[Assessment of Curative Resection in Patients with Multiple Relapses of Colorectal Cancer].

We assessed the therapeutic effect of curative resection in patients with multiple relapses of colorectal cancer using the time to surgical failure(TSF)as an index. We included 24 patients who experienced recurrence after curative resection of primary colorectal cancer at our department between 1993 and 2015. Curative resection for multiple relapses was possible in these patients. The sites of recurrence included the liver, lungs, peritoneum, lymph nodes, localized, and brain in 9, 8, 3, 3, 2, and 1 patients, respectively. The relapse occurred in 2 organs in 2 patients. The TSF after curative resection of recurrent lesions was 25.6 months, with a 5-year TSF-free rate of 40.2%. The clinicopathological factors associated with poor prognosis were age B65 years at the time of recurrence, absence of distal metastasis at primary onset, and only 2 curative resections for relapses. However, there was no difference in prognosis because of the number of twice recurrent lesions. Therefore, curative resection should be proactively performed as long as feasible in colorectal cancer patients with multiple lesions or multiple relapses.

[A Case of Unresectable Ascending Colon Cancer Treated with a Newly Devised Bypass Method].

A 74-year-old man underwent a medical examination for anemia and had a positive fecal occult blood test. Ascending colon cancer was detected by colonoscopy. Since it was unresectable, a bypass operation was performed to prevent digestive symptoms prior to chemotherapy. The bypass was performed by cutting the ileum and attaching the oral side to the transverse colon with side to side anastomosis. The other end of the terminal ileum was anastomosed to the transverse colon on the oral side of the prior anastomosis, making a pretzel shaped bypass. There were no postoperative complications and the patient was treated with chemotherapy from postoperative day 23.

[A Case of Rectal Obstruction Due to Gastric Cancer Dissemination for Which Rectal Stenting Was Performed Twice].

Malignant colorectal obstruction results in a worse quality of life and makes it difficult for patients to continue chemotherapy. In this paper, we present a case of rectal obstruction caused by gastric cancer dissemination for which rectal stent insertions were performed twice. The patient was a 72-year-old woman. She underwent gastrectomy for Stage Ⅳ gastric cancer (ypT3, N1, M1, P0, H0, CY+). Twenty-eight months after gastrectomy, she experienced rectal obstruction due to peritoneal dissemination. A rectal stent was placed at the stenosis site. She was administered chemotherapy after stenting. Seven months later, she developed rectal obstruction due to tumor in-growth. Rectal stenting was performed again. Subsequently, the patient had no abdominal symptoms until she died, 2 months after the second stenting.

[Impact of Postoperative Inflammatory Status on Colorectal Cancer Prognosis].

To clarify the prognostic impact of postoperative inflammatory status, serum CRP levels on POD3 after radical resection (POD3 CRP)were evaluated as an indicator of inflammatory response after surgery in patients with colorectal cancer. Of the colorectal cancer patients who underwent radical resection at our department between 2000 and 2015, 916 patients with Stage Ⅰto Ⅳdisease were included in the analyses. The patients were divided into 2 groups according to high and low POD3 CRP levels. The POD3 CRP levels of the patients were analyzed for the 75th percentile that was 12.16mg/dL(range, 0.06- 33.78). The cancer-specific 5-year survival rate was 80.6%in patients in the high group and 90.5%in those in the low group, indicating poor prognosis in patients with high values. POD3 CRP levels were an independent prognostic factor in the multivariate analysis. It was suggested that the degree of inflammation after surgery influences the postoperative prognosis after radical resection for colorectal cancer.

[Ethinyl Estradiol Therapy for Postmenopausal Women with Heavily Pre-Treated Endocrine-Responsive Metastatic Breast Cancer].

Ethinyl estradiol(EE2)therapy has been reported to be an effective endocrine therapy for postmenopausal hormone receptor-positive advanced breast cancer, especially in the supposed acquired resistance state. The current study retrospectively investigated the efficacy and safety of EE2 therapy in postmenopausal women with hormone receptor-positive advanced breast cancer who had previously undergone multiple endocrine therapies. Twelve patients were enrolled; median lines of endocrine therapies were seven before EE2. Median PFS was 4.8 months and median overall survival was 10.0 months. Grade 3 adverse event comprised of anorexia in only one patient. EE2 therapy may be considered effective and safe in hormone receptor-positive advanced breast cancer even in late-stage endocrine therapy.

[Assessment of Less Invasiveness Based on Serum CRP Level on Postoperative Day Three in Laparoscopic Surgery for Colorectal Cancer].

To evaluate the less invasiveness of laparoscopic surgery for colorectal cancer, we compared open and laparoscopic surgery for sigmoid or recto-sigmoid cancer operations undergoing the same procedures. One hundred forty-three patients curatively resected with D3 dissection were enrolled. All cases underwent the following procedure; high ligation of the inferior mesenteric artery(IMA)with median approach and double stapling technique(DST)for anastomosis. The clinicopathological factors were examined in 70 cases of open surgery(OC)and 73 cases of laparoscopic surgery(LAC). The mean age of all cases was 66(38-88)years, including 83 men and 60 women. The mean operation time was 189(82-413)minutes and the mean blood loss was 45(5-1,025)mL. Postoperative complications were reported in 45 cases including 10 cases with surgical site infection(SSI)and 10 cases with remote infection(RI). There was no difference in sex, BMI, PS, and ASA between the 2 groups; however, the patients were significantly older and the tumor maximum diameter significantly larger in the OC group. There was no significant difference in operation time but the blood loss was significantly lower in the LAC group. There were no differences in postoperative complications, first gait, WBC, and body temperature on postoperative day(POD)3, but the first flatus was earlier and the CRP level was significantly lower on POD 3 in the LAC group. There was no difference in the CRP level on POD 3 in the age, tumor diameter, and blood loss which showed a difference in the both group. Laparoscopic surgery was considered less invasive than open surgery because the serum CRP level was lower in the LAC group.

[A Case of Low-Grade Appendiceal Mucinous Neoplasm with Cecum Cancer].

The case was a 76-year-old man. He visited our hospital for a positive fecal occult blood test finding at a medical examination. A colonoscopy revealed a macroscopic, 30 mm, type-1 lesion in the cecum. We performed laparoscope-assisted ileocolic resection and D3 dissection, with a diagnosis of cecum cancer. In postoperative histopathological examination, the tumor in the cecum was diagnosed as a well-differentiated tubular adenocarcinoma. In addition, a low-grade appendiceal mucinous neoplasm(LAMN)was observed on the distal side of the appendix. The patient has survived for 9 months after surgery without recurrence. We report this case with a review of the literature.

[A Case of Breast Carcinoma with Cartilaginous Differentiation and Distant Metastasis with Complete Response to Post-Operative Chemotherapy].

We report a case of breast cancer with cartilaginous differentiation that responded well to chemotherapy, which completely eliminated distant metastasis. A 63-year-old woman visited our hospital complaining of a large hemorrhagic mass measuring 15 cm in diameter with ulceration of the left breast. Palpation revealed swelling of the left axillary and right supraclavicular (SC)lymph nodes, suggesting breast cancer metastasis. A CT scan revealed metastasis in the right lung measuring 2.5 cm in size. She underwent a total mastectomy with axillary dissection. The pathological findings were as follows; breast carcinoma with cartilaginous differentiation accompanied by a single lymph node metastasi(s 1/21)and skin involvement, ly0, v0, ER(-), PgR(-), HER2 0, Ki-67 80%. Four courses of AC therapy were administered as postoperative chemotherapy, which resulted in a decrease in the size of the SC lymph node to 1 cm. Subsequently, 12 courses of weekly paclitaxel yielded a complete response of the lung and SC lymph node metastasis. Oral administration of S-1 after paclitaxel therapy resulted in no recur- rence for 16 months after the operation.

[Relapse-Free Survival of over 54 Months after ESD Resection in an Elderly Patient Considered to Have Non-Curative Early Gastric Cancer].

According to the Japanese Gastric Cancer Treatment Guideline(GL), radical surgery is recommended as an additional treatment for early gastric cancer(EGC)patients with endoscopic submucosal dissection(ESD)evaluated as non-curative for fear of lymph node metastasis(LNM). However, the reported probability of LNM was approximately 10%. Therefore, the recommendation might be aggressive for elderly patients or those in poor physical conditions. Under this context, surveillance post non-curative ESD has emerged as an acceptable option. We reported a case of an elderly patient who survived EGC for over 54 months as relapse-free with ESD resection evaluated as non-curative. An 84-year-old woman underwent ESD in July 2014 for EGC, which was deemed as non-curative with negative surgical margins. The patient had pre-existing severe bronchial asthma. Given the age and the comorbidities, the patient preferred close surveillance to radical surgery. After 54 months of surveillance, no recurrence of the initial EGC was found. However, during the annual check-ups, 2 metachronous cancers were found in July 2016 and June 2018 respectively. Both metachronous cancers were curatively resected with ESD.

[Endoscopic Submucosal Dissection(ESD)as a "Loco-Regional Cancer Therapy" for Colorectal Tumors].

INTRODUCTION: Endoscopic submucosal dissection(ESD)for colorectal tumors has been covered by the national health insurance system in Japan since April 2012, and is widely used. We analyzed colorectal ESD cases we performed. PATIENTS AND METHODS: We investigated 515 patients with colorectal lesions(580 lesions)for whom ESD was performed between November 2005 and April 2017. Clinicopathological data, technical methods, complications, and outcomes were analyzed. RESULTS: Most tumors were found in the transverse colon(134 lesions). The average diameter was about 26 mm. The largest lesion was 120 mm. The en bloc resection rate was high(96.2%). The average operative time was 51 minutes. Among complications, the number of delayed major bleeding cases was 7(1.2%). Minor perforations occurred in 3 cases(0.5%). The perforation could be closed with endoscopic clips. About 70% of the cases were adenomas, and the remainder were carcinomas. One patient with carcinoma in situ showed a mucosal recurrence 4 months later and received repeat endoscopic treatment. The cure rate was 99.8%. Among 29 deep submucosal invasion cases, additional colectomy was performed in 21; 3 patients had persistent carcinoma in the colonic wall and another patient had lymph node metastasis. CONCLUSIONS: Colorectal ESD can be performed for all sites in the large intestine, and en bloc resection was possible for a large lesion. A good outcome was observed for "Loco-Regional Cancer Therapy" in early colorectal carcinoma.

[A Case of Rectal Neuroendocrine Carcinoma That Developed Two Years after Curative Resection for Sigmoid Colon Cancer].

We report a rare case ofrectal neuroendocrine carcinoma(NEC)following sigmoidectomy of sigmoid colon cancer. NEC of the rectum is a rare disease. It has an extremely poor prognosis and a high potential for malignancy with hematogenous and lymph node metastases. A 90-year-old man who had carcinoma ofthe sigmoid colon 2 years ago was found to have rectal NEC based on endoscopy findings. He underwent the Hartmann operation. Histological and immunohistochemical analyses showed NEC. Four months after the surgery, he developed local recurrence with lymph node metastasis. He was not administered chemotherapy because ofhis old age. Although the patient needed strict outpatient care, he remained symptom-free 4 months after the Hartmann operation.

[A Case of Liver Metastasis from a Primary Adenocarcinoma of the Appendix Presenting Five Months after the Initial Surgery].

A 70-year-old man with lower right quadrant abdominal discomfort was admitted to our hospital. Colonoscopy identified a villous tumor protruding into the cecal lumen from the appendiceal orifice. Abdominal computed tomography(CT)revealed a cecal tumor with a swollen appendix. An appendiceal cecal tumor with obliterative appendicitis was diagnosed, and we performed an appendicectomy with removal of part of the cecum. On pathological examination, well to moderately differentiated adenocarcinoma with infiltration of the proper muscular layer was diagnosed. No additional treatment was given as the patient refused further surgery and chemotherapy. However, a metastatic tumor in S4/8 of the liver was seen on CT 5 months after the initial surgery. A resection of liver metastasis was performed after chemotherapy. We report herein a rare case of primary appendiceal adenocarcinoma reoccurring shortly after surgery.

[Surgery for Lower Intestinal Perforation Due to Peritoneal Dissemination].

INTRODUCTION: we examined the cases in which surgery was performed for the lower intestinal perforation due to peritoneal dissemination in our hospital. SUBJECTS: Four cases of lower intestinal perforation of patients with peritoneal dissemination who underwent emergency operation in our hospital were enrolled. RESULTS: Two males and 2 females patients with median age of 65.5 year old(63-71)were included. The perforated sites were 3 cases of small intestine and 1 case of ascending colon, and the APACHE II score at the visit was 14.5(10-16)points. The surgical procedure was performed in 3 cases of resection of the perforated site and 3 cases of stoma creation. In 2 out of 4 cases, it became difficult to control bacterial peritonitis and died on the 16th postoperative day. One case could discharge hospital and continued BSC, survived 4 months after surgery. CONCLUSION: Although long-term prognosis could not be expected, there were cases in which it was possible to restart the oral intake after surgery or discharge. Surgical treatment might be selected for the lower intestinal perforation due to peritoneal dissemination.

[A Case of Thoracic Esophageal Cancer That Caused Necrosis of a Reconstructed Colon Ten Years after Esophagectomy].

Necrosis of a reconstructed organ after esophageal cancer surgery is a very serious complication that often occurs soon after the surgery. We report a case of emergency surgery that was performed to treat necrosis of a reconstructed colon 10 years after esophagectomy. A 73-year-old man was admitted to our hospital with complaints of chest pain. His history included a proximal gastrectomy for gastric cancer. His present illness includes endoscopic mucosal resection for superficial esophageal cancer in 1995. Subtotal esophagectomy and right colon interposition through the retrosternal route were performed due to a recurrence in the same lesion in 2005. The patient was immediately hospitalized due to chest pain in 2015. An upper gastrointestinal endoscopy revealed extensive necrosis in the colon. He underwent an emergency operation. The surgical operations included reconstructed colonic resection by longitudinal sternotomy, esophagostomy, gastrostomy, and drainage procedure. The patient is currently under rehabilitation at a referral hospital. There has been no report on the occurrence of necrosis in the reconstructed colon 10 years after esophagectomy.

[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.

[The Influence of Immunity, Nutrition, and Physical Function on the Onset of Pneumonia after Colorectal Cancer Resection].

PATIENTS AND METHODS: Four hundred and nineteen patients with colorectal cancer who underwent laparotomy were included in this study. Indicators that reflected immunity, nutrition, and physical function were selected, and risks associated with the presence of postoperative pneumonia were investigated. Cut-off values of factors affecting the occurrence of pneumonia were determined using the receiver-operating characteristic curve approach. RESULTS: Pneumonia was observed in 2.9%of the patients, and PNI(C40.0), CONUT(B2), BMI(<18.5 kg/m2), PS(B1), %VC(<80.0%), and FEV1.0%(<70.0%)were identified as risk factors in multivariate analysis(p<0.05). %VC(<80.0%)was extracted as an independent factor. The cutoff value of %VC was determined to be 80.0%based on the incidence of postoperative pneumonia. CONCLUSION: Low volume in %VC(<80.0%)may be a risk factor for pneumonia after resection of colorectal cancer.

[Multiple Resections for Metastases from Colorectal Cancer].

PURPOSE: We analyzed to clarify an outcome of multiple resections of metastases from colorectal cancer. PATIENTS AND METHOD: Total 7 cases who underwent several resections for metastases from colorectal cancer in Saiseikai Kurihashi Hospital after 2010 were enrolled for analysis. RESULT: Age of patients at the time of the primary site resection was 67(45-78)year-old, including 4males and 3 females. Patients located at cecum/ascending/sigmoid/rectosigmoid/upper rectum were 1/1/2/2/1 respectively. Metachronous metastases were found in 5 patients. There were 1 patient for Stage I , 2 patients for Stage III a and III b each and all Stage III patients received adjuvant chemotherapy. The resected organs were 9 in lung, 8 in liver, 1 case in lymph node, local site and peritoneum and the median resected sites were 3(2-4)lesions. In 17 months median observation periods after latest resection, 5 cases have not been prolapsed including 3 cases with chemotherapy. Two cases were relapsed with unresectble status. One case died for 24 months and one case is under the chemotherapy for 12 months. Five year survival rate was 75% and 2 year prolapse free rate was 66.7%, since the relatively good prognosis was obtained by multiple resections. CONCLUSION: The cases that multiple resections with R0 were able to perform for the metastases were analyzed. Although cases which become finally to be unresectable exist, it is suggested that the relatively good prognosis might be obtained by multiple resections for metastases.

[Prognostic Relevance of Palliative Tumor Resection and Chemotherapy in Stage â £Unresectable Colorectal Cancer].

This study was conducted to evaluate the prognostic factors in patients with unresectable Stage Ⅳ colorectal cancer. One hundred and twenty-five patients who underwent either primary resection or chemotherapy for unresectable Stage Ⅳ colorectal cancer and were treated at our hospital between April 2004 and March 2014 were enrolled this study. In multiple univariate analysis, the overall survival(OS)was significantly longer in the palliative resection and chemotherapy groups. Upon dividing the 125 patients in 3 groups(the intensive chemotherapy group[L-OHP or CPT-11 regimen], extensive chemotherapy group[other regimen], and non-chemotherapy group), the intensive chemotherapy group showed significantly longer OS. Next, upon comparing the patients based on the treatment they received(surgery plus chemotherapy, surgery alone, and chemotherapy alone), the surgery plus chemotherapy group showed longer OS. With both studies combined as 5 groups, only the surgery plus intensive chemotherapy group showed longer OS. This is shown in unresectable Stage Ⅳ cancer patients, wherein resection of the primary lesion in addition to intensive chemotherapy contributes to longer OS.

[A Case of Advanced Gastric Cancer Who Peritoneal Dissemination but Survived over 40 Months with Locoregional Therapies].

Several recent case reports have demonstrated long survival cases of advanced gastric cancer(AGC)patients suffering from peritoneal dissemination(PD)treatedwith effective chemotherapy; however, these AGC patients have poor prognosis in general. We report a case of AGC who hadsurvivedPD over 40 months with locoregional therapies. A 58-year-oldmale underwent distal gastrectomy for AGC with localized PD. Although we recommended postoperative chemotherapy, he chose surveillance as his will. Eighteen months postoperatively, CT scan revealedrecurrence of PD, andPET -CT showedonly one site of recurrent nodule. The patient chose locoregional therapy, ie, resection of the recurrent nodule instead of chemotherapy. Pathological exam confirmedthe recurrence of AGC, andabd ominal lavage cytology was classifiedas V. Even after these pathological findings, the patient refused to receive chemotherapy. At 39 months postoperatively, he developed subileus due to multiple recurrence of PD. At 40 months postoperatively, we performedchemotherapy because locoregional therapy was not supposedto be appropriate for these multiple lesions. However, the patient movedto another hospital after 1 course of chemotherapy because of his continuedrefusal to receive chemotherapy.

[Esophageal Cancer Surgery in Elderly Patients Aged 80 Years or Older].

As the population ages, the elderly are increasingly affected by esophageal cancer. We reviewed the data of elderly patients, 80 years old or older, who underwent surgery for esophageal cancer to evaluate the safety of surgery in this particular patient population. Twenty-two patients aged 80 or above underwent surgery for esophageal cancer in our department. We analyzed their preoperative assessment, concurrent disorders, surgical techniques used, postoperative course, and complications. Median age of the patients was 83 years. Eleven patients had concurrent hypertension, 5 patients had undergone a malignant tumor operation, and 5 patients had concurrent diabetes. Fifteen patients underwent esophagectomy with right thoracotomy and two-field lymph node dissection(LD), 1 patient underwent esophagectomy with right thoracotomy and three-field LD, 2 patients underwent esophagectomy with left thoracoabdominal incision and two-field LD, 2 patients underwent lower esophagectomy and proximal gastrectomy, and 2 patients underwent transhiatal esophagectomy. Postoperative complications occurred in 14 patients(63%); however, no severe pneumonia was noted. Anastomotic leakage was only observed in 1 patient. All patients were discharged with improved conditions. The mean postoperative hospital stay was 39 days. Esophageal cancer surgery can be performed safely in the oldest of elderly patients with appropriate preoperative assessment, selection of the optimal surgical technique, and perioperative care.