[A Case of Resected Diffuse Large B-Cell Lymphoma Diagnosed with Liver Metastasis and Peritoneal Dissemination after Surgery for Sigmoid Colon Cancer].

We experienced a case of diffuse large B-cell lymphoma(DLBCL)that developed around the kidney about 1 year after surgery for sigmoid colon cancer. In this case, imaging findings suggestive of liver metastasis were also observed at the same time of diagnosis, therefore, diagnosis was difficult because the possibility of peritoneal dissemination could not be ruled out. The lesion was excised by surgery and a definitive diagnosis was obtained by tissue diagnosis, leading to appropriate treatment. However, one wrong step could lead to the wrong treatment policy. Therefore, when there is any doubt about the diagnosis, it is considered important to proactively perform tissue diagnosis.

[A Case of Multiple Lung Metastases of Pancreatic Cancer with 50 Months Survival by Sequential Chemotherapy].

We hereby report a case in which a patient with multiple lung metastases of pancreatic cancer continued chemotherapy and maintained good performance status(PS)for 48 months after recurrence. But her disease progressed rapidly after withdrawal of chemotherapy, resulting in her death in a short period of time. The patient was a 66-year-old woman who underwent a substomach preserving pancreaticoduodenectomy for pancreatic head cancer at the age of 60 years. She was diagnosed as fT3N1M0, fStage ⅡB. During postoperative adjuvant chemotherapy S-1, multiple lung metastases were noted on CT scan 2 years after surgery. Thereafter, she was treated with gemcitabine(GEM)alone, GEM plus nab-paclitaxel(GnP), nal-CPT-11 plus 5-FU plus Leucovorin, and FOLFIRINOX for 48 months sequentially. Each of which achieved a best overall response SD or better. However, Trousseau syndrome developed following community-acquired pneumonia during chemotherapy withdrawal due to myelosuppression. The disease progressed rapidly and resulted in her death 50 months after relapse. The results suggest that chemotherapy may have contributed significantly to disease control in this case.

[A Case of Pathological Complete Response after Neoadjuvant Therapy for Resectable Pancreatic Cancer].

We report a case of resectable pancreas tail cancer treated with 2 courses of neoadjuvant therapy which is gemcitabine and S-1 therapy, and pathological diagnosis of the resected specimen revealed pathological complete response. A 56-year- old woman was referred to our hospital because she had back pain after eating for 5 months and her previous abdominal ultrasonography revealed an enlarged pancreatic tail. The tumor size was reduced from 30 mm to 12 mm, and the chemotherapy response was judged to be partial response. The patient underwent distal pancreatectomy, splenectomy, and D2 lymph node dissection. Intraoperative findings showed a pancreatic tail with a depression and surface erythema, thus we also diagnosed the patient as having pancreatic capsular invasion(S1). Postoperative histopathological examination revealed a 10×10 mm area of pancreatic parenchyma, which was replaced by fibrous tissue, with no evidence of active cancer cells. The patient was discharged from the hospital on the 14th after surgery.

[Significance of Transitions in Neutrophil-to-Lymphocyte Ratio before and after Transcatheter Arterial Chemoembolizaton for Hepatocellular Carcinoma].

We investigated the significance of transitions in the neutrophil-to-lymphocyte ratio(NLR)before and after TACE for HCC could be a predictor of prognosis. The subjects were 108 patients with the first TACE performed from January 2010 to December 2019. NLR was calculated before and 1 month after TACE, and the relationship with therapeutic effect and prognosis was examined. When the transition of NLR before and after TACE was classified into 3 groups with a cut-off value of 5.0, group A(less than 5.0 after TACE): 52 cases(48.1%), group B(5.0 or more after TACE): 33 cases(30.6%)and C group(5.0 or more before and after TACE): 23 cases(21.3%). Median survival time were 25.0 months in group A, 18.5 months in group B, and 12.7 months in group C(p=0.0005). In multivariate analysis, treatment effect, NLR transition, AFP value, and serum albumin level were prognostic factors for HCC after TACE. Changes in NLR before and after TACE may help predict more detailed prognosis.

[Four Cases of Liver Resection for Liver Metastases from Renal Cell Carcinoma].

We report 4 cases of liver metastasis from renal cell carcinoma(RCC). Case 1: 72 years old, female. Pancreatic metastasis was resected 7 years after resection of left RCC, and hepatic posterior sectionectomy was performed for multiple liver metastases 2 years later. After that, multi-organ metastasis appeared and she died of the primary disease. Case 2: 72 years old, male. Liver metastasis and right RCC appeared 16 years after resection of left RCC, and hepatic posterior sectionectomy and partial resection of right kidney were performed. Nine months later, liver metastasis recurred and hepatic partial resection was performed. Case 3: 55 years old, male. After surgery for right RCC with tumor thrombus in the right atrium, multiple lung and liver metastases appeared, and hepatic central bisectionectomy was performed after chemotherapy. Case 4: 60 years old, male. Multiple pancreatic and lung metastases appeared 10 years after resection of left RCC, and most of them shrank or disappeared with chemotherapy. But increasing metastases appeared in the tail of pancreas and the right lobe of liver 16 months later, and hepatic subsegmentectomy and distal pancreatectomy were performed. Multidisciplinary treatment such as aggressive chemotherapy and excision is expected to improve the prognosis for liver metastasis from RCC.

[A Case of Advanced and Recurrent Colon Cancer with Long-Term Survival after Seven Repeated Surgical Resections].

We hereby report a case of advanced and recurrent colon cancer with long-term survival after 7 repeated surgical resections. A 73-year-old woman initially underwent right hemicolectomy and partial hepatectomy for an ascending colon cancer with synchronous liver metastasis. Pathological diagnosis of the tumors were moderately differentiated adenocarcinoma and metastasis to the liver compatibly. Final clinical stage was diagnosed as fT3N2M1(H1), fStage Ⅳ. But she was interrupted oxaliplatin-based adjuvant chemotherapy after 6 courses of CAPOX because of adverse drug reaction. One year after first operation, partial resection of right lung was performed for lung metastasis. Two years after first operation, 2nd resection of liver was performed for 2 liver metastatic lesions. Three years after first operation, 3rd partial liver resection, 2nd and 3rd partial lung resections were performed for metachronous metastases during 1 year. After 3 years recurrence free period, she complained of an induration of right neck and diagnosed as neck and supra clavicular lymph nodes metastases. Lymph nodes resection was performed. After the last operation, she has no sign of cancer recurrence for 1 year and 7 months, eventually she has been alive for 7 years and 7 months after the initial operation.

[Significance of Transcatheter Arterial Chemoembolization for BCLC Stage B Hepatocellular Carcinoma with Mal-Nutrition].

Background and Aim: The recommendedind ication of transcatheter arterial chemoembolization(TACE)for hepatocellular carcinoma(HCC)is Barcelona Clinic Liver Cancer(BCLC)stage B HCC. But there are some cases in which we do not perform TACE because of liver damage with malnutrition in stage B. So we examined whether branched-chain amino acid (BCAA)improve nutritional status and perform TACE to contribute the prolongation of HCC survival. METHODS: This study included8 8 patients treatedfor liver cirrhosis with HCC. All patients initially receivedBCAA granules. In patients with unchangedor decreasedAlb levels, BCAA granules were discontinuedandBCAA enrichednutrient was started. TACE for HCC were performedin those with an improvedChild -Pugh score. RESULTS: TACE were performedfollowing the aggressive intervention with BCAA nutritional education in 66 of 88(75%)patients. Finally, overall survival time was significantly extended in TACE group(p<0.0001). CONCLUSION: Timely aggressive nutritional intervention in BCLC stage B HCC, early partial replacement with BCAA enrichednutrient before TACE may consequently contribute to improvement of the treatment outcome of HCC.

[Evaluation of Eligibility Criteria for Elderly Patients of Pancreaticoduodenectomy].

BACKGROUND/AIM: Pancreaticoduodenectomy(PD)treatment outcomes in elderly patients have been reported to be acceptable, but the eligibility criteria are not clear. To elucidate the importance of PD in octogenarians, we set beforehand the eligibility criteria in the elderly and evaluated whether the validity of the patient selection was adaptable. PATIENTS AND METHODS: The study population consisted of 244 patients aged >70 years who hadpancreaticobiliary cancer. The patients were divided into 2 groups as follows: 32 patients in the octogenarian group and 212 patients in the septuagenarian group. The eligibility criteria were as follows: (1)cardiac function as ejection fraction of at least 40%, measured using Doppler echocardiography; (2)pulmonary function as forcedexpiratory volume in 1 second(FEV1.0%)of at least 50%on spirography; (3) nutritional status as serum albumin level of at least 3.0 g/dL; (4)daily activity status as Karnofsky performance status of at least 80%; and(5)psychological independence status as the capability of self-determination with respect to surgery. Postoperative morbidity and long-term outcome were comparedbetween the 2 groups, andprognostic factors relating to survival time were identified. RESULTS: The patients in the octogenarian group showed a significantly higher incidence rates of 2 or more comorbidities(p<0.0001)andd elirium(p=0.024). The difference in mortality rate between the 2 groups was not significant. No significant difference in overall survival rate was found between the 2 groups(p=0.197). The independent prognostic factors relating to survival duration were intraoperative blood loss(p=0.0008)andd uration of surgery(p= 0.0091). CONCLUSION: The eligibility criteria for PD in elderly patients are also satisfactorily applicable to octogenarian patients. These criteria may be helpful when uncertainties arise regarding the selection of PD.

[A Case of Borderline Resectable Pancreatic Head Cancer Treated by Curative Resection after Chemotherapy].

A 77-year-old woman with back and epigastric pains was diagnosed with pancreatic head cancer according to the result of contrast computed tomography, which showed a 25mm irregular low-density area at the pancreatic head infiltrating nearly half of the superior mesenteric plexus. There were no findings of lymph node metastasis or distant metastasis. The pretreatment diagnosis was borderline resectable(BR)pancreatic head cancer, cT3, N0, M0, cStage ⅡA. The patient was treated with gemcitabine plus nab-paclitaxel therapy. She developed Grade 3 neutropenia, and the dose was adjusted in order to continue chemotherapy. The size of the tumor had reduced to 15mm after 6 courses of the therapy, and the infiltration into the superior mesenteric plexus had also reduced. Therefore, the patient underwent subtotal stomach-preserving pancreatoduodenectomy and D2 lymph node dissection. The histopathological findings were invasive ductal carcinoma with R0 radical resection. The efficacy of preoperative adjuvant chemotherapy for BR pancreatic cancer has not been established yet, but improving the R0 resection rate with preoperative chemotherapy may contribute to an improvement in the outcome of pancreatic cancer.

[Analysis of the Relationship between the Change of Drain Amylase Value and Postoperative Pancreatic Fistula after Pancreaticoduodenectomy].

To diagnose postoperative pancreatic fistula(POPF)after pancreaticoduodenectomy(PD)during early post operative days, we evaluatedwhether a change in drain amylase value(DAV), WBC value, or CRP value predicted clinically significant POPF. One hundred thirty patients underwent substomach preserving PD(SSPPD)from 2005 to 2016 in our institution andwe examinedDAV, WBC, andCRP values at POD 1, 3, and 5. Seventy-five patients(57.7%)were equivalent to ISGPF grade A at POD 3.We analyzedthese 75 cases by following 5 factors(DAV at POD 3>1,500 U/L, DAV at POD 5>1,000 U/L,WBC value at POD 5≤9,000/mL, DAV of POD 5 decreased to 1/3 from DAV of POD 3, CRP value not improved≥50%from POD 3 to 5) andwere concernedwith the crisis of the grade B/C POPF at final diagnosis after POD 5. In conclusion, DAV of POD 5 decreased to 1/3 from DAV of POD 3, andthe CRP value having not improved(≥50%from POD 3 to 5)were significant risk factors for POPF grade B andC by Cox proportional hazard models.

[Prediction of Treatment Effect of Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma Using Computed Tomography(CT)-Attenuation Value].

AIM: In general, transcatheter arterial chemoembolization(TACE)can obtain a high therapeutic effect on hypervascular tumors, but the definition of"hypervascular"is unclear. In this study, stainedtumor images on enhancedcomputedtomography( CT)were assessedaccord ing to CT-attenuation value. We investigatedwhether it is possible to estimate the treatment effect(TE)of TACE for hepatocellular carcinomas(HCCs). STUDY POPULATION AND METHODS: We studied 50 patients with unresectable HCCs who underwent TACE. A total of 141 tumors were diagnosed as HCC on enhanced CT. We measured andcalculatedthe ratios of CT-attenuation values of HCCs in the arterial phase to normal enhancedliver parenchyma in the portal phase(CT value ratio). We then evaluatedTE on each target nodule by enhancedCT, to examine the correlation between TE andthe CT value ratio. RESULTS: The CT-attenuation values were 119(range 61-180)hounsfieldunits(HU)for HCC and8 3(49-141)HU for liver parenchyma, andthe CT value ratio was 1.47(0.7-2.6). TE was positively correlatedwith the CT value ratio(p=0.0005). The cut-off value that suggestedfavorable results for TACE was 1.7 by receiver operating characteristic(ROC)analysis. CONCLUSION: The CT value ratio is useful for recognition of hypervascular tumors. We obtained favorable results in cases with a CT value ratio of 1.7 or more.

[Neuroendocrine Tumor of the Ampulla of Vater and Gastrointestinal Stromal Tumor of the Duodenum in a Patient with Von Recklinghausen's Disease].

A 57-year-old woman with von Recklinghausen's disease presented with epigastralgia. Gastroduodenoscopy revealed swelling of the ampulla of Vater in the ventral and caudal direction, forming a hard, elastic mass. She was diagnosed with a tumor of the ampulla of Vater, and a subtotal stomach-preserving pancreaticoduodenectomy and D2 lymph node dissection were performed. The isolated specimen showed an intra-ampullary tumor of the ampulla of Vater and a submucosal tumor in the descending duodenum, which were diagnosed as a somatostatin-producing neuroendocrine tumor and gastrointestinal stromal tumor, respectively, on pathological examination. We believe that the neuroendocrine tumor of the ampulla of Vater and gastrointestinal stromal tumor of the duodenum are common gastrointestinal lesions in von Recklinghausen's disease.

[Synchronous Double Cancer Involving Gastric Cancer Resembling a Submucosal Tumor with Stenosis in the Pylorus and Ascending Colon Cancer - A Case Report].

An 82-year-old woman presented to our hospital with a complaint of frequent vomiting. She was admitted for intensive examination and treatment. Abdominal computed tomography revealed that her stomach was severely expanded, and the wall of the ascending colon was thickened throughout its circumference. Upper gastrointestinal endoscopy uncovered severe stenosis in the pylorus and an elevated lesion resembling a submucosal tumor on the posterior wall of the pylorus. Biopsies of the lesion revealed that it was of Group 1. On colonoscopy, type 2 cancer was found in the ascending colon throughout the circumference, and the biopsies revealed that it was of Group 5. Upper gastrointestinal endoscopy was repeated, and the same result was obtained. The possibility of malignancy could not be excluded; therefore, distal gastrectomy and right colectomy were performed. In terms of histopathology, both resected specimens displayed poorly differentiated adenocarcinoma; however, immunohistochemical studies revealed differences in staining at the two sites. The case was diagnosed as synchronous double cancer involving gastric cancer resembling a submucosal tumor with stenosis in the pylorus and ascending colon cancer. Gastric cancer resembling a submucosal tumor is usually difficult to diagnose on biopsy. If the endoscopic findings reveal an elevated lesion resembling a submucosal tumor with stenosis, then the possibility of carcinoma should be considered, and the most suitable treatment should be selected.

Predictive Postoperative Inflammatory Response Indicators of Infectious Complications Following Gastrectomy for Gastric Cancer.

BACKGROUND: Perioperative factors are useful for predicting postoperative infectious complications (PIC) in gastric cancer. Specifically, postoperative inflammatory response indicators (PIRI), [C-reactive protein (CRP) level, body temperature (BT), and white blood cell (WBC) count], are widely used in clinical practice. We investigated predictive factors for PIC, including PIRI, to establish a simple and practical indicator of postoperative complications after gastrectomy. METHODS: We retrospectively collected clinical data from 200 patients with fStage I-III gastric cancer. Univariate/multivariate analysis was performed to evaluate the relationship of predictive factors [host factors, clinicopathological factors, and PIRI (BT, WBC count, and CRP level on postoperative day (POD) 1 and 3) ]. Cut-off values of the predictive factors were analyzed using receiver operating characteristic (ROC) curve modulated by the presence/absence of PIC Grade II, III (Clavien-Dindo classification). RESULTS: Age [Odds ratio (OR): 5.67], smoking history (OR: 3.51), and CRP level (OR: 5.65), WBC count (OR: 8.96), and BT (OR: 3.37) on POD3 were selected as independent factors from multivariate analysis. Cut-off values were 77 years, 14.8 mg/dL, 116.0×102/µL, and 37.4°C, respectively. CONCLUSIONS: Predictive factors relative to PIC in gastric cancer were CRP level ≥ 14.8 mg/dL, WBC count ≥ 116.0×102/µL, and BT ≥ 37.4°C all on POD3. Age ≥ 77 years, and history of smoking were relative to PIC, suggesting a simple and practical indicator applicable in clinical practice.

[Does interventional radiological treatment (transcatheter arterial chemoembolization/transarterial infusion) improve the prognosis of patients with unresectable and recurrent hepatocellular carcinomas?].

UNLABELLED: We report herein the usefulness of interventional radiological treatment( IVR) for hepatocellular carcinomas( HCCs), based on the results of transcatheter arterial chemoembolization( TACE) and transarterial infusion( TAI). METHODS: The study included 256 cases of HCC. TACE and TAI were performed for durations permitted by the degree of liver damage. Results(: 1) TACE was performed in 224 cases( average: 4.5 times, range: 1-14 times), and TAI was performed in 32 cases( average: 2.3 times, range: 1-8 times).( 2) The 3- and 5-year survival rates for all cases were 45.5% and 31.6%, respectively.( 3) We classified all cases according to the number of HCCs, solitary, 2-4, and multiple HCCs, and found no significant differences in the survival rate between the 3 groups( p=0.207),( 4) TAI was followed by TACE in non-responsive cases, and the median survival time of the TAI group was 8.5 months. CONCLUSIONS: We can expect benefits from repeated TACE treatment in the multiple HCCs group, compared to the solitary HCC group. TAI followed by TACE might improve the prognosis of unresectable and recurrent HCCs. Therefore, we conclude that IVR has clinical benefit as local treatment for HCC.

Preoperative Subcutaneous Fat is an Useful Indicator for Learning Totally Extraperitoneal Repair.

BACKGROUND: Totally extraperitoneal (TEP) repair is a recommended procedure for inguinal hernia repair in European hernia guidelines. However, technical challenges have limited its uptake in Japan, where transabdominal preperitoneal (TAPP) repair is more common. We evaluated the association of preoperative subcutaneous fat area (preSFA) with surgical outcomes and identified factors associated with the difficulty of TEP repair. METHODS: Clinical data from 62 patients undergoing TEP repair were collected retrospectively. Using the median for the preoperative subcutaneous fat index (preSFI; 45.9 cm2/m2), we classified patients as having a high SFI (HSFI) (n=31) and low SFI (LSFI) (n=31). Surgical outcomes and perioperative complications were then compared between these groups. Additionally, TEP repair was divided into five phases (e.g., Phase 1: dissection of the caudal side of the preperitoneal space), and operative time was measured during each phase. Phase 1 was divided into two sub-phases (1A: insertion of the first port, 1B: reaching Cooper's ligament). RESULTS: Operative time was longer (133 min vs 111 min, P = 0.028) and the peritoneal injury rate was higher (35.5% vs 9.7%, P = 0.015) for the HSFI patients. Furthermore, operative time for HSFI patients was significantly longer during Phase 1 (P = 0.014) and Phase 1A (P = 0.022). CONCLUSIONS: preSFA was associated with a higher peritoneal injury rate and longer operative time in HSFI patients, suggesting that the presence of abundant subcutaneous fat increases the difficulty of TEP repair.

[Evaluation of pre-operative chemotherapy with S-1 plus CDDP against advanced gastric cancer with paraaortic lymph node metastasis].

We evaluated the effectiveness of pre-operative chemotherapy with S-1 plus CDDP against advanced gastric cancer with paraaortic lymph node metastasis. 8 patients received pre-operative chemotherapy with S-1 plus CDDP, according to the following regimen: S-1, 80 mg/m(2), was administered for 21 consecutive days followed by a 14-day rest period, and CDDP, 60 mg/m(2), was administered on day 8. The adverse event rate was 50%. However, a grade greater than 3 was not revealed. There were 5 partial responses (PR) and 3 stable diseases (SD). We performed 7 total gastrectomies and one distal gastrectomy, and the surgical curability (cur) resulted in 6 cases of cur B and two cases of cur C. The histological antitumor effect was grade 2 in three cases. The median overall survival rate was 623 days and the one-year survival rate was 75%. Analyzing for overall survival with antitumor effect and operative curability, both groups of PR and cur B prolonged survival. Pre-operative chemotherapy with S-1 plus CDDP, when used against advanced gastric cancer with paraaortic lymph node metastasis, might be an effective treatment.

First successful case of percutaneous transabdominal thoracic duct embolization (PTTDE) for chylous ascites resulting from laparoscopic gastric cancer surgery.

A 61-year-old woman underwent laparoscopy-assisted distal gastrectomy (LADG) with extragastric lymph node dissection (D2). Two months later, she was readmitted to hospital to be treated for chylous ascites. Oral intake was discontinued and total parenteral nutrition started, but increasing body weight and decreasing serum albumin concentration was not controllable. Percutaneous transabdominal thoracic duct embolization (PTTDE) was performed on the 8th day after the readmission. Five days after PTTDE, oral intake was resumed. Seventeen days after PTTDE, the patient was discharged without recurrence of ascites. She has remained asymptomatic. We describe here the first patient with chylous ascites two months after LADG with D2 dissection for early gastric cancer who was successfully treated by PTTDE.

Changes of immunological parameters reflect quality of life-related toxicity during chemotherapy in patients with advanced colorectal cancer.

UNLABELLED: Anticancer drugs may frequently induce host immunosuppression and symptomatic toxicities. Once symptomatic toxicity occurs, the patient's quality-of-life (QOL) is reduced. Since little is known of the relationship between host immunity and the toxicity of chemotherapy, the host immunity before and after chemotherapy was compared to assess whether it is related to symptomatic toxicity during chemotherapy. PATIENTS AND METHODS: Fourteen patients with colorectal cancer underwent leucovorin /5-fluorouracil (LV/5-FU) treatment, or S-1/irinotecan (CPT-11). Host immunity (cytokine production of peripheral blood mononuclear cell (PBMC), serum soluble interleukin-2 receptor (sIL-2R) levels and phenotypic analyses of PBMC were measured before and after the first chemotherapy. RESULTS: An increase of sIL-2R, CD4+CD25+ T-cells and the CD4/8 ratio in patients with symptomatic adverse reactions were found. These changes in the first chemotherapy were significantly different (p = 0.0211, p = 0.0087, p = 0.0234). CONCLUSION: The current study indicated that there are some parameters correlated with toxicity during chemotherapy which effect QOL. In such patients, negative influences on host immunity, such as an increase of sIL-2R and regulatory T-cells, and a decrease of cytotoxic T-cells could occur.

Changes of nutritional status after distal gastrectomy in patients with gastric cancer.

BACKGROUND/AIMS: In Japan, distal gastrectomy is the most common operation performed to treat gastric cancer. However, this procedure often leads to postoperative problems such as weight loss. METHODOLOGY: We assessed the changes of nutritional status early after operation and the associations of the postoperative body weight (as a percentage of the preoperative weight) and background factors in patients who underwent distal gastrectomy. We measured the changes of nutritional indices (mean body weight, TSF, AMC and Alb) and nutrition intake on the day before operation (before operation), before postoperative resumption of oral intake (before oral intake), and on the fifth day of a soft rice porridge diet (after soft rice). Background factors included gender, age, preoperative BMI and preoperative exercise. RESULTS: Mean body weight, TSF, and AMC significantly decreased from before operation, to the day before oral intake and to the day after soft rice. The postoperative body weight was not associated with the gender, age, or preoperative BMI. The frequency of regular preoperative exercise was associated with the postoperative body weight. The total daily calorie intake was 1,664 kcal (before operation), 398 kcal (before oral intake), and 949 kcal (after soft rice). CONCLUSIONS: To conclude, nutritional status changes significantly after distal gastrectomy. Early nutrition intervention may be needed in patients who undergo distal gastrectomy for gastric cancer.