[Three Cases of Conversion Surgery Resulted in Pathological Complete Response for Unresectable Pancreatic Cancer].

Conversion surgery(CS)post chemotherapy for unresectable pancreatic cancer is often reported recently. Although it is still controversial about adaptation of CS, it could possibly be one of the useful choices of treatment for unresectable pancreatic cancer. We report 3 cases of CS which eventually turned out to be pathological complete response.

[A Case of Meningeal Carcinomatosis of Gastric Cancer Successfully Controlled with Nab-Paclitaxel].

We report a 76-year-old woman with meningeal carcinomatosis after gastric cancer surgery. During adjuvant chemotherapy, metastasis to the left axillary and Virchow's lymph node was suspected. A resection biopsy revealed gastric cancer metastasis, and PTX plus RAM therapy was started. Due to RAM adverse events, the treatment was changed to weekly nab- PTX, which was continued for about 6 months. During the 8th course, she was hospitalized due to worsening headache and lightheadedness. Meningeal carcinomatosis was diagnosed by cytology of CSF examination and MRI findings. She died on the 16th day after admission. Meningeal carcinomatosis has a rapidly progressive course with poor prognosis. This case shows nab-PTX may have been able to control the progression.

An ectopic thymoma arising in the middle mediastinum that was difficult to distinguish from a lymph node metastasis.

BACKGROUND: Ectopic thymomas often occur in the upper mediastinum; however, they rarely arise in the middle mediastinum, especially on the dorsal side of the innominate vein and superior vena cava in the peribronchial region. CASE PRESENTATION: Six years prior, a 27-year-old female presented to our department and was diagnosed with locally advanced left breast cancer. First, we administered chemotherapy including an anti-human epidermal growth factor receptor 2 antibody. The size of the tumor was markedly reduced, and a radical operation involving mastectomy and axillary lymph node dissection was then performed. The patient underwent radiotherapy after the mastectomy, followed by trastuzumab therapy; she continued to receive endocrine therapy thereafter. She underwent computed tomography once a year after the surgery, and a nodule in the middle mediastinum on the dorsal side of the innominate vein and superior vena cava in the parabronchial region was detected at 4 years. We speculated that the nodule was a solitary mediastinal lymph node metastasis from her breast cancer; therefore, we performed thoracoscopic resection of the tumor. We diagnosed the tumor as a thymoma. Currently, the patient visits our hospital to receive continuous hormone therapy for her breast cancer, and the latest computed tomography scan demonstrated no metastases from or recurrence of her breast cancer or thymoma. CONCLUSIONS: We report a case of ectopic thymoma in the middle mediastinum. The tumor, which was detected during systemic therapy for locally advanced breast cancer, was located on the dorsal side of the innominate vein and superior vena cava in the parabronchial region and was indistinguishable from a lymph node metastasis from breast cancer.

[A Case Report of Carcinoma of the Appendix Which Was Diagnosed with Ascites One Year after Appendicitis Operation].

A 68-year-old man visited our hospital in October 201X, giving abdominal bloating as his primary symptom. We found tenderness at McBurney's point, high WBC values from a blood test, and swelling of the appendix in a CT scan, so he was diagnosed with acute appendicitis. On the same day, he had an emergency laparoscopic appendectomy, and he made good progress and was discharged from the hospital on the fourth day after the surgery. In the histopathological examination, he was diagnosed with acute gangrenous appendicitis and examination was concluded. August of the following year, ascites accumulation was found by CT scan, and he was introduced to the department of gastroenterology of this hospital for further testing. Lower endoscopy showed swelling of the appendix root, and he was diagnosed with adenocarcinoma in the biopsy. A CT scan found increased granular concentration in the omentum. Because of a diagnosis of appendix cancer/peritoneal dissemination, he underwent laparoscopic examination in October. Nodules were found scattered in the small intestinal mesentery and the omentum, and peritoneal dissemination was suspected during intraoperative rapid diagnosis. The operation was concluded with only laparoscopic examination. Because of the diagnosis of appendix cancer/peritoneal dissemination, mFOLFOX6 plus bevacizumab was implemented. Primary appendix cancer is a relatively rare disease, often diagnosed after surgery for appendicitis, reported of here 0.03% to 0.5% of cases undergoing appendectomy. We report a case of primary appendix cancer diagnosed 1 year after appendectomy, with the discussion of the literature.

[A Case of Neuroendocrine Tumor of the Second Part of the Duodenum].

A 69-year-old woman was referred to our hospital when the upper gastrointestinal endoscopy performed by the previous physician for detailed examination of upper abdominal discomfort indicated a duodenal tumor. Upper gastrointestinal endoscopy revealed a submucosal tumor with a central depression in the descending part of the duodenum. Contrast- enhanced computed tomography of the abdomen revealed a 23 mm tumor with contrast effect in the descending part of the duodenum contralateral to the Vater papilla. There was no lymphadenopathy or distant metastasis. Duodenal gastrointestinal stromal tumor was suspected, and localized duodenectomy was planned. Intraoperative findings showed that the tumor was located in the descending part contralateral to the Vater papilla with no evidence of surrounding invasion. Localized duodenectomy was performed, and on intraoperative rapid histopathological examination, an adenocarcinoma was suspected. As a result, the surgery was changed into pancreaticoduodenectomy. Based on the results of immunostaining, neuroendocrine tumor grade 2 was diagnosed. No lymph node metastasis was observed. The patient did not have recurrence of lesion 7 months after surgery.

[Bladder-Infiltrating Sigmoid Colon Cancer Successfully Treated with Neoadjuvant Chemotherapy and Radical Resection-A Case Report].

A 71-year-old man presented with the chief complaints of constipation, melena, and weight loss, and sigmoid colon cancer was suspected on lower gastrointestinal endoscopy. The cancer was diagnosed as RAS wild type adenocarcinoma(tub2)on biopsy. Abdominal contrast-enhanced CT revealed a mass with a maximum diameter of 55mm in the sigmoid colon; therefore, bladder infiltration was suspected. The Group 1 lymph nodes were bulky, with a maximum diameter of 50 mm, and No. 253 lymph node was enlarged. No fistulas were found on cystoscopy. The sigmoid colon cancer was cT4b(bladder), N3, M0, cStage Ⅲc. After performing a colostomy, neoadjuvant chemotherapy with mFOLFOX6 plus panitumumab was started. Radical surgery was performed after 3 courses of chemotherapy. The clinical treatment effect was PR, and the final histopathologi- cal examination revealed ypT3, ypN0(0/17), R0, ypStageⅡa. The therapeutic effect was Grade 2a. Postoperative adjuvant chemotherapy was performed for 6 months with mFOLFOX, and there have been no signs of cancer recurrence for 9 postoperative months. We experienced a case of colon cancer with suspected bladder infiltration, successfully treated with neoadjuvant chemotherapy and radical surgery.

[A Case of Long-Term Survival in a Patient with Advanced Gastric Cancer with Virchow's Lymph Node Metastasis Which Received Multidisciplinary Treatment].

We report a case of long-term survival in a 75-year-old male with advanced gastric cancer and Virchow's lymph node metastasis[cT3N3M1(LYM)H0P0, cStage Ⅳ]which received multidisciplinary treatment. Over 1 year and 6 months, 5 courses of S-1 plus CDDP, 14 courses of S-1 plus docetaxel, and 3 courses of S-1 plus CPT-11 were administered. Following chemotherapy, FDG-PET/CT showed FDG uptake only in the primary tumor and regional lymph nodes. Total gastrectomy and D2 dissection were performed. The pathological diagnosis was Type 5, 55×50 mm, L, Less, tub1>tub2, T3, int, INF b, ly2, v1, pPM0, pDM0, pN2(3/29), HER2(-). S-1 was used as adjuvant chemotherapy. Four years and 7 months after resection, cervical lymph node swelling was detected. The cervical lymph node was resected, followed by radiotherapy administration(56 Gy/28 Fr). No relapse occurred, and the patient has survived more than 7 years and 1 month and 8 years and 11 months after conversion surgery and diagnosis, respectively.

[A Case Report of Accessory Breast Cancer in the Right Axillary Region].

An 80-year-old woman visited a previous hospital complaining of a lump in the right axillary region. Because it was suspected of accessory breast cancer from the findings of image inspection, she was referred for surgery. Based on mammography and ultrasonography, both bilateral mammary glands were reported normal, but an irregular mass was found in the right axillary region. Resection biopsy showed adenocarcinoma like invasive ductal carcinoma. In addition, ER and PgR were positive. With a preoperative diagnosis of accessory breast cancer, she underwent wide local resection of the right axillary region with lymph-node dissection(Level Ⅰ), and local pedicle flap formation. Histopathological findings revealed that the tumor was composed of invasive ductal carcinoma. The center of tumor was consisted of ductal tissue discontinuous with normal mammary gland. So, a diagnosis of accessory breast cancer in the right axillary region was confirmed. She is currently in recurrence-free survival. Accessory breast cancer is relatively rare. We report a case of accessory breast cancer in the axillary region with some review of the literature.

[A Case Report of Long-Term Survival of Metastatic Breast Cancer Treated with Mohs Paste and Systemic Therapy].

The patient was a 75-year-old woman who had experienced left breast cancer(BT plus AX)in 1988. Local recurrences in the skin of the left chest wall appeared and were treated with operation, radiotherapy, and systemic therapy. Twenty-four years later, she developed continuous bleeding due to skin metastasis of the breast cancer and received Mohs chemosurgery and continued systemic therapy. After using Mohs paste 10 times, the skin surface healed and dried up. Improving the quality of life of patients with several symptoms such as skin cancer or metastatic skin lesions is essential in multidisciplinary therapy and Mohs paste was useful for the local control of the unresectable skin lesion.

[A Case of Sigmoid Colon Cancer with Locally Advanced Infiltration Curatively Resected after CapeOX Therapy].

A 68-year-old man presented with malaise and abdominal swelling.Lower gastrointestinal endoscopy revealed a type 2 circumferential sigmoid colon cancer.Computed tomography suggested the cancer infiltrating bladder and abdominal wall with abscess.Because of locally advanced infiltration, the patient was treated with capecitabine plus oxaliplatin(CapeOX) plus bevacizumab therapy after loop-colostomy.After 2 courses of chemotherapy, a CT revealed tumor reduction and increased abscess, which was punctured drainage.After 4 courses of chemotherapy, a CT revealed abscess reduction, we tried to operation.Sigmoidectomy with combined resection of abdominal wall and bladder total hysterectomy and fascia lata grafting were performed.The pathological diagnosis was tub1, T4b, ly2, v2, PN0, N0, M0, Stage II, pR0, Grade I a.We reported a case of curative resection of locally advanced sigmoid colon cancer treated with combined resection of bladder and abdominal wall after CapeOX therapy.

[A Case of a Bulky Axillary Ectopic Breast Cancer Which Successfully Resected after Chemotherapy(Docetaxel)].

A 78-year-old woman presented with a right axillary mass.With an incisional biopsy a diagnosis of invasive ductal carcinoma was achieved.In the whole body search, any primary focus including the breast was unclear, advanced occult breast cancer with supraclavicular lymph node metastases was diagnosed.Administration of 3 courses of docetaxel achieved disappearance of supraclavicular lymph node and reduction of an axillary mass.Right axillary lymph node dissection could be successfully performed.Pathological report showed a right ectopic cancer with right axillary lymph node metastases.The patient has been well without any relapse for 3 years.

[Prolonged Survival Achieved with Surgical Resection and Multidisciplinary Therapy for Acinar Cell Carcinoma of the Pancreas with Liver Metastases].

We report 2 cases of prolonged survival achieved with surgical resection and multidisciplinary therapy for acinar cell carcinoma of the pancreas with liver metastases.Case 1: The patient was a 55-year-old woman.She presented with upper right abdominal pain and anemia.We diagnosed a tumor originating from the pancreas and multiple liver metastases.To avoid death caused by bleeding from the tumor, we performed pancreaticoduodenectomy and right-hemi hepatectomy, and a rapid diagnosis of acinar cell carcinoma of the pancreas was confirmed intraoperatively.After the hospital discharge, we administered hepatic intra-arterial chemotherapy and performed microwave ablation for the remnant liver metastases.Additionally, systemic chemotherapy with gemcitabine was administered; however, multiple metastases of the lung and liver became uncontrollable and she died 2 and half years postoperatively.Case 2: The patient was a 42-year-old woman.Through a medical checkup, gastric varix and elevated tumor markers were detected.The examination revealed a tumor at the tail of the pancreas and liver metastasis.We performed distal pancreatomy and partial liver resection.The pathological diagnosis was acinar cell carcinoma and liver metastasis.We administered adjuvant chemotherapy by using gemcitabine and achieved 5 years of relapse-free survival.The prognosis of ACC is better than that for PDAC.However, prognosis of unresectable cases is still unfavorable.Therapeutic strategies including aggressive surgical resection for metastatic ACC are worthy of consideration.

[A Study of Gemctabine plus Nab-Paclitaxel Therapy for Advanced Local Progressive Pancreatic Cancer].

We studied the significance of gemcitabine plus nab-paclitaxel(GnP)therapy for locally progressive pancreatic cancer. We enrolled 10 patients with local progression without distant metastasis. We used GnP therapy for the ablative borderline resectable(BR)and unresectable(UR)cases based on images that followed NCCN pancreatic cancer treatment guidelines. In 1 case of resectable(R)pancreatic cancer, the tumor was located in the pancreas body but we determined that surgery was impossible because of the underlying disease detected on imaging analysis. The 10 cases involved R(n=1), UR(n=5), and BR(n=4). Treatment toxicities were reported in all cases. We withheld treatment in the R case because of toxicities. The objective response rate was 40%, and the tumor control rate was 70% with CR 0, PR 4, SD 3, and PD 2. Resection was possible in 5 cases. The response rate to the GnP therapy was 40%, with a tumor control rate of 70%, allowing excision of 50%. We believe GnP therapy is feasible for operative resistant cases.

[A Case of Advanced Gastric Cancer with a Pathological Complete Response after Neoadjuvant Chemotherapy(S-1/Oxaliplatin)].

A 63-year-old man was seen by his family doctor for epigastric distress, and he was referred to our hospital with a diagnosis of gastric cancer. Upper gastrointestinal endoscopy revealed type 3 gastric cancer(por1>tub2>tub1)at the lesser curvature of the stomach. Computed tomography suggested thickening of the wall of the stomach at the lesser curvature and bulky lymph node swelling. After a diagnosis of cT4a cN2M0, cStage III B advanced gastric cancer, we treated him with neoadjuvant chemotherapy consisting of 3 courses of SOX(oxaliplatin 100mg/m / 2 on day 1, S-1 120mg/day on day 1-14, followed by 7 days of rest). After the chemotherapy, because the primary tumor and lymph nodes were reduced, we performed distal gastrectomy with D2 lymph node dissection. Histopathological examination revealed no residual cancer cells, indicating a pathological complete response(Grade 3). We report a case of advanced gastric cancer with a pathological complete response after neoadjuvant chemotherapy.

[A Case of Hemodialysis Patients with Resected Synchronous Multiple Metastases from Colorectal Cancer Successfully Treated with CapeOX Therapy].

A 65-year-old man had been receiving hemodialysis for chronic renal failure. We diagnosed colonic ileus with transverse colon cancer and synchronous multiple liver metastases(liver segments 4 and 6)based on symptoms of abdominal pain and distension. After stent placement in the region of the colonic stenosis, left hemicolectomy was performed for transverse colon cancer. After surgery, the patient received capecitabine plus oxaliplatin(CapeOX)therapy. The dose of capecitabine was 1,250mg/m2, and the dose of oxaliplatin was 70 mg/m2 until the second course, after which it was increased to 100 mg/m2 for the third course. Peripheral neuropathy(Grade 1)was the only adverse event observed. After 6 courses of treatment, the size of the liver metastases and the levels of tumor markers had reduced. For control of liver metastases, partial hepatectomy (liver segments 4 and 6)was performed. We report this case with a review of the literature.

[Combination Chemotherapy Using Oxaliplatin plus S-1 for Well-Advanced Gastric Cancer].

We studied the clinical efficacy of pre-operative combination chemotherapy using S-1 plus oxaliplatin for advanced gastric cancer. Four patients hadclinical Stage IV disease, 1 patient had clinical Stage III C disease, 2 patients had clinical Stage III B disease, and 1 patient had clinical Stage III A disease. The patients received 2-8 courses of oxaliplatin(130mg/m2)on day 1, andS -1 on days 1-14 every 3 weeks. The response rate was 56%(5 PR, 1 PD, and2 SD), andthe disease control rate was 88%. Toxicities were Grade 2 anemia, Grade 1 peripheral neuropathy, Grade 1 fatigue, and anorexia. Five of the 8 patients underwent R0 surgery after SOX chemotherapy, and no severe complications occurred. Histological responses were Grade 3 for 2 cases, Grade 2 for 2 cases, andGrad e 1a for 1 case. The SOX regimen showeda high objective tumor response, andis one of the promising regimens in the neoadjuvant setting for well-advanced gastric cancer.

[A Study of Preoperative Chemotherapy with S-1 plus Cisplatin for Advanced Gastric Cancer].

We studied the effects of preoperative chemotherapy with S-1 plus cisplatin for advanced gastric cancer. There were 16 patients who underwent radical surgery with neoadjuvant chemotherapy between 2000 and 2015. The indications for this were advanced gastric cancer with bulky N2 or N3 lymph nodes, or stage above T4a. Seven patients (43%) showed adverse events, all of which were tumors above Grade 3. Response evaluation showed PR in 13 cases (81%). The histopathological evaluation was Grade 0 in 8 patients (50%) and Grade 1a or above in 8 (50%). Death from recurrence within a year occurred in 4 cases, and 7 patients survived with no recurrence for over 5 years. All cases of survivors with no recurrence had a histopathological evaluation of Grade 1 or above. Three cases (75%) with recurrence and death within a year all had with Grade 0 tumors. We concluded that neoadjuvant chemotherapy with S-1 plus cisplatin was effective for advanced gastric cancer and that histopathological evaluation was invaluable for accurate prognosis.

[A Case of Gemcitabine Refractory Lung Metastasis after Distal Pancreatectomy for Pancreatic Cancer, Effectively Treated with S -1 as Second Line Chemotherapy].

A 64-year-old man was diagnosed with pancreatic cancer by abdominal computed tomography (CT). The examination showed a pancreatic tail cancer and a distal pancreatectomy was performed in 2010. Histopathologically, this tumor was a moderately-differentiated tubular adenocarcinoma. He received gemcitabine adjuvant chemotherapy for a year. In 2012, a chest CT scan revealed 4 nodules in the lower left lobe. We diagnosed gemcitabine-refractory lung metastases after distal pancreatectomy for pancreatic cancer. S-1 chemotherapy was administered as a second line chemotherapy for metastatic pancreatic cancer. After 2 courses of this regimen, the lung metastases were reduced. After 6 courses, a clinical complete response was obtained. Four years and 6 months after the operation, the patient is well without any signs of recurrence, and S-1 chemotherapy is still ongoing.

[A Case of Advanced Gastric Cancer with Peritoneal Dissemination Effectively Treated with S-1 and Docetaxel Combination Chemotherapy].

A 72-year-old man underwent surgery for advanced gastric cancer. Systemic chemotherapy was started, using a regimen of S-1/CDDP for 4 courses, followed by 8 courses of S-1. Three years and 8 months after the surgery, abdominal CT demonstrated ascites, and the serum CA19-9 level was abnormally high (1,165.1 U/mL). Adenocarcinoma cells were found in the ascites. Treatment with S-1/docetaxel (DOC) was started. After 10 courses, the ascites disappeared and the serum CA19-9 value returned to normal. Four years and 7 months after the operation, the patient has been in good health, with no signs of recurrence.

[A Case of Advanced Gastric Cancer with Long-Term Survival after Chemotherapy with Combined S-1 and CPT-11].

Here, we report a 54-year-old man diagnosed with type 3 advanced gastric cancer who underwent a total gastrectomy and splenectomy plus D2 lymphadenectomy. The pathologic diagnosis was Stage Ⅳ (T3N0H0P0CY1M1). Sixteen courses of combined S-1/CPT-11 chemotherapy were completed, at which time the CPT-11 was discontinued because of malaise, and S-1 alone was continued for a year. The patient is well and has been recurrence-free for 7 years. Thus, he is considered a long- term survivor who was treated with combination S-1/CPT-11 chemotherapy.