[A Case of Juvenile AFP-Producing Gastric Cancer with Virchow Lymph Node Metastasis Achieved Long-Term Survival with Multimodal Therapy].

A 25-year-old male received palliative total gastrectomy plus D1 dissection plus Roux-en-Y reconstruction for hemorrhagic gastric cancer with left Virchow lymph node metastasis in 2013. The final diagnosis was Type 2, pT4a(se), pap>tub2 >hepatoid adenocarcinoma, pN3b, sM1, fStage Ⅳ. Because AFP was as high as 11,000 ng/mL, he was diagnosed with AFP-producing gastric cancer and started S-1 plus CDDP therapy. Left adrenal gland metastasis and #106pre, #16b1int lymph node metastasis were observed after 9 courses, and the therapy was changed to irinotecan plus CDDP therapy. After 17 courses, the patient was diagnosed with CR, and the drug was discontinued. Recurrence of the left adrenal gland and an increase in AFP were confirmed by CT after 8 months of suspension, and the drug was resumed. After 8 courses of resumption, PET-CT showed mediastinal and #16b1lat lymph node metastasis and changed to weekly PTX plus Ram therapy. After 2 courses, enlargement of lymph nodes and elevation of AFP was observed, and CapeOX therapy was changed. Diagnosis of left adrenal metastasis recurrence by PET-CT after 21 courses. Nivolumab was used, and radiotherapy(total 39 Gy)was performed locally. After the continuation of nivolumab for 3 years, no findings of recurrent metastasis were observed on imaging, and it was judged as CR, and nivolumab was terminated. As of June 2023, he is alive without recurrence. AFP-producing gastric cancer in the young is rare, and no cases with Virchow metastasis or para-aortic lymph node metastasis have been reported. We report a case of long-term survival in which CR was obtained with combined modality therapy.

[A Rare Case of Primary Splenic Malignant Lymphoma Associated with Esophagogastric Junction Neuroendocrine Carcinoma(NEC)].

A 75-year-old man was showed wall thickening just below esophagogastric junction(EGJ)by gastroscopy(GS). Biopsy indicated mucinous carcinoma. He was referred to our hospital. Computed tomography(CT), PET-CT showed EGJ cancer and splenic tumor. EGJ cancer was diagnosed GE, Siewert Type Ⅱ, GrePostAnt, Type 1, cT2, cN0, cM0, cStage Ⅰ. The patient underwent total gastrectomy, lower esophagectomy, D2+ #19, 20, 110, 111, 112 lymph nodes dissection, Rou-en- Y reconstruction, distal pancreatectomy, splenectomy, cholecystectomy, and enterostomy. Postoperative complication was pancreatic fistula(Grade Ⅱ). Pathological diagnosis was esophagogastric junction cancer, neuroendocrine carcinoma(NEC), GE, Siewert Type Ⅱ, GrePostAnt, Type 1, pT2(MP), pN1, pM0, pStage ⅡA. Splenic tumor was diagnosed splenic malignant lymphoma, large B-cell, diffuse(DLBCL), NOS, low-immediate risk. Patient was discharged 15 days after the operation and underwent adjuvant chemotherapy with S-1. In this case, he started taking S-1 because the prognosis of NEC is poorer than PSML. There was no evidence of recurrence after 5 months from gastrectomy. As a result of searching for"neuroendocrine tumor"and"malignant lymphoma"in the JAMAS, there was no report of NEC associated with malignant lymphoma. We experienced the rare case of primary splenic malignant lymphoma associated with EGJ NEC. In the case of gastric cancer with splenic tumor, malignant lymphoma of spleen should be concerned.

[A Case of Laparoscopic Total Gastrectomy for Juvenile Polyposis of Stomach with Synchronous Multiple Intramucosal Carcinomas].

The patient was a 57-year-old woman. She was referred to our hospital because severe anemia. Upper gastrointestinal endoscopy revealed polyposis throughout the stomach and lobulated polyps in cardia, greater curve of middle body of the stomach, and angulus. Colonoscopy and small bowel endoscopy showed no obvious abnormal findings. Based on these findings, a laparoscopic total gastrectomy with D1 lymph node dissection was performed for suspected juvenile polyposis of stomach with severe anemia. The gross examination of the resection specimen revealed diffuse polyposis throughout the stomach, and histopathological examination revealed hyperplasia of the orbital epithelium throughout the stomach and lack of edema in lamina propria of mucous and eosinophil leukocytic infiltration, leading to the diagnosis of juvenile polyposis of stomach. Two well differentiated adenocarcinomas were found in 2 locations, which remained within the mucosa. We report a case of laparoscopic total gastrectomy for juvenile polyposis of the stomach with gastric cancer, with some discussion of the literature.

Use of near-infrared imaging using indocyanine green associates with the lower incidence of postoperative complications for intestinal and mesenteric injury.

Anastomotic leakage after intestinal resection is one of the most serious complications of surgical intervention for hollow viscus injury. Adequate vascular perfusion of the anastomotic site is essential to prevent anastomotic leakage. Near-infrared imaging using indocyanine green (NIR-ICG) is useful for the objective assessment of vascular perfusion. The aim of this study was to evaluate the association of NIR-ICG with intestinal and mesenteric injuries. This was a retrospective, single-center study of patients undergoing surgery for intestinal and mesenteric injuries. NIR-ICG was used to evaluate vascular perfusion. Postoperative complications were assessed between NIR-ICG and non-NIR-ICG groups.The use of NIR-ICG was associated with a lower incidence of Clavien-Dindo grade ≥ III complications with a statistical tendency (p = 0.076). When limited to patients that underwent intestinal resection, the use of NIR-ICG was significantly associated with a lower risk of perioperative complications (p = 0.009). The use of NIR-ICG tended to associate with the lower incidence of postoperative complications after intestinal and mesenteric trauma surgery. NIR-ICG was associated with a significantly lower risk of complications in patients undergoing intestinal resection. The NIR-ICG procedure is simple and quick and is expected to be useful for intestinal and mesenteric trauma.

[A Case of Gastric Cancer Treated with Resection and Adjuvant Chemotherapy in Japan after FOLFOX Neoadjuvant Chemotherapy in USA].

A 73‒year‒old man, living in the United States since 1985, visited the University of Minnesota Medical Center with a complaint of upper abdominal pain in December 2019. Gastroendoscopy revealed a depressed lesion in the U area of the stomach, and the biopsy results indicated a diagnosis of por/sig. On further examination, the condition was diagnosed as gastric cancer of cStage II/III. A gastrectomy procedure was planned after treatment with neoadjuvant chemotherapy(NAC). After 1 course of mFOLFOX6, the patient decided to undergo treatment in Japan. He travelled to Japan in February and visited our hospital. In March, he underwent total gastrectomy plus D2 dissection plus Roux‒en‒Y reconstruction. The final diagnosis was gastric cancer, U, Less, ypType 2, ypT3(ss), ypN1, sM0, yfStage IIB, and the therapeutic effect was Grade 2. DS therapy was started as adjuvant chemotherapy in April. After 8 courses, he returned to the United States. After moving to the United States, he personally imported S‒1 and continued adjuvant chemotherapy at the University of Minnesota Hospital. The guidelines in Japan do not recommend NAC. Given that Grade 2 therapeutic effect was obtained even with 1 course of the treatment, FOLFOX therapy could be effective as preoperative chemotherapy for advanced gastric cancer cases.

Predictive factors for bile leakage after hepatectomy for hepatic tumors: a retrospective multicenter study with 631 cases at Yokohama Clinical Oncology Group (YCOG).

BACKGROUND: International Study Group of Liver Surgery (ISGLS) proposed the standardized definition for bile leakage (BL) after hepatectomy (Hx) at 2011 to precisely perceive incidence and predictive factors of this critical condition. METHODS: We conducted a multicenter retrospective study using the ISGLS definition of BL after Hx. RESULTS: Perioperative data regarding 631 patients undergoing elective Hx for hepatic tumors without biliary reconstruction performed between January 2009 and December 2011 were analyzed. BL was observed in 30 patients (4.8%). (Grade A, 8 (1.3%); B, 21(3.3%); C, 1 (0.2%)). Five independent predictors (diagnosis of liver metastases, prolonged operation, high risk procedures defined as Hx with broad exposure of the hilar Glissonean sheath, low platelet count and high serum total bilirubin on postoperative day 1) for grade B/C BL were elucidated by the multivariate analysis. When the study cohorts were divided into groups by number of accompanying these predictors, the more the accompanying independent predictors, the higher the incidence of BL. Notably, incidence of BL exceeded 40% in patients with four or more of these predictors. CONCLUSIONS: Risk stratification for BL after Hx can be achievable using independent predictors clarified in this study. However, proper management for high risk patients remains to be elucidated.

[A Case of Advanced Gastric Cancer Responding to Neoadjuvant Docetaxel/CDDP/S-1 Therapy with Metallic Stent Placement, Leading to Curative Surgery].

A 59-year-old man presented with epigastralgia. A diagnosis of advanced gastric cancer MLU, Circ, Type 3, 160 mm, tub2, cT4b (SI: panc), cN1, cM0, cH0, cP0, cCY0, cStage ⅢB was made. Because of difficulty with oral intake due to malignant outlet obstruction and tumor bleeding, endoscopic self-expanding metallic stent placement was performed. We administered chemotherapy involving docetaxel, cisplatin, and S-1(DCS). After 2 courses of chemotherapy, the primary lesion and regional lymph nodes had reduced in size. His response was judged as SD according to the RECIST criteria. The patient elected to undergo explorative laparotomy for assessment of the gastric cancer. The intraoperative findings showed that there was no pancreatic invasion, peritoneal dissemination, or distal metastasis, so a total gastrectomy and D2 lymph node dissection was performed. The pathological findings showed that there were very few cancer cells in the primary lesion, and a lymph node metastasis was found. The final stage was gastric cancer MLU, Circ, Type 3, 100 mm, muc, ypT4a(SE), ypN3a (13/51), ypM0, ypH0, ypP0, ypCY0, ypStage ⅢC. The therapy evaluation was Grade 1b. In summary, we encountered a patient with gastric cancer in whom curative surgery was made possible by undergoing chemotherapy and metallic stent placement.

[Clinical efficacy of low-dose CDDP and CPT-11 therapy as second- or third-line chemotherapy for advanced and recurrent gastric cancer].

We retrospectively studied the clinical efficacy and safety of the combination therapy with low-dose cis-diamminedichloroplatinum ( CDDP) and irinotecan hydrochloride(CPT-11)as a second- or third-line chemotherapy in 41 patients with advanced and recurrent gastric cancer. Low-dose CDDP (20mg/m²) and CPT-11 (80 mg/m²) were administered intravenously once every 2 or 3 weeks. The patients comprised 31 men and 10 women, with ages ranging from 42 to 81 years (mean, 67.4 years). The overall treatment response rate was 12%, including 5 partial responses but no complete response. The mean survival time was 8 months, and the disease-free survival time was 3.7 months from the start of the regimen. The median number of treatment cycles was 7.1 (range, 1.0-26.0). The most common grade 3/4 toxicity was neutropenia (2 cases), followed by dehydration (1 case) and allergy (1 case). Our data suggest that the combination of low-dose CDDP and CPT-11 has mild therapeutic toxicities and may effectively prolong the median survival time in patients with advanced and recurrent gastric cancer.

[A case of consciousness disorder induced by the syndrome of inappropriate secretion of antidiuretic hormone following cisplatin and 5-fluorouracil chemotherapy in a patient with esophageal cancer].

We report a case of consciousness disorder following the fourth course of chemotherapy with cisplatin (CDDP) and 5- fluorouracil (5-FU) in a patient with esophageal cancer. A 74-year-old man was admitted to our hospital to receive chemotherapy for esophageal cancer. Six days after chemotherapy, the patient showed impaired consciousness and his serum sodium concentration was found to be 125 mEq/L, but no edema or dehydration was noted. This hyponatremic state was diagnosed as CDDP-induced syndrome of inappropriate secretion of antidiuretic hormone (SIADH) on the basis of serum and urine hypo-osmolality. Accordingly, fluid intake was restricted and sodium supplements were administered, resulting in an appropriate increase in the serum sodium concentration to 132 mEq/L in 4 days.

[Pathological complete response in 2 patients with cT4 esophageal cancer treated with neoadjuvant chemoradiation therapy].

We report the cases of 2 patients with clinical T4( cT4) esophageal cancer who achieved pathological complete response on treatment with neoadjuvant chemoradiation therapy. Case 1 involved a 68-year-old woman who was diagnosed as having cT4 advanced esophageal cancer( with involvement of the aorta and left pulmonary vein). Neoadjuvant chemoradiation therapy with 5-fluorouraci(l 5-FU)( 800 mg/m2, days 1-5 and days 29-33), cisplatin( CDDP 80 mg/m2, days 1 and 29), and radiation (39.6 Gy/22 Fr) was administered, and the tumor showed a partial response (PR). Case 2 involved a 69-year-old man who was diagnosed as having cT4 advanced esophageal cancer( with involvement of the main bronchus). Neoadjuvant chemoradiation therapy with 5-FU( 800 mg/m2, days 1-5 and days 29-33), CDDP( 80 mg/m2, days 1 and 29), and radiation( 39.6 Gy/22 Fr) was administered, and the tumor showed a clinical PR. After tumor response was noted, curative esophagectomy was performed in both cases, without any complications, and a pathological complete response was achieved in both patients.

Prognostic factors after resection of pancreatic cancer.

OBJECTIVES: The purpose of this study was to identify important prognostic factors related to the status of a pancreatic tumor, its treatment, and the patient's general condition. METHODS: Between April 1992 and December 2006, 140 patients underwent a pancreatic resection for invasive ductal carcinoma. Prognostic factors were defined by univariate and multivariate analyses. RESULTS: The study included 103 tumors in the head of the pancreas and 37 tumors in the body or tail. The median survival time and the actuarial 5-year survival rate for all patients were 14.5 months and 12.3%, respectively. Using the significant prognostic factors identified by univariate analysis, multivariate analysis revealed that a preoperative serum CA19-9 concentration>100 U/ml (HR=1.84, p=0.0074), a tumor size>3 cm (HR=1.74, p=0.0235), venous involvement (HR=2.39, p=0.0006), a transfusion requirement of >or=1000 ml (HR=2.23, p=0.0006), and a serum albumin concentration on 1 postoperative month (1POM)<3 g/dl (HR=2.40, p=0.0009) were significant adverse prognostic factors. The presence of hypoalbuminemia on 1POM significantly correlated with a longer surgical procedure (p=0.0041), extended nerve plexus resection around the superior mesenteric artery (p=0.0456), and a longer postoperative hospital stay (p=0.0063). CONCLUSION: To improve long-term survival, preserving the patient's general condition by performing a curative resection with a short operation time and minimal blood loss should be the most important principle in the surgical treatment of pancreatic cancer.