Predictors of 1-year mortality after gastrectomy for gastric cancer.

PURPOSE: One-year mortality is important for referrals to specialist palliative care or advance care planning (ACP). This helps optimize comfort for those who cannot be cured or have a lower life expectancy. Few studies have investigated the risk factors for 1-year mortality after gastrectomy for gastric cancer (GC). METHODS: A total of 1415 patients with gastric cancer (stages I-IV) who underwent gastrectomy between 2005 and 2020 were included. The patients were randomly assigned to the investigation group (n = 850) and validation group (n = 565) in a 3:2 ratio. In the investigation group, significant independent prognostic factors for predicting 1-year survival were identified. A scoring system for predicting 1-year mortality was developed which was validated in the validation group. RESULTS: Multivariate analysis revealed that the following seven variables were significant independent factors for 1-year survival: age ≧78, preoperative comorbidity, total gastrectomy, postoperative complication (Clavien-Dindo classification CD â‰§ 3a), stage III and IV, and R2 resection. While developing a 1-year mortality score (OMS), an age ≧78 was scored 2, preoperative comorbidity, total gastrectomy, and postoperative complication (CD â‰§ 3a) were scored 1, and stage III, IV, and R2-resection were scored 2, 3, and 3, respectively. OMS 3 had a sensitivity of 91% and a specificity of 66% for predicting death within 1 year. In the validation group, OMS 5 had a sensitivity of 55% and a specificity of 93% for predicting death within 1 year. CONCLUSIONS: OMS may provide important information and help surgeons select the timing of ACP in patients with GC.

Local excision versus radical surgery for anal squamous cell carcinoma: a multicenter study in Japan.

BACKGROUND: The standard treatment for anal squamous cell carcinoma is chemoradiation therapy (CRT), but there is a possibility of over-treatment for early-stage disease. cTisN0 and cT1N0 disease is currently indicated for local excision, but it is unclear whether the indication of local excision can be expanded to cT2N0 disease. METHODS: 126 patients with cTis-T2N0 anal cancer treated at 47 centers in Japan between 1991 and 2015 were included. Patients were first classified into the CRT group and surgical therapy group according to the initial therapy, and the latter was further divided into local excision (LE) and radical surgery (RS) groups. We compared prognoses among the groups, and analyzed risk factors for recurrence after local excision. RESULTS: The CRT group (n = 87) and surgical therapy group (n = 39) showed no difference in relapse-free survival (p = 0.29) and overall survival (p = 0.94). Relapse-free survival curves in the LE (n = 23) and RS groups (n = 16) overlapped for the initial 3 years, but the curve for the LE group went lower beyond (p = 0.33). By contrast, there was no difference in overall survival between the two groups (p = 0.98). In the LE group, the majority of recurrences distributed in locoregional areas, which could be managed by salvage treatments. Muscular invasion was associated with recurrence after local excision (hazard ratio: 22.91, p = 0.011). CONCLUSION: LE may be applied to selected patients with anal cancer of cTis-T2N0 stage. Given the high risk of recurrence in cases with muscular invasion, it may be important to consider close surveillance and additional treatment in such patients.

Preoperative chemoradiotherapy using tegafur/uracil, oral leucovorin, and irinotecan (TEGAFIRI) followed by oxaliplatin-based chemotherapy as total neoadjuvant therapy for locally advanced rectal cancer: the study protocol for a phase II trial.

BACKGROUND: Total neoadjuvant therapy (TNT) is a novel treatment strategy that is an alternative to preoperative chemoradiotherapy (CRT) for locally advanced rectal cancer (LARC). However, an optimal protocol for TNT has not yet been established. The present study will be an open-label, single-arm, single-center trial to develop a new protocol. METHODS: Thirty LARC patients at high risk of distant metastasis will receive CRT consisting of long-course radiation, concurrent with tegafur/uracil, oral leucovorin, irinotecan (TEGAFIRI), followed by mFOLFOX-6 or CAPOX before undergoing surgery. DISCUSSION: Since previous findings showed a high percentage of grade 3-4 adverse events with the TEGAFIRI regimen for CRT and TNT, the primary outcome of this study will be safety and feasibility. Our regimen for CRT consists of the biweekly administration of irinotecan for good patient compliance. The novel combination approach of this treatment may improve the long-term outcomes of LARC. TRIAL REGISTRATION: Japan Registry of Clinical Trials jRCTs031210660.

Clinical features and risk factors for appendiceal diverticulitis: a comparative study with acute appendicitis.

PURPOSE: Despite their similar clinical characteristics, appendiceal diverticulitis (AD) and acute appendicitis (AA) are pathologically distinct. This study compared the clinical features of AD and AA and identified relevant risk factors. METHODS: Patients who underwent appendectomy with a preoperative diagnosis of either AD or AA were categorized based on histopathological findings. The two groups were compared in terms of various clinical factors. RESULTS: Among the 854 patients included in the study, a histopathological evaluation revealed 49 and 805 cases of AD and AA, respectively. A univariate analysis demonstrated that AD was more prevalent than AA among older, taller, and heavier males. A multivariate analysis revealed that male sex, a white blood cell (WBC) count < 13.5 × 103/µL, an eosinophil count ≥ 0.4%, and a mean corpuscular volume (MCV) ≥ 91.6 fL were significant factors differentiating AD from AA. In addition, pathological AD emerged as an independent risk factor for abscess and/or perforation. CONCLUSIONS: AD was associated with an older age, robust physique, and significant risk of abscess and/or perforation despite a low WBC count. In addition to imaging modalities, the preoperative factors of male sex, a WBC count < 13.5 × 103/µL, an eosinophil count ≥ 0.4%, and a MCV ≥ 91.6 fL may be useful for distinguishing AD from AA.

Optimal cutoff value of preoperative CEA and CA19-9 for prognostic significance in patients with stage II/III colon cancer.

PURPOSE: This unicentric, retrospective cohort study aimed to identify the optimal cutoff values of preoperative serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) for the prognosis in patients with stage II/III colon cancer. METHODS: After excluding 43 patients with CA19-9 levels < 0.2 U/mL, 588 were included. Receiver operating characteristic curves were constructed to determine the optimal cutoff values of CEA and CA 19-9 for disease relapse. RESULTS: The median CEA and CA19-9 values were 3.6 (interquartile range: 2.1-7.2 ng/mL) and 14.3 (interquartile range: 8.1-30.0) U/mL, respectively. The optimal cutoff values of CEA and CA19-9 were 5.4 ng/mL and 22.4 U/mL, respectively. A multivariate analysis of relapse-free survival (RFS) showed that cancer stage, CEA, and CA19-9 were significant independent factors. The RFS of patients with stages II and III colon cancer was significantly stratified by CEA (< 5.4/ ≥ 5.4 ng/mL) and CA19-9 (< 22.4/ ≥ 22.4 U/mL). Prognostication based on the reference values (< 5.0 ng/mL for CEA and < 37.0 U/mL for CA19-9) was less significant than that based on the optimal cutoff values. Both elevated CEA and CA19-9 had no value dependency on RFS: RFS curves were similar between extremely elevated CEA (≥ 54.0 ng/ml) and intermediate CEA (5.4-54.0 ng/ml) and between extremely elevated CA19-9 (≥ 224.0 U/ml) and intermediate CA19-9 (22.4-224.0 U/ml). CONCLUSION: The optimal cutoff values of preoperative CEA and CA19-9 for RFS were 5.4 ng/ml and 22.4 U/mL, respectively, in patients with stages II and III colon cancer. Further relapse risk stratification is possible using these values.

Late complications associated with totally implantable venous access port implantation via the internal jugular vein.

PURPOSE: Several studies have analyzed late complications associated with totally implantable venous access ports (TIVAP) implantation via the internal jugular vein (IJV); however, the reported results are inconclusive. The aim of the study is to elucidate the characteristics and risk factors of late complications associated with TIVAP implantation via the IJV. METHODS: The study included 482 patients who underwent TIVAP implantation for long-term chemotherapy and/or nutritional support between April 2012 and December 2017. Most patients (95.2%) had malignant diseases. Events requiring TIVAP removal were defined as TIVAP-related complications. RESULTS: The median TIVAP and global follow-ups were 319 days (IQR 152-661) and 218,971 catheter days, respectively. The 3-year cumulative TIVAP availability rate was 70%. There were 44 complications (incidence of 9.1%; 0.201 complications/1000 catheter days). Infectious, catheter-related, and port-related complications occurred in 21, 14, and 9 patients, respectively with infectious complications occurring earlier and more frequently than catheter- and port-related complications. Multivariate analysis revealed that age < 65 years and presence of non-gastrointestinal diseases were significant unfavorable factors for TIVAP-related complications. Patients with 1 and 2 of these factors had an elevated risk (2.2 and 5.4 times, respectively) compared with those without. CONCLUSIONS: Among the late complications associated with TIVAP implantation via the IJV, infectious complications occur earlier and more frequently than catheter- and port-related complications. Patients with an age < 65 years and having non-gastrointestinal diseases have a significantly high risk of TIVAP-related complications.

Chronological Changes in Appendiceal Pathology Among Patients Who Underwent Appendectomy for Suspected Acute Appendicitis.

BACKGROUND: Given recent advances in imaging and the development of diagnostic parameters, the rate of unnecessary appendectomy (i.e., negative appendectomy) has been decreasing. However, the incidence of acute appendicitis (AA) in elderly patients is rising due to the aging of society. We aimed to identify chronological changes in demographics and appendiceal pathology among patients who underwent appendectomy for suspected AA. METHODS: Data from 881 patients who underwent appendectomy for suspected AA between January 2006 and December 2017 were analyzed. The final diagnosis was based on intraoperative findings, pathological reports, and clinical course. Negative appendectomy was defined as the absence of appendiceal diseases including inflammation, fibrosis, and neoplasm. We compared demographics and appendiceal pathology between early (2006-2011) and late study phases (2012-2017). RESULTS: The mean age of patients with pathologically proven AA (n = 761) was significantly greater in the late phase than in the early phase (38.6 ± 19.8 years vs. 44.0 ± 20.3 years, p = 0.0002), and the ratio of patients with AA aged ≧ 75 years was also increased (from 5.6 to 8.6%, p = 0.1120). The incidences of complicated appendicitis (defined as perforated or gangrenous appendicitis) and appendiceal diverticulitis (AD) were increased in the late phase compared to those in the early phase (61.3% vs. 77.2% and 3.7% vs. 6.6%, respectively). The negative appendectomy rate was significantly reduced in the late phase compared to that in the early phase (10.0% vs. 2.5%, p < 0.0001). CONCLUSIONS: During a 12-year period, the mean age of patients with AA and the incidences of complicated appendicitis and AD increased, whereas the negative appendectomy rate decreased.

Clinical and prognostic differences between surgically resected right-sided and left-sided colorectal cancer.

PURPOSE: A growing body of evidence suggests that right-sided colorectal cancer (RCRC) differs from left-sided colorectal cancer (LCRC) in certain clinicopathological features. Therefore, we investigated the difference between RCRC and LCRC in a series of 899 patients. METHODS: We reviewed data retrospectively, from 899 patients who underwent R0-resection for stage II and III CRC and compared the clinicopathological factors between patients with RCRC and LCRC. RESULTS: The patients with RCRC tended to be older, more likely female, with a larger tumor, higher pathological T stage, and a greater proportion of their tumors were poorly differentiated adenocarcinoma, mucinous adenocarcinoma, or signet ring cell carcinoma than the patients with LCRC,. Recurrence-free survival (RFS) of the patients with RCRC tended to be higher than that of the patients with LCRC and was significantly better among patients with stage II cancer. The overall survival (OS) was similar for patients with RCRC and LCRC, irrespective of cancer stage. CONCLUSION: Compared with the patients with LCRC, those with RCRC had several oncologically unfavorable factors, with better RFS in stage II and similar OS in stages II and III. These results suggest that the biological aggressiveness of RCRC is lower than that of LCRC in stage II; however, it can increase after relapse.

Overweight or Obesity is an Unfavorable Long-Term Prognostic Factor for Patients who Underwent Gastrectomy for Stage II/III Gastric Cancer.

BACKGROUND: Obesity has been reported to be a prognostic factor for many diseases in epidemiological studies; however, the results of studies examining the relationship between obesity and gastric cancer (GC) prognosis are inconsistent. METHODS: A total of 460 patients with Stage II and III GC who underwent open R0 gastrectomy were included. Age, sex, body mass index (BMI classified into < 18.5, 18.5-25, and ≥ 25 kg/m2), stage, and postoperative adjuvant chemotherapy were analyzed to investigate the correlation with relapse-free survival (RFS). RESULTS: Five-year RFS was 51% for the study patients. Five-year RFS values were 47.6%, 54.3%, and 40.1% for patients with BMI < 18.5, 18.5-25, and ≥ 25 kg/m2, respectively. The forest plot for relapse risk according to BMI showed a U shape. Multivariate analysis for RFS showed significant differences in stage and BMI; the hazard ratio for recurrence in patients with BMI ≥ 25 kg/m2 was 1.42 (95% confidence interval: 1.01-2.02, p = 0.0423) with reference to patients with BMI < 25 kg/m2. BMI ≥ 25.0 was associated with longer operation times, more blood loss, fewer lymph nodes dissected, more frequent postoperative surgical site infection, and intra-abdominal abscesses. CONCLUSIONS: BMI ≥ 25 kg/m2 is an unfavorable prognostic factor for patients who underwent gastrectomy for Stage II and III GC.

The mean corpuscular volume as a prognostic factor for colorectal cancer.

PURPOSE: The aim of the present study was to identify the factors investigated during routine blood examinations which can predict the disease outcome independent of the tumor stage. METHODS: Data from 1174 patients with stage I, II, and III CRC who underwent R0 resection were included. We investigated the correlations between the preoperative routine blood examination data, and clinicopathological factors, and disease-free survival (DFS) using univariate and multivariate analyses. RESULTS: The univariate analysis showed that tumor location, tumor stage, CRP, serum albumin, creatine kinase, neutrophil-to-lymphocyte ratio, red blood cell count, mean corpuscular volume (MCV), and the administration of postoperative adjuvant chemotherapy were significantly correlated with the DFS. The multivariate analysis of the factors associated with the DFS showed that stage and MCV were significant factors; an MCV of <80 fL was associated with a superior DFS in comparison to an MCV of 80-100 fL (hazard ratio: 0.31, 95% confidence interval: 0.13-0.61, p = 0.0003). The DFS in patients with an MCV of <80 fL was superior to that in patients with an MCV of ≥80 fL, irrespective of whether the patients underwent postoperative adjuvant chemotherapy. CONCLUSION: MCV was a prognostic factor for the DFS, independent of the tumor stage, in CRC patients who underwent R0 resection.

Effects of SMYD2-mediated EML4-ALK methylation on the signaling pathway and growth in non-small-cell lung cancer cells.

A specific subtype of non-small-cell lung cancer (NSCLC) characterized with an EML4-ALK fusion gene, which drives constitutive oncogenic activation of anaplastic lymphoma kinase (ALK), shows a good clinical response to ALK inhibitors. We have reported multiple examples implying the biological significance of methylation on non-histone proteins including oncogenic kinases in human carcinogenesis. Through the process to search substrates for various methyltransferases using an in vitro methyltransferase assay, we found that a lysine methyltransferase, SET and MYND domain-containing 2 (SMYD2), could methylate lysine residues 1451, 1455, and 1610 in ALK protein. Knockdown of SMYD2 as well as treatment with a SMYD2 inhibitor in two NSCLC cell lines with an EML4-ALK gene significantly attenuated the phosphorylation levels of the EML4-ALK protein. Substitutions of each of these three lysine residues to an alanine partially or almost completely diminished in vitro methylation of ALK. In addition, we found that exogenous introduction of EML4-ALK protein with the substitution of lysine 1610 to an alanine in these two cell lines reduced the phosphorylation levels of AKT, one of the downstream oncogenic molecules in the EML4-ALK pathway, and suppressed the growth of the two cell lines. We further showed that the combination of a SMYD2 inhibitor and an ALK inhibitor additively suppressed the growth of these two NSCLC cells, compared with single-agent treatment. Our results shed light on a novel mechanism that modulates the kinase activity of the ALK fused gene product and imply that SMYD2-mediated ALK methylation might be a promising target for development of a novel class of treatment for tumors with the ALK fused gene.

[Secondary Dementia Due to Leptomeningeal Metastasis of Breast Cancer Improved by Whole Brain Radiation].

A 62-year-old woman received chemotherapy for breast cancer with bone metastasis and malignant pleural and pericardial effusion. She was examined by imaging for progressive cognitive impairment and headache. Enhanced MRI findings showed multiple solid tumors on brain surface, and brain perfusion scintigraphy showed blood flow decrease in both parietal lobes. She was diagnosed with secondary dementia due to leptomeningeal metastases of breast cancer, and whole brain external irradiation was performed(30 Gy/15 Fr). After treatment, multiple tumors were decreased in size and her cognitive impair- ment was improved.

MRI and FDG-PET for assessment of response to neoadjuvant chemotherapy in locally advanced rectal cancer.

BACKGROUND: The purpose of this study was to assess the value of magnetic resonance imaging (MRI) and additional (18)F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) for tumor response to neoadjuvant chemotherapy (NAC) in patients with locally advanced rectal cancer (LARC). METHODS: Data on 40 patients with LARC, who were treated with NAC and underwent MRI and FDG-PET/CT before and after NAC, were analyzed retrospectively. Surgery was performed at a median of 6 weeks after NAC and the images were compared with the histological findings. The tumor regression grade 3/4 was classified as a responder. RESULTS: Sixteen patients were pathological responders. Receiver operating characteristic (ROC) analysis revealed that MRI total volume after NAC (MRI-TV2) and ΔMRI-TV had the highest performance to assess responders (area under the ROC curve [AUC] 0.849 and AUC 0.853, respectively). The reduction rate of the maximum standardized uptake value (ΔSUVmax) was also an informative factor (AUC 0.719). There seems no added value of adding FDG-PET/CT to MRI-TV2 and ΔMRI-TV in assessment of NAC responders judging from changes in AUC (AUC of ΔSUVmax and MRI-TV2 was 0.844, and AUC of ΔSUVmax and ΔMRI-TV was 0.846). CONCLUSIONS: MRI-TV2 and ΔMRI-TV were the most accurate factors to assess pathological response to NAC. Although ΔSUVmax by itself was also informative, the addition of FDG-PET/CT to MRI did not improve performance. Patients with LARC who were treated by induction chemotherapy should receive an MRI examination before and after NAC to assess treatment response. A more than 70 % volume reduction shown by MRI volumetry may justify the omission of subsequent radiotherapy.

Postoperative complications following neoadjuvant bevacizumab treatment for advanced colorectal cancer.

PURPOSES: Attempts have been made to use bevacizumab (BEV) in an adjuvant or neoadjuvant setting. However, BEV is known to cause various adverse events, and the safety of neoadjuvant BEV has not yet been fully evaluated. This study assessed the postoperative complications in patients receiving neoadjuvant BEV for colorectal cancer. METHODS: The data for 78 patients with resectable advanced or metastatic colorectal cancer who received neoadjuvant BEV followed by surgical resection were retrospectively analyzed. RESULTS: The median interval between the last BEV dose and surgery was 9 weeks. The most common postoperative complication was pelvic sepsis, which occurred in 11 patients (14 %). A biliary fistula developed in four of 23 patients who underwent liver resection. Anastomotic leakage occurred in six of 24 patients with a colorectal anastomosis, four of whom required re-laparotomy. In a univariate analysis, male gender and a greater intraoperative blood loss were associated with postoperative complications of any grade. Colorectal anastomosis was a risk factor for major complications. In a multivariate analysis, intraoperative blood loss was an independent risk factor for postoperative complications of any grade (HR 6.338; P = 0.003). With regard to major postoperative complications, colorectal primary anastomosis was the only independent predictive risk factor (HR 8.285; P = 0.013). CONCLUSIONS: In patients with colorectal cancer who underwent elective surgery after BEV treatment, the interval between BEV and surgery was not a risk factor for postoperative complications (based on a median interval of 9 weeks). Colorectal primary anastomosis was the only independent risk factor for major postoperative complications.

Cowden syndrome complicated by a gastrointestinal stromal tumor.

To our knowledge, this is the first report of Cowden syndrome complicated by a gastrointestinal stromal tumor (GIST) of the small bowel. A 42-year-old female patient was found to have an abdominal mass that was diagnosed as the cause of anemia and was surgically extracted. The surgical specimen was found to be a GIST. During the same period, the patient underwent an endoscopic examination of the entire gastrointestinal tract. She was also diagnosed as having Cowden syndrome based on gastrointestinal polyps and skin, thyroid and breast lesions. Cowden syndrome is associated with germline mutations in the tumorsuppressor gene PTEN. PTEN expression may be essential to tumor growth and is a predictive biomarker of the prognosis of both diseases. The present report of such a case is expected to further the analysis of Cowden syndrome.

[Concept of perihilar cholangiocarcinoma in the General Rules for Clinical and Pathological Studies on Cancer of the Biliary Tract, 6th edition].

Hilar cholangiocarcinoma is clinically characterized by biliary obstruction in the porta hepatis. Because the boundary between the intrahepatic and extrahepatic bile duct is unclear, hilar cholangiocarcinoma can potentially arise from both ducts. Therefore, the definition of hilar cholangiocarcinoma remains under debate. In November 2013, the 6th edition of the General Rules for Clinical and Pathological Studies on Cancer of the Biliary Tract was released, following the American Joint Committee on Cancer (AJCC) or International Union Against Cancer (UICC) TNM system. In that edition, as an alternative to "hilar cholangiocarcinoma," the new term "perihilar cholangiocarcinoma" is defined as cholangiocarcinoma involving the perihilar bile duct, despite the presence or absence of a significant liver mass component. This definition clearly indicates that some intrahepatic as well as extrahepatic perihilar tumors are involved in the perihilar tumor category. From the clinical point of view, there is no need for a differential diagnosis between intrahepatic or extrahepatic tumors therefore, the new definition is readily applicable in multidisciplinary team management. Japanese clinicians were previously required to distinguish between the proper use of the AJCC/UICC and the Japanese staging systems, but now the current revision will allow the more convenient use of a single, globally standardized staging system in daily practice.

Neoadjuvant oxaliplatin and capecitabine and bevacizumab without radiotherapy for poor-risk rectal cancer: N-SOG 03 Phase II trial.

OBJECTIVE: This Phase II trial was designed to evaluate the safety and efficacy of neoadjuvant oxaliplatin and capecitabine and bevacizumab without radiotherapy in patients with poor-risk rectal cancer. METHODS: Patients with magnetic resonance imaging-defined poor-risk rectal cancer received neoadjuvant oxaliplatin and capecitabine and bevacizumab followed by total mesorectal excision or more extensive surgery. RESULTS: Between February 2010 and December 2011, 32 patients were enrolled in this study. The completion rate of the scheduled chemotherapy was 91%. Reasons for withdrawal were refusal to continue therapy in two patients and disease progression in one, with two of these three patients not undergoing surgery. Among the 29 patients who completed the scheduled chemotherapy, one refused surgery within 8 weeks after the completion of chemotherapy, which was the period stipulated by the protocol, and another had rectal perforation, requiring urgent laparotomy. As a result, the completion rate of this experimental treatment was 84%. Of the 30 patients who underwent surgery, the R0 resection rate was 90% and a postoperative complication occurred in 43%. A pathological complete response was observed in 13% and good tumor regression was exhibited in 37%. CONCLUSIONS: Neoadjuvant oxaliplatin and capecitabine plus bevacizumab for poor-risk rectal cancer caused a high rate of anastomotic leakage and experienced a case with perforation during chemotherapy, both of which were bevacizumab-related toxicity. Although the short-term results with the completion rate of 84.4% and the pathological complete response rate of 13.3% were satisfactory, we have to reconsider the necessity of bevacizumab in neoadjuvant chemotherapy (UMIN number, 000003507).

Combination therapy with single incision laparoscopic surgery and double-balloon endoscopy for small intestinal bleeding: report of three cases.

The clinical introduction of double-balloon endoscopy (DBE) has brought about a revolution in the diagnosis and the treatment of diseases of the small intestine. DBE allows not only direct observation of the entire small intestine, but also interventional therapies, tissue sampling and India ink marking (tattooing). Single incision laparoscopic surgery (SILS) was developed from conventional laparoscopic surgery to further reduce the degree of invasiveness. SILS requires only one umbilical incision, thus resulting in almost scarless surgery. This report presents three cases of small intestinal bleeding successfully treated by SILS following tattooing under DBE. The average operative time was 67 min and average blood loss was 5 ml. All patients immediately recovered without any complications. SILS, in conjunction with presurgical tattooing by DBE for small intestinal bleeding is considered to be an ideal approach in terms of minimal surgical trauma and aesthetics.

[A case of mediastinal lymph node gastric cancer recurrence during S-1 adjuvant therapy successfully treated with cisplatin + capecitabine as second-line chemotherapy].

S-1 adjuvant chemotherapy following radical surgery has been the standard therapy for the pStage II/III gastric cancer in Japan. However, there are few reports regarding treatment for gastric cancer recurrence during S-1 therapy. Here, we present a case of recurrent gastric cancer during S-1 adjuvant therapy that showed partial response to CDDP + capecitabine therapy. A 72-year-old man was diagnosed as having gastric cancer. We performed a distal gastrectomy+D2 dissection, with Roux-en Y reconstruction. The patient was treated with S-1 for adjuvant chemotherapy. Six months after operation, multiple mediastinal lymph node recurrence developed. CDDP + CPT-11 was applied for two courses as first-line treatment for the recurrence. However, the disease progressed with worsening mediastinal lymph node metastases (progressive disease). After two courses of CDDP + capecitabine as second-line chemotherapy, the recurrence site became smaller. After five courses, partial response (PR) had been achieved. Two years and five months after gastrectomy, capecitabine monotherapy was applied as third-line chemotherapy.

Significance of Preoperative Pulmonary Function on Short- and Long-Term Outcomes Following Gastrectomy for Gastric Cancer.

BACKGROUND: Preoperative pulmonary function assessment is useful for selecting surgical candidates and operative methods and assessing the risk of postoperative pulmonary complications. However, few studies have investigated the relationship between preoperative pulmonary function and short- and long-term outcomes in patients who underwent gastrectomy for gastric cancer. METHODS: Of the 1040 patients with gastric cancer (stages I-III) who had undergone R0 gastrectomy between 2009 and 2020, 750 who underwent preoperative spirometry were included. Restrictive ventilatory impairment was defined as a vital capacity of the predicted value (%VC) < 80%, while obstructive ventilatory impairment was defined as forced expiratory volume in one second (FEV1%) < 70%. Postoperative complications were assessed using the Clavien-Dindo (CD) classification. The relationship between clinical factors, including %VC, FEV1%, severe postoperative complications (CD ≥ 3b), overall survival (OS), and relapse-free survival, were assessed. RESULTS: The mean age of the 750 patients was 68 ± 10.5 years. Severe postoperative complications were observed in 25 (3.3%) patients and were significantly associated with FEV1% < 70% in the univariate analysis. The 5-year OS was 72.5%. Multivariate analysis showed that the cancer stage, age > 75 years, preoperative comorbidities, %VC < 80%, total gastrectomy, severe postoperative complications, and postoperative adjuvant chemotherapy were the significant independent factors affecting OS. Pneumonia was significantly associated with %VC < 80%. CONCLUSIONS: FEV1% < 70%was associated with the development of severe postoperative complications, while %VC < 80% was associated with poor OS independent of the cancer stage because of death from pneumonia. Spirometry helps surgeons and patients discuss the risks and benefits of surgery.