[A Case of Advanced Cardia Gastric Cancer with Pernicious Anemia].

A 70s male was referred to our hospital with anemia that was detected during a medical checkup. Upper gastrointestinal endoscopy showed advanced cardia gastric cancer. A diagnosis of pernicious anemia was made due to the macrocytic hyperchromic anemia and detection of intrinsic factor antibody. A CT scan showed fundic wall thickening and regional lymph node metastasis. After anemia improved following vitamin B12 injection, total gastrectomy with lymphadenectomy was performed. The histopathological findings showed adenocarcinoma(tub1>tub2), Type2 , pT3(SS), pN1(2/24), Stage ⅡB, INF b, ly1, v2, PM0, DM0, EW(+), pR1. He was administered systematic chemotherapy using S-1 for one year after surgery and has been followed up without recurrence for 5 years.

[Consideration of Surgical Treatment for Ileus Symptoms Associated with Progressing Cancer in Our Hospital].

INTRODUCTION: Many cases of terminal cancer develop ileus symptoms such as vomiting and abdominal distension. The causes of ileus symptoms include peritoneal dissemination, localized recurrence, etc. The treatments include octreotide acetate, decompression measures such as ileus tube, and surgical treatment. We evaluated the results of cases that underwent surgical methods to reduce ileus symptoms. METHODS: The subjects were 31 patients comprising 38 cases with ileus symptoms between January 2013 and January 2018. The surgical procedures included bypass(17 cases), tumor extirpation(7 cases), stoma(11 cases), and other(3 cases). RESULTS: Dietary intake information was available for 27 of the 38 cases; in cases that underwent tumor excision, all meals were able to be ingested and there were many cases of long-term survival. DISCUSSION: Surgical procedures can allow patients to eat food and should be considered as dietary intake after treatment is associated with survival duration.

[A Case of Hepatocellular Carcinoma with Portal Vein Tumor Thrombus Successfully Treated by Three-Dimensional Conformal Radiotherapy].

A man in his 50s was referred to our hospital with a liver tumor detected by ultrasonography during a medical checkup. Enhanced CT scan and MRI showed hepatocellular carcinoma(HCC)in S8 of the liver. Laparoscopic partial hepatectomy was performed. The histopathological findings showed well differentiated HCC. Two years later, his serum PIVKA-Ⅱ levels were slightly elevated. A new lesion was detected by US, CT, and MRI at S5 of the liver. A second laparoscopic partial hepatectomy was performed. The histopathological findings showed moderately differentiated HCC. After 1 year, MRI detected 2 new HCCs(S4, S8). The tumor at S8 had invaded the right branch of the portal vein. There was no indication for right hepatectomy because of liver dysfunction. Lipiodol-TACE followed by DEB-TACE was not effective on the tumor. The HCC at S8 had enlarged and formed a portal vein tumor thrombus. PIVKA- / Ⅱ levels increased to 3,596 mAU/mL. The patient was adminis- tered Three-dimensional conformal radiotherapy(45 Gy/15 Fr)and his PIVKA-Ⅱ levels decreased to the normal range. He has been followed-up without recurrences for 2 years and 9 months.

[Endoscopic Topical Therapy Using Mesh for Refractory Suture Failure after Rectal Cancer Surgery].

We reported a case that could be cured with endoscopic topical therapyusing mesh for refractorysuture failure after rectal cancer surgery. The patient was a 73-year-old man. He was diagnosed as lower rectal cancer, and underwent laparoscopic super law anterior rectum resection. On the 13th postoperative day, abdominal pain appeared, suspected ileal necrosis, emergencylaparoscopic examination laparotomywas performed. Upper gastrointestinal perforation was suspected from pus and food on the whole intraperitoneal cavity, and we moved laparotomy. But any perforations were not found, we resected ileum and inserted a drain tube to Douglas fossa. After second surgerydischarge of the juice from the drain was confirmed, diagnosis was made of suture failure of the anastomosis of the rectal cancer. He rejected artificial stomy, we chose conservative therapy. On 114th day after second surgerywe put a mesh for inguinal hernia in the puncture under the endoscope. On the next dayafter the treatment discharge of the juice from the drain was stopped. And finallyhe was discharged. This endoscopic treatment is considered to be useful for refractorysuture failure.

[Jejunal Interposition after Totally Laparoscopic Proximal Gastrectomy Using Overlap Method].

There are several reconstruction methods in laparoscopic proximal gastrectomy(LPG)for earlygastric cancer at the upper part of the stomach. To prevent the esophageal reflux after gastrectomy, we chose jejunal interposition(JI)via the retrocolic route for LPG. We performed totallyLPG with JI using overlap method. METHODS: Five ports were placed. After the lymph nodes dissection bythe standard procedure, the esophagus and the proximal side of the stomach were transected byliner staplers. The jejunum was moved to the upper abdomen through the small hole of the mesocolon. The interposing jejunum was made, and the esophagojejunostomyand jejunogastrostomywere done byusing overlap method. At the end, the jujunum was pulled under the mosocolon escluding the interposing jejunum. The JI reconstruction via a retrocolic route after LPG was completed. DISCUSSION: Following LPG, the JI reconstruction is not so popular because the surgical procedure is complicated. In our technique, the JI reconstruction accomplished easier byoverlap method. CONCLUSION: Our procedure is a considerable operation of reconstruction following LPG.

[Two Cases of Stage IV Pancreatic Cancer Has Gained Relatively Long Free Survival in Multimodality Therapy].

We experienced 2 cases in which Stage IV pancreatic cancer(General rules for the study of pancreatic cancer, The 6th edition, Japanese Pancreas Society)underwent chemotherapy and radiotherapy after surgical operation and had relatively long term relapse-free survival. Local control by adding radiation therapy to surgical resection and suppressing the distant metastases in adjuvant chemotherapy may improve the prognosis.

[A Case of Long-Term Survival of Breast Cancer with Lymph Node and Liver Metastases Treated with Sequential Anti-HER2 Drugs, Chemotherapy, and Endocrine Therapy].

A 50s-year-old woman underwent left partial mastectomy with axillary lymphadenectomy for breast cancer. Histological examination indicated invasive ductal carcinoma, pT1c, pN0, Stage I , ly(+), ER(+), PgR(+). She received adjuvant therapy with tamoxifen and 50 Gy of irradiation to the residual breast. Four years after mastectomy, she was found to have left Rotter lymph node metastasis; then, anastrozole was administered instead of tamoxifen. Nine months later, she was found to have liver metastasis. Immunohistostaining revealed that the breast cancer was HER2-positive; she received AC followed by paclitaxel(PTX)with trastuzumab(T), and achieved complete response(CR). Subsequently, abdominal, cervical lymph node, and liver metastases appeared. Letrozole followed by lapatinib with capecitabine, FEC100, PTX with T, eribulin, S-1, docetaxel with pertuzumab and T, everolimus with exemestane, bevacizumab, and PTX were then administered, resulting in long-term disease control. Sixteen years after mastectomy, she receives outpatient chemotherapy in performance status 1 state.

[A Case of Small Intestinal Gastrointestinal Stromal Tumor(GIST)with Synchronous Colonic Cancer and Gastric Cancer at a Different Time].

The patient was a 70-year-old woman with a gastrointestinalstromaltumor (GIST)of the small intestine and synchronous colonic cancer, who underwent laparoscopic right colectomy and resection of the small intestine. We started imatinib therapy because GIST belongs to a high-risk group, according to the modified Fletcher classification. Gastric cancer was diagnosed 2 years after the start of imatinib therapy. Only 4 of the 12 GIST cases seen at our institution over the last 5 years were complicated by another cancer. This is the first case of GIST in which 2 other cancers occurred at both the same and different times. We suggest that imatinib might be a factor in the development of gastric cancer.

[A Case of Laparoscopic Gastrectomy for Gastric GIST after Neoadjuvant Chemotherapy with Imatinib Mesylate].

We report the case of a 68-year-old woman who underwent laparoscopic gastrectomy for a gastric gastrointestinal stromal tumor (GIST) after neoadjuvant chemotherapy with imatinib mesylate. After conducting gastroscopy because of weight loss and anemia, we identified a submucosal tumor in the cardia. A GIST of 8 cm in diameter invaded the pancreatic tail and excluded the splenic vein. We administered imatinib 400 mg/day as neoadjuvant chemotherapy. We performed laparoscopic partial gastrectomy 5 months after the initiation of chemotherapy. According to the histopathological diagnosis, the surgical margin was positive. As an additional excision, we performed laparoscopic proximal gastrectomy. Without postoperative complications, it passes smoothly as of 5 months after surgery.

[A case of early gastric cancer with multiple synchronous bone metastases treated complete response with S-1+CDDP].

We report a case of complete response (CR) following induction chemotherapy using S-1 for a patient with early gastric cancer accompanied by multiple synchronous bone metastases. An asymptomatic 70-year-old woman was diagnosed with early gastric cancer by upper gastrointestinal endoscopy during a periodic medical examination. An abdomino-pelvic computed tomography (CT) scan revealed no primary tumor in the stomach and the absence of lymph node or liver metastases. However, osteoplastic changes were detected in the lumbar vertebrae and the ilium. Multiple synchronous bone metastases from early gastric cancer were detected on magnetic resonance imaging, bone scintigraphy, and positron emission tomography- CT. After a regimen consisting of 15 courses of S-1 plus cisplatin (CDDP), and an additional 5 courses of S-1 were administered, clinical CR was confirmed for the bone metastases. Laparoscopic distal gastrectomy with D1 lymphadenectomy was performed for treating the primary gastric cancer 33 months after the initiation of chemotherapy. Pathological CR was also achieved for the primary gastric cancer. Imaging analysis did not show disease progression 48 months after the initiation of chemotherapy. Synchronous bone metastases from early gastric cancer are extremely rare, and a good outcome was achieved in the present case through induction chemotherapy.

[Lymphadenectomy performed along the left recurrent laryngeal nerve after anterior detachment of the esophagus via thoracoscopic esophagectomy in the prone position under artificial pneumothorax].

Thoracoscopic esophagectomy was performed in the prone position under artificial pneumothorax and did not affect the surgical area during lung ventilation; tracheal mobility was also improved. Lymphadenectomy around the left recurrent laryngeal nerve was performed by separating the left main bronchus and trachea between the esophagus and pericardium before detaching the dorsal side of the esophagus.

[A case of rectal cancer treated with aggressive surgery for liver and anal metastases].

A 64-year-old man underwent laparoscopic surgery for rectal cancer and lateral lymph node dissection. The histopathological findings indicated adenocarcinoma (moderate>well), pA, pN3(4/25No 263 1/1), pM0, Stage IIIb. After the surgery, he received 12 courses of adjuvant chemotherapy with modified 5-fluorouracil Leucovorin oxaliplatin (mFOLFOX6). Liver metastasis( S8)was present, and open hepatectomy was performed 1 year after the first surgery. Three months after the second surgery, the carcinoembryonic antigen (CEA) level increased and chemotherapy TS-1 was started. However, the CEA level continued to increase, and positron emission tomography-computed tomography revealed peritoneal dissemination, and multiple lymph node, bone, and local metastases(in the liver and rectum). Accordingly, 11 courses of chemotherapy with 5- fluorouracil Leucovorin irinotecan (FOLFIRI) and bevacizumab was administered. The patient recently experienced anal bleeding during each bowel evacuation, which developed owing to the recurrence of the cancer in the anus. To improve his quality of life, the anal tumor was excised 2 years 6 months after the first surgery. Chemotherapy with FOLFIRI and bevacizumab was restarted. The CEA level stopped increasing. We think that the anal surgery did not affect our patient's prognosis but helped improve his quality of life.

[A case report of scirrhous gastric cancer with peritoneal dissemination treated effectively with various chemotherapy regimens after laparoscopic distal subtotal gastrectomy].

We report a 44-year-old male patient who was diagnosed with scirrhous gastric cancer with peritoneal dissemination using laparoscopy. The patient underwent a non-curative resection with laparoscopic distal subtotal gastrectomy. In addition, we placed a port into the patient's abdomen for intraperitoneal chemotherapy administration. Postoperatively, we administered capecitabine (per os)+ paclitaxel (intraperitoneally) and, after 2 cycles, the oral anticancer agent 5-FU was given. The patient died of peritonitis carcinomatosa 25 months after the operation. The combined therapies contributed to improve the quality of life, specifically oral ingestion, for 2 years.

[Multidisciplinary therapy for 3 patients with lymph node recurrence after curative gastrectomy].

We report multidisciplinary treatment of 3 patients with lymph node recurrence after curative gastrectomy. Case 1: A 71- year-old woman had a history of distal gastrectomy with D2 lymphadenectomy for the treatment of advanced gastric cancer. Para-aortic lymph node metastasis was observed 36 months after surgery. Complete response( CR) was achieved after concurrent chemoradiotherapy with S-1 plus radiation. Case 2: A 51-year-old man had a history of total gastrectomy with D2 lymphadenectomy for the treatment of advanced gastric cancer. Right cervical lymph node metastasis was observed 48 months after surgery. CR was achieved after concurrent chemoradiotherapy with S-1 plus radiation. Case 3: A 68-year-old man had a history of distal gastrectomy with D2 lymphadenectomy followed by neoadjuvant chemotherapy for the treatment of advanced gastric cancer. CR was achieved after sequential treatment with irinotecan( CPT-11) plus cisplatin( CDDP), radiation, and 5-fluorouraci(l 5-FU) plus Leucovorin therapy for lymph node recurrence near the head of the pancreas. These cases suggest that the combination of systemic chemotherapy and local radiation therapy might be effective for the treatment of lymph node recurrence in patients with gastric cancer.

[Clinical study to evaluate EPA-enriched immunonutrition with ProSureTM during chemotherapy in cancer patients].

We report a prospective, single-arm, pilot study conducted by the Tokyo Metropolitan Oncology Group in order to evaluate the effect of a fish-oil enriched nutritional supplement(ProSureTM) during cancer chemotherapy in patients with advanced cancer. ProSureTM was given for more than 1 month to patients with advanced cancer whose prognosis was more than 3 months before enrollment. Laboratory data including serum albumin level, body weight, body composition, and functional status data were collected at baseline, 14 days, and 28 days. Oral supplementation consisted of 2 packs of ProSureTM per day for more than 28 days during chemotherapy. The study population included 50 patients. This study is now ongoing.

[Inhibitory effect of CXCR4 blockers on a CXCR4-expressing gastric cancer cell line in nude mice].

BACKGROUND AND OBJECTIVE: CXCR4, one of the chemokine receptors, plays a major role in cell migration in metastasis and cancer dissemination. However, it is not known whether CXCR4 is associated with tumor growth in vivo. In the present study, we investigated the inhibitory effect of CXCR4 blockers on CXCR4-expressing gastric cancer in vivo. METHODS: Cells of a CXCR4-expressing gastric cancer cell line, K-MK-2, were transplanted into nude mice. A CXCR4 blocker, AMD3100 (2 mg/kg), was injected and another blocker, KRH3955 (1 mg/kg or 10 mg/kg), was administered orally. Both drugs were administered for 5 days followed by 2 days of rest. The mice were sacrificed on the 35th day following transplantation and the weights of the tumors were measured. RESULTS: The mean weights of the tumors were 7.092±1.221 g in the control mice, 5.137±1.001 g in the ADM3100-injected mice, 3.895±2.120 g in mice treated with 1 mg/kg of KRH3955, and 4.257±1.169 g in mice treated with 10 mg/kg of KRH3955. The 2 CXCR4 blockers significantly inhibited the growth of gastric cancer cells transplanted into the nude mice. CONCLUSION: The CXCR4 blockers AMD3100 and KRH3955 inhibit tumor growth in vivo. These drugs are possible candidates for personalized therapy of gastric cancer.

[Para-aortic lymph node dissection for far-advanced gastric cancer followed by chemotherapy].

We evaluated the safety of preoperative chemotherapy against advanced gastric cancer with para-aortic lymph node metastasis. In this study, we compared 11 patients who received preoperative chemotherapy(PC group) to 56 patients who did not receive preoperative chemotherapy (NPC group). We performed 47 total gastrectomies and 2 distal gastrectomies in the PC group and 9 total gastrectomies and 9 distal gastrectomies in the NPC group. In the PC group, the mean operation time was 275 min for distal gastrectomy and 297 min for total gastrectomy. In the NPC group, the mean operation time was 265 min for distal gastrectomy and 296 min for total gastrectomy. Regarding blood loss during operation, in the PC group, the mean blood loss was 650 mL for distal gastrectomy and 760 mL for total gastrectomy. In the NPC group, the mean blood loss was 530 mL for distal gastrectomy and 825 mL for total gastrectomy. No significant differences were seen between the 2 groups. In conclusion, preoperative chemotherapy against advanced gastric cancer with para-aortic lymph node metastasis appears to be a safe treatment, but we need to conduct clinical trials for confirmation.

[A clinical case of lymph node recurrence after the resection of esophagogastric junction cancer treated by chemoradiation therapy].

A 52-year-old man who was diagnosed with esophagogastric junction cancer underwent left thoracolaparotomy and total gastrectomy. At 3 years and 11 months after the surgery, his carcinoembryonic antigen value was elevated, and cervical and right paraesophageal lymph node enlargement was detected by chest computed tomography(CT). Although lymph node dissection was performed, the presence of microscopic cancer-positive surgical stumps was confirmed. Since then, combination chemoradiotherapy using S-1 and radiation(60 Gy) has been applied. Currently, the patient is alive with no signs of lesion recurrence according to CT findings 8 years and 11 months after the initial surgery.

[Therapeutic strategy for gastric cancer with positive peritoneal lavage cytology without peritoneal dissemination].

We analyzed the prognosis of patients with positive lavage cytology, excluding other unresectable factors.From 2002 to 2008, 76 advanced gastric cancer patients positive for malignant cells(CY1)were investigated for our study.There were 60 patients undergoing gastric cancer surgery.Sixteen patients were treated by chemotherapy only. The MST of the chemotherapy group was 427 days, and that of the gastrectomy group was 442 days, although this was not statistically significant.The multimodality therapy group undergoing gastrectomy and chemotherapy consisted of 42 patients.The MST of this group was 647 days.In the multimodality therapy group, there were 28 patients undergoing chemotherapy using S-1.The MST of this group was relatively better(1, 249 days).CY1 appeared to be a worse prognostic factor, but P0CY1 survival was better than in P1. As a therapeutic strategy for gastric cancer with positive peritoneal lavage cytology, multimodality therapy with gastrectomy and chemotherapy using S-1 may be effective.

A novel procedure for Roux-en-Y reconstruction following laparoscopy-assisted distal gastrectomy: transoral placement of anvil and intracorporeal gastrojejunostomy via umbilical mini-laparotomy.

We describe herein our procedures for Roux-en-Y reconstruction using a transoral anvil following laparoscopy-assisted distal gastrectomy (LADG). The procedure consists of three technical processes: transoral placement of the anvil with the head pre-tilted, extracorporeal preparation of the Roux-en-Y limb, and intracorporeal gastrojejunostomy with a circular stapler introduced via an umbilical mini-laparotomy. We applied the procedure to 33 patients with early gastric cancer between December 2008 and June 2010. None of the patients suffered from surgical complications related either to the transoral placement of the anvil or the anastomoses. The postoperative wound appearance was much less conspicuous than that of conventional laparoscopic distal gastrectomy, because our procedure needed only a 4-cm mini-laparotomy on the umbilicus, except for the trocar ports. This technique involving transoral anvil placement enables intracorporeal anastomosis for gastrojejunostomy via an umbilical mini-laparotomy, and may be one of the surgical choices for anastomosis and Roux-en-Y reconstruction following LADG.