Risk factors of "loss of independence" in elderly patients who received gastrectomy for gastric cancer.

OBJECTIVE: The aim of this study was to clarify the risk of loss of independence (LOI) following gastrectomy in elderly patients with gastric cancer (GC). METHODS: In this prospective study, frailty was assessed preoperatively by a frailty index (FI) in 243 patients aged ≥ 65 years who underwent gastrectomy for GC between August 2016 and December 2020. Patients were assigned into two groups (high FI vs. low FI) to investigate frailty and the risk of LOI after gastrectomy for GC. RESULTS: Overall and minor (Clavien-Dindo classification [CD] 1, 2) complication rates were significantly higher in the high FI group, but the two groups had similar rates of major (CD ≥ 3) complications. The frequency of pneumonia was significantly higher in the high FI group. In univariate and multivariate analyses for LOI after surgery, high FI, older age (≥ 75 years), and major (CD ≥ 3) complications were independent risk factors. A risk score assigning 1 point for each of these variables was useful in predicting postoperative LOI (LOI: score 0, 7.4%; score 1, 18.2%; score 2, 43.9%; score 3, 100%; area under the curve [AUC] = 0.765.) CONCLUSIONS: LOI after gastrectomy was independently associated with high FI, older age (≥ 75 years), and major (CD ≥ 3) complications. A simple risk score assigning points for these factors was an accurate predictor of postoperative LOI. We propose that frailty screening should be applied for all elderly GC patients before surgery.

The Cancer Cachexia Index Can Be Used to Prognostically Predict Patients with Gastric Cancer Undergoing Gastrectomy.

INTRODUCTION: Cancer cachexia occurs in cancer patients more frequently as the cancer progresses, with a negative impact on treatment outcomes. In this study, we sought to clarify the clinical impact of a cancer cachexia index (CXI) in patients with gastric cancer (GC) undergoing gastrectomy. METHODS: Between January 2013 and December 2018, we reviewed data from 556 patients treated for GC at our hospital. CXI was calculated using skeletal muscle index (SMI), serum albumin, and neutrophil-lymphocyte ratios (NLR). Patients were divided into high (n = 414) or low CXI (n = 142) groups. We investigated the clinical impact of CXI in patients with GC undergoing gastrectomy. RESULTS: Multivariate analyses of 5-year overall survival (OS) and cancer-specific survival (CSS) rates indicated that a low CXI was independently associated with unfavorable outcomes for patients with GC. In multivariate analyses, SMI was independent predictor of OS but not CSS. NLR was not an independent predictor of either OS or CSS. Complication incidences (≥ Clavien Dindo 3) were non-significantly higher in the low (vs. high) CXI group. CONCLUSION: CXI was a more valuable prognostic biomarker when compared with SMI or NLR in GC patients undergoing gastrectomy. We suggest that patients with low CXI values should be given more comprehensive treatment, including exercise and nutritional therapy to improve clinical outcomes.

[Surgical Resection of Pulmonary Oligometastases of Ampullary Cancer-A Case Report and Review of Seven Cases].

A 62-year-old woman underwent a subtotal stomach-preserving pancreatoduodenectomy for ampullary carcinoma (T3bN0M0, Stage Ⅱb). Histopathologically, the tumor was a tubular adenocarcinoma with mixed features, predominantly the intestinal type, following which adjuvant chemotherapy was not performed. Computed tomography performed 32 months after surgery showed a tumor measuring 6.7 mm in diameter at the apex of the right lung. The tumor had gradually increased in size and measured 10 mm in diameter, 47 months postoperatively. Since other metastatic lesions were absent, partial resection of the right lung under video-assisted thoracic surgery was performed 48 months postoperatively. Histopathological testing confirmed a diagnosis of lung metastasis from the resected specimen of ampullary carcinoma without mediastinal lymph node metastasis. Adjuvant chemotherapy was not performed, and recurrence was not observed even after 53 months following the partial lung resection. Previously, 7 resected cases of solitary lung metastasis from ampullary cancer have been reported. The histopathological sub-type of these 7 cases were intestinal type in 5 and pancreatobiliary type in 2 cases, respectively. No mortality or recurrence was observed for 8-119 months in any of the 7 cases(median, 19 months). In conclusion, owing to the good prognosis, solitary lung metastasis from an ampullary cancer can be classified as an oligometastatic disease, based on the concept proposed by Hellman and Weichselbaum.

[Synchronous Double Primary Non-B, and Non-C Intrahepatic Cholangiocarcinoma and Hepatocellular Carcinoma-A Case Report].

A 78-year-old man without hepatitis virus B or C underwent right hemi-hepatectomy and lymph node dissection for a tumor 5 cm in diameter located in the hepatic hilum of the posterior segment of the liver with portal vein thrombi extending into the main portal trunk and a tumor 1.5 cm in diameter in the peripheral side of segment 5 of the liver. Histopathologically, the former was diagnosed as intrahepatic cholangiocarcinoma and the latter as hepatocellular carcinoma(HCC). Five months after the surgery, intrahepatic and lymph node metastases were diagnosed based on computed tomography(CT); therefore, chemotherapy with S-1 for 3 months and gemcitabine and cisplatin(GC)for 5 months was administered, after which the metastatic lesions were not detected. Nineteen months after the surgery, partial resection of segment 2 of the liver was performed for a tumor 3 cm in diameter, which was diagnosed as HCC histopathologically. Two years after the second surgery, 2 recurrent nodules in the liver in segments 3 and 4 were detected on CT. Platinum-based hepatic arterial infusion chemotherapy(HAIC)and transcatheter arterial chemoembolization(TACE)were performed, and chemotherapy with GC was then administered for 7 months. For a new tumor detected in segment 1 in the liver, TACE was performed 17 months after initial HAIC. Seventy-four months after the initial surgery, 5 new nodules less than 1 cm in diameter were detected, and chemotherapy with sorafenib was administered for 5 months, after which the patient died of coronavirus disease 2019.

[A Case of pStage IB Gastric Cancer Relapsed on Both Pleura and Peritoneum Eight Year after Radical Gastrectomy].

An 86-year-old man presented with upper abdominal pain and was diagnosed with type 0-Ⅲ gastric cancer located at the posterior wall of the upper stomach by upper gastrointestinal endoscopy. Laparoscopic total gastrectomy(D1+)was performed for gastric cancer of cStage Ⅰ. As final pathological diagnosis was pT2N0(0/27)M0H0P0CY0, pStage ⅠB, adjuvant chemotherapy was not administrated. The patient has been alive with no recurrence for 5 years after surgery. 8 years and 1 month after procedure, he visited our hospital with chief complaint of abdominal distention and anorexia. Chest and abdominal CT showed pleural fluid and ascites, but PET-CT could not detect any sites of recurrence. Cytopathology and cell blocks by immunohistochemical staining of ascites proved recurrence of previous gastric cancer. Any treatment was rejected, and the patient died 3 months after recurrence and 8 years and 4 months after gastrectomy. Late recurrence on both pleura and peritoneum of gastric cancer is very rare. We report a case of pStage ⅠB gastric cancer relapsed on both pleura and peritoneum 8 year after radical gastrectomy.

[A Case of Recurrent Gastric Cancer of Multiple Organ Metastasis with Long-Term Survival Due to Multimodal Treatment].

A 67-year-old man was introduced to examine for abnormal findings in physical examination. Upper gastrointestinal endoscopy detected the 3 lesions and diagnosed multiple gastric cancers with biopsy. Laparoscopic total gastrectomy was performed and final pathological diagnosis was pT2N1M0, pStage ⅡA with HER2 positive(3+). Adjuvant chemotherapy was not administrated. CT findings 6 months after procedure showed 2 liver metastases(S6, S7)and laparoscopic partial liver resection was performed. Pathological findings proved the metastasis of previous gastric cancer. Although adjuvant chemotherapy of S-1 was started 2 months after hepatectomy, CT findings showed second recurrences in liver and right adrenal gland. Chemotherapy was changed to S-1 plus cisplatin(SP)plus trastuzumab. AS these recurrence sites and ascites could not be detected by CT after 6 courses, therapeutic effect was judged as clinical CR(cCR)and SP plus trastuzumab was stopped due to side effect. Since then, regular follow-up CT showed preservation of status of cCR without chemotherapy and he has been alive without recurrence for 8 years and 9 months after gastrectomy. We report a case of recurrent gastric cancer of multiple organ metastasis with long-term survival due to multimodal treatment.

[Laparoscopic Liver Resection for Liver Metastasis from Unresectable Pancreatic Ductal Adenocarcinoma Well-Controlled by Chemotherapy-A Case Report].

A 45-year-old man with unresectable locally advanced pancreas head cancer with multiple synchronous liver metastases was treated with gemcitabine plus nab-paclitaxel therapy as a first-line chemotherapy. During 24 months of 30 courses of this therapy, the primary lesion remained stable and liver metastases were completely disappeared on CT. Three months later, however, solitary relapse of liver metastasis occurred in segment 2. Therefore, we changed the chemotherapy regimen to the second-line treatment, FOLFIRINOX. After 3 courses of FOLFIRINOX, the primary lesion was kept well-controlled, but the solitary metastatic liver lesion was enlarged. An interdisciplinary team suggested surgical resection of the liver metastasis to control disease progress. We performed laparoscopic lateral segmentectomy of the liver. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. The patient underwent another round of gemcitabine therapy owing to the good response of the primary pancreatic lesion to this drug. Three years after starting the first-line chemotherapy, the patient is still alive with well-controlled PDAC without distant metastasis. Surgical intervention for liver metastases may be a promising treatment option when unresectable primary PDAC is well controlled by chemotherapy.

[Descending Colon Cancer with Synchronous Solitary Small Intestinal Metastasis-A Case Report].

A 77-year-old man presented with biliary colic and was diagnosed with descending colon cancer and cholelithiasis.During the surgery, a mass was detected in the upper jejunum, located 5 cm from the Treitz ligament on the anal side.Open left hemicolectomy with partial jejunal resection was performed.The mass in the small intestine was diagnosed as solitary small intestinal metastasis of colon cancer through immunohistopathological examination.Isolated intestinal metastases of colorectal cancers are rare.Furthermore, synchronous metastases are rare among these cases.A previous study reported poor prognosis in patients with small intestinal metastasis; therefore, more studies on the small intestinal metastasis of colorectal cancer are necessary.

[A Case of Disturbance of Consciousness Due to Hyperammonemia during Chemotherapy for Metastasis of Sigmoid Colon Cancer].

A 76-year-old woman had underwent 5-fluorouracil(5-FU), oxaliplatin(L-OHP)combination therapy(mFOLFOX6)as first-line chemotherapy for peritoneal recurrence after resection of sigmoid colon cancer. She showed severe general fatigue and disturbance of consciousness on the second day of the 12th course of chemotherapy. Computed tomography of the head detected no abnormal findings in the central nervous system. The laboratory results revealed a marked hyperammonemia. She was diagnosed as a disturbance of consciousness due to hyperammonemia and treated her with branched- chain amino acid solution. Then the disturbance of consciousness resolved on the following day. After changing the regimen of chemotherapy, the disturbance of consciousness was not found. Recently, it has been reported that high-dose 5-FU regimen such as mFOLFOX6 causes hyperammonemia as a rare adverse event. We should take hyperammonemia into account when disturbance of consciousness occurs during high-dose 5-FU chemotherapy.

[Laparoscopic Resection of Solitary Lymph Node Metastasis of Hepatocellular Carcinoma after Transcatheter Arterial Chemoembolization and Percutaneous Locoregional Therapies].

A 75-year-old woman underwent transcatheter chemoembolization(TACE)for 2 small hepatocellular carcinoma(HCC) lesions associated with severe alcoholic liver cirrhosis that necessitated management for ascites. Over 5 years after the initial TACE, she received multidisciplinary therapies with TACE, transcatheter arterial infusion of anticancer agents, percutaneous ethanol injections, or percutaneous radiofrequency ablation performed on 5 occasions for small recurrent HCC lesions. Computed tomography performed after the last therapy for HCC revealed a solitary lymph node swelling(39 mm in diameter) around the common hepatic artery. Magnetic resonance imaging performed 3 months later revealed that the lymph node had enlarged to 45 mm, without recurrence of the primary HCC, and after 4 months, to 60 mm; she then underwent laparoscopic lymph node resection. Histopathological examination of the resected specimen showed HCC metastasis. A recurrent metastatic lymph node(30 mm in diameter)was detected around the common hepatic artery and was resected laparoscopically 17 months postoperatively. Pancreatic head cancer was diagnosed 22 months after the second surgery; however, the patient refused cancer therapy and died 16 months after this diagnosis. No recurrence of the primary HCC or lymph node metastasis was observed over the 38 months after the second surgery.

[A Case of Rupture of Esophageal Varices during a Course of CAPOX with Bevacizumab Therapy for Sigmoid Colon Cancer with Multiple Liver Metastases].

The patient was a 67-year-old man with multiple liver metastases from sigmoid colon cancer and had received capecitabine, oxaliplatin, and bevacizumab(CAPOX plus Bev)combination chemotherapy. After 11 courses of this therapy, he had a rupture of esophageal varices and was treated with endoscopic variceal ligation(EVL). Esophageal varices are rare during the course of oxaliplatin-based chemotherapy. More studies are necessary for early detection of esophageal varices during this therapy.

[A Resected Case of Retroperitoneal Metastasis and Small Bowel Metastasis from HCC].

A 71-year-old man underwent right hemi-hepatectomyfor a hepatocellular carcinoma(HCC)measuring 18 cm in diameter. The pathological diagnosis was poorlydifferentiated HCC. Ten months after the surgery, computed tomographyrevealed a nodule 12mm in diameter in the right lung as well as 2 nodules measuring 19 and 11mm in diameter in the retroperitoneum at the cranial aspect of the left kidney. Four months later, the nodule in the right lung had enlarged to 44 mm, while the 2 nodules in the retroperitoneum had enlarged to 68mm and 34 mm. These nodules were resected and histopathologicallydiagnosed as metastasis from HCC. Twenty-one months after liver resection, computed tomographyrevealed nodules 16 and 25mm in diameter in the retroperitoneum around the urinarybladder and jejunum, respectively. One month later, intussusception resulted from the jejunal tumor. Laparoscopic surgerywas performed for both tumors, which were diagnosed as metastases from HCC. Twenty-five months after liver resection, metastasis from the HCC appeared in the left adrenal grand, at the site of the jejunal anastomosis, and in the fattytissue around the right scapula. Twenty-nine months after liver resection, the patient died of respiratoryfailure from multiple metastases in the left lung.

[A Resected Case of Adenosquamous Carcinoma of Pancreas That Relapsed in Remnant Pancreas].

A 70's man underwent subtotal stomach preserving pancreatoduodenectomy(SSPPD)for pancreatic head cancer. The pathological diagnosis was adenosquamous carcinoma(ASC)of the pancreas. Two months after surgery, a recurrent tumor in the remnant pancreas was confirmed with a CT scan and suspected to be ASC by endoscopic ultrasound-guided fine needle aspiration(EUS-FNA). As the recurrent lesion was limited in the pancreas, total remnant pancreatectomy(TP)was performed 4 months after SSPPD. The final pathological diagnosis was ASC. Two months after TP, liver and para-aortic lymph node metastases were revealed. The patient has been alive for 14 months after SSPPD with chemotherapy. Because of its rarity, it is difficult to implement treatment plans for recurrent ASC in the remnant pancreas.

Side overlap esophagogastrostomy to prevent reflux after proximal gastrectomy.

BACKGROUND: No optimal method of reconstruction for proximal gastrectomy has been established because of problems associated with postoperative reflux and anastomotic stenosis. It is also important that the reconstruction is easily performed laparoscopically because laparoscopic gastrectomy has become widely accepted in recent years. METHODS: We have developed a new method of esophagogastrostomy, side overlap with fundoplication by Yamashita (SOFY). The remnant stomach is fixated to the diaphragmatic crus on the dorsal side of the esophagus. The esophagus and the remnant stomach are overlapped by a length of 5 cm. A linear stapler is inserted in two holes on the left side of the esophageal stump and the anterior gastric wall. The stapler is rotated counterclockwise on its axis and fired. The entry hole is closed, and the right side of the esophagus is fixated to the stomach so that the esophagus sticks flat to the gastric wall. The surgical outcomes of the SOFY method were compared with those of esophagogastrectomy different from SOFY. RESULTS: Thirteen of the 14 patients in the SOFY group were asymptomatic without a proton pump inhibitor, but reflux esophagitis was observed in 5 of the 16 patients in the non-SOFY group and anastomotic stenosis was observed in 3 patients. Contrast enhancement findings in the SOFY group showed inflow of Gastrografin to the remnant stomach was extremely good, and no reflux into the esophagus was observed even with patients in the head-down tilt position. CONCLUSIONS: SOFY can be easily performed laparoscopically and may overcome the problems of postoperative reflux and stenosis.

[A Case of Liver Metastasis from Esophageal Cancer Successfully Treated by Surgical Resection after Chemotherapy with Weekly-Paclitaxel].

A 58-year-old man complaining of dysphagia was admitted to our hospital and diagnosed with esophageal cancer.He underwent thoracoscopic subtotal esophagectomy with 3-field lymph node dissection and reconstruction with a gastric tube created by hand-assisted laparoscopy.The pathological diagnosis was classified as AeLtG, pT3N2M0, pStage III .He was subsequently treated with systemic chemotherapy with 5-fluorouracil and cisplatin.After 2 courses, a single liver metastatic tumor appeared at segment 5.As chemotherapy against the recurrence, weekly-paclitaxel was administered.After 2 courses, the metastatic liver tumor reduced in size.Subsequently, laparoscopic partial liver resection was performed 11 months after first surgery.The pathological finding was negative for malignancy(pathological complete response).

Impact of the Japanese gastric cancer screening system on treatment outcomes in gastric gastrointestinal stromal tumor (GIST): an analysis based on the GIST registry.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) of the stomach are found incidentally during gastric cancer screening in Japan. This study investigated whether the Japanese gastric cancer screening system helps to improve treatment outcomes in gastric GIST based on an analysis of the GIST registry conducted by the Kinki GIST Study Group. METHODS: The registry was designed to collect data on background characteristics, treatment methods, pathologic characteristics, and prognosis of GIST from January 2003 through December 2007 at 40 participating institutions. RESULTS: The study enrolled 672 GIST patients, 482 of whom had gastric GIST. According to the modified National Institutes of Health consensus criteria, 22.6 % of the patients were classified as high risk for recurrence, 18.5 % as intermediate risk, 35.9 % as low risk, and 13.9 % as very low risk. After exclusion of the patients inevaluable for treatment outcome, the study included 137 symptomatic patients (symptomatic group) and 147 asymptomatic patients (asymptomatic group). The diagnosis of the asymptomatic patients was determined through gastric cancer screening. The median tumor size in the asymptomatic group was significantly smaller than in the symptomatic group (3.5 vs. 5.3 cm; P < 0.0001). The 5-year recurrence-free survival rate in the asymptomatic high-risk patients (72.4 %) was lower than in their symptomatic counterparts (46.3 %) (P = 0.017). More patients in the asymptomatic group underwent laparoscopic surgery (42.2 vs. 27.2 %; P = 0.0081). CONCLUSIONS: By identifying asymptomatic patients, the Japanese gastric cancer screening system contributes to early detection of gastric GIST and favorable treatment outcomes.

Prognostic significance of the preoperative serum C-reactive protein level in patients with stage IV colorectal cancer.

PURPOSE: Previous studies have revealed that an elevated preoperative serum C-reactive protein (CRP) level is associated with a poor prognosis in patients with various malignant tumors. The aim of this study was to determine the clinical significance of the preoperative serum CRP level in patients with stage IV colorectal cancer. METHODS: We enrolled 144 patients who underwent surgery for stage IV colorectal cancer. A total of 53 patients with a serum CRP level of ≥ 1.0 mg/dl were classified as the high CRP individuals. The association between the preoperative serum CRP level and survival was retrospectively assessed. RESULTS: The cancer-specific survival of the patients with a high CRP level was significantly worse than that of the patients with a low CRP level. A multivariate analysis indicated that the curability (non-curative surgery), the number of organs with metastasis (more than one organ), the tumor diameter (≥ 5 cm), lymphatic involvement, histological differentiation (non-differentiated) and a high CRP level (≥ 1.0 mg/dl) were independent risk factors for a poor survival. CONCLUSIONS: A high preoperative serum CRP level is a convenient biomarker for identifying patients with a poor prognosis for stage IV colorectal cancer.

[A Case of Multiple HCC with Vp2 and Vv3 Invasion Controlled by Multidisciplinary Treatment Including Surgery].

The prognosis of HCC with vascular invasion is dismal, but surgery is elected when the hepatic reserve is adequate. The case involved a 68-year-old male HCV carrier. A 10 cm diameter tumor occupying the central 2 segments of the liver and liver metastasis in the left lobe were detected. The patient was diagnosed with multiple HCC with severe vascular invasion of Vp2 and Vv3. The tumor shrunk dramatically after starting HAIC therapy with cisplatin and oral administration of sorafenib. A laparoscopic partial hepatectomy was performed for the viable lesion. The tumor showed almost complete coagulative necrosis. Multiple hepatic metastases were found 4 months after surgery, but the tumor was under control at 25 months after the first HAIC due to HAIC, oral administration of sorafenib, and RFA. An improved prognosis for multiple HCC with severe vascular invasion can be expected by performing multidisciplinary treatments including surgery.

[A clinical study of fulminant amebic colitis].

The administration of metronidazole is generally effective to treat amebic colitis. Fulminant amebic colitis is relatively rare, and it is associated with a high mortality rate. Three cases of fulminant amebic colitis were diagnosed in our hospital between 1993 and 2014. One of these patients died despite our efforts. Amebic colitis often presents with no obvious risk factors and with atypical clinical symptoms. Therefore, the diagnosis of amebic colitis can be difficult. Early diagnosis is the most important factor in successful treatment of fulminant amebic colitis. The present cases demonstrate that it is important to consider the possibility of amebic colitis during evaluation of the acute abdomen.

Outcome of sentinel lymph node biopsy in breast cancer using dye alone: a single center review with a median follow-up of 5 years.

PURPOSE: Various techniques are used for sentinel lymph node biopsy (SLNB) in breast cancer. While subareolar injection with dye alone is a relatively easy method, few studies have reported the outcome with a follow-up period. This study presents our results of SLNB using dye alone. METHODS: Between November 2002 and December 2010, 701 patients with breast cancer underwent SLNB using subareolar injection of indocyanine green or indigo carmine. Sentinel lymph node (SLN)-negative patients were followed without axillary lymph node dissection (ALND). RESULTS: SLNs were detected in 654 of 701 patients (93.3%), and the rate increased to 98.1% over the course of the study. The mean number of SLNs removed was 1.5. There was no significant difference in the detection rate between two dyes. No adverse events resulted from the injection of dyes. Of the 654 patients, 136 (20.8%) had SLN metastasis. Five hundred patients were followed without ALND. Thirty-six patients experienced disease relapse during a median follow-up of 60 months. Thirteen patients (2.6%) had regional lymph node relapse, and eight of them could undergo salvage lymph node dissection. The 5-year disease-free and overall survival rates were 92.4 and 96.1 %, respectively. CONCLUSION: SLNB using subareolar injection with dye alone was safe and feasible even after a long follow-up.