[A Case of Radical Resection after Neoadjuvant Chemotherapy for Rectal Cancer with Pelvic Abscess].

A 66-year-old man with a history of frequent diarrhea was diagnosed with rectal cancer with obstruction and a pelvic abscess. Following a transverse colostomy, he was referred to our hospital. The initial diagnosis was rectal cancer(cT4a N1bM0, cStage Ⅲb)and a pelvic abscess due to tumor perforation. To address this condition, we performed neoadjuvant chemotherapy using a combination of 5-fluorouracil, Leucovorin, oxaliplatin, and irinotecan(FOLFOXIRI). Following 6 courses of FOLFOXIRI, the abscess disappeared and no signs of tumor progression and distant metastases were detected. Subsequently, we performed radical resection with D3LD2 lymph node dissection, leading to a pathological diagnosis of ypT3N1aM0, ypStage Ⅲb. The patient then underwent adjuvant chemotherapy with capecitabine and oxaliplatin(CAPOX). No recurrence was observed after 9 months of follow-up.

A case of infectious heterotopic ossification in the appendectomy scar, which formed an inflammatory granuloma.

Inflammatory granulomas often develop in surgical scars due to the presence of foreign bodies, such as sutures. These granulomas are called Schloffer's tumors. Here, we report a case of heterotopic ossification(HO) in an appendectomy scar that formed an inflammatory granuloma following HO infection. A 90-year-old woman was referred to our hospital with a chief complaint of a painful mass in the right lower quadrant of her abdomen. She had a history of acute appendicitis, for which she underwent an appendectomy approximately 70 years previously. Imaging studies demonstrated a tumor containing a linear-shaped agent located in the abdominal wall under the surgical scar where the appendectomy was performed. She was then diagnosed with Schloffer's tumor, for which she underwent surgical resection. However, histopathological examination revealed that the tumor was a fibrous connective tissue mass with a lamellar bone inside.

Coexistence of multiple liver metastases from sigmoid colon cancer and a gastrointestinal stromal tumor in the small intestine.

A 60-year-old man was referred to our hospital for the evaluation and treatment of general malaise. Contrast-enhanced computed tomography detected sigmoid colon cancer that had invaded the bladder, multiple liver metastases, and a small intestinal tumor. Hartmann's procedure was performed, with partial bladder and small bowel resection. A pathological examination revealed that the patient had sigmoid colon cancer and a gastrointestinal stromal tumor. The biopsy findings of a tumor in segment 8 of the liver indicated the presence of adenocarcinoma, thereby indicating the origin of multiple liver metastases from sigmoid colon cancer. On chemotherapy, the tumors in liver segments 2/3 and 8 shrank. However, the tumor in segment 6 enlarged. Since radical resection of all metastatic liver tumors was possible, hepatectomy was performed 10 months after the initial surgery. A pathological examination revealed that the tumors in segments 2/3, 4, and 8 were adenocarcinomas and the tumors in segments 4, 6, and 7 had originated from the gastrointestinal stromal tumor. This suggested the coexistence of liver metastases from sigmoid colon cancer and the gastrointestinal stromal tumor. In cases involving multiple primary tumors, it is necessary to consider the possible coexistence of multiple metastases from different primary tumors.

Retrograde endoscopic submucosal dissection for early thoracic esophageal carcinoma.

Although the standard treatment for intramucosal esophageal cancer without lymph node metastasis is endoscopic submucosal dissection (ESD), we sometimes encounter patients who are not able to undergo a transoral endoscopic examination. Here, we report a surgical procedure consisting of transgastric retrograde ESD to treat early esophageal cancer (T1a-EP, N0, M0) because of a stricture after hypopharyngeal cancer surgery. This retrograde ESD procedure can be a safe and effective treatment option for early esophageal cancer. This is the first report of a surgical retrograde ESD method for esophageal cancer.

Feasibility and safety of laparoscopic lateral pelvic lymph node dissection for locally recurrent rectal cancer and risk factors for re-recurrence.

INTRODUCTION: Lateral pelvic lymph node (LPLN) metastasis is considered a distant metastasis. It is often treated by systemic chemotherapy and/or radiation therapy, but complete radical resection of LPLN metastasis can sometimes achieve cure. However, the safety and efficacy of radical resection for recurrent LPLN after curative rectal surgery have not been well elucidated. Therefore, we evaluated the feasibility of laparoscopic radical surgery for recurrent LPLN compared with the conventional open approach and assessed oncological outcomes between patients with and without re-recurrence. METHODS: We retrospectively reviewed 17 cases (4 open, 13 laparoscopic) who underwent radical resection for LPLN metastasis after curative rectal surgery between July 2012 and August 2016 at the National Hospital Organization Osaka National Hospital. Operative factors and short-term outcomes were compared. Oncological outcome was evaluated based on the pathologic response to preoperative adjuvant therapy. RESULTS: The laparoscopic group's median blood loss and C-reactive protein elevation were lower than that of the open group on postoperative day 3. The laparoscopic group also had a shorter postoperative hospital stay. The median operative time, R0 resection rate, and morbidity rate were similar between the two groups. Local re-recurrence after LPLN resection occurred more frequently in pathologic non-responders than responders. CONCLUSION: Laparoscopic surgery for LPLN metastasis is feasible and less invasive than open surgery. Laparoscopic radical resection of LPLN may be justified for curative intent. Patients with incomplete pathologic response to neoadjuvant therapy have a greater risk of re-recurrence.

Safety and Feasibility of Laparoscopic Pelvic Exenteration for Locally Advanced or Recurrent Colorectal Cancer.

PURPOSE: Pelvic exenteration (PE) for locally advanced or recurrent colorectal cancer is often used to secure negative resection margins. The aim of this study was to evaluate the feasibility of laparoscopic PE. MATERIALS AND METHODS: The clinical records of 24 patients (9, open; 15, laparoscopic) who underwent total or posterior PE for locally advanced or recurrent colorectal cancer between July 2012 and April 2016 at Osaka National Hospital were retrospectively reviewed. Operative factors were compared between the 2 groups. RESULTS: The R0 resection rate was 100% in the laparoscopic group and 89% in the open group. The operative time and the incidence of postoperative complications were not significantly different between the 2 groups. The laparoscopic group showed less intraoperative blood loss (P=0.019), a lower C-reactive protein elevation on postoperative day 7 (P=0.025), and a shorter postoperative hospital stay (P=0.0009). CONCLUSIONS: Laparoscopic PE is a safe and feasible procedure to reduce postoperative stress.

[A Case of Long-Term Survival after Total Pancreatectomy for Recurrent Pancreatic Cancer in the Remnant Pancreas after Pancreatoduodenectomy].

We report a case of recurrent pancreatic cancer in the remnant pancreas after pancreatoduodenectomy(PD)that was successfully treated by surgical resection. A woman in her 70s who was treated for multiple lung metastases of breast cancer was referred to our hospital because of obstructive jaundice. A low-density area in the pancreas head(19mm in diameter) and dilatation of the main pancreatic duct were observed on abdominal CT. She was diagnosed with pancreatic head cancer and underwent PD. Twenty months after PD, abdominal CT revealed a tumor in the pancreas tail, and she started receiving chemotherapy containing gemcitabine(GEM)for the diagnosis of recurrent pancreatic cancer in the remnant pancreas. Twelve months after the induction of chemotherapy, we performed surgical resection of the tumor(total pancreatectomy). The pathological diagnosis was moderately differentiated adenocarcinoma, which was similar to the primary lesion, and the tumor was confirmed as recurrence of pancreatic cancer. Although she died of multiple lung metastases of breast cancer 62 months after the total pancreatectomy, the recurrence of pancreatic cancer was not observed without adjuvant therapy during that time.

Laparoscopic sigmoidectomy in a case of sigmoid colon cancer with situs inversus totalis.

Situs inversus totalis (SIT) is a rare anatomic anomaly in which organs in the chest and abdomen exist in a mirror image reversal of their normal positions. SIT can complicate surgical procedures, and few reports have described laparoscopic surgery for colorectal cancer in patients with SIT. Here, we report a case of successful laparoscopic surgery in a patient with SIT and sigmoid colon cancer. Laparoscopic sigmoidectomy involved colonic mobilization with high ligation of the inferior mesenteric vessels and complete mesocolic excision. The operating surgeon stood on the patient's left side, opposite the normal location for sigmoidectomy. By placing a 12-mm trocar in the left iliac fossa and using an automatic endoscopic linear stapler, the operating surgeon was able to perform left-handed colon resection without having to change position or move the laparoscopic monitor mid-procedure. An automatic endoscopic linear stapler is useful for laparoscopic left-side colon surgery in a patient with SIT.

[A Case of Two Curative Resections for the Peritoneal Dissemination of Transverse Colon Cancer].

No large clinical trials have been conducted to prove the efficacy of peritoneal dissemination resection for colorectal cancer, and no evidence has shown the usefulness of resection for metachronous peritoneal dissemination. An elderly woman in her 70s underwent a laparoscopic transverse colectomy for transverse colon cancer in 2014, which was performed by another physician. The pathological diagnosis was tub2-por>muc, pT3, ly2, v0, pN2, and pStage Ⅲb. The patient was followed up with capecitabine plus oxaliplatin(CapeOX)therapy as an adjuvant chemotherapy for 6 months. Three years postoperatively, the CEA level increased to 10 ng/mL, and CT showed a nodular shadow in front of the left prerenal fascia. After the diagnosis of peritoneal dissemination recurrence and 8 courses of capecitabine plus bevacizumab therapy, other metastases were not observed. She was referred to our hospital for surgery and underwent laparoscopic peritoneal dissection at 3 years and 6 months after the first operation. Only one apparent disseminated recurrent lesion, which was resectable, was observed. However, at 4 years and 9 months after the initial operation, CT showed a recurrence of Douglas pouch peritoneal dissemination without any other obvious metastasis. Laparoscopic low anterior resection of the rectum and hysterectomy were performed. Here, we encountered a case that could be radically resected for peritoneal dissemination twice after the colon cancer surgery.

[A Case of Multimodality Treatment Including Carbon Ion Radiotherapy to Multiple Distant Lymph Node Metastasis after a Surgery for Sigmoid Cancer].

We reported a case of a 30s woman who underwent Hartmann's surgery for sigmoid cancer. Her pathological stage was Stage Ⅳ(pT4b, N1b, M1b[liver and lung]). Postoperatively, 10 courses of systemic chemotherapy with FOLFOX plus cetuximab( Cmab)or bevacizumab(Bmab)were administered. After the chemotherapy, partial liver dissection and radiofrequency ablation(RFA)for multiple liver metastasis were performed. After 2 years of systemic chemotherapy with FOLFIRI plus ramucirumab(RAM), no liver or lung metastasis was observed; however, left supraclavicular lymph node and para-aortic lymph node metastases existed and gradually increased. For the purpose of local control, the para-aortic lymph node metastasis was treated with cervical dissection and carbon ion radiotherapy. Therefore, carbon ion radiotherapy was a useful treatment for local control.

[A Case of Peritoneal Dissemination of Metastatic Gastric Cancer with Successful Docetaxel and S-1 Combination Therapy].

Here, we report a long-term survival case treated with docetaxel and S-1 combination therapy(DS therapy)for peritoneal dissemination of gastric cancer. A 58-year-old man was diagnosed with gastric cancer in 2006. Distal gastrectomy, D2 dissec- tion, and RY reconstruction were performed. The pathological diagnosis was gastric cancer, por2, pT3(SS), pN3a(8/27), pStage ⅢB. S -1 monotherapy was administered as an adjuvant chemotherapy for 1 year from 3 months after surgery. Five years after surgery, peritoneal dissemination and bladder recurrence caused rectal stenosis and hydronephrosis. We performed ileostomy and left nephrostomy. DS therapy was started 5 years and 2 months after the initial surgery. A complete clinical remission was observed 2 years and 10 months after starting DS therapy(23 courses). Multiple lymph node metastasis and bone metastasis were confirmed at 5 years and 5 months(57 courses). Even though irinotecan monotherapy was performed for five courses, the bone and lymph node metastasis increased at 5 years and 9 months after starting DS therapy, and the patient died at 69 years of age. DS therapy may be a useful option for peritoneal metastasis of gastric cancer.

[A Case of Hepatic Resection after Neoadjuvant Chemotherapy for Single Liver Metastasis from Gastric Cancer with Positive Human Epidermal Growth Factor Receptor 2].

A man in his 70s was diagnosed with gastric cancer and underwent total gastrectomy with D2 lymphadenectomy. The final diagnosis was T3(SS)N2M0, Stage ⅢA. After surgery, S-1 was administered for 1 year. One year and 6 months after surgery, abdominal computed tomography showed a single liver tumor(S4: 30mm). Based on overexpression of the human epidermal growth factor receptor 2(HER2)protein in the primary tumor, we selected capecitabine plus cisplatin plus trastuzumab as the combination chemotherapy. After the second course, the therapeutic response was stable. S4 partial liver resection was performed. The liver tumor was histologically evaluated as Grade Ⅰb metastatic gastric adenocarcinoma. After surgery, capecitabine plus trastuzumab was administered for 1 year. One year after resection of liver metastasis, the patient is alive without any relapse.

Risk factors for bleeding in patients receiving fondaparinux after colorectal cancer surgery.

OBJECTIVE: The aim of this study was to identify risk factors for bleeding complications in patients who receive Venous thromboembolism (VTE) prophylaxis with fondaparinux (FPX) after colorectal cancer surgery. METHODS: Records of 546 patients who underwent VTE prophylaxis with intermittent pneumatic compression and FPX after colorectal cancer surgery between January 2009 and May 2014 were reviewed. Patient characteristics, surgical procedures, and patient laboratory data were examined to identify risk factors for bleeding complications using univariate and multivariate logistic regression. RESULTS: We reviewed the records of 324 males and 222 females. Median age and BMI were 68.5 years and 22.7 kg/m2, respectively. The number of laparoscopic surgeries was 366. Median operative time and blood loss were 188.5 min and 20 ml, respectively. The incidence (%) of bleeding events was 5.3%. In univariate analysis, age ≥80 years, BMI ≥25.0 kg/m2, hypertension, and antithrombotic therapy were associated with a significantly higher incidence of bleeding events. Multivariate analysis identified age ≥80 years (odds ratio 5.814; 95% confidence interval 2.502-13.278) as an independent risk factor. CONCLUSION: Age ≥80 is a risk factor for bleeding in patients who receive FPX for VTE prophylaxis after colorectal cancer surgery.

[A Case of Long-Term Survival of Recurrent Bile Duct Cancer with Peritoneal Metastasis Successfully Treated with Surgical Resection].

We report a case of peritoneal metastasis of bile duct cancer that was successfully treated by surgical resection. A 70s man underwent pancreatoduodenectomy(PD)for bile duct cancer, and abdominal CT revealed a tumor in the peritoneum along the right kidney at 55 months after PD. As FDG uptake was seen at the lesion on PET-CT, he was diagnosed as recurrence of bile duct cancer or primary malignant tumor in the retroperitoneum. Because the tumor was solitary on CT and PET-CT, we conducted surgical resection of the tumor. Pathological diagnosis was well differentiated adenocarcinoma that was similar to the primary lesion, and the tumor was confirmed as recurrence of bile duct cancer. He remains alive without 2nd recurrence for 60 months since tumor resection(117 months since PD).

[A Case of Duodenum Neuroendocrine Tumor with Multiple Liver Metastasis Treated with Multimodal Therapy].

The patient is a 65-year-old woman with anemia. The multiple liver tumors detected by ultrasonography, it was diagnosed as neuroendocrine tumor(NET), G2 by biopsy. There was an ulcer at the bulb of the duodenum, so we diagnosed liver metastasis of duodenum NET. Because the liver tumors spreaded to both right and left lobes, we carrying out a transcatheter arterial embolization(TAE)twice to liver metastasis, and chemotherapy by octreotide was performed. 20 months after the beginning of treatment, a 4 cm tumor was remained in the left lobe but others were not detected by computed tomography, so we performed cytoreductive surgery. Duodenum bulb resection and left hepatectomy was performed and the specimens were NET, G2 in the pathological findings. We detected a lot of tumors less than 1 cm in the right lobe during the operation, so TAE was carried out for the right lobe after surgery. The disease showed no progression for 28 months after the first admission(post operation5 months).

[A Case of Anal Canal Cancer with Skin Invasion to Which Abdominoperineal Resection and Perineum Reconstruction Were Performed after Neoadjuvant Chemoradiotherapy].

A 74-year-old man visited our hospital with an awareness of anal mass and bleeding. He was diagnosed as adenocarcino- ma of anal canal with wide spreading skin invasion. After neoadjuvant chemoradiotherapy(radiationtotal 45 Gy/25 Fr; cape- citabine 825mg/m2)was performed to reduce the mass volume, laparoscopic abdominoperineal resection with large perineum skin resection and lateral lymph node dissection was carried out. The perineal defect was repaired with a rectus abdominis musculocutaneous flap. Six days after surgery, the rectus abdominis musculocutaneous flap necrotized, and second perineum reconstruction by the bilateral gracilis musculocutaneous flaps was performed after debridement of necrotic tissue. We reported a case of radical resection of local advanced anal canal cancer with skin invasion by performing combined modality therapy and perineum reconstruction.

[Gastrectomy with Intra-Aortic Balloon Pumping Support for a Hemorrhagic Advanced Gastric Cancer Patient with Severe Coronary Stenosis].

Here we report a case of a hemorrhagic gastric cancer patient with severe coronary artery disease, in whom the cancer was successfully resected with the support of intra-aortic balloon pumping(IABP). An 80-year-old man was referred to our hospital for further examination of his anemia and tumor around the pancreatic head. He was diagnosed with type 3 gastric cancer with multiple bulky lymph node metastases invadingto the pancreas(cT4b[LN-Panc], N3a, M1[LYM No.16a2int], cStage IV ). Tarry stools continued and blood transfusion was repeatedly required. To control tumor bleeding, we considered that gastrectomy should be performed prior to chemotherapy. Since he had a history of acute myocardial infarction, coronary angiography was performed, which showed severe coronary stenosis in 3 vessels. Preoperative percutaneous coronary intervention or coronary artery bypass grafting were inappropriate because of tumor bleeding. We performed palliative distal gastrectomy under the support of IABP. The postoperative course was uneventful and he could initiate subsequent chemotherapy smoothly. IABP may be a useful option for hemorrhagic gastric cancer patients with severe coronary stenosis.

Anti-metastatic Effect of Short-term Postoperative Anticoagulation for Patients Undergoing Curative Resection of Colorectal Cancer.

BACKGROUND: The purpose of this study was to examine the efficacy of anticoagulant fondaparinux postoperatively for preventing recurrence after curative resection of colorectal cancer with lymphnode metastasis. PATIENTS AND METHODS: The records of 279 patients who underwent curative resection of colorectal cancer with lymph-node metastasis between 2006 and 2013 were reviewed. Patients were divided into two groups based on the type of prophylaxis for postoperative venous thromboembolism: the FPX group, treated with subcutaneous fondaparinux plus intermittent pneumatic compression; and the IPC group, treated with intermittent pneumatic compression alone. Recurrence-free survival was compared using propensity score matching. RESULTS: In the propensity score-matched cohort, the 3-year recurrence-free survival rate was 74.9% and 74.4% in the FPX (n=61) and IPC groups (n=61), respectively (p=0.830). CONCLUSION: Our results do not suggest that short-term postoperative anticoagulation as prophylaxis for venous thromboembolism prevents colorectal cancer recurrence after curative resection.

[A Case of Subacute Thyroiditis during Chemotherapy after Distal Pancreatectomy].

A 68-year-old woman who underwent distal pancreatectomy combined with resection of the celiac axis had an abdominal wall recurrence and resection 2 years after the first surgery. She was treated with S-1 at an outpatient clinic following the surgery. She returned to the clinic with a high fever after the S-1 administration and was diagnosed with febrile neutropenia. However, treatment for febrile neutropenia including antibiotics and G-CSF did not improve her symptoms. Her history of chronic severe neck pain and painful enlargement of her thyroid gland suggested thyroiditis. After blood tests and thyroid scintigraphy, she was diagnosed with subacute thyroiditis and was treated with prednisolone. Her symptoms improved within a week. Although patients with neutropenia and a high fever during chemotherapy are likely to have febrile neutropenia, the possibility of another cause of neutropenia with fever should be considered if treatments for febrile neutropenia are not effective.

[A Case of Recurrent Esophagogastric Junction Cancer Responding to Trastuzumab].

We report a case of recurrent esophagogastric junction cancer successfully treated with chemotherapy including trastuzumab. A 66-year-old man reporting black stool was examined, and through upper gastrointestinal endoscopy was found to have a tumor at the esophagogastric junction. Video-assisted thoracoscopic surgery of the esophagus with 3-field lymph node dissection was performed. The final diagnosis was adenocarcinoma(tub1-pap-muc), pT3N3M0, pStage III C. The tumor was at the squamo-columnar junction and classified as Siewert type II . Following surgery, 6 months of adjuvant therapy with S-1 was administered. Computed tomography(CT)confirmed metastases in the lung, liver, and recurrence in the reconstructed stomach. In spite of chemoradiotherapy(FP plus RT)and weekly PTX, these metastases had grown. Pathological examinationshowed overexpressionof humanepidermal growth factor receptor 2(HER2), and treatment with CPT- 11 plus trastuzumab was initiated at postoperative 15 months. A partial response was achieved 3 months later. The lesions in the lung, liver, and reconstructed stomach were controlled with this therapy, but he died from meningeal seeding at postoperative 20 months. These findings suggest that inclusion of trastuzumab in chemotherapy regimens is effective for recurrent HER2-positive esophagogastric junction cancers.