[A Case of Diffuse Large B-Cell Lymphoma Which Was Diagnosed during the Best Supportive Care of Recurrent Ascending Colon Cancer].

A 70s male, who had undergone single-incision laparoscopic ileocecal resection for ascending colon cancer with pathological diagnosis of T3N3M0, Stage Ⅲc(without adjuvant chemotherapy), had enhanced-computed tomography(CT)for 3-month follow-up and a hepatic low-density area, an newly emergent nodule behind inferior vena cava and distal ileal tumor were found. Three months later, enhanced CT showed that the distal ileal tumor got exponentially larger and the diagnosis of"malignant lymphoma"was suspected. The patient became sepsis, so we planned and safely performed partial resection of the tumor. The pathological diagnosis was diffuse large B-cell lymphoma. Postoperative course was smooth except for the Clostridium difficile colitis and he was discharged on postoperative day 19. Although the regrowth of the remnant tumor was observed soon after surgery, partial response was confirmed after introduction of systemic chemotherapy. When we cope with malignant lymphoma of small intestine, we need to keep it in mind that surgery is an option for the prevention of perforation and bacterial translocation.

[A Case of Fibromatosis-Like Tumor Which Was Difficult to Differentiate from Local Recurrence of Ascending Colon Cancer].

A 60s female, who had undergone single-incision laparoscopic ileocecal resection for ascending colon cancer with pathological diagnosis of T3N1bM0, Stage Ⅲb, followed by adjuvant therapy with 8 courses CAPOX 2 years ago, had enhanced- computed tomography(CT)for follow-up and a 15-mm nodule near anastomotic site was found. 18F-fluorodeoxyglucose (FDG)-positron emission tomography(PET)CT revealed abnormal accumulation of 18F-FDG only to the lesion and diagnosis of"anastomotic recurrence"was made. We planned and safely performed resection of the anastomotic site and the nodule. The pathological diagnosis was fibromatosis-like tumor without evidence of recurrence, and margin was negative. Postoperative course was smooth and she was discharged on postoperative day 9. When we diagnose local recurrence, we need to keep it in mind that fibromatosis is one of the differential diagnoses, although its incidence rate is low.

[Questionnaire Survey on Oral Care and Oral Troubles for Patients with Gastric Cancer Received Chemotherapy].

BACKGROUND: The actual situation of oral care and oral troubles for patients with gastric cancer received chemotherapy is not clear. METHODS: Questionnaire survey in the form of oral questions was performed for patients with gastric cancer who received chemotherapy from December 2021 to February 2022. The relevance between the survey results and background factors was examined using the χ2 test. RESULTS: We performed the questionnaire survey for 36 patients. Of the 36 patients, 29 patients received dental check-up before starting chemotherapy. Fourteen of the 29 patients(48%)continued the dental check-up. Of 14 patients who continued the dental check-up, 9 patients were 65 years or older, while 14 of 15 patients who discontinued the dental check-up were 65 years or older. Continuity of dental check-up was low among the elderly patients. The rate of dysgeusia were 78 vs 30% in the patients who adopted and who did not adopt oral care other than toothbrushing(p=0.01). The frequency of oral troubles was dysgeusia(47%), stomatitis(42%), and dry mouth(36%). The severity of the oral troubles was, in order, dysgeusia, dry mouth, and pain. The most common side effect due to chemotherapy causing decreased food intake was dysgeusia. CONCLUSIONS: Dysgeusia was the most frequent and severe oral trouble.

[Regimen Selection by Narrative Approach in Patients with Advanced Gastric Cancer-Paclitaxel or Nab-Paclitaxel?]

BACKGROUND: According to the sixth Gastric Cancer Treatment Guideline, the regimen included nab-paclitaxel(nab-PTX) is a conditional recommendation as second-line treatment for advanced gastric cancer. However, the selection criteria of nab-PTX is not clear. METHOD: Questionnaire survey as narrative approach on the problems of paclitaxel premedication, the symptoms due to paclitaxel containing alcohol, and infusion time was conducted for patients who had been treated with paclitaxel. RESULTS: Thirty-six patients answered the questionnaire. Nonelderly patients(<65 years)or patients without comorbid medications complained of dissatisfaction with the inconvenience due to premedication significantly more than elderly patients(≥65 years)or patients with comorbid medications. Females or nonelderly patients were significantly more troubled by sleepiness due to premedication than males or elderly patients. Eight out of 11 patients who had visited hospital by driving a car for first-line treatment were troubled by prohibition of driving on the day of treatment. Thirty out of 36 patients answered that they would feel benefits from 30-minutes shortening of infusion time. CONCLUSION: Questionnaire survey suggests that we may select the patients for nab-PTX properly by clarifying the inconvenience of daily life associated with premedication, the way of transportation for visiting hospital, and the benefits by shortening of infusion time.

[A Case of 30s Female with Advanced Anal Canal Adenocarcinoma Managed with Adolescent-And-Young-Adult Team].

A 30s female complaining of anal pain and melena was referred to our hospital. The support by adolescent-and-young- adult(AYA)team was initiated after the first encounter. Colonoscopic examination revealed an ulcerated tumor on the anterior wall of anal canal with its anal margin on anal verge and the tumor was diagnosed as an adenocarcinoma. Contrast- enhanced CT and MRI revealed adjacency of tumor and vagina, enlarged lymph nodes and multiple pulmonary nodules. 18F-fluorodeoxyglucose(FDG)-positron emission tomography(PET)additionally revealed tracer accumulation in left sciatica, which led us to the diagnosis of advanced anal cancer. We planned and safely performed concomitant partial vaginal resection in robot-assisted laparoscopic abdominoperineal resection for the palliative purpose after discussion on physical and psychosocial issues including stoma and fertility with the patient, her family and AYA members. The pathological diagnosis was pT4b(vagina)N1aM1b, pStage ⅣB, and the local margin was pathologically negative. The postoperative course was smooth and she was discharged on postoperative day 16. Fifty one days after operation, she started systemic chemotherapy after decision on not to take ovarian samples and continues systemic chemotherapy as of writing. Support by AYA team was effective to facilitate the patient's decision-making and the communication between the patient and the medical team.

The effect of specimen processing time on HER2 expression in gastric cancer and esophagogastric junction cancer: a single-center retrospective observational study.

BACKGROUND: Recent developments in the field of companion diagnosis and molecular-targeting therapeutic agents have helped in developing treatments targeting human epidermal growth factor receptor 2 (HER2) in gastric cancer (GC) and esophagogastric junction cancer (EGJC), and the importance of accurate diagnosis of HER2 expression is increasing. However, the HER2-positivity rate significantly differs among reports in GC and EGJC, and factors that affect HER2-positivity require elucidation. METHODS: The present study retrospectively examined factors related to HER2-positivity in a single institution, including age, sex, body mass index, the American Society of Anesthesiologists physical status, tumor information, and surgery information, including time to specimen processing. RESULTS: Our study included 165 patients tested for HER2 using GC and EGJC surgery specimens among the 1,320 patients who underwent gastrectomy from January 2007 to June 2022. In total, 35 (21.2%) and 130 (78.8%) patients were HER2-positive and -negative, respectively. Multivariate analysis revealed that intestinal type (odds ratio [OR]: 3.41, 95% confidence interval [CI]: 1.44-8.09, p = 0.005), pM1 (OR: 3.99, 95% CI: 1.51-10.55, p = 0.005), and time to specimen processing of < 120 min (OR: 2.65, 95% CI: 1.01-6.98, p = 0.049) were independent factors that affected HER2-positivity. CONCLUSIONS: The outcomes of the present study indicated that intestinal type, pM, and time to specimen processing are important factors affecting HER2-positive rates in GC and EGJC. Therefore, the risk of false-negative HER2 results may be reduced by decreasing the time required to process the resected specimen. Additionally, accurate diagnosis of HER2 expression may increase the opportunity to administer molecular-targeted drugs that can expect therapeutic effects to patients appropriately. TRAIL REGISTRATION: Retrospectively registered.

[A Case Report of SOX Therapy for an Elderly Patient with Hemorrhagic Primary Duodenal Carcinoma].

BACKGROUND: Although pancreatoduodenectomy is recommended as a radical surgery for duodenal carcinoma, it has been reported that pancreatoduodenectomy in elderly patients has a high risk of surgical complications. CASE PRESENTATION: A man in his 80's was diagnosed with advanced duodenal carcinoma, presenting with anemia(Hb 5.4 g/dL). Computed tomography scanning showed wall thickening in the descending leg of the duodenum, pancreatic invasion was suspected, and clinical diagnosis was Stage ⅡB(cT4N0M0). Although radical surgery was possible, the patient refused surgery considering the risks of surgical complications. The gastroduodenal bypass surgery was performed to control bleeding, and the patient was treated with S-1 plus oxaliplatin(SOX; S-1 100 mg/body, days 1-14; oxaliplatin 100 mg/m2, day 1 q21 days). After 6 courses of the SOX regimen, the wall thickening of duodenum disappeared, and SOX was switched to S-1 monotherapy (S-1 100 mg/body, days 1-28, q42 days)according to Grade 2 thrombocytopenia and decreased performance status. After 11 courses of S-1, upper gastrointestinal endoscopy showed that the tumor had disappeared, the biopsy of duodenum showed no evidence of malignancy, and chemotherapy was terminated. The patient has been followed up for 7 months without recurrence. CONCLUSIONS: SOX for elderly patient showed efficacy against hemorrhagic duodenal carcinoma.

[Conversion Surgery Performed after SOX plus Nivolumab Therapy for Advanced Gastric Cancer with Para-Aortic Lymph Node Metastasis].

The patient was a 78-year-old woman. She presented with anemia and a positive fecal occult blood test. Endoscopic findings revealed type 3 advanced gastric cancer. As it had metastasized to the para-aortic lymph node(PALN: No. 16a2 lat), it was diagnosed as gastric cancer at cardia cT4aN1(No.1)M1(No.16a2 lat), cStage Ⅳ. She was administered S-1, oxaliplatin, and nivolumab(SOX plus Nivo)therapy as a first-line treatment. SOX plus Nivo resulted in a remarkable reduction of the lymph nodes, which were PR. After 3 courses of chemotherapy, a laparoscopic proximal gastrectomy was performed, with D2 plus No. 16a2 int/lat lymph nodes dissection as conversion surgery. Histopathological examination was pT3N0M0, and R0 resection was pStage ⅡA. She was discharged at POD21 and started S-1 from POD69. The patient is alive with no signs of recurrence 10 months postoperatively.

[A Case of Preoperative Chemotherapy for Advanced Gastric Cancer, Laparoscopic Total Gastrectomy, Pancreaticoduodenectomy, and Para-Aortic Lymph Node Dissection].

Bulky N+ gastric cancer has a poor prognosis. The results of JCOG0405 showed the efficacy of neoadjuvant chemotherapy with S-1 plus cisplatin combination therapy for Bulky N+ gastric cancer. JLSSG0901 demonstrated the safety and efficacy of laparoscopic surgery for advanced gastric cancer. But the safety of laparoscopic surgery for locally advanced and extensive nodal metastasis cancer(T4b, para-aortic lymph node metastasis)is not apparent. After DOS therapy, we performed total laparoscopic gastrectomy, DP(distal pancreatectomy), D2+ #16a2/b1 lat, and Roux-en-Y reconstruction, and histopathological results showed that the aortic lymph node metastasis disappeared. We controlled extensive lymph node metastasis using preoperative triplet chemotherapy. Laparoscopic surgery after preoperative chemotherapy for Bulky N+ gastric cancer can be a treatment option because we performed laparoscopic resection and para-aortic lymph node dissection with no complications, including pancreatic complications.

[Our Experience with Atezolizumab plus Bevacizumab for Unresectable Hepatocellular Carcinoma].

We report our experience with atezolizumab plus bevacizumab for unresectable hepatocellular carcinoma. METHODS: Fourteen patients with unresectable hepatocellular carcinoma treated with atezolizumab plus bevacizumab at our department were retrospectively evaluated for antitumor efficacy and adverse events. RESULTS: Age ranged from 66-91 years(median 77.5 years), 11 males and 3 females, number of doses ranged from 2-26(median 13), and observation period ranged from 31-790 days (median 427 days). Antitumor efficacy was CR in 3 patients, PR in 3, SD in 6, and PD in 2. One patient with PD died 650 days after the start of treatment, but the others are still alive. Adverse events included proteinuria in 9 patients who discontinued bevacizumab, hypothyroidism requiring levothyroxine sodium hydrate in 7 patients, dermatitis in 2 patients, and colitis requiring hospitalization in 2 patients. DISCUSSION: Despite the small number of cases, a high antitumor effect was observed with a CR rate of 21%. Although proteinuria and hypothyroidism were observed relatively frequently as adverse events, they were easily controlled and did not pose a major clinical problem.

[Clinical Outcome of Five Patients with Perforated Colorectal Cancer].

We studied the clinicopathological findings of 5 patients with perforated colorectal cancer. Three patients were male, and the primary cancer site was left side colon in 4 patents. Two patients had endoscopy-related perforation. The chief complaint was abdominal pain in all cases. All patients underwent emergency surgery. Two patients had Stage Ⅱ cancer, 3 had Stage Ⅳ. The mean ICU stay was 2.8 days. The average postoperative hospital stay was 71.8 days. Three patients were discharged home and 2 were transferred to other hospitals. The 3 patients who were discharged home received chemotherapy. Perforation of the cancer site is a risk factor for recurrence, and early recovery and additional treatment should be considered.

[A Case Report of the Ascending Colon Cancer with Bullous Pemphigoid].

The patient was a 70-year-old man. The patient had progressive anemia while taking 10 mg/day of prednisolone and 100 mg/day of mizoribine orally for bullous pemphigoid, a colonoscopy diagnosed ascending colon cancer. Adenocarcinoma, Group 5 was detected on biopsy. Abdominal computed tomography showed no metastases. The tumor was diagnosed as ascending colon cancer, cT4aN0M0, cStage Ⅱb. We performed laparoscopic right hemicolectomy and D3 dissection. Histopathological examination revealed pT3N0M0, pStage Ⅱa. In the present report, we describe a case of the ascending colon cancer with bullous pemphigoid, and discuss the case with a review of the literature.

[Tolerability and Outcome of Neoadjuvant GS Therapy for Resectable Pancreatic Cancer].

INTRODUCTION: Neoadjuvant chemotherapy with gemcitabine plus S-1(NAC GS)has been reported to prolong the prognosis of resectable pancreatic cancer, and is now being used in daily practice. In this study, we investigated the tolerability and outcome of neoadjuvant GS therapy for resectable pancreatic cancer in our hospital. PATIENTS: Fifty-two patients who underwent NAC GS for resectable pancreatic cancer between November 2019 and March 2023 were included in this study. RESULTS: The mean age of all 52 patients was 75 years, 28 were male and 24 were female. Tumor site was pancreatic head cancer in 32 patients, pancreatic body cancer in 13 patients, and pancreatic tail cancer in 8 patients. Only 2 patients of the 52 patients completed 2 cycles of GS therapy with full dose, and dose reduction and treatment deferral were performed in remaining 50 patients. The dose intensity was 78.4% for gemcitabine and 66.7% for S-1. Grade 3 or higher adverse events included neutropenia in 21 patients(40.4%), biliary tract infection in 6 patients(11.5%), fatigue, anorexia, hepatic dysfunction, and constipation in 1 patient each(1.9%). 47 patients(90.4%)underwent R0 resection. 4 patients had pancreatic fistula, which was classified as Grade Ⅲ by Clavien-Dindo, and one of them died in the hospital due to bleeding from a pseudoaneurysm. CONCLUSION: NAC GS therapy for resectable pancreatic cancer was considered feasible with appropriate management of adverse events.

[A Case of Effective Plasma Exchange for Thrombotic Microangiopathy during Chemotherapy for Pancreatic Cancer].

The patient was a 78-year-old man. After 4 courses of GEM plus nab-PTX therapy for multiple recurrent liver metastases after pancreatic body cancer surgery, the patient was aware of general malaise and edema of the extremities. Blood tests showed pancytopenia, and he was admitted to the hospital with a diagnosis of chemotherapy-induced pancytopenia. On the second day, hemolytic anemia with crushed red blood cells was observed, suggesting thrombotic microangiopathy (TMA). Considering the possibility of thrombotic thrombocytopenic purpura(TTP), the patient was started on plasma exchange with steroids. After 7 days of plasma exchange, his thrombocytopenia, hemolytic anemia, and renal dysfunction improved, and he was discharged from the hospital on the 28th day. Although GEM-induced TMA is a life-threatening complication, there is no established treatment for it. We report a case of GEM-induced TMA that was successfully treated with plasma exchange.

[A Case of Peritoneal Recurrence from Ascending Colon Cancer Successfully Treated with Laparoscopic Concomitant Right Seminal Vesiculectomy in Low Anterior Resection].

A 60s male, who had laparoscopic ileocecal resection for ascending colon cancer 2 years ago, had enhanced computed tomography(CT)for follow-up and a 12-mm nodule in Douglas' pouch adjacent to right seminal vesicle and rectum was found. 18F-fluorodeoxyglucose(FDG)-positron emission tomography CT revealed abnormal accumulation of 18F-FDG only to the lesion(standardized uptake value max 2.60)and the diagnosis of peritoneal recurrence of ascending colon cancer was made. We planned and safely performed laparoscopic concomitant right seminal vesiculectomy in low anterior resection. The pathological diagnosis was peritoneal dissemination of colon cancer and the margin was pathologically negative. The postoperative course was smooth except for temporary dysuria and he was discharged on postoperative day 17. As of writing 1 year after surgery, the patient continues to do well with no sign of recurrence. Laparoscopic concomitant seminal vesiculectomy in low anterior resection can be a good option for the curative resection of peritoneal recurrence.

[A Case of Anal Canal Adenocarcinoma with Perianal Pagetoid Spread without a Macroscopic Finding].

We report a case of anal canal cancer with Pagetoid spread without a macroscopic skin lesion. A 54-year-old man was admitted to a hospital with complaints of bloody stools. Endoscopic examination revealed a polyp in the anal canal, and endoscopic mucosal resection was performed. Pathological examination revealed an adenocarcinoma accompanied by Pagetoid spread and the positive surgical margin. We additionally performed trans-anal resection twice, but the resected horizontal margin was positive. Mapping biopsy of rectal mucosa and perianal skin revealed adenocarcinoma in only rectal mucosa. Abdominoperineal resection was performed. Histopathological examination showed invasive adenocarcinoma with pagetoid spread and that the surgical margin was negative. Pagetoid spread of anal canal adenocarcinoma usually showed macroscopic abnormal findings, but in this case, there was no skin lesion. It suggests that preoperative mapping biopsy is helpful for determining the excision range. It is necessary to keep in mind that anal canal adenocarcinoma with no skin lesion may cause Pagetoid spread.

[A Case of Recurrent Hepatocellular Carcinoma Successfully Treated by Radiation Therapy].

We report a case of recurrent hepatocellular carcinoma(HCC)successfully treated by radiation therapy. A 79-year-old woman was diagnosed with HCC and underwent liver resection. Seven months after resection, CT and MRI detected a new HCC, and she had a surgery again. One year after the surgery, CT and MRI detected local recurrence, and she underwent the third operation. Three months after the operation, the third liver recurrence was treated by transcatheter arterial chemoembolization( TACE). Four months later, a new lesion was detected and treated by stereotactic body radiation therapy(SBRT) twice. She remains alive without recurrence 27 months after the last radiation therapy. Very few evidence is reported of radiation therapy for HCC, but this case suggests that radiation therapy provides a benefit for patients with HCC after other treatments.

[A Case of Advanced Gastric Cancer with Peritoneal Metastasis Achieved Pathological Complete Response by Chemotherapy(SOX Regimen)].

A 68-year-old woman was presented with anorexia. Upper gastrointestinal endoscopy revealed type 4 gastric cancer at corpus of the stomach. Peritoneal metastasis was detected by staging laparoscopy. After a diagnosis of cT4aN1M1, cStage ⅣB advanced gastric cancer, we performed chemotherapy(SOX regimen; S-1 100 mg/body on day 1-14, followed by 7 days of rest, oxaliplatin 130 mg/m2 on day 1). After the 3 courses of chemotherapy, the primary tumor had been reduced. Second staging laparoscopy revealed no peritoneal metastasis. Then, we performed total 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 peritoneal metastasis achieved pathological complete response by chemotherapy.

Long-term outcome after one-stage surgery without preoperative decompression for stage II/III malignant colorectal obstruction: a propensity score-matched analysis.

PURPOSE: Whether malignant colorectal obstruction (MCO) after one-stage curative surgery without preoperative decompression has a poor prognosis remains unclear. We assessed long-term outcomes of one-stage surgery without preoperative decompression for stage II/III MCO. METHODS: We retrospectively enrolled patients with stage II/III colorectal cancer (CRC) between April 2011 and December 2017. Propensity score-matched (PSM) analysis was used to reduce the possibility of selection bias. RESULTS: In total, 464 stage II/III CRC patients were identified, of which 145 (31%) had obstruction (MCO group) and 319 (69%) did not (non-MCO group). In the MCO group, 59 (40.7%) had emergency MCO (E-MCO) and 86 (59.3%) had semi-emergency MCO (SE-MCO). The median follow-up was 37.0 (range 0-86.5) months. The tumor was deeper and larger, and serum carcinoembryonic antigen level was higher (p < 0.001, respectively) in the MCO group (including E-MCO and SE-MCO). Venous invasion-positivity rate was significantly higher (MCO and SE-MCO only, p = 0.003 and 0.009, respectively) than that in the non-MCO group. Laparoscopic surgery rate was significantly lower (MCO and E-MCO only, p < 0.001) than that in the non-MCO group. Before PSM, disease-free survival (DFS) of the SE-MCO patients was worse than that of the non-MCO patients (p = 0.046). After PSM, DFS was not significantly different between the non-MCO and MCO, E-MCO, and SE-MCO groups (p = 0.619, 0.091, and 0.308, respectively). CONCLUSIONS: Long-term prognosis in patients with stage II/III MCO after one-stage surgery without preoperative decompression was similar to that in patients without MCO.

[Clinical Outcomes of Cardiovascular Surgery in Jehovah's Witness Patients].

Cardiovascular surgery in Jehovah's Witness is challenging for surgeons on the ground that they refuse blood transfusion. We report 11 cases of cardiovascular surgery. All of the patients underwent elective surgery with cardiopulmonary bypass. Two cases underwent minimally invasive procedures. The mean preoperative hemoglobin level was 13.0 g/dl, and hematopoietic medicines were preoperatively administrated in 4 patients. Although 10 patients recovered satisfactory without blood transfusion, 1 surgical case was lost due to uncontrollable postoperative bleeding. The clinical outcomes of the Jehovah's Witness patients are considered to be satisfactory. However, careful indication is recommended in high risk cases.