"Conversion surgery" for locally advanced pancreatic cancer: A position paper by the study group at the joint meeting of the International Association of Pancreatology (IAP) & Japan Pancreas Society (JPS) 2022.

Locally advanced pancreatic cancer (LAPC), which progresses locally and surrounds major vessels, has historically been deemed unresectable. Surgery alone failed to provide curative resection and improve overall survival. With the advancements in treatment, reports have shown favorable results in LAPC after undergoing successful chemotherapy therapy or chemoradiation therapy followed by surgical resection, so-called "conversion surgery", at experienced high-volume centers. However, recognizing significant regional and institutional disparities in the management of LAPC, an international consensus meeting on conversion surgery for LAPC was held during the Joint Congress of the 26th Meeting of the International Association of Pancreatology (IAP) and the 53rd Annual Meeting of Japan Pancreas Society (JPS) in Kyoto in July 2022. During the meeting, presenters reported the current best multidisciplinary practices for LAPC, including preoperative modalities, best systemic treatment regimens and durations, procedures of conversion surgery with or without vascular resections, biomarkers, and genetic studies. It was unanimously agreed among the experts in this meeting that "cancer biology is surpassing locoregional anatomical resectability" in the era of effective multiagent treatment. The biology of pancreatic cancer has yet to be further elucidated, and we believe it is essential to improve the treatment outcomes of LAPC patients through continued efforts from each institution and more international collaboration. This article summarizes the agreement during the discussion amongst the experts in the meeting. We hope that this will serve as a foundation for future international collaboration and recommendations for future guidelines.

Identification of salivary microRNA profiles in male mouse model of chronic sleep disorder.

Chronic sleep disorders (CSD) comprise a potential risk factor for metabolic and cardiovascular diseases, obesity and stroke. Thus, the identification of biomarkers for CSD is an important step in the early prevention of metabolic dysfunctions induced by sleep dysfunction. Diagnostic saliva samples can be easily and noninvasively collected. Thus, we aimed to identify whole microRNA (miRNA) profiles of saliva in control and psychophysiologically stressed CSD mouse models and compare them at Zeitgeber time (ZT) 0 (lights on) and ZT12 (lights off). The findings of two-way ANOVA revealed that the expression of 342 and 109 salivary miRNAs was affected by CSD and the time of day, respectively. Interactions were found in 122 miRNAs among which, we identified 197 (ZT0) and 62 (ZT12) upregulated, and 40 (ZT0) and seven (ZT12) downregulated miRNAs in CSD mice. We showed that miR-30c-5p, which is elevated in the plasma of patients with hypersomnia, was upregulated in the saliva of CSD mice collected at ZT0. The miRNAs, miR-10a-5p, miR-146b-5p, miR-150-5p, and miR-25-3p are upregulated in the serum of humans with poor sleep quality, and these were also upregulated in the saliva of CSD mice collected at ZT0. The miRNAs miR-30c, miR146b-5p, miR150, and miR-25-5p are associated with cardiovascular diseases, and we found that plasma concentrations of brain natriuretic peptides were significantly increased in CSD mice. The present findings showed that salivary miRNA profiles could serve as useful biomarkers for predicting CSD.

Gastrectomy reduces pancreatic secretory function via pancreatic atrophy.

PURPOSE: Although reports suggest that the pancreatic volume decreases after gastrectomy for gastric cancer, the relationship between the pancreatic volume and secretory function after gastrectomy remains unclear. In this study, we examined the relationship between the pancreatic volume and exocrine and endocrine functions after total gastrectomy. METHODS: The pancreatic volumes of 18 distal gastrectomy and 15 total gastrectomy patients were retrospectively measured using computed tomography volumetry up to 5 years postoperatively. Ten low anterior resection patients were selected as controls. In addition, the pancreatic volume and exocrine function evaluated by fecal elastase and the insulin secretory function evaluated by glucagon tolerance testing were prospectively examined before and one year after surgery in nine cases of total gastrectomy. RESULTS: After low anterior resection, the pancreatic volume did not change, but after distal and total gastrectomy, the pancreatic volume decreased continuously until the fifth year. After total gastrectomy, fecal elastase decreased significantly from 865.8 µg/g to 603.2 µg/g in the first year (p = 0.0316), and the insulin secretion capacity also decreased significantly from 3.83 ng/mL to 2.26 ng/mL (p = 0.0019). CONCLUSIONS: The pancreatic volume decreases continuously after gastrectomy for gastric cancer, and the pancreatic exocrine and endocrine functions decrease along with pancreatic atrophy after total gastrectomy.

Impacts of Subchronic and Mild Social Defeat Stress on Plasma Putrefactive Metabolites and Cardiovascular Structure in Male Mice.

Psychosocial stress precipitates mental illnesses, such as depression, and increases the risk of other health problems, including cardiovascular diseases. In this study, we observed the effects of psychosocial stress on the histopathological features of systemic organs and tissues in a mouse psychosocial stress model, namely the subchronic and mild social defeat stress (sCSDS) model. There were several pathological findings in the tissues of both sCSDS and control mice. Mild fibrosis of the heart was observed in sCSDS mice but not in control mice. Extramedullary hematopoiesis in the spleen and hemorrhage in the lungs were observed in both the control and sCSDS mice. Focal necrosis of the liver was seen only in control mice. Furthermore, putrefactive substances in the blood plasma were analyzed because these metabolites originating from intestinal fermentation might be linked to heart fibrosis. Among them, plasma p-cresyl glucuronide and p-cresyl sulfate concentrations significantly increased owing to subchronic social defeat stress, which might influence cardiac fibrosis in sCSDS mice. In conclusion, several pathological features such as increased cardiac fibrosis and elevated plasma putrefactive substances were found in sCSDS mice. Thus, sCSDS mice are a potential model for elucidating the pathophysiology of psychosocial stress and heart failure.

Taste buds are not derived from neural crest in mouse, chicken, and zebrafish.

Our lineage tracing studies using multiple Cre mouse lines showed a concurrent labeling of abundant taste bud cells and the underlying connective tissue with a neural crest (NC) origin, warranting a further examination on the issue of whether there is an NC derivation of taste bud cells. In this study, we mapped NC cell lineages in three different models, Sox10-iCreERT2/tdT mouse, GFP+ neural fold transplantation to GFP- chickens, and Sox10-Cre/GFP-RFP zebrafish model. We found that in mice, Sox10-iCreERT2 specifically labels NC cell lineages with a single dose of tamoxifen at E7.5 and that the labeled cells were widely distributed in the connective tissue of the tongue. No labeled cells were found in taste buds or the surrounding epithelium in the postnatal mice. In the GFP+/GFP- chicken chimera model, GFP+ cells migrated extensively to the cranial region of chicken embryos ipsilateral to the surgery side but were absent in taste buds in the base of oral cavity and palate. In zebrafish, Sox10-Cre/GFP-RFP faithfully labeled known NC-derived tissues but did not label taste buds in lower jaw or the barbel. Our data, together with previous findings in axolotl, indicate that taste buds are not derived from NC cells in rodents, birds, amphibians or teleost fish.

Efficacy of the slow firing method using a reinforced triple-row stapler for preventing postoperative pancreatic fistula during laparoscopic distal pancreatectomy.

PURPOSE: Postoperative pancreatic fistula (POPF) remains the most clinically relevant complication of laparoscopic distal pancreatectomy (LDP). The present study evaluated the efficacy of the "slow firing method" using a reinforced triple-row stapler (Covidien, Tokyo, Japan) during LDP. METHODS: This retrospective single-center study included 73 consecutive patients who underwent LDP using the slow firing method. A black cartridge was used in all patients. The primary endpoint was the rate of clinically relevant POPF (CR-POPF) after LDP. Secondary endpoints included perioperative outcomes and factors associated with CR-POPF as well as the correlation between the transection time and thickness of the pancreas. RESULTS: Four patients (5.5%) developed CR-POPF (grade B). Overall morbidity rates, defined as grade ≥ II and ≥ III according to the Clavien-Dindo classification, were 21 and 11%, respectively. The median postoperative hospital stay was 10 days. Preoperative diabetes (13.6 vs. 0.2%, P = 0.044) and thickness of the pancreas ≥ 15 mm (13.8% vs. 0%, P = 0.006) were identified as independent risk factors for CR-POPF. The median transection time was 16 (8-29) min. CONCLUSION: The slow firing method using a reinforced triple-row stapler for pancreatic transection is simple, safe, and effective for preventing CR-POPF after LDP.

Salivary microRNA and Metabolic Profiles in a Mouse Model of Subchronic and Mild Social Defeat Stress.

Identification of early biomarkers of stress is important for preventing mood and anxiety disorders. Saliva is an easy-to-collect and non-invasive diagnostic target. The aim of this study was to characterize the changes in salivary whole microRNAs (miRNAs) and metabolites in mice subjected to subchronic and mild social defeat stress (sCSDS). In this study, we identified seven upregulated and one downregulated miRNAs/PIWI-interacting RNA (piRNA) in the saliva of sCSDS mice. One of them, miR-208b-3p, which is reported as a reliable marker for myocardial infarction, was upregulated in the saliva of sCSDS mice. Histological analysis showed frequent myocardial interstitial fibrosis in the heart of such mice. In addition, gene ontology and pathway analyses suggested that the pathways related to energy metabolism, such as the oxidative phosphorylation and the pentose phosphate pathway, were significantly related to the miRNAs affected by sCSDS in saliva. In contrast, salivary metabolites were not significantly changed in the sCSDS mice, which is consistent with our previous metabolomic study on the plasma of sCSDS mice. Taken in the light of previous studies, the present study provides novel potential stress biomarkers for future diagnosis using saliva.

Periostin Contributes to Fibrocartilage Layer Growth of the Patella Tendon Tibial Insertion in Mice.

Background and Objectives: The influence of periostin on the growth of the patella tendon (PT) tibial insertion is unknown. The research described here aimed to reveal the contribution of periostin to the growth of fibrocartilage layers of the PT tibial insertion using periostin knockout mice. Materials and Methods: In both the wild-type (WD; C57BL/6N, periostin +/+; n = 54) and periostin knockout (KO; periostin -/-; n = 54) groups, six mice were euthanized on day 1 and at 1, 2, 3, 4, 6, 8, 10, and 12 weeks of age. Chondrocyte proliferation and apoptosis, number of chondrocytes, safranin O-stained glycosaminoglycan (GAG) area, staining area of type II collagen, and length of the tidemark were investigated. Results: Chondrocyte proliferation and apoptosis in KO were lower than those in WD on day 1 and at 1, 4, and 8 weeks and on day 1 and at 4, 6, and 12 weeks, respectively. Although the number of chondrocytes in both groups gradually decreased, it was lower in KO than in WD on day 1 and at 8 and 12 weeks. In the extracellular matrix, the GAG-stained area in KO was smaller than that in WD on day 1 and at 1, 4, 8, 10, and 12 weeks. The staining area of type II collagen in KO was smaller than that in WD at 8 weeks. The length of the tidemark in KO was shorter than that in WD at 4 and 6 weeks. Conclusion: Loss of periostin led to decreased chondrocyte proliferation, chondrocyte apoptosis, and the number of chondrocytes in the growth process of the PT tibial insertion. Moreover, periostin decreased and delayed GAG and type II collagen production and delayed tidemark formation in the growth process of the PT tibial insertion. Periostin can, therefore, contribute to the growth of fibrocartilage layers in the PT tibial insertion. Periostin deficiency may result in incomplete growth of the PT tibial insertion.

Overlapping distributions of mammalian types I, II, and III taste cell markers in chicken taste buds.

Mammalian taste buds comprise types I, II, and III taste cells, with each type having specific characteristics: glia-like supporting cells (type I), taste receptor cells (type II), and presynaptic cells (type III). In this study, to characterize the peripheral taste-sensing systems in chickens, we analyzed the distributions of the mammalian types I, II, and III taste cell markers in chicken taste buds: glutamate-aspartate transporter (GLAST) for type I; taste receptor type 1 members 1 and 3 (T1R1 and T1R3), taste receptor type 2 member 7 (T2R7), and α-gustducin for type II; and synaptosomal protein 25 (SNAP25) and neural cell adhesion molecule (NCAM) for type III. We found that most GLAST+ taste cells expressed α-gustducin and SNAP25 and that high percentages of T1R3+ or α-gustducin+ taste cells expressed SNAP25 and NCAM. These results demonstrated a unique subset of chicken taste cells expressing multiple taste cell type marker proteins. Taken together, these results provide new insights into the taste-sensing mechanisms in vertebrate taste buds.

Subchronic and mild social defeat stress downregulates peripheral expression of sweet and umami taste receptors in male mice.

Depression is associated with taste disorders; however, the mechanisms by which mental stress affects taste perception are not well understood. This study aimed to elucidate the effects of psychosocial stress on peripheral taste-sensing systems using a mouse depression model. Male mice were subjected to subchronic and mild social defeat stress (sCSDS). Results showed that sCSDS significantly increased body weight, food and water intake, and social avoidance behavior and that sCSDS did not change reward-seeking behavior on sucrose preference but tended to decrease pheromonal preference for female urine. Furthermore, sCSDS downregulated the mRNA levels of sweet and umami taste receptor subunits, i.e., sweet taste receptor type 1 members 2 and 3 (T1R2 and T1R3), but not the umami taste receptor subunit, i.e., taste receptor type 1 member 1 (T1R1), in the circumvallate papillae of mice. It is known that sucrose preference is mediated by the gut-brain axis without taste perception; thus, it was considered that sCSDS affected the peripheral taste-sensing systems, rather than the central reward systems, which mediate sucrose preference. This is the first study to report that psychosocial stress affects peripheral sweet and umami taste-sensing systems.

Conversion to open laparotomy during laparoscopic distal pancreatectomy: lessons from a single-center experience in 70 consecutive patients.

PURPOSE: The purpose of this study was to determine the factors influencing conversion from laparoscopic distal pancreatectomy (LDP) to open surgery, and the effect of such conversion on the outcome. METHODS: This retrospective single-center study included 70 consecutive patients undergoing LDP. The primary endpoint was the rate of conversion to open surgery during LDP. The secondary endpoints were determining the reasons for conversion to open surgery, with detailed analyses of these cases and a comparison of the surgical outcome with and without conversion. RESULTS: Seven patients (10%) required conversion to open surgery during LDP. Pancreatic ductal adenocarcinoma (PDAC) was identified as a risk factor for conversion (p = 0.010). The reasons for conversion included technical difficulty (two bleeding, one severe adhesion) and pancreatic stump-related issues (two margin-positive, two stapling failures). Although the overall morbidity rate (29 vs. 11%, p = 0.48) and the rate of clinically relevant postoperative pancreatic fistula (14 vs. 5%, p = 0.82) were no different for the patients with or without open conversion, the postoperative hospital stay was significantly longer in the former (median 15 vs. 10 days, p = 0.03). CONCLUSIONS: Careful preoperative assessment is required when planning LDP for PDAC. Although conversion to open surgery does not result in failure of LDP, efforts to reduce the duration of postoperative hospital stay and the occurrence of complications are desirable to improve the outcome of LDP.

[A Case of Emergency Pancreaticoduodenectomy for Tumor Bleeding in Duodenal Cancer with Multiple Liver Metastases].

A 62 year-old female presenting with shortness of breath and severe anemia(Hb level 4.4 g/dL)was diagnosed with tumor bleeding and duodenal cancer by gastrointestinal endoscopy.Computed tomography scan revealed multiple liver metastases.After admission, the Hb level dropped from 9.1 g/dL to 5.1 g/dL in one night, and emergency pancreaticoduodenectomy( PD)was performed to control the bleeding.The postoperative course was uneventful, and the patient was discharged on postoperative day(POD)16.Systemic chemotherapy was initiated 1 month after surgery, but the patient died from the disease 13 months after surgery.Emergency PD could be a treatment option in patients with uncontrolled tumor bleeding and fatal conditions.

Bitter taste receptor T2R7 and umami taste receptor subunit T1R1 are expressed highly in Vimentin-negative taste bud cells in chickens.

In the mammalian taste system, the taste receptor type 2 (T2R) family mediates bitter taste, and the taste receptor type 1 (T1R) family mediates sweet and umami tastes (the heterodimer of T1R2/T1R3 forms the sweet taste receptor, and the heterodimer of T1R1/T1R3 forms the umami taste receptor). In the chicken genome, bitter (T2R1, T2R2, and T2R7) and umami (T1R1 and T1R3) taste receptor genes have been found. However, the localization of these taste receptors in the taste buds of chickens has not been elucidated. In the present study, we demonstrated that the bitter taste receptor T2R7 and the umami taste receptor subunit T1R1 were expressed specifically in the taste buds of chickens labeled by Vimentin, a molecular marker for chicken taste buds. We analyzed the distributions of T2R7 and T1R1 on the oral epithelial sheets of chickens and among 3 different oral tissues of chickens: the palate, the base of the oral cavity, and the posterior tongue. We found that the distribution patterns and numbers were similar between taste bud clusters expressing these receptors and those expressing Vimentin. These results indicated broad distributions of T2R7 and T1R1 in the gustatory tissues of the chicken oral cavity. In addition, 3D-reconstructed images clearly revealed that high levels of T2R7 and T1R1 were expressed in Vimentin-negative taste bud cells. Taken together, the present results indicated the presence of bitter and umami sensing systems in the taste buds of chickens, and broad distribution of T2R7 and T1R1 in the chicken oral cavity.

Laparoscopic versus open distal pancreatectomy for benign and low-grade malignant lesions of the pancreas: a single-center comparative study.

PURPOSE: The purpose of the study was to compare the outcomes of laparoscopic distal pancreatectomy (LDP) and open distal pancreatectomy (ODP) for benign and low-grade malignant lesions to determine the safety and efficacy of LDP. METHODS: This retrospective comparative study included 67 consecutive patients who underwent LDP (n = 32) and ODP (n = 35) for benign or low-grade malignant lesions of the pancreas from January 2012 to March 2017. Thirty-five patients who were eligible for LDP in the ODP group were carefully selected. The clinical outcomes were compared in an intention-to-treat analysis. RESULTS: LDP was associated with significantly less operative blood loss (182 ± 232 vs. 505 ± 376 ml, P < 0.001) but a longer operation time (327 ± 89 vs. 173 ± 48 min, P < 0.001), than ODP. There were no significant differences between the 2 groups in the overall morbidity rates defined by Clavien-Dindo classification ≥ grade II (13% vs. 11%), clinically relevant postoperative pancreatic fistula rates (6% vs. 9%), and lengths of postoperative hospital stay (11 vs. 11 days). CONCLUSION: The study showed that LDP was safe and feasible. LDP should be considered as the first-line treatment for benign and low-grade malignant lesions in the left side of the pancreas.

Identification of functional bitter taste receptors and their antagonist in chickens.

Elucidation of the taste sense of chickens is important not only for the development of chicken feedstuffs for the chicken industry but also to help clarify the evolution of the taste sense among animals. There are three putative chicken bitter taste receptors, chicken T2R1 (cT2R1), cT2R2 and cT2R7, which were identified using genome information and cell-based assays. Previously, we have shown that cT2R1 is a functional bitter taste receptor through both cell-based assays and behavioral tests. In this study, therefore, we focused on the sensitivities of the other two bitter receptors, cT2R2 and cT2R7, by using their agonists in behavioral tests. We tested three agonists of cT2R2 and three agonists of cT2R7. In a 10-min drinking study, the intakes of cT2R2 agonist solutions were not different from that of water. On the other hand, the intakes of cT2R7 agonist solutions were significantly lower compared to water. In addition, we constructed cT2R1-and cT2R7-expressing cells in order to search for an antagonist for these functional bitter taste receptors. By using Ca2+ imaging methods, we found that 6-methoxyflavanone (6-meth) can inhibit the activities of both cT2R1 and cT2R7. Moreover, 6-meth also inhibited the reduction of the intake of bitter solutions containing cT2R1 or cT2R7 agonists in behavioral tests. Taken together, these results suggested that cT2R7 is a functional bitter taste receptor like cT2R1, but that cT2R2 is not, and that 6-meth is an antagonist for these two functional chicken bitter taste receptors. This is the first identification of an antagonist of chicken bitter receptors.

[A Case Report of Inguinal Malignant Lymphoma after Surgery for Hepatocellular Carcinoma].

An 81-year-old woman was followed up for hepatitis C from 1994. Sheh ad a previous history of hypertension and appendicitis. In October 2014, the patient underwent subsegmentectomy(S8)and cholecystectomy for hepatocellular carcinoma (HCC)(T2N0M0, Stage II ). From December 2015, the patient had taken ledipasvir-sofosbuvir orally for hepatitis C virus (HCV). In January 2016, we confirmed HCV-RNA shade transformation. In September 2016, enhanced CT showed a mass in theright lower quadrant of her abdomen. Shehad a hard 3 cm mass in thesameplaceon physical exam. PET-CT showed no significant abnormality except for the mass in the right lower quadrant of her abdomen. Therefore, we identified the differential diagnosis as a lymph node metastasis of HCC, an abdominal wall primary tumor, or a malignant lymphoma. We resected theinguinal malignant lymphoma to confirm thediagnosis. Examination of tissuefrom theinguinal malignant lymphoma indicated diffuselargeB -cell lymphoma. We report an interesting case of an inguinal malignant lymphoma in a patient with chronic HCV who had experienced hepatectomy.

[Anorectal Malignant Melanoma Is a Very Rare Disease and Has a Poor Prognosis].

We performed abdomino-perineal-resection(APR)on 2 cases of anorectal malignant melanoma. The first case was a 70- year-old woman suffering from bloody stool. Colonoscopy showed a black tumor in the rectum. Biopsy revealed a malignant melanoma. A CT scan showed multiple lung metastases and liver metastasis. She underwent surgery for the purpose of bleeding control, but died shortly thereafter because her liver and lung metastases had worsened. The second case was a 43- years-old man suffering from bloody stool. He had a black type 3 tumor in the rectum. A biopsy revealed malignant melanoma. A CT scan showed lateral lymph node swelling. He underwent APR with right side-lateral dissection. An established treatment for anorectal malignant melanoma has not been agreed upon and it is controversial. We experienced 2 cases that underwent surgery and we report them along with relevant information from the literature.

De novo assembly and comparative transcriptome analysis of Euglena gracilis in response to anaerobic conditions.

BACKGROUND: The phytoflagellated protozoan, Euglena gracilis, has been proposed as an attractive feedstock for the accumulation of valuable compounds such as ß-1,3-glucan, also known as paramylon, and wax esters. The production of wax esters proceeds under anaerobic conditions, designated as wax ester fermentation. In spite of the importance and usefulness of Euglena, the genome and transcriptome data are currently unavailable, though another research group has recently published E.gracilis transcriptome study during our submission. We herein performed an RNA-Seq analysis to provide a comprehensive sequence resource and some insights into the regulation of genes including wax ester metabolism by comparative transcriptome analysis of E.gracilis under aerobic and anaerobic conditions. RESULTS: The E.gracilis transcriptome analysis was performed using the Illumina platform and yielded 90.3 million reads after the filtering steps. A total of 49,826 components were assembled and identified as a reference sequence of E.gracilis, of which 26,479 sequences were considered to be potentially expressed (having FPKM value of greater than 1). Approximately half of all components were estimated to be regulated in a trans-splicing manner, with the addition of protruding spliced leader sequences. Nearly 40 % of 26,479 sequences were annotated by similarity to Swiss-Prot database using the BLASTX program. A total of 2080 transcripts were identified as differentially expressed genes (DEGs) in response to anaerobic treatment for 24 h. A comprehensive pathway enrichment analysis using the KEGG pathway revealed that the majority of DEGs were involved in photosynthesis, nucleotide metabolism, oxidative phosphorylation, fatty acid metabolism. We successfully identified a candidate gene set of paramylon and wax esters, including novel ß-1,3-glucan and wax ester synthases. A comparative expression analysis of aerobic- and anaerobic-treated E.gracilis cells indicated that gene expression changes in these components were not extensive or dynamic during the anaerobic treatment. CONCLUSION: The RNA-Seq analysis provided comprehensive transcriptome information on E.gracilis for the first time, and this information will advance our understanding of this unique organism. The comprehensive analysis indicated that paramylon and wax ester metabolic pathways are regulated at post-transcriptional rather than the transcriptional level in response to anaerobic conditions.

[Clinical Experience with Nutrition and Anticoagulation Therapy for a Patient with a 30 cm Residual Jejunum].

Patients with short bowel syndrome experience malabsorption and digestive disorders. They are unable to maintain adequate nutrition by the oral or enteral route alone, and their requirements for liquids, electrolytes, nutrients, microelements, vitamins, etc., are not completely met. Managing the nutritional needs of these patients is important. Another concern is these patients' inability to absorb medication, because the small intestine that is shortened in short bowel syndrome is the principal site of drug absorption. Here, we report a case of a 74-year-old woman with a 30 cm residual jejunum after surgery for acute occlusion of the superior mesenteric artery and the clinical management of nutrition and anticoagulant medication in this patient.

[Pathological Complete Response in a Case of Multiple Liver Metastases from Rectal Cancer Treated with XELOX plus Bevacizumab(Bev)Therapy].

The patient was a 56-year-old woman who had synchronous multiple liver metastases and underwent laparoscopic-assisted high anterior resection for rectal cancer. According to the Japanese classification of colorectal carcinoma(8th edition), the tumor was considered to be pStage IV (pT4bN2M1a[H3]). Following resection of the primary tumor, she received XELOX plus bevacizumab(Bev)therapy. After 5 courses, the tumors were markedly reduced in size. According to the RECIST criteria, the tumor response was determined to be a partial response(-44%). Therefore, on the basis of the morphologic response criteria, the patient had Group 1 disease. Because the chemotherapy seemed to be effective, we performed partial hepatectomies. Histologically, no cancer cells were detected in any of the resected tumors. After the partial hepatectomies, she received no additional chemotherapy. Her CEA levels decreased to a normal range and no tumor recurrence was detected over 2 and a half years. XELOX plus Bev therapy may be effective for unresectable multiple liver metastasis from rectal cancer.