in asymptomatic patients.

[A Case of Recurrent Gastric Cancer with Grade 3 Proteinuria Caused by Ramucirumab plus Paclitaxel Therapy].

Proteinuria is one of the characteristic adverse events by ramucirumab(RAM)plus paclitaxel(PTX)combination therapy for advanced gastric cancer. We reported a case of recurrent gastric cancer with grade(gr)3 proteinuria caused by RAM plus PTX therapy. 77-year-old woman was underwent distal gastrectomy in 76 years old for gastric cancer that was diagnosed mucinous adenocarcinoma, fStage III C(T4aN3H0P0CY0M0)and received adjuvant chemotherapy of S-1 for 1 year. She suffered from peritoneal recurrence with ascites after 1 year and 4 months of the operation and RAM(8mg/kg; day 1 and 15)plus PTX(80mg/m2; day 1, 8 and 15)therapy was administrated as second-line chemotherapy. After 1 course, weekly PTX has been continued for gr 3 proteinuria and the ascites disappeared after 4 courses. This successful case might indicate that it was important for patients with gr 3 proteinuria as adverse event to consider discontinuance of RAM and continuation of PTX according to the proper usage guide of RAM.

[Examination of Patients with Malignant Obstruction Treated with Chemotherapy after Ileo/Coleostomy].

Management for obstructive cancer of the colon diverges into many ways. The aim of this study was to evaluate the treatment course of patients with malignant obstruction after ileo/coleostomy. Thirty-six patients with malignant obstruction who underwent ileo/coleostomy in our hospital from May 2012 to January 2016were enrolled in the study. Clinical outcomes were the period before treatment initiation, chemotherapy, radiotherapy, primary lesion resection, and death, and these were retrospectively analyzed. Although 9 stomal complications occurred, no case experienced a delayed treatment start. However, patients with perioperative complications, sepsis due to the tumor, pneumonia, cerebral infractions, and ileus needed a long recovery period before treatment initiation. Patients who need ileo/coleostomy must be considered for performance status and ways to decrease perioperative complications to prevent stomal complications from chemo/radiotherapy.

[A Case of Self-Expandable Metallic Stent Placement to Treat Colon Obstruction Due to Metastatic Gastric Cancer].

A66 -year-old woman presented with abdominal pain and nausea. She was diagnosed with wall thickening of the gastric antrum and bowel obstruction caused by tumors of the splenic flexure on computed tomography. Aself -expandable metallic stent(SEMS)was placed in the splenic flexure of the colon 4 days after transanal ileus tube replacement. No complication was observed, and she could ingest a normal diet, permitting her discharge from the hospital 12 days after SEMS placement. She was diagnosed with gastric cancer(Type 4, cT4a[SE], N2, H0, P1, M1[LYM], cStage IV )on upper gastrointestinal endoscopy and computed tomography, and administration of S-1 plus oxaliplatin(SOX)was started. Nab-paclitaxel as the second-line chemotherapy was administered after 8 courses of SOX therapy because of an increase in the amount of ascites. No late complication associated with stent placement was recognized. SEMS placement was suggested to be effective for treating colon obstruction due to metastatic gastric cancer.

[Eye Disorders Associated with S-1 Chemotherapy in Gastric Cancer Patients].

Eye disorders are one of the characteristic adverse events associated with S-1 chemotherapy. In this retrospective study, we investigated the frequency and outcome of eye disorders associated with S-1 chemotherapy in gastric cancer patients. This retrospective study included 75 advanced gastric cancer patients who received S-1 monotherapy between January 2014 and December 2015. We retrospectively evaluated the frequency, Grade, and treatment of eye disorders. Eye disorders were observed in 16 patients(21%). The median time of onset was 3(range, 1-8)months. Grade 2 watering eyes, eye discharge, and conjunctivitis were reported in 14, 8, and 4 patients, respectively. Artificial tears, fluorometholone eye-drops, and both of these treatments were used in 7, 1, and 8 patients, respectively. Ophthalmologic examination was performed for 3 patients. No delay or reduction of S-1 therapy was required for the eye disorders. Eye disorders associated with S-1 therapy in gastric cancer patients did not affect treatment if managed properly using eye drops.