Surgeons have hesitated early cholecystectomy because of cardiovascular comorbidities during adoption of guidelines.

The introduction of the guidelines has resulted in an increase of laparoscopic surgeries performed, but the rate of early surgery was still low. Here, the initial effect of the introduction of the guideline was confirmed in single center, and factors disturbing early cholecystectomy were analyzed. This study included 141 patients who were treated for acute cholecystitis from January 2010 to October 2014 at Kanazawa Medical Center. Each patient was assigned into a group according to when they received treatment. Patients in Group A were treated before the Tokyo Guidelines were introduced (n = 48 cases), those in Group B were treated after the introduction of the guidelines (93 cases). After the introduction of the guidelines, early laparoscopic cholecystectomy was significantly increased (P < 0.001), however, the rate of early operations was still 38.7% only. There are many cases with cardiovascular disease in delayed group, the prevalence had reached 50% as compared with early group of 24% (P < 0.01). Approximately 25% of patients continued antiplatelet or anticoagulant therapy. In the early days of guidelines introduction, the factor which most disturbed early surgery was the coexistence of cardiovascular disease. These contents could be described in the next revision of the guidelines.

[Three Cases of Resectable Advanced Gastric Cancer Treated with Neoadjuvant Chemotherapy].

Three patients diagnosed with HER2-negative resectable advanced gastric cancer with extensive regional lymph node metastases were treated with neoadjuvant chemotherapy(NAC), followed by gastrectomy with D2lymph node dissection. One patient received four 21-day courses of S-1 plus oxaliplatin(G-SOX), and pathological effect(PE)was Grade 3. Two patients received four 21-day courses of capecitabine plus oxaliplatin(CapeOX), and each PE was Grade 2and Grade 1a, respectively. One patient in poor PE was with recurrent liver and peritoneal metastases. This suggested that for resectable advanced gastric cancer with extensive regional lymph node metastases, NAC by SOX or CapeOX was effective for some patients.

[A Case of HER2-Positive Unresectable Gastric Cancer with Multiple Lymph Node and Liver Metastases Controlled Effectively by Combination Chemotherapy with Capecitabine, Oxaliplatin, and Trastuzumab].

A 77-year-old woman was diagnosed with HER2-positive unresectable gastric cancer with multiple lymph node and liver metastases(cT3-4, cN3, cM1[HEP, LYM], cStage IV ). Four courses of combination chemotherapy with capecitabine, oxaliplatin, and trastuzumab(XELOX plus Tras)were administered. Though all lesions showed a complete or partial response, anorexia and body weight loss appeared because of the stenosis in the primary gastric lesion. After another course, these symptoms became worse and she underwent laparoscopic gastrojejunostomy. She progressed favorably after the surgery, her anorexia improved and her weight increased. Thirty-four days after the surgery, the same chemotherapy was continued. At present, the metastases are well controlled 12months after the initial treatment. It is suggested that XELOX plus Tras is an effective chemotherapy regimen for HER2-positive unresectable gastric cancer.

Sigmoid colon diverticula perforation associated with sevelamer hydrochloride administration: A case report.

INTRODUCTION: Sevelamer is an anion exchange resin used to treat hyperphosphatemia. A common adverse effect of sevelamer is constipation. According to a review of the available literature, colon perforation associated with this resin agent was less common. PRESENTATION OF CASE: A 66-year-old man complaining of lower abdominal pain was transferred to our hospital. The patient had been undergoing hemodialysis for chronic renal failure due to rapidly progressive glomerulonephritis, and had been receiving sevelamer hydrochloride 4.5 g/day for 8years as treatment for hyperphosphatemia. Abdominal computed tomography revealed ascites, free air in the abdominal cavity, multiple diverticula of the sigmoid colon, as well as increased fat tissue surrounding the sigmoid colon. We diagnosed colonic perforation and performed emergency surgery, which revealed a 5 × 5 mm perforation in the sigmoid colon surrounded with soft stool. Histopathologically, sevelamer crystals were detected at the perforation site. DISCUSSION: We theorize that physical stimulation by sevelamer crystals contributed to colon perforation at the already vulnerable diverticulum site. CONCLUSION: When sevelamer is administered to patients with hemodialysis, the risk of intestinal perforation should be considered.

[A case of recurrent sigmoid colon cancer with multiple peritoneal and liver metastases controlled effectively by resection].

A 71 year -old man underwent sigmoid colectomy for sigmoid colon cancer. A solitary liver metastasis found on examination 8 months after the initial surgery was resected. One year after the second surgery, 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) and computed tomography (CT) revealed multiple peritoneal and liver metastases, and laparotomy was performed. All metastatic lesions were resectable or controllable. Eight peritoneal and 3 hepatic lesions were removed surgically and 1 hepatic lesion was treated with radiofrequency ablation. Eight months after the third surgery FDGPET and CT examination again revealed recurrence of liver and peritoneal metastases. Chemotherapy was ineffective and metastases progressed and resulted in death 26 months after the third surgery (39 months after the initial recurrence). We suggest that aggressive resection for multiple peritoneal and liver metastases can be an effective therapy for selected patients with recurrent colon cancer.

[A case of recurrent duodenal carcinoma successfully controlled with FOLFOX treatment].

A 60-year-old woman was diagnosed as having duodenal cancer by upper gastrointestinal endoscopy and biopsy. Pylorus-preserving pancreatoduodenectomy was performed. Pathological findings suggested T4(CBD)N1M0 primary duodenal carcinoma. Adjuvant chemotherapy with S-1(80 mg/m² of S-1 administered for 2 weeks followed by a 1-week drug-free period)was administered after surgery. One year after the surgery, computed tomography(CT)scans showed swelling of the paraaortic lymph nodes. Recurrence of the duodenal carcinoma was diagnosed, and gemcitabine chemotherapy was initiated. Eight months later, CT scans revealed lung metastasis. The patient was then treated with oxaliplatin in combination with infusional 5-fluorouracil/Leucovorin(FOLFOX regimen). After completing 6 courses of the chemotherapy regimen, CT scans showed a partial response(PR). Currently, at 1 year, PR has been maintained. Therefore, we suggest that the FOLFOX regimen can be highly effective for the treatment of patients with duodenal carcinoma.

[A case in which chemotherapy-resistant sigmoid colon cancer was controlled effectively by radiotherapy and resection].

A 53-year-old woman underwent sigmoid colectomy for sigmoid colon cancer with peritoneal metastasis. Liver and intrapelvic metastases were found upon examination 6 months after surgery during adjuvant chemotherapy with XELOX plus bevacizumab. After hepatic subsegmentectomy, the patient received S-1 treatment in combination with radiotherapy for the intrapelvic metastasis. One year after the second surgery, abdominoperineal rectal resection was performed as the intrapelvic tumor had increased in size. At 16 months after the third surgery, computed tomography( CT) revealed a small lung nodule that gradually increased in size. The patient underwent partial lung resection. The nodule was a recurrence of the sigmoid colon cancer. During this period, the patient was treated again with S-1 combined with radiotherapy because 2 intrapelvic metastases had been identified. At present, these metastases have been well controlled for 3 years after the initial recurrence. Thus, it is suggested that aggressive radiotherapy and resection are effective therapies for recurrence of chemotherapy-resistant colon cancer.

[A case of advanced gastric cancer responding to combined systemic and intraperitoneal chemotherapy with docetaxel, cisplatin, and S-1].

The patient was a 50-year-old man diagnosed as having a large type 3 advanced gastric cancer with para-aortic lymph node metastasis and with positive peritoneal cytology. We administered a combined systemic and intraperitoneal chemotherapy involving docetaxel, cisplatin, and S-1 (DCS). After 2 courses of treatment, the primary tumor and lymph nodes were significantly reduced in size, suggesting that this therapy induced a partial response (PR). No cancer cells were observed in the peritoneal cytology, and therefore, we performed curative total gastrectomy with para-aortic lymph node dissection. Histological findings revealed that there were no cancer cells in either the primary tumor or the lymph nodes, and pathological grading indicated that the resected lesions were grade 3. Adjuvant chemotherapy with S-1 was administered after surgery. At 18 months after surgery, the patient is still alive and free of disease.

Xanthogranulomatous cholecystitis mimicking gallbladder carcinoma with a false-positive result on fluorodeoxyglucose PET.

Recently, several reports have demonstrated that fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) is useful in differentiating between benign and malignant lesions in the gallbladder. However, there is a limitation in the ability of FDG-PET to differentiate between inflammatory and malignant lesions. We herein present a case of xanthogranulomatous cholecystitis misdiagnosed as gallbladder carcinoma by ultrasonography and computed tomography. FDG-PET also showed increased activity. In this case, FDG-PET findings resulted in a false-positive for the diagnosis of gallbladder carcinoma.

FR901228, a novel histone deacetylase inhibitor, induces cell cycle arrest and subsequent apoptosis in refractory human pancreatic cancer cells.

Histone deacetylase (HDAC) inhibitors have antiproliferative activity against human cancer cells via cell cycle arrest, differentiation, and apoptosis. However, no report has focused on the apoptotic potential of HDAC inhibitors in refractory human pancreatic cancer. This study was designed to examine the apoptotic potential of FR901228, a novel HDAC inhibitor, in five human pancreatic cancer cell lines: Capan-1, BxPC-3, HPAF, Panc-1, and MIAPaCa-2. FR901228 markedly inhibited the proliferation of all five cell lines (IC50: 1-500 nM), with the greatest effect in MIAPaCa-2 cells. Treatment of each cell line with FR901228 (10-100 nM) caused cell cycle arrest at the G1 or G2/M phase and subsequent apoptosis. FR901228 induced expression of hyperacetylated histone H3 after 3 h of treatment and overexpression of p21Waf-1 after 6 h. In addition, FR901228 induced apoptosis by activating caspase-3, which led to cleavage of p21Waf-1 into a 15-kDa breakdown product and drove cancer cells from cell cycle arrest into apoptosis. FR901228 also decreased the protein level of survivin dramatically. Our results show that FR901228 markedly inhibits the growth of pancreatic cancer cells, not only through cell cycle arrest, but also through subsequent apoptosis; this was accompanied by caspase-3 activation, survivin degradation, and p21Waf-1 cleavage. FR901228 may prove clinically useful as an agent for refractory pancreatic cancers.