[Long-Term Survival Following Multidisciplinary Therapy for Pancreatic Head Cancer with Liver Metastasis].

A 71-year-old female was referred to our hospital for liver dysfunction. After careful examination, she was diagnosed with resectable pancreatic head cancer. Pancreatoduodenectomy was scheduled. In the laparotomy, 2 nodules on the liver were found. A frozen section examination of the liver nodule revealed adenocarcinoma. S-1 chemotherapy was administered for about 17 months to treat the unresectable pancreatic cancer. After chemotherapy, computed tomography(CT) revealed that the pancreatic tumor remained unchanged, and there was no distant metastasis. Positron emission tomography( PET)-CT revealed no significant uptake in the pancreatic tumor and no distant metastasis. The patient was then observed for about 10 months without chemotherapy. After that, CT showed that the size of the pancreatic tumor had increased, but there were no signs of distant metastases. Therefore, pancreatoduodenectomy was performed. Histopathological examination revealed invasive ductal adenocarcinoma in the pancreas head. The patient underwent adjuvant chemotherapy with S-1 for 5 months. So far, she has survived without any recurrence for 57 months after the initial surgery.

Influence of incomplete neoadjuvant chemotherapy on esophageal carcinoma.

BACKGROUND: Neoadjuvant chemotherapy (NAC) involving two cycles of cisplatin plus fluorouracil is recommended in Japan as a standard treatment for resectable, locally advanced esophageal squamous cell carcinoma (ESCC). We have encountered patients who were administered incomplete chemotherapy because of adverse events or the patient's refusal of treatment. Here, we retrospectively investigated the influence on perioperative outcomes and long-term prognosis of patients with ESCC who underwent complete (two cycles) or incomplete (one cycle) NAC. METHODS: We retrospectively investigated 133 patients with locally advanced ESCC of the thoracic esophagus who underwent NAC. We compared the perioperative results and prognoses of patients who underwent complete or incomplete NAC because of adverse events or the patient's refusal of treatment. RESULTS: Of 133 patients, 37 patients did not receive the second cycle of NAC; the remaining 96 patients received the second cycle of NAC as scheduled. There were no significant differences in the clinical backgrounds, surgical results, or operative morbidity rates between the groups. Patients in both groups were similarly administered postoperative chemotherapy regimens. There was no significant difference in disease-free survival or overall survival. CONCLUSIONS: We suggest that perioperative outcomes and long-term prognosis of patients with locally advanced ESCC were not significantly influenced, even if the patients did not receive a complete cycle of NAC. When certain adverse events occur after the first cycle of NAC, we believe that it is nevertheless possible to discontinue chemotherapy.

Safety and feasibility of thoracoscopic esophagectomy after neoadjuvant chemotherapy for esophageal cancer.

PURPOSE: Neoadjuvant chemotherapy (NAC) with cisplatin and fluorouracil is the recommended standard treatment for resectable locally advanced esophageal cancer (EC) in Japan. We investigated the effects of NAC on the safety and feasibility of thoracoscopic esophagectomy with total mediastinal lymphadenectomy for EC. METHODS: This retrospective study analyzed data from 225 consecutive patients who underwent thoracoscopic esophagectomy with lymph node dissection between April 2007 and December 2015. Patients with clinical stage IB, IIA, IIB, IIIA, or IIIB EC, and no active concomitant malignancy were included. We compared intraoperative outcomes, and postoperative morbidity and mortality between patients who received NAC (n = 139; NAC group) and patients who did not (n = 86; non-NAC group). RESULTS: Preoperative laboratory data revealed that anemia, thrombopenia, and renal dysfunction were more common in the NAC group than in the non-NAC group. There were no differences between the groups in operating times, blood loss, number of dissected lymph nodes, overall complication rates, or length of postoperative hospital stay. CONCLUSION: Based on our findings, thoracoscopic esophagectomy is safe and effective for locally advanced EC, even after NAC.

[Pneumocystis Pneumonia during Adjuvant Chemotherapy for Advanced Colon Cancer - A Case Report].

We report a case of pneumocystis pneumonia (PCP) during adjuvant chemotherapy for advanced sigmoid colon cancer. A 70-year-old Japanese man was referred to our hospital after complaining of bloody stools. He was diagnosed with advanced sigmoid colon cancer, T2N2aM1b, Stage IV B. After 3 cycles of mFOLFOX6 plus panitumumab as first-line chemotherapy, he received FOLFIRI plus bevacizumab as second-line chemotherapy because of progressive disease. Aprepitant and steroids were administered as antiemetic agents for a short period during each chemotherapy session. During the 2 cycle of FOLFIRI plus bevacizumab, he developed a high fever without respiratory symptoms. Chest CT revealed ground-glass opacities in both the lungs. We first treated him with antibiotics (PIPC/TAZ plus GRNX), suspecting bacterial pneumonia. However, based on the elevation of serum b -D-glucan (148 pg/mL), we diagnosed PCP and initiated SMX/TMP in addition to PIPC/TAZ. The inflammation promptly decreased, and follow-up chest CT revealed the disappearance of the ground-glass opacities. If a patient develops a fever or respiratory symptoms during a course of chemotherapy, we should consider the possibility of PCP and perform careful examinations.

C-reactive Protein is a Useful Marker for Early Prediction of Anastomotic Leakage after Esophageal Reconstruction.

BACKGROUND: Esophageal anastomotic leakage is one of the most fatal complications after esophagectomy and increases the hospitalization length. We aimed to identify a convenient clinical marker of anastomotic leakage in the early postoperative period. METHODS: In total, 108 patients who underwent esophagectomy were retrospectively screened, and 96 were used to validate the overall results. All 108 patients underwent physical examinations and determination of their white blood cell count, C-reactive protein level, platelet count, fibrinogen level, fibrin degradation product level, and antithrombin III level until postoperative day 6. RESULTS: Anastomotic leakage occurred in 21 of the 108 patients (median detection, 8 days). The C-reactive protein level on postoperative day 3 and fibrinogen level on postoperative day 4 in the leakage group were significantly higher than those in the nonleakage group. Receiver operating characteristic curves for detection of anastomotic leakage were constructed; the cutoff value of C-reactive protein on postoperative day 3 was 8.62 mg/dL, and that of fibrinogen on postoperative day 4 was 712 mg/dL. Anastomotic leakage occurred in 23 of the 96 patients in the validation group. There was a significant difference between the leakage and nonleakage groups when the C-reactive protein threshold on postoperative day 3 was set at 8.62 mg/dL. However, there was no difference between the groups when the fibrinogen threshold on postoperative day 4 was set at 712 mg/dL. CONCLUSIONS: The C-reactive protein level on postoperative day 3 is a valuable predictor of anastomotic leakage after esophagectomy and might allow for earlier management of this complication.

Cytomegalovirus-associated ulceration of gastric conduit after chemoradiotherapy following esophagectomy for cancer.

A 64-year-old man underwent radical esophagectomy for cancer and simultaneous reconstruction using the gastric conduit through the posterior mediastinum. Two courses of adjuvant chemotherapy were performed. Twenty-eight months postoperatively, recurrence of the cancer was detected in the mediastinal lymph nodes, and he underwent concurrent chemoradiotherapy and boost chemotherapy. Endoscopy was then performed to investigate the cause of epigastralgia, and multiple ulcerations were found in the lesser curvature of the gastric conduit. Although a proton-pump inhibitor was orally administered, the ulceration was intractable. Re-examination of the original biopsy specimens and serological testing revealed positivity for cytomegalovirus. The ulcers began to heal after administration of foscarnet sodium. After the treatment, no signs of exacerbation associated with reinstitution of chemotherapy were observed.

Carcinosarcoma of the liver: report of a case.

A 64-year-old Japanese woman without a history of viral hepatitis was admitted for investigation of a huge liver mass. The tumor, measuring 14 × 12 × 22 cm, had invaded the diaphragm, right lung, and inferior vena cava. Serum examinations demonstrated high levels of carbohydrate antigen 19-9 (CA19-9), and the Child-Pugh score was A. She underwent right lobectomy of the liver and partial resection of the right diaphragm, right lung, and inferior vena cava. Radio- and chemotherapy were also given, but she died of recurrence 3 months after surgery. Microscopically, the tumor exhibited intermingled adenocarcinomatous and atypical mesenchymal components. The carcinomatous component was positive for cytokeratins 7, 19, and 20, chromogranin A, epithelial membrane antigen, c-KIT, and vimentin. The sarcomatous component was positive for vimentin and c-KIT. A review of 36 cases of hepatic carcinosarcoma revealed the following: chronic hepatitis or cirrhosis in 57 % of the patients; increased serum CA19-9 levels in 30 %; a mean tumor diameter of 10 cm; invasion of the adjacent organs or metastasis to distant organs in 47 %; wide intrahepatic infiltration in 44 %; and 50 % survival of only 5 months. Significant differences were seen according to tumor diameter (diameter >5 cm; p < 0.05), wide intrahepatic infiltration (p < 0.05), and extrahepatic invasion/metastasis (p < 0.01). Neither chemotherapy nor radiotherapy contributed to prognosis, but surgical resection resulted in some improvement (p < 0.05).

Incisional intercostal hernia with prolapse of the colon after right partial nephrectomy.

A 75-year-old woman with a history of myocardial infarction, gallstones, and right renal cancer was referred to our department because of right flank pain. She had a surgical scar on the right abdomen between the 10th and 11th ribs; computed tomography demonstrated intercostal herniation of the colon. Recognizing the possibility of adhesions of the hernia and colon, we used a median skin incision and patched a polyester mesh coated with absorbent collagen. The patient had an uneventful postoperative course, with no pain for 6 months postoperatively. Transdiaphragmatic intercostal hernias with abdominal contents commonly develop after trauma or thoracic surgery. Incisional intercostal hernias seldom develop after nephrectomy; the present case is only the fourth report. We conjecture that a costochondral incision can induce subluxation of the costotransverse joint, intercostal nerve injury, and atrophy of the intercostal and abdominal oblique muscles. Surgeons must therefore recognize the potential, albeit rare, for intercostal hernia after nephrectomy.

Management of postoperative intraabdominal abscess in laparoscopic versus open appendectomy.

BACKGROUND: Complicated appendicitis (gangrenous or perforated appendicitis) is a risk for postoperative intraabdominal abscess, but management of intraabdominal abscess may differ between laparoscopic and open appendectomy. METHODS: We reviewed 67 patients who underwent appendectomy for complicated appendicitis, including 26 who received laparoscopic appendectomy (LA group) and 41 who underwent open appendectomy (OA group). The operation was performed under general anesthesia in all 26 patients in the LA group and in 10 (24%) in the OA group. Patient characteristics, operative factors, and postoperative complications (especially postoperative intraabdominal abscess) were compared between the two groups. Management of postoperative intraabdominal abscess was also investigated. RESULTS: Postoperative intraabdominal abscess occurred in 3 patients (12%) in the LA group and in 10 (24%) in the OA group (p = 0.23). All 3 patients in the LA group were treated conservatively. Of the 10 patients in the OA group, 6 were treated conservatively, but 4 needed a reoperation, including 3 who had undergone right pararectal skin incision under spinal analgesia and in whom sufficient irrigation was not possible because anesthesia had worn off. CONCLUSIONS: Our results suggest that insertion of abdominal drainage may be appropriate treatment for intraabdominal abscess after laparoscopic appendectomy. Light anesthesia may induce residual abscess in open appendectomy performed under spinal analgesia.

Colorectal cancer metastasis to the thyroid.

A 69-year-old Japanese woman underwent a curative operation for rectal cancer (T2, N0, M0, Dukes B, R0, and stage IIA of American Joint Committee on Cancer) 3 years ago. On subsequent routine follow-up, a right-side thyroid nodule and a regional lymph node of up to 1.5 cm in diameter was palpated. FDG-PET demonstrated high FDG accumulation in the right lobe of the thyroid gland, neck lymph nodes, and sacral periosteum. We diagnosed a local recurrence of rectal cancer and a primary thyroid cancer. We chose radiotherapy for the periosteal recurrence, and then right hemithyroidectomy with regional lymph node dissection for the thyroid tumor was performed. Pathological examination demonstrated mucinous carcinoma, the same as the previous surgical specimen from the rectum. She had been treated with postoperative chemotherapy and had been alive and well for 26 months with lung metastases. Although thyroid gland metastasis from colorectal cancer is rarely reported, physicians should consider the possibility of thyroid gland metastasis when performing routine follow-up examinations for recurrence of colorectal cancer.

[Thoracoscopic radical esophagectomy for cancer treatment].

More than 15 years have passed since thoracoscopic surgery was first employed in Japan as a treatment for esophageal cancer with curative intent. Because of the proliferation of techniques that can be used to obtain an adequate operative field, such as hand assist, placing the patient in the prone position, etc., the number of approaches to thoracoscopic surgery has been increasing, contrary to expectations of standardization. The technique of mediastinal dissection has been refined with increasing knowledge of microanatomy, which can be clarified under the magnified view provided in thoracoscopic surgery. Comparable pulmonary function and survival are achieved after both thoracoscopic surgery and open-chest surgery. The accreditation board of the Japan Society for Endoscopic Surgery is now standardizing the thoracoscopic technique. To avoid surgical mistakes, thorough knowledge and adherence to the proper indications are essential.

[A case of SIADH developed during neoadjuvant chemotherapy using nedaplatin and 5-fluorouracil in a patient with esophageal cancer].

A 77-year-old male with thoracic esophageal cancer (cT3N3M0, Stage III) received nedaplatin at 80mg/m2 for 1 day and 5-fluorouracil at 800mg/m2 for 5 days as neoadjuvant treatment. On the fifth day of treatment, he lapsed into a coma (Japan Coma Scale 30), and his serum sodium concentration was found to be decreased to 116mEq/L. We concluded hyponatremia due to SIADH (syndrome of inappropriate secretion of antidiuretic hormone) induced by chemotherapy based on the fact that the patient had no finding of dehydration, particular history of related disorders, serum hypoosmolality accompanied by urine hyperosmolality and persistent urinary sodium excretion. We treated him with fluid restriction, sodium supplement and administration of loop diuretic. Then he regained consciousness and appropriate serum sodium level. Thereafter, hyponatremia was corrected without recurrence, and the patient underwent radical esophagectomy safely. He has been in good condition without recurrence of esophageal cancer after surgery.