[A Case of Resected Esophageal Endocrine Cell Carcinoma That Responded to Combination Therapy Comprising Irinotecan and Cisplatin].

We report a case of resected esophagealcancer that responded wellto first-line combination therapy comprising irinotecan and cisplatin. The patient was a 71-year-old woman being treated for liver cirrhosis. She was admitted to our hospital in April 2015 because of dysphasia. Endoscopic examination revealed a tumor in the mid-thoracic esophagus, which was diagnosed as an endocrine cell carcinoma following pathological examination. Contrast-enhanced computed tomography and positron emission tomography did not show lymph node or distant metastases. She was treated with irinotecan and cisplatin combination therapy. After 6 courses of treatment, the tumor size had remarkably reduced. Subsequently, we performed subtotal esophagectomy and gastric tube reconstruction through the retroposterior mediastinalroute and the histologicaleffect was reported as a partial response. No viable tumor cells were observed in the extracted lymph nodes. However, bone metastasis and lymph node swelling occurred after 4 months. She received other therapeutic regimens, such as etoposide and carboplatin combination therapy. However, the tumor gradually progressed, and she died 18 months after the first treatment. Irinotecan and cisplatin combination therapy is a possible option for the management of esophageal endocrine cell carcinoma as a first-line treatment.

Acute diffuse peritonitis due to spontaneous rupture of a primary gastrointestinal stromal tumor of the jejunum: A case report.

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Overt peritonitis caused by GIST rupture is very uncommon. Three types of GIST rupture have been described: closed perforation due to abscess (abscess type), hemoperitoneum leading to rupture of the hematoma capsule in the tumor (hemoperitoneum type), and perforation of the digestive tract via a fistula leading to central necrosis of the tumor (bowel perforation type). This report describes a patient with spontaneous tumor rupture and diffuse peritonitis, a variant of the bowel perforation type of GIST rupture. PRESENTATION OF CASE: A 74-year-old man presented with symptoms of vomiting and abdominal pain. Computed tomography (CT) scan revealed an approximately 10×7-cm mass in the pelvis with free air and fluid collection. Emergency laparotomy revealed a tumor in the jejunum, which was ruptured with a hole measuring 5mm in diameter. The tumor and part of the jejunum were resected. Immunohistochemically, the mass was diagnosed as a GIST originating from the gastrointestinal tract. Despite chemotherapy with imatinib mesylate, the patient died 22 months after surgery. CONCLUSIONS: This report describes a patient with acute diffuse peritonitis due to spontaneous rupture of a primary GIST of the jejunum.

A colovesical fistula with a persistent descending mesocolon due to partial situs inversus: A case report.

INTRODUCTION: Situs inversus viscerum, a congenital condition in which the visceral organs are a mirror image of their normal physiological positions, could be total or partial. Persistent descending mesocolon (PDM) is a congenital anomaly that is asymptomatic because of its short length. PDM causing intestinal obstruction is a known clinical complication. PRESENTATION OF CASE: A 74-year-old woman presented with pneumaturia and enteruria for two months, and recurrent cystitis for a month. An enhanced computed tomography (CT) showed air in the bladder along with sigmoid colonic diverticula adherent to it, suspecting a fistula. The CT also showed partial situs inversus with the common hepatic artery, and left colic artery arising abnormally from the superior mesenteric artery (SMA). Minimally invasive endoscopic closure using the over-the-scope clipping system was difficult because of thickening and scar tissue due to chronic inflammation from diverticulitis. Thus, a sigmoidectomy was performed to close the fistula. Intraoperatively, we noted an abnormally fixed descending mesocolon. An emergency reoperation was performed on the sixth postoperative day owing to an anastomotic leak. Suture failure was attributed to these congenital abnormalities due to insufficient blood flow from an absent marginal vessel and a high endocolonic pressure by adhesions. Sigmoid colon re-resection and maturation of an ileostomy was performed. The patient had no specific postoperative complications, and the ileostomy was closed after three months. CONCLUSION: We report an extremely rare case of colovesical fistula due to a PDM in a patient having partial situs inversus with abnormal branches originating from the SMA.

[A Case of Effective Chemoradiotherapy Using mFOLFOX6 for Locally Advanced Rectal Cancer].

We report a case of locally advanced rectal cancer, treated effectively with chemotherapy consisting of mFOLFOX6 combined with radiotherapy. A 63-year-old man was admitted to our hospital in March 2012 for diarrhea and anal and perineal pain. Advanced rectal cancer with invasion ofthe right perineum was diagnosed based on computer tomography(CT) findings. Surgery was performed; however, the rectal cancer was unresectable. A sigmoid colostomy was performed, and a central venous port was implanted. In April 2012, the patient was treated with chemotherapy using 3 courses ofmFOLFOX6 and concurrent radiotherapy. Radiotherapy at 2 Gy/day was administered 25 times(total dose, 50 Gy). After chemoradiotherapy, the patient underwent 3 courses ofmFOLFOX6 as an additional therapy. By June 2012, CT showed resolution ofthe tumor in the right perineum and a marked decrease in the size ofthe primary rectal cancer. Because the patient refused surgery, we started treatment with combination chemotherapy using oral S-1 and intravenous CPT-11 in August 2012. After 18 courses, the treatment was changed to oral administration ofS -1 alone, which was continued for 1 year. The patient remained well without recurrence for 54 months since the original diagnosis. Therefore, chemoradiotherapy with mFOLFOX6 is a possible option for the management of advanced rectal cancer.

[A Case of Resected Advanced Esophageal Cancer That Responded to Combination Therapy Comprising Docetaxel, Cisplatin, and 5-Fluorouracil].

We report a case of resected advanced esophagealcancer that responded wellto first-line combination therapy with docetaxel, cisplatin, and 5-fluorouracil(DCF therapy). A 72-year-old man was admitted to our hospital in January 2013 because of dysphagia. On the basis of the computed tomography(CT)and gastroendoscopy findings, he was diagnosed with advanced esophagealcancer with lymph node metastasis. The patient was treated with DCF therapy. After 2 courses of treatment, the primary tumor and lymph node metastasis were reduced on CT. After 3 courses of treatment, we performed subtotalesophagectomy and gastric tube reconstruction through the retroposterior mediastinalroute. No residualcancer cells were found in the esophagus or lymph nodes. The patient subsequently received oral administration of tegafur-uracilal one for 24 months. The post-operative course was uneventful, and there was no detectable lymph node metastasis 42 months after the originaldiagnosis. Therefore, DCF therapy is a possible option for the management of advanced esophagealcancer.

Sphincter-saving resection by cluneal arched skin incision for a gastrointestinal stromal tumor (GIST) of the lower rectum: a case report.

BACKGROUND: Planning the surgical strategy for a gastrointestinal stromal tumor (GIST) at the posterior wall of the lower rectum is difficult, as the procedures for the lower rectum are hampered by poor visualization and may cause anal dysfunction or discomfort. We report a novel procedure to resect a submucosal tumor of the rectum. CASE PRESENTATION: A 75-year-old woman presented with metrorrhagia. Endovaginal ultrasonography showed a low echoic tumor. Computed tomography showed an enhanced tumor, measuring 5.3 × 4.2 cm, behind the rectum. Magnetic resonance imaging revealed a submucosal tumor of the rectum, measuring 5.3 cm at its greatest dimension. Colonoscopy showed that the distal tumor margin was 1 cm above the dentate line. Core needle biopsy of the tumor revealed the rectal GIST. After receiving neoadjuvant imatinib treatment, the tumor size decreased to 3.5 cm. During the operation, we approached the rectum and resected the posterior rectal wall, including the 3.5 × 3.5 cm tumor with a safety margin, making an arched incision at the buttocks to form a skin flap with the patient in a jackknife position. The histopathological diagnosis was GIST of the rectum. Her anorectal sphincter function was well preserved. No recurrence was seen during the 2-year follow-up. CONCLUSIONS: This novel approach improves the operative field visibility in resecting a tumor with a safety margin and preserves a patient's anorectal sphincter function.

A mixed adenoneuroendocrine carcinoma of the pancreas: a case report.

A tumor consisting of an adenocarcinoma component and a neuroendocrine carcinoma component, with each component accounting for at least 30% of the tumor, is defined as a mixed adenoneuroendocrine carcinoma (MANEC). We report a case of MANEC of the pancreas. A 63-year-old man presented with hyperglycemia and was referred to our hospital for further examination. Abdominal contrast-enhanced computed tomography (CT) revealed a mass of 2 cm in size in the pancreas head with portal vein narrowing. Fluorin-18 fluorodeoxyglucose-positron emission tomography (FDG-PET) CT revealed increased accumulation in the mass of the pancreas head. Endoscopic retrograde cholangiopancreatography (ERCP) showed severe narrowing of the main pancreatic duct. Cytological analysis by endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) suggested a neuroendocrine tumor. Under the diagnosis of neuroendocrine tumor, pancreaticoduodenectomy with portal vein resection and regional lymph node dissection was performed with curative intent. Histological examination revealed that the tumor consisted of two cell populations. One was well- to moderately differentiated tubular adenocarcinoma. This cell component accounted for 45% of the whole tumor. The second component was non-adenocarcinoma cells arranged in a nest, and the cells had round nuclei, abundant cytoplasm, and coarse chromatin. The Ki67 labeling index was 40%. Immunohistochemically, the adenocarcinoma cells were positive for CEA but negative for chromogranin A (CgA) and synaptophysin (Syn), while the non-adenocarcinoma cells were positive for the expression of CgA and Syn but negative for CEA. Based on the findings, a diagnosis of MANEC of the pancreas was made. Postoperatively, lymph node metastasis and peritoneal dissemination developed rapidly and he died the 6 months after the operation. Due to the small number of reported cases of MANEC of the pancreas, its clinical behavior remains unclear and a standardized management protocol has not been established. Further investigation of more cases of this rare entity is necessary.

[A Case of HER2-Positive Advanced Gastric Cancer with Multiple Liver Metastases Effectively Treated with Trastuzumab, Capecitabine, and Cisplatin Combination Therapy].

We reported a case of human epidermal growth factor receptor 2(HER2)-positive advanced gastric cancer with multiple liver metastases that responded well to a combination of trastuzumab, capecitabine, and cisplatin(T-XP therapy)as first-line chemotherapy. A 73-year-old man was admitted to our hospital in December 2012 for liver dysfunction. Based on computed tomography(CT)and gastroendoscopy findings, he was diagnosed with advanced gastric cancer with multiple liver metastases. Because HER2 protein overexpression was observed in the primary tumor, he was treated with T-XP therapy. After 5 courses of treatment, the sizes of the primary tumor and multiple liver metastases were reduced on CT scans. In March 2013, a Billroth I distal gastrectomy with D2 lymph node dissection was performed. Liver metastasis was not detected. No residual cancer cells were found in the stomach or lymph nodes. The patient subsequently received oral administration of S-1 alone for 2 weeks followed by a 2-week rest period as 1 course. This was repeated for 19 courses. The postoperative course was uneventful, and there was no detectable liver metastasis 36 months after the original diagnosis. Therefore, T-XP therapy is an option for the management of HER2-positive advanced gastric cancer with liver metastasis.

[Resection of Advanced Intrahepatic Cholangiocarcinoma after an Effective Response to S-1 and Gemcitabine Combination Therapy].

We report curative resection of an advanced intrahepatic cholangiocarcinoma that responded well to combined S-1 and gemcitabine chemotherapy(GS therapy). A 67-year-old woman was admitted to our hospital in July 2011 for upper right abdominal pain. She was diagnosed with intrahepatic cholangiocarcinoma with abdominal para-aortic lymph node metastasis on the basis of the computed tomography (CT) findings. She was treated with GS therapy. One course of S-1(80 mg/m(3)) consisted of the administration of the drug for 14 days, followed by 14 days of rest; GEM(1,000 mg/m(3)) was administered on days 1 and 15 after initiating S-1. After 2 courses of treatment, the sizes of the primary tumor and the lymph node metastasis were observed to be reduced on CT. In September, partial hepatectomy and regional lymph node dissection were performed. The patient subsequently received 22 postoperative courses of GS therapy. The patient's postoperative course was uneventful, and she remains free of recurrence 49 months since diagnosis. Therefore, GS therapy is a possible option for the management of advanced intrahepatic cholangiocarcinoma.

[A case of advanced gastric cancer with carcinomatous pericarditis effectively treated by S-1/CDDP combined therapy].

The patient was a 48-year-old woman, admitted for pleural effusion detected on chest X-ray in July 2005. Computer tomography(CT)scan showed massive pericardial and pleural effusion. We performed pericardial drainage, and the cytological diagnosis of the pericardial effusion was class V. Because endoscopic examination revealed advanced gastric cancer, we diagnosed it as gastric cancer complicated with carcinomatous pericarditis. The serum tissue polypeptide antigen(TPA) level was markedly elevated. In August 2005, we started combination chemotherapy using oral S-1(100mg/body/day; day 1- 21)and intravenous CDDP(100mg/body/day; day 8)for 5 weeks. After 2 courses, TPA was reduced and pericardial effusion disappeared. However, after 3 courses, pericardial effusion recurred. We changed treatment to weekly docetaxel. After 2 courses, we changed it to paclitaxel/CDDP. However, TPA was increased and pleural effusion and dyspnea occurred. There- fore, we changed to a course of combination chemotherapy using oral S-1(100mg/body/day; day 1-14)and intravenous CPT-11(100mg/body/day; day 1 and 8)for 4 weeks from March 2006. After 10 courses, we were unable to control pleural effusion, and dyspnea recurred. She died in December 2006. Gastric cancer complicated with carcinomatous pericarditis has a poor prognosis, but systemic chemotherapy mainly with S-1 was effective.

[A case of drug-induced interstitial pneumonia caused by S-1 and CPT-11 combination therapy for advanced colon cancer].

The patient was a 77-year-old woman admitted for nausea and abdominal pain. Computed tomography (CT) revealed advanced ascending colon cancer with liver metastasis. After operation, we started combination chemotherapy of S-1 and irinotecan (CPT-11); S-1(80 mg/m²) administered orally for consecutive days followed by 14 days rest.CPT -11 (100 mg/m²) was given as a 2-hour infusion on day 1 and 15. The patient complained of high fever and subsequent dyspnea with severe hypoxemia after the first course of combination chemotherapy of S-1 and CPT-11.CT scan showed diffuse interstitial lesions with ground glass opacity on both lungs. Steroid pulse therapy with oxygen therapy remarkably improved her symptoms, and abnormal findings on CT scan also resolved. Drug lymphocyte stimulation test was positive against S-1 and negative against CPT-11. These findings were consistent with S-1-induced lung injury. Drug -induced pneumonia needs to be considered in the differential diagnosis when patients treated with S-1 and CPT-11 combination therapy present high fever and dyspnea.

Clinical and endoscopic features of responders and non-responders to adsorptive leucocytapheresis: a report based on 120 patients with active ulcerative colitis.

BACKGROUND AND OBJECTIVE: Elevated/activated myeloid leucocytes, like the CD14(+)CD16(+) monocytes are sources of TNF-α, and therefore, selective depletion of these cells by granulocyte/monocyte (GM) adsorption (GMA) should promote remission or enhance drug efficacy. However, studies in ulcerative colitis (UC) reported contrasting efficacy, from an 85% to statistically insignificant level. We investigated patients' demography in responders and non-responders. METHODS: In 120 UC patients, 61 steroid naive and 59 steroid dependent, we looked for entry clinical or endoscopic features to identify responders (or non-responders) to GMA. Patients received up to an 11 Adacolumn GMA sessions over 12 weeks. Patients were clinically and endoscopically evaluated, allowing each patient to serve as her/his own control. Immunohistochemistry on colonic biopsies was to reveal the impact of GMA on leucocyte infiltration of the mucosa. RESULTS: Entry average clinical activity index (CAI) was 12.6, 10-16. An 80 of 120 patients responded (CAI≤4); 45 steroid naïve (73.8%) and 35 steroid dependent (59.3%). Over 900 biopsies were processed. Infiltrating leucocytes were overwhelmingly polymorphonuclear and macrophages around and within crypt abscesses. There was a marked reduction of infiltrating leucocytes in responders. Most non-responders had extensive colonic lesions with virtually no mucosal tissue left at the lesions. CONCLUSIONS: Steroid naïve patients with short duration of UC were the best responders, while patients with deep colonic lesions and extensive loss of the mucosal tissue were non-responders.

[A case of effective chemotherapy using S-1 and CPT-11 following chemoradiotherapy with UFT and Leucovorin for unresectable advanced sigmoid colon cancer].

The patient was a 75-year-old man who was admitted because of diarrhea and anemia. Endoscopic examination revealed advanced sigmoid colon cancer. Serum CEA levels were markedly elevated. In July 2007, surgery was performed, but the sigmoid colon cancer was unresectable. After surgery, the patient was treated with chemotherapy and concurrent radiotherapy. The chemotherapy consisted of oral UFT (420 mg/body/day)and Leucovorin (75 mg/body/day) administered for 6 weeks. Radiotherapy at 2 Gy/day was administered 30 times (total dose 60 Gy). The tumor decreased slightly in size and serum CEA levels also decreased. The patient refused surgery as an additional therapy. In August 2007, we started combination chemotherapy using oral S-1 (100 mg/body/day, day 1-14) and intravenous CPT-11 (140 mg/body/day, day 1 and 15) as one course for 4 weeks. After 4 courses, serum CEA levels were normal, the sigmoid colon cancer was not found by endoscopy and a biopsy specimen revealed no malignant cells. Moreover, after 8 courses, the tumor disappeared, as confirmed by computed tomography (CT) and positron emission tomography-CT, representing a complete response. Chemoradiotherapy using UFT and Leucovorin, and chemotherapy consisting of S-1 and CPT-11 as an additional therapy may be effective for treating unresectable advanced sigmoid colon cancer.

[A case of effective chemoradiotherapy using S-1 and CDDP for left inguinal lymph node metastasis of anal canal carcinoma].

We report a case of left inguinal lymph node metastasis of anal canal carcinoma, treated effectively with chemotherapy consisting of S-1 and CDDP combined with radiotherapy. In February 2006, a 76-year-old woman underwent resection of a tumor diagnosed as squamous cell carcinoma of the anal canal. The patient refused additional surgical therapy. In August 2007, a painful lymphnode swelling was noticed in the left inguinal region. Biopsy was performed, and specimens were shown to include squamous cell carcinoma cells. The patient was treated using chemotherapy concurrent with radiotherapy. The chemotherapy consisted of oral S-1 (80 mg/body/day; 5 days/week) and intravenous CDDP (5 mg/body/day; 5 days/week), both administered for 4 weeks. Radiotherapy at 2 Gy/day was administered 25 times (total dose 50 Gy). The metastatic tumor in the lymph node responded well to the treatment and decreased remarkably in size by December 2007. After chemoradiotherapy, the oral administration of S-1 alone (80 mg/body) for 2 weeks followed by a 2-week rest period as one course was continued for 1 year. The lymph node metastasis had disappeared 1 year after chemoradiotherapy, as determined by computed tomography (CT) and positron emission tomography-CT, representing a complete response. Chemotherapy consisting of S-1 and CDDP concurrent with radiotherapy maybe effective for treating metastatic lymph node metastasis of anal canal carcinoma.

[Yakon tea induced hepatitis in a patient with alcoholic liver cirrhosis].

A 66-year-old woman, given a diagnosis of alcoholic liver cirrhosis in 2004, had improved her liver function by abstinence from drinking. Since then, she has drunk 1 to 2 liters of Yakon tea per day. Her liver function deteriorated and T. Bil was 13.2mg/dl and AST was 291U/l in February 2005. Given the positive DLST for Yakon tea, Yakon tea-induced hepatitis was diagnosed. After cessation of the intake of the tea, her liver function gradually improved. Since there has been no report on Yakon induced hepatitis and it has been thought to be a safe supplement, we here report this intriguing case.

Angiotensin-converting enzyme insertion/deletion genotype is associated with the activities of plasma coagulation factor VII and X independent of triglyceride metabolism.

BACKGROUND: The D allele of angiotensin-converting enzyme (ACE) insertion/deletion (I/D) polymorphism and coagulation activity play important roles in cardiovascular events, however, the precise association between these two risk factors remains unclear. METHODS: We identified the ACE I/D genotype and measured the plasma coagulation factor VII and X (FVII and FX) activities and serum lipids in 172 patients (110 men and 62 women, mean age 56.7+/-13.3 years) undergoing coronary angiography. RESULTS: The frequency of the D allele was significantly higher in those with a history of myocardial infarction (MI) than in those with normal coronary arteries, but there was no significant association between FVII and FX activities and the stage of coronary disease. Plasma coagulation factor VII and FX activities were significantly lower in the DD genotype (n=42) than in the II genotype (n=67, P<0.001 and P<0.001, respectively) or the ID genotype (n=63, P<0.01 and P<0.05, respectively). The association of the ACE D allele with lower activities of FVII and FX was also seen in patients with coronary artery disease (CAD). There was a significant association between serum triglyceride levels with FVII and FX, but not with the ACE I/D genotype. CONCLUSION: We concluded that the ACE I/D polymorphism may contribute more to the onset of MI than the activities of FVII and FX and that the ACE D allele might be associated with lower plasma activities of FVII and FX. The potential link between ACE I/D polymorphism and the plasma activities of FVII and FX is probably independent of triglyceride metabolism.