[A Case of Sarcoid‒Like Reaction with Multiple Lymphadenopathy by Rectal Cancer after an Operation].

We are reporting on a case of lymphadenopathy after surgery for rectal cancer. The case was a 66‒year‒old female. Laparoscopic high anterior resection(D3 dissection)was performed for rectal cancer(pT1bpN0M0, pStage Ⅰ)in April 2018, and she was followed up with on an outpatient basis. In July of the same year, a painless mass had formed in the right groin. An abdominal contrast‒enhanced CT showed lymph node swelling around the right groin and external iliac artery, but the tumor markers, CEA 2.3 ng/mL and CA19‒9 <2 U/mL, were within the standard values. An inguinal lymph node biopsy was performed during the same month. Pathological examination revealed no cancer cells and formation of epithelioid granuloma with giant cells. There was no suspicion of systemic sarcoidosis based on the test results and clinical findings. From the above, the patient was diagnosed with sarcoid reaction due to the tumor. Abdominal contrast‒enhanced CT scan 2 months after the biopsy showed lymph node shrinkage and there was no recurrence 2 years after the biopsy.

[Hemorrhage of Peritoneal Dissemination of the Ascending Colon Cancer Successfully Controlled by Palliative Radiotherapy-A Case Report].

An 81-year-old man underwent laparoscopic right hemicolectomy for ascending colon cancer. The postoperative diagnosis was tub1>tub2, pT4apN1bM0, pStage Ⅲb, ascending colon cancer. At 1 year 4 months after operation, abdominal CT showed dissemination around anastomosis. The patient has been treated with first-line systematic chemotherapy(capecitabine, oxaliplatin and bevacizumab). Epigastralgia and grade 4 anemia were observed at 5 years 7 months after initiation of chemotherapy when he was treated with second-line chemotherapy(capecitabine, irinotecan and bevacizumab). As abdominal CT showed that the dissemination progressed rapidly in size 30 mm to 100 mm, we diagnosed tumor bleeding in the dissemination. Palliative radiotherapy(30 Gy/10 Fr)for the dissemination was performed. Hemostasis and tumor shrinkage were achieved, and epigastralgia improved after receiving the radiation therapy. The patient discharged our hospital on 31 days form admission. We believe that palliative radiotherapy is effective to recurrent colon cancer with tumor bleeding.

[A Case of Intra-Abdominal Desmoid Tumors Occuring Four Years after Open Radical Prostatectomy].

Desmoid tumor is one kind of fibromatosis, and much occurs the abdominal wall and outside the abdominal wall. Intra- abdominal desmoid tumor is rare at about 8%. We experienced a case of intra-abdominal desmoid tumors occurring 4 years after open radical prostatectomy with some literature review. A 72-year-old man had undergone open radical prostatectomy for prostate cancer. Four years after that resection, multiple intra-abdominal tumors measuring 56 mm in maximum diameter was identified on follow-up computed tomography, and he was referred to our department for management. We performed laparotomy and investigation of the biopsy. Immunohistochemistry of the resected specimen indicated the tumor cells were positive for vimentin and ß-catenin, and the diagnosis was desmoid. We performed partial resection of the small intestine and ileocecal resection. His postoperative course was uneventful and he was discharged on the 12th postoperative day. He has shown no sign of recurrence in the 4 months follow-up since surgery. In the past, an operation was the best treatment for intra-abdominal desmoid tumor. But it is reported that watchful waiting is also possible by the case which has no symptom and dysfunction in NCCN guidelines 2019. Further research is needed.

[Hyperammonemia with Disturbance of Consciousness during 5-FU plus Nedaplatin Therapy for Esophageal Cancer-A Case Report].

Hyperammonemia is a rare adverse event of 5-FU. Here, we report a case of hyperammonemia with disturbance of consciousness during 5-FU plus nedaplatin therapy for esophageal cancer and present a literature review. A 69-year-old man was diagnosed with cT2N2M0, cStage Ⅲ esophageal cancer. He was administered with DCF therapy as the first-line neoadjuvant chemotherapy. After the first course, he showed renal dysfunction. Therefore, as the second-line neoadjuvant chemotherapy, he was administered with 5-FU plus nedaplatin. He vomited on treatment day 5 and suddenly presented with disturbance of consciousness on treatment day 6. Blood tests showed hyperammonemia(114 µg/dL). He was treated with rehydration and branched-chain amino acid solutions, resulting in a gradual improvement of symptoms. Hyperammonemia has been reported in patients with colorectal cancer but rarely in patients with esophageal cancer. A case of hyperammonemia during the 5-FU plus nedaplatin therapy has never been reported in Japan. We should be aware that 5-FU may cause hyperammonemia and resultant disturbance of consciousness during chemotherapy with 5-FU.

[A Case of Obstructing Rectal Cancer with Obstructive Colitis Resected after Neoadjuvant Chemotherapy to Avoid Anastomotic Leakage].

A 61-year-old male was referred to our department after decompression of the transanal ileus tube due to a rectal cancer obstruction. Colonoscopy revealed a circumferential type 2 tumor, 4 cm from the anal verge. The tumor was diagnosed as rectal cancer tub1-2, Group 5 on biopsy analysis. Longitudinal ulcers descending to the sigmoid colon were present and obstructive colitis was suspected. Enhanced computed tomography showed wall thickness in the Ra, Rb rectum and swelling of the mesorectum lymph node, but distant metastases were not identified. We diagnosed the patient with Ra, Rb rectal cancer cT4aN1aM0, cStage Ⅲb. Because of the risk of anastomotic leakage with obstructive colitis, we planned neoadjuvant chemotherapy(SOX therapy)after laparoscopic transverse colostomy. After neoadjuvant chemotherapy, colonoscopy revealed improvements in the obstructive colitis. The tumor was reduced in size and the chemotherapy appeared effective. We performed laparoscopic rectal super low anterior resection with resection of the D3 lymph node. Histopathological examination revealed tub1, ypT3, ypN0, and the chemotherapeutic outcome was rated as Grade 1a. The final diagnosis was Ra, Rb rectal cancer with ypT3ypN0M0, ypStage Ⅱa.

[A Case of Disseminated Carcinomatosis of the Bone Marrow with Carcinoma of the Rectum Diagnosed by Disseminated Intravascular Coagulation].

A 77-year-old man with rectal cancer was admitted to our hospital. After neoadjuvant chemotherapy, laparoscopic abdominoperineal resection of rectum with D3 dissection was performed. The pathological diagnosis was poorly differentiated carcinoma, pT3, N1a, M0, pStage Ⅲa. Adjuvant chemotherapy was not performed. Fifteen months after operation, his chief complaint was fatigue. Thrombocytopenia and elevation of tumor maker was detected by blood test and disseminated intravascular coagulation(DIC)was suspected. He was admitted to our hospital and we started anti DIC therapy immediately. Bone scintigraphy revealed multiple bone metastases, then we diagnosed disseminated carcinomatosis of the bone marrow. He died 10 days after hospitalization. Disseminated carcinomatosis of the bone marrow with colon cancer is rare and prognosis is very poor. It is important to diagnose and start treatment as early as possible.

[Effective Palliative Radiation for Hemostasis of Recurrent Colon Cancer in the Lymph Node with Gastric Wall Invasion].

A 76-year-old man underwent laparoscopic left hemicolectomy D3(pStage Ⅱb)for sigmoid colon cancer in 2015. Later, partial transverse colectomy D2(pStage Ⅱb)was performed because transverse cancer was also detected. Recurrent peritoneal dissemination was found in 2018. In 2019, hematemesis/black stool, as well as prominent anemia(Hb 3.1 g/dL)and bleeding from recurrent gastric wall invasion of the lymph nodes on the lesser curvature side of the stomach, was observed. Although hemostasis was performed endoscopically, palliative irradiation(30 Gy in 10 fractions)was performed to control bleeding because the risk of rebleeding was high. After irradiation, endoscopy showed that the ulcer in the infiltrated area of the gastric wall had a tendency to improve. No bleeding or progression of anemia was observed, and oral intake became possible. However, the patient's general condition deteriorated, and he died 80 days after palliative irradiation. For palliative radiation therapy, alleviation of pain owing to bone metastasis, as well as alleviation of the narrowed airway and esophagus, is known. Palliative radiation therapy has recently been performed for symptom relief and prognosis extension against tumor bleeding. Palliative radiation therapy for controlling bleeding has limited hemostatic effect compared with surgical resection, and it takes some time before hemostasis is achieved, but it is less invasive and less adverse event and may be an effective treatment option.

Nonfunctional adrenocortical carcinoma initially presenting as retroperitoneal hemorrhage.

BACKGROUND: Acute adrenal hemorrhage is an uncommon entity. Although trauma is the most common cause of adrenal hemorrhage, non-traumatic etiologies have also been reported. We report an unusual case of a spontaneously ruptured adrenocortical carcinoma that initially presented as a critical massive retroperitoneal hemorrhage. The case was treated successfully using a combination of emergency interventional radiology and elective surgery. CASE PRESENTATION: A 47-year-old woman was transported to our hospital because of the sudden onset of severe pain in her left lower back. The shadow of a tumor-like soft mass accompanied by bleeding was observed in the upper pole of the left kidney, together with vascular leakage from the middle suprarenal artery on computed tomography. Transcatheter embolization of the left middle adrenal artery was administered based on a diagnosis of acute adrenal hemorrhage. Further observation indicated that the bleeding was caused by rupture of an adrenocortical carcinoma. Left adrenalectomy was subsequently carried out via laparotomy. CONCLUSIONS: We experienced an unusual case of acute massive adrenal hemorrhage caused by the rupture of a non-functional adrenocortical carcinoma, which was treated successfully by ambulatory transcatheter embolization therapy and elective surgery.

Clinical and pathological features of five-year survivors after pancreatectomy for pancreatic adenocarcinoma.

BACKGROUND: Clinical factors determining short-term survival after pancreatectomy have been well studied, but factors predicting long-term survival with curative resection are poorly understood in pancreatic carcinoma. Our objective was to identify clinical and pathological features of five-year disease-free survivors after surgical resection of pancreatic adenocarcinoma. METHODS: The clinical and pathological data from 147 patients who underwent a potentially curative resection for pancreatic adenocarcinoma at our institution between 1988 and 2012 were retrospectively analyzed. RESULTS: Of 147 patients, 18 survived for more than five years after surgery without disease recurrence. A univariate analyses demonstrated that: two or fewer lymph node metastases (P=0.014), a preoperative serum carbohydrate antigen 19-9 (CA19-9) level of 40 U/mL or less (P=0.0018), an absence of intrapancreatic nerve invasion (P=0.028), and undergoing an R0 resection (P=0.011) were significantly associated with five-year survival. A logistic regression model identified the following independent cancer-related predictors of five-year survivors: having two or fewer lymph node metastases (odds ratio (OR): 6.02; 95% confidence interval (CI): 1.08 to 112.98; P=0.0385), a preoperative serum CA19-9 level of 40 U/mL or less (OR: 5.02; 95% CI: 1.68 to 16.48; P=0.0036), and undergoing an R0 resection (OR: 3.63; 95% CI: 1.12 to 14.28; P=0.0316). CONCLUSIONS: We conclude that number of lymph node metastases being two or less, a preoperative serum CA19-9 level of 40 U/mL or less, and undergoing an R0 resection may be independent predictive factors to identify actual five-year survivors after pancreatectomy for pancreatic adenocarcinoma.

IGF-1 receptor and IGF binding protein-3 might predict prognosis of patients with resectable pancreatic cancer.

BACKGROUND: The present study aimed to elucidate the clinicopathologic role of insulin-like growth factor-1 receptor (IGF1R) and IGF binding protein-3 (IGFBP3) in patients with pancreatic cancer. The function of IGFBP3 is controversial, because both inhibition and facilitation of the action of IGF as well as IGF-independent effects have been reported. In this study, IGF1R and IGFBP3 expression was examined, and their potential roles as prognostic markers in patients with pancreatic cancer were evaluated. METHODS: Clinicopathological features of 122 patients with curatively resected pancreatic cancer were retrospectively reviewed, and expression of IGF1R and IGFBP3 was immunohistochemically analyzed. RESULTS: Expression of IGF1R and IGFBP3 was observed in 50 (41.0%) and 37 (30.3%) patients, respectively. IGF1R expression was significantly associated with histological grade (p = 0.037). IGFBP3 expression had a significant association with tumor location (p = 0.023), and a significant inverse association with venous invasion (p = 0.037). Tumors with IGF1R-positive and IGFBP3-negative expression (n = 32) were significantly frequently Stage II and III (p = 0.011). The prognosis for IGF1R positive patients was significantly poorer than that for IGF1R negative patients (p = 0.0181). IGFBP3 protein expression did not correlate significantly with patient survival. The subset of patients with both positive IGF1R and negative IGFBP3 had worse overall survival (8.8 months versus 12.6 months, respectively, p < 0.001). CONCLUSION: IGF1R signaling might be associated with tumor aggressiveness, and IGFBP3 might show antiproliferative effects in pancreatic cancer. Both high IGF1R expression and low IGFBP3 expression represent useful prognostic markers for patients with curatively resected pancreatic cancer.

In vitro effects of lapatinib with gemcitabine for pancreatic cancer cells.

BACKGROUND/AIMS: We investigated whether lapatinib plus gemcitabine has synergistic or antagonistic effects on the pancreatic cancer cell lines MiaPaca-2 and PANC-1. Furthermore, the changes of gemcitabine sensitivity-related genes by lapatinib treatment were examined. METHODOLOGY: The effects of lapatinib, gemcitabine, and combined treatment with both agents on cell viability were examined by methyl thiazolyl tetrazolium analysis. Synergy between lapatinib and gemcitabine was assessed by median effect analysis. The mRNA amounts of human equilibrative nucleoside transporter (hENT1), deoxycytidine kinase (dCK) and ribonucleotide reductase subunit M1 (RRM1) genes were measured by quantitative real-time polymerase chain reaction in cells exposed to lapatinib for 48 h, as compared with untreated cells. RESULTS: No synergistic effects were observed with combined treatment in either cell line. In contrast, antagonistic effects occurred on MiaPaca-2 cells with the two agents. Specific changes in gemcitabine sensitivity-related genes induced by lapatinib were not detected in either MiaPaca-2 or PANC-1. CONCLUSIONS: Lapatinib may not enhance the anti-tumor effects of gemcitabine for pancreatic cancer.

[A case of locally advanced pancreatic cancer with hepatic artery invasion treated with neoadjuvant chemoradiotherapy].

A 64-year-old man with a high serum level of cancer antigen 19-9 (CA19-9) was diagnosed with pancreatic head cancer by computed tomography. Because the tumor was found to have directly invaded the hepatic artery for long segment on laparotomy, we diagnosed it as an unresectable locally advanced pancreatic cancer. Radiation therapy( 50.4 Gy/28 Fr) with gemcitabine( GEM)( 1,000 mg/m2 on days 1, 8, and 15, every 4 weeks) for 3 courses was administered. Subsequently, additional systemic chemotherapy with GEM( 800 mg/m2 on days 1 and 15, every 3 weeks) and S-1( 100 mg/body on days 1-14, every 3 weeks) was administered for 4 courses. After the treatment, the main tumor shrunk without distant metastasis. Thus, we performed pancreaticoduodenectomy with resection of the common hepatic artery. An end-to-end microvascular anastomosis was made between the left gastric artery and the right hepatic artery. Pathological examination revealed that > 90% of the tumor cells had disappeared and confirmed a negative margin status (R0). Eight months postoperatively, the patient is healthy and shows no signs of recurrence.

[Clinical experience of chemotherapy with S-1/CDDP for highly-advanced gastric cancer].

BACKGROUND: We evaluated the efficacy and safety of chemotherapy with S-1/CDDP for advanced and recurrent gastric cancer at Fuchu Hospital. METHODS: The participants were 24 patients treated at our hospital. S-1 was given orally at 80 mg/m/2 for days 1-21, and 60 mg/m2 of CDDP was administered on day 8, followed by a 2-week rest period, within a 5-week course. RESULTS: Results were rated as a partial response in 12 cases and a stable response in 4 cases. The response rate was 50% (12/24), and median survival time was 273 days. The total incidence of grade 3 or greater adverse reactions including leucopenia, neutropenia, anemia, general fatigue, and eruption, was 25% (6/24). CONCLUSION: The combination of S-1/CDDP therapy appears to be highly efficacious and safe and showed promise as a useful treatment strategy, even in an outpatient clinic.

Predictive factors for change of diabetes mellitus status after pancreatectomy in preoperative diabetic and nondiabetic patients.

INTRODUCTION: This study aimed to determine risk factors for exacerbation of diabetes mellitus (DM) after pancreatectomy. METHODS: Medical records of 167 patients with benign and malignant pancreaticobiliary diseases who underwent pancreaticoduodenectomy or distal pancreatectomy were retrospectively analyzed. DM was diagnosed by diabetic history or American Diabetes Association criteria. Worsened and improved DM after pancreatectomy was defined when treatment intensity or insulin/oral antidiabetic drug dosage increased or decreased, respectively, postoperatively. Long-standing DM was defined as a duration of >2 years. RESULTS: In 76 preoperative diabetic patients, worsened and improved DM was observed postoperatively in 46 (60.5 %) and 9 (11.8 %) patients, respectively. In 91 preoperative nondiabetic patients, 22 (24.2 %) developed new-onset DM after pancreatectomy. Multivariate logistic analysis of the preoperative diabetic patients demonstrated long-standing DM and malignancy as independent predictors for postoperative worsened DM. No patients with long-standing DM or insulin treatment experienced improved DM after pancreatectomy. Multivariate logistic analysis of the preoperative nondiabetic patients showed body mass index of ≥25 and hard pancreatic texture as independent risk factors for new-onset postoperative DM. CONCLUSIONS: These results may enable preoperative evaluation of risk factors for worsened or new-onset DM after pancreatectomy and may help plan intensive care for patients at a high risk of postoperative worsened DM.

Portal vein stenting to treat portal vein stenosis in a patient with malignant tumor and gastrointestinal bleeding.

This report describes the successful use of portal venous stent placement for a patient with recurrent melena secondary to jejunal varices that developed after subtotal stomach preserved pancreatoduodenectomy (SSPPD). A 67-year-old man was admitted to our hospital with tarry stool and severe anemia at 2 years after SSPPD for carcinoma of the head of the pancreas. Abdominal computed tomography examination showed severe stenosis of the extrahepatic portal vein caused by local recurrence and showed an intensely enhanced jejunal wall at the choledochojejunostomy. Gastrointestinal bleeding scintigraphy also revealed active bleeding near the choledochojejunostomy. Based on these findings, jejunal varices resulting from portal vein stenosis were suspected as the cause of the melena. Portal vein stenting and balloon dilation was performed via the ileocecal vein after laparotomy. Coiling of the jejunal varices and sclerotherapy of the dilate postgastric vein with 5% ethanolamine oleate with iopamidol was performed. After portal stent placement, the patient was able to lead a normal life without gastrointestinal hemorrhage. However, he died 7 months later due to liver metastasis.