[A Case of Liver Metastasis of Colorectal Cancer Successfully Treated with Hepatic Arterial Infusion Chemotherapy after Systemic Chemotherapy Was Difficult to Administer].

The patient underwent partial sigmoid colon resection for sigmoid colon cancer with hyper CEA blood(1,110.6 ng/mL) and concurrent liver metastases mostly in the right lobe of the liver, followed by systemic chemotherapy(SOX plus BEV). Seven courses of chemotherapy resulted in PR on imaging, and CEA was reduced to 5.0 ng/mL, which was within reference values. As he continued chemotherapy, frequent hematologic toxicities and adverse events forced frequent dose reductions and changes in the chemotherapy schedule. About 2 years after surgery(19 courses of SOX plus BEV), the liver metastases became slightly enlarged on imaging, and the CEA was also increasing. The patient did not wish to undergo systemic chemotherapy and requested hepatic arterial infusion chemotherapy(HAIC), which has relatively few side effects and adverse events. HAIC with pyrimidine fluoride alone is ongoing for 22 courses, and tumor markers have decreased again with PR on imaging. Performance status has been good without hematologic toxicity or adverse events for approximately 1 year during the course of HAIC. HAIC is a weakly recommended therapy in the colorectal cancer treatment guidelines, but it is considered one of the most effective therapies with relatively few side effects.

[A Case of Small Intestinal Metastasis from Lung Cancer].

An 88-year-old man underwent thoracoscopic lower lobectomy for left lung cancer at the age of 87. Ten months later, he was examined closely for abdominal distention, frequent constipation, and anemia with a decreased Hb of 6.1 g/dL. The CT scan revealed an irregular tumor with contrast effect. The patient was diagnosed with malignant tumor of small intestine. At laparotomy, a tumor of 5 cm in diameter was found in the jejunum, and small bowel resection was done. Pathological examination revealed that the tumor was a metastasis of lung cancer. Seven months later, the patient is currently an outpatient, with no evidence of cancer recurrence.

[A Case of Complete Remission in a Patient with Synchronous Double Cancers of the Breast and Lung].

The patient is a 74-year-old woman. She had breast cancer(invasive ductal carcinoma, ER[+], PgR[+], HER2[-], Ki-67: 30-40%)and primary right lung cancer with lumbar metastasis, which led to the diagnosis synchronous double cancers of the breast and the lung. We decided to precede surgery for lung cancer because breast cancer was indicated hormonal receptor positive. Breast cancer is treated with anastrozole, thoracoscopic right upper lobectomy was performed for the lung cancer. Radiation therapy was performed for metastatic bone tumors. 13 months later, partial mastectomy sentinel lymph node biopsy performed. The histopathological diagnosis of breast cancer was pT2, pN0, cM0, pStage ⅡA, and histological response was Grade 2a. The remaining breast was treated radiation therapy. The breast cancer has not recurred and is doing well 6 months after surgery. As for primary lung cancer, 19 months have passed since surgery, and the patient is in complete remission without recurrence.

[The Short-Term and Long-Term Outcomes of Laparoscopic and Open Distal Gastrectomy].

We compared laparoscopic gastrectomy and open gastrectomy for the early gastric cancer. Laparoscopic surgery was comparable to laparotomy in terms of operation time and number of lymph node dissections, significantly less bleeding volume, postoperative hospital stay, and lower postoperative complication rate. As a result of E-PASS, surgical invasion was significantly low and the overall risk score was also significantly low. There was no difference in cancer-specific survival, and overall survival was significantly better with laparoscopic distal gastrectomy. Based on the above, laparoscopic gastrectomy is considered to be superior to open gastrectomy as a surgical technique for the early gastric cancer.

[A Case of Rectal GIST under Long-Term Follow-Up with Oral Imatinib].

The patient was a 79-year-old man with complaints of defecation difficulties and constipation. CT scan showed a 7.5 cm diameter mass in the lower rectum, and biopsy revealed GIST. MRI findings suggested prostate invasion, and the patient was started treatment with imatinib. Six months later, the tumor shrank to 4.5 cm in diameter. However, the patient refused surgery and continued taking Imatinib. The tumor continued to shrink gradually. Currently, 7 years later at the age of 86, it is only 2 cm in diameter and its inside has almost completely been replaced with calcifications.

[A Case of Colon Cancer with Synchronous Multiple Metastases Successfully Treated with Combined Chemotherapy].

A 68-year-old man having a descending colon cancer with multiple metastases of up to 9.5 cm in the right lobe of the liver(T3, N0, M1a)underwent laparoscopic colon resection for anemia control. Chemotherapy with mFOLFOX6 plus Bmab was administered postoperatively. Because this treatment had little effect, FOLFIRI plus Pmab was initiated 3 months later. A significant reduction in the tumor size was observed. Therefore, we performed laparotomy. However, the liver metastasis had invaded the inferior vena cava, which was not resectable. After the second surgery, we introduced the 5-FU hepatic arterial injection port ia plus Pmab iv, which was effective for 8 months. We then restarted chemotherapy with FOLFIRI plus Pmab. However, the tumor became more enlarged; therefore, we changed the chemotherapy regimen to SOX plus Bmab. Partial reduction in the tumor size was observed again, and the effects lasted for a while. The patient continued visiting the outpatient clinic with almost no symptoms for more than 1 year. He died of the primary cancer 3 years and 8 months after the first visit. We report a case of liver metastasis of colon cancer that could have been controlled successfully by repeatedly using the same pharmacotherapy.

[A Case of Hyaline Vascular-Type Castleman's Disease].

The patient was a 29-year-old female with a chief complaint of transient right-sided abdominal pain. A CT scan revealed homogenously contrasted tumor of 4 cm in diameter with smooth margins and clear borders in the lower part of the pancreatic head. The tumor was contrast-enhanced on MRI and stained on abdominal angiography using the proximal branch of the right colonic artery as a feeding vessel. PET scan showed moderate accumulation. Malignancy could not be ruled out, and tumor resection including the ascending colon was performed. The pathological diagnosis was hyaline vascular-type Castleman's disease in the mesentery of the colon.

[Comparison of Laparoscopic Gastrectomy and Open Gastrectomy Outcomes in the Elderly].

In this study, we compared the outcomes of laparoscopic gastrectomy and open gastrectomy in the elderly. Laparoscopic surgery was comparable to laparotomy in terms of the operation time and number of lymph node dissections and was significantly associated with less bleeding volume, duration of postoperative hospital stay, and a lower postoperative complication rate. Surgical invasion and overall risk scores were significantly low as assessed by the Estimation of Physiologic Ability and Surgical Stress(E-PASS)system. Based on these findings, laparoscopic gastrectomy can be considered to be superior to open gastrectomy as a surgical technique for the elderly.

[Study on Gastric Cancer Surgery in an Aged Society].

We examined the occurrence of complications following gastric cancer surgery in the elderly and its influence on the prognosis of reduction surgery.The study included 805 surgical cases of gastric cancer; elderly, middle-aged, and young patients were examined.In the elderly patients, there was a tendency to undergo reduction surgery.According to the gastric cancer treatment guidelines, 28.9% of the elderly patients, 5.3% of the middle-aged patients, and 0% of the young patients did not satisfy the criteria for lymph node dissection. The incidences of postoperative complications were 25.6%, 23.0%, and 13.4%in the elderly, middle-aged, and young patients, respectively, with a higher tendency seen in elderly patients.In elderly patients, the survival rate was examined separately for each postoperative complication, but no significant difference was noted.Additionally, the survival rate was assessed for the limited surgery and standard surgery groups; however, no significant difference was noted.Therefore, it is recommended that the optimal lymph node dissection range be determined in the elderly with respect to the general condition.

[A Case of Unresectable Sigmoid Colon Cancer with Peritoneal Dissemination Treated with Chemotherapy after an Unintended Emergency Jejunostomy Formation].

A 33-year-old man was diagnosed with bowel obstruction due to advanced sigmoid colon cancer and underwent an emergency laparotomy. The sigmoid colon cancer turned out to be unresectable because of firm invasion to the retroperitoneum with severe adhesions and diffuse dissemination. Therefore, unplanned jejunostomy was performed, which was complicated by high-output stoma and short bowel syndrome. His condition was stable enough to receive chemotherapy via parenteral nutrition and parenteral electrolyte solution infusion added to the diet. mFOLFOX6 plus cetuximab therapy was started 4 weeks postoperatively. Although oxaliplatin was discontinued because of worsening numbness, he was sustained without cancer progression by receiving chemotherapy for a year. Chemotherapy was interrupted by a Candida fungemia 13months postoperatively, and he died 4 months later. Patients with jejunostomy may have difficulty absorbing enough water and nutrients in the intestine; therefore, they are at risk of dehydration and electrolyte depletions due to high stomal output, and malnutrition due to the short bowel. These complications may prevent colorectal cancer patients with jejunostomy to be indicated for chemotherapy.

[Stage â £ Breast Cancer with Difficulty in Initiating Chemotherapy-A Case Report].

We report a case of breast cancer(T4b[skin], N1, M1[lung], ER-, PR-, HER2 3+)in a 63-year-old woman with liver dysfunction of unknown cause(T-Bil 3.6mg/dL, ALP 3,483 U/L, AST 214 U/L, ALT 320 U/L, g / -GTP 1,943 U/L). Further- more, serum CA19-9(4,670 U/mL)and HbA1c(8.8%)levels were both elevated. First, she underwent chemotherapy with trastuzumab and capecitabine. Subsequently, liver dysfunction relieved gradually. CA19-9 and HbA1c levels were also decreased, but the tumor size was NC. Subsequently, trastuzumab, pertuzumab, and docetaxel were administered, as liver function became normal. The tumor shrank significantly after this treatment. Finally, she underwent mastectomy. Five years after the first visit, she has continued chemotherapy, with lung metastases almost scarred(CR).

[A Case of Successful Treatment with Gemcitabine plus Nab-Paclitaxel Therapy for Nonresected Pancreatic Body Cancer(Stage IVb)].

A 61-year-old woman was introduced for consultation with a chief complaint of frequent vomiting. CT revealed a pancreatic body cancer approximately 40mm in size; an invading stenosis from the horizontal part of the duodenum to the jejunum, superior mesenteric artery, and portal vein, splenic vein obstruction, lymphadenopathy, and some ascitic fluid. We diagnosed a passage disorder due to the invasive stenosis from the horizontal part of the duodenum of the pancreatic body cancer to the jejunum, and subsequently performed a duodenum and jejunum bypass operation. We controlled cancer pain with opioid analgesia, and S-1 monotherapy was chosen as the primary chemotherapy. A tendency to increase and the cancer pain of the tumor was aggravated when 5 courses took effect, so gemcitabine plus nab-paclitaxel(GEM plus nab-PTX)therapy was chosen as the second-line chemotherapy because of adverse Grade 3 events due to difficulties with S-1 internal use. We tapered off the opioid analgesia dosage because the cancer pain was relieved after 1 course. The imaging top indicated stable disease at the end of 5 courses, but the pain was relieved so opioid pain killers were unnecessary. Foreign continuation is under treatment with 10-course GEM plus nab-PTX therapy after initial diagnosis. Currently, the patient has undergone 5 courses of S-1 for approximately 18 months, and has achieved stable disease. The only adverse events were nausea, fatigue, Grade 1 malaise, and Grade 2 alopecia, as detected with imaging.

[A Case of Advanced Rectal Cancer in Which Long-Term Disease-Free Survival Was Achieved by Multidisciplinary Therapy].

The is a case involving a 55-year-old man with advanced rectal cancer(type 3). MRI showed urinary tract and regional lymph node metastases without distant metastasis. The tumor was reduced(PR)after neoadjuvant chemotherapy(mFOL FOX6 plus Bmab, 4 courses). The patient underwent an abdominoperineal resection. Because infiltration of the tumor into the lower urinary tract was deep, it was also resected and repaired. The clip was placed to mark the repaired region. Pathological examination revealed that excision stump at the anterior wall of the urethra was cancer positive without lymph node metastasis. He was then administered chemotherapy(mFOLFOX6 4 courses)and irradiated 60 Gy in both sides of the inguinal lymph node to prevent metastasis to the pelvicdomain. One year and 6 months postoperatively, as the left inguinal lymph node swelled at 3.7 cm irregularly, he further received chemotherapy(FOLFIRI 8 courses). The size of the lymph node became normal with a good response to FOLFIRI. Six years postoperatively, he remains alive and well with no evidence of recurrence.

Risk Factors for Esophagojejunal Anastomotic Leakage in Gastric Cancer Patients after Total Gastrectomy.

BACKGROUND: Leakage at the esophagojejunal anastomosis site is an important postoperative complication of total gastrectomy. We analyzed our surgical cases to determine the risk factors for esophagojejunal anastomotic leakage. METHODS: This study included 309 patients who underwent total gastrectomy and esophagojejunal anastomosis. The onset of esophagojejunal anastomotic leakage according to age, gender, performance status, American Society of Anesthesiologists classification, body mass index, presence or absence of diabetes, invasion depth, lymph node metastasis, histological type, presence or absence of esophageal infiltration, operative duration, amount of blood loss, experience of blood transfusion, procedural approach, and the prognostic nutritional index was analyzed. RESULTS: Univariate analyses revealed a significant difference in the rate of esophagojejunal anastomotic leakage due to advanced age, male gender, the presence of diabetes, the presence of esophageal infiltration, and blood loss ≥1,100 g. In the multivariate analysis, which included factors identified in the univariate analyses, advanced age, male gender, the presence of diabetes, and blood loss ≥1,100 g were identified as independent risk factors for esophagojejunal anastomotic leakage. CONCLUSIONS: Advanced age (≥68 years), male gender, diabetes, and massive blood loss are risk factors for esophagojejunal anastomotic leakage.

Surgical resection of late solitary locoregional gastric cancer recurrence in stomach bed.

BACKGROUND: Late-onset and solitary recurrence of gastric signet ring cell (SRC) carcinoma is rare. We report a successful surgical resection of late solitary locoregional recurrence after curative gastrectomy for gastric SRC carcinoma. CASE REPORT: The patient underwent total gastrectomy for advanced gastric carcinoma at age 52. Seven years after the primary operation, he visited us again with sudden onset of abdominal pain and vomiting. We finally decided to perform an operation, based on a diagnosis of colon obstruction due to the recurrence of gastric cancer by clinical findings and instrumental examinations. The laparotomic intra-abdominal findings showed that the recurrent tumor existed in the region surrounded by the left diaphragm, colon of splenic flexure, and pancreas tail. There was no evidence of peritoneal dissemination, and peritoneal lavage fluid cytology was negative. We performed complete resection of the recurrent tumor with partial colectomy, distal pancreatectomy, and partial diaphragmectomy. Histological examination of the resected specimen revealed SRC carcinoma, identical in appearance to the previously resected gastric cancer. We confirmed that the intra-abdominal tumor was a locoregional gastric cancer recurrence in the stomach bed. The patient showed a long-term survival of 27 months after the second operation. CONCLUSIONS: In the absence of effective alternative treatment for recurrent gastric carcinoma, surgical options should be pursued, especially for late and solitary recurrence.

The Prognostic Nutritional Index as a Predictor of Gastric Cancer Progression and Recurrence.

BACKGROUND: Gastric cancer can recur soon after treatment. We evaluated the prognostic nutritional index (PNI), a predictor of postoperative complications, and examined the association of PNI with progression and recurrence of gastric cancer. METHODS: We retrospectively investigated data from 697 patients who had undergone surgery for gastric carcinoma (excluding those with stage IV disease) and analyzed associations of age, sex, performance status (PS), American Society of Anesthesiologists (ASA) classification, diabetes, depth of main tumor (T), lymph node metastasis, postoperative complications, recurrence, and survival with PNI. We also performed multivariate analysis to identify factors associated with survival. RESULTS: PNI significantly decreased with age and was significantly lower in women. PNI was significantly positively correlated with PS. PNI was significantly lower for ≥T2 cancers and in patients with lymph node metastasis. There was no association between postoperative complications and PNI. PNI was significantly lower for patients who developed recurrence than for those who did not. The survival rate was examined for groups with a PNI of ≥45 (high PNI) and <45 (low PNI). Both 5-year overall survival (OS) and cancer-specific survival (CS) were significantly worse for the low PNI group. Multivariate analysis showed that PNI was an independent predictor of OS and CS. CONCLUSIONS: PNI was associated with progression and recurrence of gastric cancer.

The Influences of Obesity in Laparoscopic and Open Distal Gastrectomy for Patients with Early Gastric Cancer.

BACKGROUND: A recent increase in the number of surgeries performed on obese patents has raised several issues. In this study, we examined the effects of obesity on laparoscopic and open distal gastrectomy. METHODS: A total of 262 patients with gastric cancer (cStage I) who underwent distal gastrectomy were classified into open distal gastrectomy (ODG) (145 patients) and laparoscopic distal gastrectomy (LDG) (117 patients) groups. According to their body mass index (BMI), they were subdivided into obese (BMI ≥ 25) and non-obese patients (BMI < 25) to examine the duration of surgery, blood loss, the number of lymph node dissections, postoperative hospital stay, and incidence of postoperative complications. RESULTS: The duration of surgery was longer and blood loss was higher for obese patients than for non-obese patients in both groups. The results for these two endpoints were significantly reduced in the LDG group than in the ODG group both in obese and non-obese patients. Furthermore, the number of lymph nodes dissected tended to be higher in the LDG group than in the ODG group in obese patients. Postoperative hospital stay was not significantly different between obese and non-obese patients in both groups, but was significantly shorter in the LDG group than in the ODG group regardless of the body weight. The incidence of postoperative complications was significantly higher in obese patients than in non-obese patients, although the difference between the groups was not significant. CONCLUSIONS: These findings indicate that LDG may be useful for obese patients with cStage I gastric cancer.

T tube drainage for spontaneous perforation of the extrahepatic bile duct.

BACKGROUND: Spontaneous perforation of the extrahepatic bile duct is very rare. We report a patient with a spontaneous perforation of the left hepatic bile duct who was diagnosed preoperatively. CASE REPORT: A 65-year-old woman was admitted to our hospital complaining of a right upper quadrant pain lasting for two days. She was diagnosed as having a perforated bile duct and peritonitis and underwent a laparotomy. After a cholecystectomy, T-tube drainage of the left hepatic duct was performed. The postoperative course was uneventful. The T tube was removed 25 days after the surgery. CONCLUSIONS: A more noninvasive procedure, such as endoscopic treatment, should play a central role in the management of extra bile duct perforation. For this case, however, we chose to perform a laparotomy based on the patient's general condition and the presence of peritonitis. T tube decompression is effective and a safe and reliable method. The goal of treatment is to stop the bile leakage, resolve the choledocholithiasis and cholangitis, and reconstruct the bile duct.

Chemosensitivity test for 5-fluorouracil and 5-chloro-2, 4-dihydroxypyridine predicts outcome of gastric cancer patients receiving S-1 postoperatively.

BACKGROUND: Chemosensitivity tests have long been discussed but remain a topic of research. In this study, we investigated the correlation between the results of a chemosensitivity test for 5-fluorouracil and 5-chloro-2, 4-dihydroxypyridine and the clinical outcomes of gastric cancer patients treated with S-1, an oral fluoropyrimidine, as adjuvant chemotherapy. METHODS: For gastric cancer patients, we performed surgical treatment and a lymph node dissection of D2 or more. Afterwards, a chemosensitivity test for 5-fluorouracil and 5-chloro-2, 4-dihydroxypyridine was performed, using the collagen gel droplet embedded culture drug-sensitivity test (CD-DST), in surgical specimens. All the patients received postoperative adjuvant chemotherapy with S-1 for 1 year, and the overall survival (OS), relapse-free survival (RFS), and adverse events were investigated. RESULTS: The chemosensitivity test was performed for 27 patients. The growth inhibition rate (IR) was 50% or more (high-sensitivity group) in 59.3% (16 cases) and it was under 50% (low-sensitivity group) in 40.7% (11 cases). The 3-year OS rate was 100% in the high-sensitivity group and 62.34% in the low-sensitivity group. The 3-year RFS rate was 83.33% in the high-sensitivity group and 24.24% in the low-sensitivity group. Thus, the 3-year OS rate and the 3-year RFS rate were higher in the high-sensitivity group than in the low-sensitivity group. No adverse events of grade 3 or greater severity were observed. CONCLUSIONS: The results of the chemosensitivity test were correlated with the patient outcome. Therefore, such results might be useful for individualizing cancer chemotherapy and for determining future indications for postoperative adjuvant chemotherapy.

Two successful curative operations using stomach-preserving distal pancreatectomy with celiac axis resection for the treatment of locally advanced pancreatic body cancer.

Large vessel invasion is a serious factor determining whether an operation for pancreatic body cancer is feasible. The Appleby operation is a radical operation for the treatment of pancreatic body cancer that has infiltrated the celiac axis. Since this procedure includes a total gastrectomy, the operation is associated with a high morbidity, mortality, and deteriorating postoperative quality of life (QOL). We experienced two cases in which radical operations consisting of a stomach-preserving distal pancreatectomy with en bloc resection of the celiac, common hepatic, and left gastric artery were performed. The use of adjuvant chemotherapy in these cases led to a good postoperative QOL.