[Experience of Using Immune Checkpoint Inhibitors and Chemotherapy in the Upper Gastrointestinal Tract at Our Hospital].

We investigated the gastric and esophageal cancer cases treated with immune checkpoint inhibitors and chemotherapy at our hospital. Out of 17 gastric cancer cases, 9 were treated with nivolumab(Nivo)plus S-1/oxaliplatin(SOX), 5 with Nivo plus 5-fluorouracil/Leucovorin/oxaliplatin(FOLFOX), and 3 with Nivo plus capecitabine/oxaliplatin(CapeOX), yielding a response rate of 35.3%. We also treated 3 cases of esophageal cancer. Two of these were treated with Nivo plus cisplatin/5- fluorouracil(CF)and 1 case with pembrolizumab(Pembro)plus CF, with a response rate of 33.3%. The incidence of Grade 3 or higher adverse events was 29.4% in gastric cancer and 33.3% in esophageal cancer, and no serious immune-related adverse events were observed. Further case accumulation and long-term studies are required to evaluate efficacy and adverse events in clinical practice.

[A Case of Advanced Gastric Cancer with Bone Marrow Metastasis Treated with Low-Dose Combination Chemotherapy Containing S-1 and Docetaxel].

A 77-year-old woman was admitted to our hospital with complaints of lumbago. Based on MRI, bone marrow biopsy, and upper endoscopy, she was diagnosed as having advanced gastric cancer accompanied by bone marrow metastasis and multiple bone metastases. She underwent combination chemotherapycontaining S-1 and docetaxel(TXT). However, during the first course of chemotherapy, she developed Grade 4 neutropenia and sepsis, and her ADL worsened. The anticancer agent doses were reduced drasticallyto 40% of the initial dose from the next course of chemotherapy. She was able to continue treatment without developing severe adverse events, and the disease did not progress for 11 months. However, during the 6 course of chemotherapy, she developed Grade 4 neutropenia and sepsis again, and it became difficult to continue treatment. Subsequent S-1 monotherapywas not efficacious, and she died 17 months after diagnosis. From the view of persistence and efficacy, we believe that low-dose combination chemotherapycontaining S-1 and TXT maybe a suitable regimen for advanced gastric cancer with bone marrow metastasis.

[Preoperative Chemoradiotherapy for Stage II or III Esophageal Squamous Cell Carcinoma].

BACKGROUND: The goal of this retrospective study was to investigate the efficacy and safety of preoperative chemoradiotherapy( NACR)in patients with Stage II or Stage III esophageal squamous cell carcinoma(SCC). METHODS: Between 2004 and 2014, a total of 86 patients underwent surgical resection in conjunction with NACR for esophageal SCC at our institute. Thirty-one patients(36.0%)had Stage II disease and 55 patients(64.0%)had Stage III disease. RESULTS: The median age was 64(43-81)years. A total of 78 patients received the full NACR regimen. The most common major Grade 3 hematologic toxic effects of NACR were leukopenia and neutropenia(48 cases), while the most common major Grade 3 non-hematologic toxic effect was anorexia(12 cases). One patient died in the hospital and no patients died within 30 days after surgery. A pathological complete response was achieved in 23 cases. Pathological staging(number of cases)was Stage 0(23), Stage I (8), Stage II (28), Stage III (25), and Stage IV (2). The 5-year overall survival rate(OS)was 51.0%, and was 83.2% in Stage II patients and 29.9% in Stage III patients. CONCLUSION: Preoperative NACR is safe and may improve OS and downstaging rates in patients with esophageal SCC.

Human epidermal growth factor 2 overexpressed alpha-fetoprotein-producing-gastric cancer.

PURPOSE: This study aimed to elucidate the clinicopathological characteristics of α-fetoprotein (AFP)-producing gastric carcinoma (AFP-GC) with human epidermal growth factor receptor (HER)2 overexpression to extend the treatment strategy for AFP-GC. METHODS: We analyzed 41 patients with AFP-GC who underwent surgical resection or chemotherapy from 1989 to 2019, and who had over 20ng/mL of serum AFP or positive immunohistochemical AFP expression. HER2 expression status was investigated by immunohistochemistry (IHC) for all patients and by fluorescence in situ hybridization (FISH) for cases with an IHC score of 2+. AFP-GC with an IHC score of 3 + or 2 + and FISH positivity was defined as HER2 overexpressed AFP-GC. The correlation between HER2 status and clinicopathological characteristics and prognosis in AFP-GC was analyzed. RESULTS: HER2 overexpression was detected in 17.1% of AFP-GC patients. The prognosis of the patients with HER2 overexpressed AFP-GC was not significantly different compared to HER2 non-overexpressed AFP-GC. HER2 overexpressed AFP-GC consisted of heterogeneous histology with a higher proportion of mixed-type tumors (p = 0.002). The clinical outcome of AFP-GC with mixed-type of histology tended to be better than other intestinal or diffuse types (p = 0.05). CONCLUSION: HER2 overexpressed AFP-GC consisted of a mixed type of histology, which showed a better prognosis. The results presented that HER2 status in AFP-GC is one of the molecular candidates to improve the prognosis.

Laparoscopic-assisted modified Kugel herniorrhaphy for obturator hernia: a case report.

Obturator hernia (OH) is a relatively rare disease and there are various surgical procedures for treating it. We report the case of a patient with an OH who underwent laparoscopic-assisted modified Kugel herniorrhaphy. The patient was a 74-year-old woman admitted to our hospital with nausea and abdominal distension. A diagnosis of intestinal obstruction was made because abdominal computed tomography revealed incarcerated right OH. No apparent strangulation findings were observed, and reduction was performed under ultrasound guidance. Laparoscopic-assisted modified Kugel herniorrhaphy for OH was performed. There were no signs of the bowel necrosis. Pneumoperitoneum was temporarily discontinued, and the OH was repaired by the modified Kugel herniorrhaphy. Laparoscopy confirmed that the direct Kugel patch was placed at the appropriate position. Laparoscopic-assisted modified Kugel herniorrhaphy is considered to be safe and useful for patients with OH and is considered as one of the treatment options.

Predictive value of perfusion CT for blood loss in liver resection.

Blood loss is associated with the degree of damage in liver stiffness. Severe liver steatosis is a matter of concern in liver surgery, but does not correlate with liver stiffness. This study aimed to assess the relationship between blood perfusion of the liver and blood loss in liver pathologies. Data from elective liver resection for liver cancer were analyzed. All patients underwent preoperative assessments including perfusion CT. Patients were divided into 4 groups in accordance with the pathological background of liver parenchyma. Relationships between portal flow as assessed by perfusion CT and perioperative variables were compared. Factors correlating with blood loss were analyzed. In 166 patients, portal flow from perfusion CT correlated positively with platelet count and negatively with indocyanine green retention rate at 15 min. Background liver pathology was normal liver (NL) in 43 cases, chronic hepatitis (CH) in 56, liver cirrhosis (LC) in 42, and liver steatosis (LS) in 25. Rates of hepatitis viral infection and pathological hepatocellular carcinoma were more frequent in LC and CH groups than in the other groups (p < 0.05). LC and LS showed significantly worse liver function than the NL and CH groups. Portal flow from perfusion CT correlated positively with damage to liver parenchyma and negatively with blood loss at liver transection. Low portal flow on perfusion CT predicts blood loss during liver transection.

Neoadjuvant Chemoradiotherapy for Stage II or III Esophageal Squamous Cell Carcinoma.

BACKGROUND/AIM: The goal of this retrospective study was to investigate the efficacy and safety of neoadjuvant chemoradiotherapy (CRT) in patients with Stage II or Stage III esophageal squamous cell carcinoma (SCC). PATIENTS AND METHODS: Between January 2004 and December 2014, a total of 86 patients underwent surgical resection in conjunction with preoperative CRT for esophageal SCC in our Institute. RESULTS: A pathological complete response was achieved in 38.7% of patients with Stage II cancer and 20% of patients with Stage III. Postoperative complications were observed in 61.3% of Stage II and 76.4% of Stage III patients. The 5-year overall survival rate (OS) was 83.2% in Stage II and 22.8% in Stage III (p=0.0001). The 5-year disease-free survival (DFS) rate was 67.9% in Stage II and 29.9% in Stage III (p=0.0007). CONCLUSION: Neoadjuvant CRT may improve OS and DFS rates in patients with Stage II esophageal SCC.

Focal Sinusoidal Obstruction Syndrome Caused by Oxaliplatin-Induced Chemotherapy: A Case Report.

INTRODUCTION: Sinusoidal obstruction syndrome (SOS) is a severe adverse event of long-term chemotherapy in patients with colorectal cancer. It usually develops as liver congestion due to diffuse microscopic obstruction in liver parenchyma. In contrast, it sometimes appears as a liver mass occurring with local parenchymal hemorrhaging, and is often misdiagnosed as liver metastasis. CASE PRESENTATION: A 40-year-old woman with rectal cancer underwent high anterior resection and partial liver resection of segment 7 due to synchronous liver metastasis. She received oxaliplatin-based chemotherapy (mFOLFOX6) as adjuvant chemotherapy for 6 months. A 13-mm irregular low-echoic mass was detected by CT in segment 3 of the liver 12 months after the operation. The mass was again resected as a liver metastasis because it had increased in size. The pathological diagnosis was focal SOS, which showed sinusoidal dilation and congestion by hepatocyte trabeculae in the liver parenchyma. CONCLUSIONS: Atypical irregular tumors should be considered as SOS when the patient has received oxaliplatin-based chemotherapy. A qualitative imaging modality diagnosis, such as with diffusion-weighted MRI, is superior to a morphological diagnosis in focal SOS. This imaging modality can prevent unnecessary operations.