Clinical Outcome of Additional Esophagectomy After Endoscopic Treatment for Superficial Esophageal Cancer.

BACKGROUND: Endoscopic treatment is one of the options for superficial esophageal cancer, but additional therapy such as esophagectomy or chemoradiotherapy (CRT) is sometimes needed due to noncurative resection. However, the outcome of additional therapy after endoscopic treatment has not been fully evaluated. METHODS: In 160 patients with superficial esophageal cancer, including 37 patients who underwent esophagectomy and 123 patients who underwent CRT after noncurative endoscopic resection, outcomes were investigated. RESULTS: The CRT group included more elderly patients than the surgery group, although there were no significant differences in tumor depth or lymphovascular invasion between the two groups. Overall survival was significantly better in the surgery group than in the CRT group (5-year overall survival: 94.3% vs. 79.9%; p = 0.039). Two (5.4%) patients in the surgery group who developed lymph node recurrence achieved complete response by chemotherapy or CRT, and 9 of 16 patients (13.0%) in the CRT group who developed recurrence underwent salvage esophagectomy or lymphadenectomy. As a result, the 5-year cause-specific survival was 100% in the surgery group and 92.8% in the CRT group. SM2 invasion (≥ SM2) was significantly associated with recurrence after CRT, while lymphatic invasion was associated with lymph node metastasis in the surgery group. CONCLUSION: Endoscopic treatment combined with esophagectomy or CRT can be a curative treatment option in patients with superficial esophageal cancer. However, esophagectomy rather than CRT should be recommended for patients with massive submucosal tumor invasion due to the risk of recurrence after CRT.

[A case of successful treatment with intra-arterial infusion chemotherapy with cisplatin for advanced hepatocellular carcinoma with portal vein tumor thrombus].

A 69-year-old man with recurrent hepatocellular carcinoma (HCC) in S7/8 after radiofrequency ablation therapy (RFA)was admitted to our hospital. Serum alpha-fetoprotein and protein induced by vitamin K absence or antagonists (PIVKA-II) were elevated to 367 ng/mL and 18,973 mAU/mL, respectively. Abdominal computed tomography scan revealed that the size of the tumor was 56 mm and a portal vein tumor thrombus progressed from the right anterior branch to the left main branch(Vp3). The clinical stage was cT3N0M0, cStage III(JPS). He received 3 courses of intra-arterial infusion chemotherapy with cisplatin(CDDP IA-call)into the right hepatic artery at a dose of 65 mg/m2 every 2 months. Elevated serum alpha-fetoprotein(AFP)and PIVKA-II markedly decreased and returned to normal levels after the second course of treatment. The liver tumor and portal vein tumor thrombus disappeared, and only arterioportal shunting remained. The response to treatment was partial response (PR) and complete response (CR), according to the Response Evaluation Criteria In Solid Tumors and the modified version, respectively. He has been alive for more than 1 year without recurrence. CDDP is an effective treatment for advanced HCC with portal vein tumor thrombus.

[A case of advanced cholangiolocellular carcinoma successfully treated by neoadjuvant chemotherapy with gemcitabine followed by radical resection].

A 57-year-old woman who was diagnosed with cholangiolocellular carcinoma underwent neoadjuvant chemotherapy with gemcitabine (GEM). The clinical stage was cT3N1M1 (right adrenal grand),cStage IVB (JPS) with invasion to the inferior vena cava (IVC). We were willing to perform hepatectomy if the response to chemotherapy was stable disease (SD) or better according to the Response Evaluation Criteria In Solid Tumors. After 2 courses of preoperative chemotherapy with GEM, SD was obtained. She underwent right lobectomy of the caudate lobe and resection of the right adrenal gland. The IVC was also resected and reconstructed. The pathological diagnosis was as follows: cholangiolocellular carcinoma, im (-), eg, fc(-), sf(-), s0, n0, vp0, vv0, va0, b1, p0, sm(-), 200 µm, pT2N0M0, pStage II, and Cur A2. The IVC was not invaded and the right adrenal gland was diagnosed with adrenocortical adenoma. She underwent continuing adjuvant chemotherapy with GEM for 4 months without recurrence. Therapy for cholangiolocellular carcinoma has not yet been established, but multimodal treatment with GEM and surgical resection is potentially effective for cholangiolocellular carcinoma.

[A case of primary neuroendocrine carcinoma of the bile duct].

A 74-year-old man presented to a physician with a chief complaint of jaundice. He was diagnosed with bile duct carcinoma and admitted to our hospital. Laboratory data revealed abnormally elevated levels of total bilirubin, serum hepatic transaminase, and CA19-9. Endoscopic retrograde cholangiopancreatography revealed neoplastic stenosis from the hilus hepatis to the common bile duct. Abdominal computed tomography (CT) revealed an enhancing tumor in the hilus hepatis bile duct, and positron emission tomography-CT (PET-CT) revealed abnormal fluorodeoxyglucose accumulation in the tumor. Under a diagnosis of hilar cholangiocarcinoma, the patient underwent an extended right hepatectomy and left hepatico -jejunostomy. Immunohistochemically, the tumor cells were positive for neuroendocrine markers such as chromogranin A, synaptophysin, and CD56. The tumor was diagnosed as primary neuroendocrine carcinoma of the bile duct. The patient exhibited multiple liver metastasis 6 months after the operation. Transcatheter arterial chemoembolization (TACE) was performed for the liver metastasis. Although TACE exerted a cytoreductive effect temporarily, multiple liver abscesses developed. The patient died of liver failure 16 months after the operation. We report this rare case of primary neuroendocrine carcinoma of the bile duct.

Nonconvulsive Status Epilepticus Caused by Cerebrospinal Fluid Dissemination of a Salivary Duct Carcinoma: A Case Report.

Salivary duct carcinoma (SDC) is a rare and highly aggressive salivary gland tumor with rapid growth, distant metastasis, and a high recurrence rate. Moreover, the parotid gland is the most common site with a poor prognosis. A lower frequency of distance metastasis to the liver, skin, and brain has also been reported, although the lungs, bones, and lymph nodes are the most common sites of SDC metastasis. We report a case of nonconvulsive status epilepticus (NCSE) in a 73-year-old male comatose patient having SDC of the parotid gland with an unusual metastasis to the skin and brain diagnosed by frequent cerebrospinal fluid examinations. Meningeal carcinomatosis usually has a poor prognosis, and NCSE is a reversible cause of altered mentation. Clinicians should know the unique set of epilepsy etiologies in patients with malignant tumors.

Clinical impact of body composition on postoperative outcomes during neoadjuvant chemoradiation therapy for distal bile duct cancer.

Body composition changes during neoadjuvant therapy and their clinical significance have not been clarified. The present study aimed to investigate body composition changes during neoadjuvant chemoradiation therapy (NACRT) in patients with distal bile duct cancer and the clinical impact on postoperative complications and the prognosis. A total of 16 patients with distal bile duct cancer who underwent curative resection after NACRT were retrospectively evaluated. The area of skeletal muscle, visceral fat and subcutaneous fat on computed tomography and immunological and nutritional indices were assessed before and after NACRT. All 16 patients completed NACRT followed by pancreaticoduodenectomy without mortality. There was no significant change in the skeletal muscle mass index (SMI) during NACRT. Of the 16 patients, nine (56%) were defined as sarcopenic before NACRT, and eight (50%) met the criteria for sarcopenic after NACRT. The SMI and total fat area were significantly associated with postoperative pancreatic fistula (POPF) (P=0.019 and P=0.007, respectively). The patients with sarcopenia had a shorter disease-free survival time and overall survival time in comparison to patients without sarcopenia (P=0.025 and P=0.115, respectively). In conclusion, NACRT for distal bile duct cancer did not significantly affect the body composition, or the immunological or nutritional indices. Sarcopenia after NACRT was significantly associated with early recurrence in patients with distal bile duct cancer who received NACRT.

[Wallflex duodenal stenting for gastric outlet obstruction caused by inoperable advanced gastric cancer].

INTRODUCTION: Wallflex duodenal stent (WDS) placement for gastric outlet obstruction caused by malignant disease has been covered by health insurance in Japan since April 2010. We have placed five-WDS for three gastric outlet obstructions caused by inoperable advanced gastric cancer. CASE 1: A 67-year-old male diagnosed as having Stage IV gastric cancer with liver, lung, and lymph node metastases underwent a WDS placement during first-line chemotherapy. He was able to consume a soft diet orally for about five months thereafter. He underwent a WDS replacement for stent obstruction by tumor ingrowth and finally died due to the primary tumor 11 months after the first visit. CASE 2: A 63-year-old male diagnosed as having Stage IV gastric cancer with liver and lymph node metastases underwent a WDS placement during the first-line chemotherapy. He was able to consume a soft diet orally for about three months thereafter. He died due to the primary tumor six months after the first visit. CASE 3: A 72-year-old male diagnosed as having Stage IV gastric cancer with liver and lymph node metastases underwent a WDS placement during the first-line chemotherapy. He was able to consume a soft diet orally for about four months and subsequently received the fourth-line chemotherapy. He underwent a WDS replacement for stent obstruction by tumor ingrowth and finally died due to the primary tumor nine months after the first visit. CONCLUSIONS: WDS stent placements for gastric outlet obstruction caused by inoperable advanced gastric cancer were performed safely and enabled the consumption of a soft diet orally for at least three months. This approach is expected to be a safe and effective treatment option.

[Successful treatment of advanced esophageal cancer with lymph node metastases by docetaxel, cisplatin and 5-FU followed by salvage lymphadenectomy--a case report].

We present a case of advanced esophageal cancer with multiple lymph node metastases successfully treated by combination therapy of docetaxel, cisplatin and 5-FU (DCF) followed by salvage lymphadenectomy. The patient was a 60-year-old female with the diagnosis of squamous cell carcinoma of the middle thoracic esophagus. The clinical stage diagnosis was cT2N4M0, cStage IVa. Systemic chemotherapy with DCF was started as the initial treatment. The changes noted on endoscopy and CT scan in the primary lesion and lymph nodes after two cycles of DCF were judged as complete response (CR). However, recurrence was diagnosed in the left cervical lymph nodes based on FDG uptake on FDG-PET. Salvage cervical lymphadenectomy was performed. Thereafter, the patient again achieved CR after the second administration of DCF for upper mediastinal lymph node recurrence. At present, she is still alive three years after the first visit. Combination therapy of DCF and salvage lymphadenectomy is potentially effective for advanced esophageal cancer with lymph node metastases.

[Case report--a long-term surviving patient who received lymph node dissection of skip metastasis from rectosigmoid cancer to bilateral lateral lymph nodes].

Skip metastasis in colorectal cancer consists of about 10% of lymph node metastases. We report a rare long-term surviving patient of skip metastasis to lateral nodes after lymph node dissection. A forty-two years old female received anterior resection for advanced rectosigmoid cancer. Because pathological stage of the patient was stage IIIa (T3N1M0), standard adjuvant chemotherapy was provided. Serum CEA increased just two years after the first operation. PET scan showed abnormal FDG uptake in lymph nodes along the aorta. Lymph nodes along the inferior mesenteric artery (IMA), bilateral common iliac artery and aorta were dissected. There were metastases to nodes along the common iliac artery but no metastasis along the IMA was observed. So we diagnosed it as skip metastasis. The patient is still alive without any metastasis after 6 years from the second operation.