[A Case of Neuroendocrine Carcinoma of the Stomach Treated with TAS-102].

A 77-year-old-woman underwent distal gastrectomy D2 lymph node dissection and cholecystectomy followed by Roux- en-Y reconstruction for Stage ⅢC gastric neuroendocrine cell carcinoma in January 2017. In July of the same year, an abdominal computed tomography scan revealed liver metastasis in segment 4. For treatment of recurrence, SP therapy(S-1 and cisplatin), ramucirumab plus weekly paclitaxel therapy, and nivolumab were administered in that order. TAS-102 was started as the fourth-line agent for multiple liver metastases, para-aortic lymph node metastases, and cancerous peritonitis. Although Grade 2 anemia, Grade 1 oral mucositis and general fatigue were observed during the treatment, both liver metastases and para-aortic lymph node metastases showed improvement after three courses, and the patient was able to continue 11 courses in 1 year. She died 1 year and 5 months after the first administration of TAS-102. TAS-102 can be effective after immune checkpoint inhibitor as a late treatment for gastric cancer and NEC. The appropriate timing for switching drug therapy may be important in the future. We report a favorable therapeutic effect of TAS-102 after immune checkpoint inhibitor treatment along with a review of the literature.

Laparoscopic surgery for appendiceal cancer with intestinal malrotation in an adult: A case report.

INTRODUCTION: Intestinal malrotation is a congenital anatomical anomaly resulting from abnormal midgut rotation. Many cases occur during childhood and present with intestinal obstruction and midgut volvulus. Intestinal malrotation rarely occurs in adults and is found incidentally because it is asymptomatic. We herein report a case of intestinal malrotation, and colorectal cancer operated laparoscopically. PRESENTATION OF CASE: A 78-year-old man presented to our Department of Surgical Gastroenterology with fecal occult blood. There were no abnormal findings in the physical examination. Colonoscopy revealed a type 3 tumor in the cecum. Contrast-enhanced computed tomography revealed that the tumor was located in the appendix along the midline of the abdomen. The small intestine and colon occupied the right and left sides of the abdominal cavity, respectively. The diagnosis was appendiceal cancer with nonrotation-type intestinal malrotation. A laparoscopy-assisted ileocecal resection was performed. During surgery, the right-side colon was not fixed to the retroperitoneum, and the right-side colon could be extracted out of the abdominal cavity through the umbilical wound with only adhesive dissection, and mesenteric and lymph node dissection can be performed outside the body. The postoperative course was uneventful. DISCUSSION: Appendiceal cancer with intestinal malrotation is managed with laparoscopic surgery because this method is safe and minimally invasive. CONCLUSION: The laparoscopic approach may be safer and less invasive than laparotomy, and extracorporeal lymph node dissection is safe and reliable for patients with intestinal malrotation.

Spontaneous bacterial peritonitis caused by Edwardsiella tarda: A case report.

INTRODUCTION: Edwardsiella tarda is a member of the Enterobacteriaceae family of gram-negative bacilli isolated from animals. Gastroenteritis is the most common manifestation of E. tarda infection. However, extraintestinal infections can occur in immunocompromised hosts as well as patients with hepatobiliary disease, malignancy, and/or diabetes mellites. The prognosis of sepsis caused by E. tarda is extremely poor, with a mortality rate of 38%. Here we report the occurrence of spontaneous bacterial peritonitis associated with E. tarda infection. PRESENTATION OF CASE: An 87-year-old man with Child-Pugh A cirrhosis secondary to hepatitis C virus infection presented with diarrhea and sudden-onset pain in the abdomen. On arrival, guarding and rebound tenderness were observed over the entire abdomen. Computed tomography revealed circumferential thickening of the cecum and a small volume of ascites in the pelvic cavity. A diagnosis of peritonitis was made, and surgery was performed. Surgical findings included redness and thickening of the cecal wall and purulent ascites without intestinal contents. Peritoneal fluid culture revealed E. tarda as the sole pathogen. The abdominal cavity was washed, a drain was placed in the pelvic cavity, and postoperative intravenous antibiotic therapy was initiated. The postoperative course was uneventful. DISCUSSION: E. tarda infection in the presence of an underlying disease such as hepatobiliary disease, malignancy, and/or diabetes mellitus has a poor prognosis. CONCLUSION: Although E. tarda infection is extremely rare, it is a life-threatening illness that can cause intestinal and extraintestinal infections. If necessary, early surgical intervention should be considered for cases of extraintestinal infection.

Complete resection of rectal cancer with a synchronous solitary adrenal metastasis: A case report.

INTRODUCTION: Solitary adrenal metastasis derived from colorectal cancer is rare. Adrenal metastasis is usually associated with systemic spread of the disease and is considered to be unsuitable for surgical resection. However, it has been reported that an aggressive surgical resection of adrenal metastasis results in improved overall survival in selected patients. We herein report an extremely rare case of complete resection of rectal cancer with a synchronous solitary adrenal metastasis. PRESENTATION OF CASE: A 70-year-old woman who presented with bloody stool was diagnosed with rectal cancer with a synchronous solitary adrenal metastasis and was suspected of having liver invasion. After a total of 2 cycles of chemotherapy with capecitabine and oxaliplatin, an abdominoperineal resection with D2 (proxD3) lymph node dissection and right adrenalectomy was performed and complete resection was possible. According to the TNM classification, the diagnosis was stage IVA (fT3N1bM1a[ADR]). At 18 months after surgery, the patient is alive with no evidence of recurrence and distant metastasis. DISCUSSION: Complete resection of adrenal metastasis may have a possibility of leading to a good prognosis in patients with a synchronous solitary adrenal metastasis. CONCLUSION: Adrenalectomy should be considered in patients who can undergo complete resection, as it may offer a good long-term prognosis.

p53/Mieap-regulated mitochondrial quality control plays an important role as a tumor suppressor in gastric and esophageal cancers.

Mitochondria-eating protein (Mieap) plays a critical role in mitochondrial quality control (MQC) and functions as a p53-inducible tumor suppressor. This study aimed to examine its role in gastric cancer (GC) and esophageal cancer (EC). GC cells were infected with Mieap-overexpressing adenovirus (Ad-Mieap) and subjected to fluorescence-activated cell sorting (FACS), western blotting, and caspase assays. Thereafter, we evaluated the potential disruption of the p53/Mieap-regulated MQC pathway in vivo. Methylation-specific PCR (MSP) for Mieap, NIX, and BNIP3 promoters was performed and p53 mutations were detected using cryopreserved surgical specimens. Exogenous Mieap in GC cells induced the formation of vacuole-like structures (called MIVs, Mieap-induced vacuoles) and caspase-dependent cell death, with the activation of both caspase-3 and caspase-9. Of the 47 GC patients, promoter methylation in Mieap, BNIP3, and NIX was identified in two (4.3%), 29 (61.7%), and zero (0%) specimens, respectively. In total, 33 GC patients (70.2%) inactivated this MQC pathway. Amazingly, BNIP3 promoter in the normal epithelium was highly methylated in 18 of the 47 GC patients (38.3%). In EC patients, this MQC pathway was also inactivated in ten of 12 patients (83.3%). These results indicate that p53/Mieap-regulated MQC plays an important role in upper gastrointestinal (GI) tumor suppression, possibly, in part, through the mitochondrial apoptotic pathway.

[A Case of Stage IV Gastric Cancer Curative Resection by Conversion Therapy].

We experienced a case of curative resection as a multidisciplinary treatment for unresectable gastric cancer that attributed to peritoneal disseminations and direct invasion to other organs.Two courses of triplet chemotherapy(DCS therapy)were performed under enteral stent placement and nasoenteral nutrition for direct infiltration into the transverse colon with entire circumference stenosis.Distal gastrectomy and right hemicolectomy were performed as conversion therapy, and R0 resection was achieved.After the operation, S-1 as adjuvant chemotherapy was performed and there has been no relapse survival for 13 months since the operation.From this case, it seems that conversion therapy plays an important role in prognosis extension as a treatment strategy for Stage IV gastric cancer.