A comparison of the effects of anti-reflux procedures during esophagogastrostomy after proximal gastrectomy on the postoperative quality of life.

PURPOSE: To investigate the postoperative quality of life (QOL) in patients with proximal gastric cancer (PGC) or esophago-gastric junction cancer, a nationwide multi-institutional study (PGSAS NEXT trial) was conducted. METHODS: Patients who had undergone radical resection more than 6 months previously were enrolled from 70 Japanese institutions between July 2018 and June 2020. The Postgastrectomy Syndrome Assessment Scale (PGSAS)-45 questionnaire was distributed to eligible patients, and responses were collected by mail. The main outcome measures of the PGSAS-45 were then calculated and compared. RESULTS: Questionnaires were retrieved from 1950 participants, and data from 300 patients who had undergone a proximal gastrectomy (PG) with esophagogastrostomy for PGC were analyzed. The mean esophageal reflux subscale value was 1.9 among the 276 patients who underwent an anti-reflux procedure, which was significantly better than the mean value (2.6) for the 21 patients who did not undergo an anti-reflux procedure (p = 0.002). The esophageal reflux subscale values were also compared among 3 major anti-reflux procedures: the double-flap technique (N = 153), the pseudo-fornix and/or His angle formation (N = 67), and fundoplication (N = 44); no statistically significant differences were observed. CONCLUSION: An anti-reflux procedure during esophagogastrostomy after PG for PGC is necessary to improve postoperative esophageal reflux symptoms, regardless of the type of procedure. TRIAL REGISTRATION: The PGSAS NEXT study was registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR; registration number: 000032221).

Impact of COVID-19 on gastric cancer treatment in Japanese high-volume centers: a JCOG stomach cancer study group survey.

PURPOSES: The spread of coronavirus disease 2019 (COVID-19) has affected socioeconomic and healthcare systems in many countries. Accordingly, many individuals may have canceled their annual health-check programs, including esophagogastroduodenoscopy, which would have resulted in lower numbers of newly diagnosed patients with gastric cancer in comparison to other times. METHODS: Questionnaires were distributed to 62 hospitals every week from May 2020 to August 2020 (total 744) through mailing lists of the Stomach Cancer Study Group of the Japan Clinical Oncology Group. The number of patients with gastric cancer and hospital systems during the COVID-19 pandemic were surveyed. RESULTS: In total, 74% (551 out of 744) of the questionnaires were answered and analyzed. In early May, approximately 50% of hospitals had to restrict surgical slots due to the COVID-19 pandemic. However, they gradually loosened the restrictions thereafter. The number of gastrectomies was < 80% that of the same period in the previous year, and hospitals in Tokyo were seriously affected by a 50% decrease in the number of gastrectomies. CONCLUSIONS: The number of gastrectomies was lower than that in the previous year. Further multi-center follow-up studies are required to evaluate the long-term effects of COVID-19 on the clinical outcomes of patients with gastric cancer.

[Case of Gastric Malignant Lymphoma Invading Other Organs with Bleeding Treated by Surgery].

A female in her late 50s experienced dyspnea and was transported by an ambulance. Her hemoglobin score was low, and CT imaging showed a giant tumor in her stomach. The tumor perforated her liver and invaded the abdominal wall and duodenum around the Treitz ligament. She required surgery because of the massive hemorrhage due to the tumor. Total gastrectomy with lateral segmentectomy of the liver and resection of the duodenum and the ileum around the Treitz ligament were performed. At 1.5 months after surgery, chemotherapy for malignant lymphoma was successfully initiated.

[A Case of Successful CDDP plus CPT-11 Therapy for Recurrent Carcinomatous Lymphangiosis Occurring during Postoperative Adjuvant Therapy for Gastric Cancer].

The case involved a 67-year-old man. Type 2 gastric cancer in the body of stomach was discovered, and the patient was referred to this department, where distal gastrectomy with Roux-en-Y reconstruction was carried out. The pathological classification was pT2N2H0P0CY0M0, pStage II B, and S-1 administration was started as postoperative adjuvant therapy. After 10 months of administration, a chest computed tomography(CT)scan revealed fine nodular shadows and irregular thickening of the alveolar septa in both lungs, a finding that was judged to be carcinomatous lymphangiosis. CDDP plus CPT- 11 therapy was subsequently started. Chest CT scan after 2 courses of administration showed the disappearance of the carcinomatous lymphangiosis. However, peritoneal metastasis was noted immediately below the abdominal wall. After completing 6courses of administration, the recurrence of peritoneal metastasis disappeared, and the administration of chemotherapy was terminated. There was no subsequent recurrence, and the patient remains alive today, 6years after the surgery. In the present case, the CT scan did not show clear mediastinal or hilar lymph node enlargement, but nodular shadows were noted at the periphery of the lung field, which were thought to be carcinomatous lymphangiosis as a result of haematogenous or anterograde metastasis into the lungs.

[A Case of Malignant Obstruction of the Colon Due to Peritoneal Dissemination of Gastric Carcinoma Treated with Colon Stenting and Colectomy after Chemotherapy].

A man in his 60s underwent gastrectomy to treat gastric carcinoma. Approximately 2.5 years after the surgery, he was admitted to the hospital because of abdominal pain. He was diagnosed with obstruction of the transverse colon due to a colon tumor. A stent was placed to treat the obstruction and avoid oncologic emergency. Biopsy results and imaging showed that the patient did not have colon cancer, but his previous gastric cancer had disseminated peritoneally. Chemotherapy was selected as treatment for recurrent gastric cancer. After chemotherapy, the patient underwent colectomy with removal of the stent. His postoperative course was good, and he was discharged from hospital without complications. The patient received additional chemotherapy. We encountered a case of colon obstruction due to peritoneal dissemination of gastric cancer that was successfully treated using a metallic colorectal stent. Colon stenting for malignant bowel obstruction is useful to avoid oncologic emergencies. However, there is no evidence at this time that long-term placement of a stent is safe. The decision to remove or retain the stent should be made upon carefully considering the condition of the patient and progression of the disease.

[A Case of Locally Advanced Pancreatic Cancer Showing R0 Resection after Resection of the Portal Vein Following Preoperative Chemoradiotherapy].

We report a case of pancreatic cancer showing R0 resection after resection of the portal vein(PV)following preoperative chemoradiotherapy. A 71-year-old woman was admitted to our hospital with back pain. We diagnosed the patient with pancreatic cancer using computed tomography scan and fine-needle aspiration biopsy. Because the tumor directly invaded the PV, we diagnosed it as a borderline resectable locally advanced pancreatic cancer. Radiation therapy(40 Gy/20 Fr)was administered with S-1 monotherapy(120 mg/body/day on days 1-5 and days 8-12). After the treatment, the main tumor was stable without distant metastasis. Therefore, we performed pancreaticoduodenectomy with resection of the PV. Pathological examination confirmed negative margin status. The patient was healthy and showed no sign of recurrence eight months after surgery.

[Assessment of Endoscopic Resection and Partial Duodenectomy for Duodenal Mucosal Tumor].

INTRODUCTION: The risk of perforation following endoscopic resection is high. We analyzed the outcome of partial duodenectomy and discussed the therapeutic strategy for duodenal mucosal tumor(DMT). PATIENTS AND METHODS: We analyzed 19 cases who have undergone endoscopic resection, and 11 cases who have undergone partial duodenectomy for DMT in our institute since 2007. We divided them into the first period(ESD actively indicated)and late period(ESD carefully indicated according to the alteration of indication of ESD for DMT in 2013)groups. RESULTS: In the first period, all 17 cases initially underwent endoscopic resection and 4 cases were complicated by perforation. On the other hand, in the late period, 6 of 12 cases initially underwent endoscopic resection and 1 case was complicated by perforation. Emergent partial duodenectomy was performed with additional resection in the perforation cases. There were no complications associated with surgery, and all 29 cases achieved curative resection, based on the histology results. CONCLUSION: We can safely indicate endoscopic resection for DMT with surgical back-up and cooperation with the endoscopic internal department.

[A Long-Surviving Case of Unresectable Gall Bladder Carcinoma Treated with Gemcitabine-Based Chemotherapy].

We report a 5-year surviving patient with unresectable gall bladder carcinoma treated with gemcitabine(GEM)-based chemotherapy. A 64-year-old man was diagnosed with unresectable gall bladder carcinoma with peritoneal dissemination based on laparotomy findings. Two months later, he started to receive GEM chemotherapy. Twelve months after surgery, the patient chose to suspend GEM treatment. One year and 10 months later, multiple lung metastases appeared and GEM was restarted in combination with UFT. Although the primary lesion and lung metastases gradually progressed, the patient maintained a good quality of life. After 3 years and 2 months, chemotherapy was changed to GEM plus S-1 because of progressive disease. Five years and 2 months after surgery, his condition was complicated by a secondary pneumothorax, and the patient received home oxygen therapy. Five years and 8 months after surgery he died of respiratory distress caused by the progression of lung metastases. Even in the case of unresectable advanced gall bladder carcinoma, effective chemotherapy could improve quality of life and prolong survival.

[Outcome of Pulmonary Metastasectomy for Hepatocellular Carcinoma].

Pulmonary metastasis of hepatocellular carcinoma (HCC) is considered a poor prognostic feature of the disease, and the utility of pulmonary resection is unclear. We evaluated clinical outcomes following pulmonary resection in 7 patients. All patients underwent video-assisted thoracic surgery (VATS). The median disease-free interval (DFI) was 14 (6-23) months. During pulmonary resection in 1 of the patients, intrahepatic recurrence was discovered and, 18 months later, this patient died of the recurrence. Of the remaining 6 patients, 2 patients developed intrahepatic recurrence and brain metastasis and died at 66 months and 10 months after pulmonary resection. Three patients are still alive and disease-free to date with a median follow-up duration of 42 (18-55) months. Of these 3 surviving patients, 2 patients had solitary pulmonary metastases and 1 patient had multiple bilateral pulmonary metastases; these patients underwent VATS once. The 7th patient underwent VATS 3 times for pulmonary metastasis and had no evidence of intrahepatic or extrahepatic recurrence. This patient died of an unrelated cause 15 months after the last pulmonary resection (47 months after the primary pulmonary resection). This study indicates that surgical resection of metachronous pulmonary metastases is associated with a favorable outcome in selected patients.

[Efficacy of Neoadjuvant Therapy for Borderline Resectable Pancreatic Cancer Involving the Superior Mesenteric Artery].

Multidisciplinary therapy is essential in the treatment of borderline resectable pancreatic cancer involving the superior mesenteric artery (BR-SMA). We analyzed the outcomes of multidisciplinary treatment for BR-SMA and evaluated the efficacy of neoadjuvant therapy (NAT). We reviewed the clinical courses of 10 patients with BR-SMA. Seven patients were treated with preoperative neoadjuvant therapy (NAT group), and 3 patients underwent radical pancreaticoduodenectomy first (SF group). In the NAT group, the rate of R0 was 7/7 (100%), the induction rate of postoperative adjuvant chemotherapy (AC) was 6/7 (86%), and the first recurrence sites were the lung in 4 patients, and the liver and peritoneum in one patient each, respectively. In the SF group, the rate of R0 was 2/3 (67%) because of a positive pathological dissecting peripancreatic margin in 1 case. The induction rate of AC was 3/3 (100%), and the first recurrence sites were the liver in 2 patients, the peritoneum in 1, and a local site in 1. The disease free survival of the NAT group (median survival time [MST] 19.3 months) was significantly better than that of the SF group (MST 5.7 months) (log rank test, p=0.002). The median overall survival of the NAT and SF groups was 51.6 months and 19.5 months, respectively (p=0.128). An R0 resection could be performed in all cases in the NAT group. The NAT extended disease-free survival. We conclude that NAT is recommended in the treatment of BR-SMA.

[Gastric cancer with liver metastasis and peritoneal dissemination treated with conversion surgery to achieve r0 resection after capecitabine, cisplatin, and trastuzumab chemotherapy-a case report].

Herein, we present a case report suggesting the importance of conversion surgery and the effectiveness of adjuvant chemotherapy with trastuzumab. A 77-year-old woman was diagnosed with gastric cancer complicated by multiple liver metastases and peritoneal dissemination. Owing to a HER2 immunohistochemistry (IHC) tumor score of 3+, we initiated capecitabine plus cisplatin (CDDP) plus trastuzumab chemotherapy. Subsequently, the liver metastases and peritoneal dissemination were absent on computed tomography images, and no new metastatic lesions developed during chemotherapy. After 10 chemotherapy courses, the patient underwent distal gastrectomy and 2 partial liver resection procedures. The liver metastasis remained, and it received a score of 2+ on the HER2 IHC test. We have continued to administer postoperative capecitabine plus trastuzumab chemotherapy because no metastatic lesions have appeared.

[Three cases of surgical resection of peritoneal recurrence of hepatocellular carcinoma following hepatectomy].

Surgical treatment of peritoneal recurrence (PR) of hepatocellular carcinoma (HCC) is still controversial. We report herein 3 cases of PR treated by surgical resection. Firstly, a 55-year-old woman presented with recurrences in the peritoneum and mediastinal lymph nodes 12 months after hepatectomy for ruptured HCC. After the administration of sorafenib, the mediastinal lesions shrank and the PRs were resected. There has been no recurrence 20 months after PR resection. The second case was of a 56-year-old man with recurrences in the remnant liver and the peritoneum 41 months after hepatectomy for ruptured HCC. The remnant liver lesions were controlled by transcatheter arterial chemoembolization (TACE), and the PRs were resected twice. However, multiple bone and lung metastases developed and the patient died of HCC 73 months after peritoneal resection. In the third case, a 63-year-old man had recurrences in the remnant liver and the peritoneum 78 months after hepatectomy. Remnant liver lesions were controlled by radiofrequency ablation (RFA) and TACE, and PRs were resected. However, the hepatic lesions had progressed and he died 102 months after initial hepatectomy. Based on our observations, patients with PRs who have no other distant metastases and whose intrahepatic lesions are controllable and PRs are completely resectable may have relatively long-term survival. Surgical treatment of PR may also improve the quality of life and prognosis.

[Experiences of laparoscopic repeat hepatectomy for recurrent hepatic cancer after open hepatectomy].

We report 3 cases of recurrent hepatic cancer in patients who underwent laparoscopic repeat hepatectomy (LRH). Case 1: A 70-year-old female with ascending colon cancer and liver metastases underwent open right colectomy followed by open S5 resection. Seven months later, the patient experienced a recurrence in the lateral segment and underwent laparoscopy-assisted ( L-A) partial resection. The adhesiolysis around the left liver was performed through a 7-cm upper median incision. Partial resection of the lateral segment was performed by hand-assisted laparoscopic surgery (HALS) using a median incision. Case 2: A 63-year-old female with metachronous liver metastases from rectal cancer underwent open S4a and S5 resection. Nineteen months later, she experienced a recurrence in S4b and underwent an L-A S4b resection. Adhesiolysis around the previous hepatic transection was performed through a small upper median incision. Mobilization of the liver was performed by HALS. A hepatic transection of S4b was also performed in the upper median incision. Case 3: An 80-year-old female with hepatocellular carcinoma (HCC) recurrence in the lateral segment after open S4 resection underwent L-A lateral segmentectomy. An adhesiolysis, mobilization of the liver, and a hepatic transection were performed by HALS and hybrid technique as described in case 2. In a patient with a history of open hepatectomy, LRH may be extensively indicated by utilizing HALS or a hybrid procedure.

[A case of AFP-producing esophagogastric junction cancer with liver metastases with a good response to chemotherapy].

A 62-year-old man was diagnosed with esophagogastric junction cancer following esophagogastroduodenoscopy in response to hematemesis. Although liver metastasis was detected during surgery, a total gastrectomy and lower esophagus resection for local control was performed. Alpha-fetoprotein(AFP)-producing tumor with hepatoid adenocarcinoma was diagnosed on the basis of the pathological examination. Serum AFP levels remained high postoperatively and multiple liver metastases were detected on computed tomography imaging. After 6 courses of chemotherapy with S-1 and cisplatin (CDDP), a significant reduction in the size of the liver metastases and a decrease of serum AFP levels were achieved. Postoperative 2-year tumor control using S-1 single agent chemotherapy was obtained. AFP-producing esophagogastric junction cancer has a poor prognosis. This case raises the possibility that long-term survival can be obtained by combining surgery for local control with systemic chemotherapy.

[An examination of the utility of high-precise radiation therapies for the recurrence of postoperative esophageal cancer].

We analyzed 16 cases (23 therapeutic sites) of post-operative recurrence of esophageal cancers that were treated with high-precise radiation therapies.The recurrence sites were cervical lymph nodes (5 cases), superior mediastinal lymph nodes (5 cases), posterior mediastinal lymph nodes (3 cases), regional lymph nodes with anastomosis (2 cases), abdominal paraaortic lymph node (3 cases), and regions with hematogenous metastasis (5 cases: liver, lung, spleen, and dissemination to the diaphragm bottom).By recurrence number, 10 cases presented with a single lesion, and 6 cases had multiple lesions.The effect of the treatment was complete response (CR) in all cases, and 6 cases maintained CR.The median of the overall survival after radiotherapy was 562 (132-1,231) days.Analysis of the prognostic factors for the overall survival from a recurrence revealed that the metastatic number (single) (p=0.003), and the metastatic pattern(hematogenous metastasis) (p= 0.004), significantly improved prognosis.We conclude that radiotherapy is an option to extend prognosis in some recurrence cases.

[A case of fixing an anastomotic site to the abdominal wall out of the abdominal cavity for a small intestinal perforation during chemotherapy].

A 53-year-old man presented with a continuous high fever and was diagnosed with diffuse large B-cell lymphoma with metastasis to the lung, spleen, and mesenterium. He was treated with cyclophosphamide and prednisolone followed by administration of cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP) chemotherapy 20 days later. Two days after initiation of CHOP therapy, the patient complained of severe abdominal pain. Perforative peritonitis was diagnosed using abdominal computed tomography. A perforation of the small intestine approximately 160 cm distal to the Treitz ligament was uncovered during emergency laparotomy. The risk of leakage was considered too high for anastomosis of the small intestine to be performed. Further, construction of an intestinal stoma could result in a high-output syndrome that could lead to difficulty in resuming chemotherapy. Based on these considerations, we fixed the anastomotic region to the abdominal wall using a technique similar to construction of an intestinal stoma. Post-operative anastomotic leakage did not occur. Nine days later, a perineal hernia was noted near the anastomotic site and a second operation was performed. The anastomotic site was placed back into the abdominal cavity during this operation. CHOP therapy was resumed 16 days after the first operation.

[A case of intrahepatic cholangiocarcinoma with peritoneal dissemination treated successfully with surgical resection and adjuvant chemotherapy].

A 72-year-old woman was diagnosed with liver dysfunction during a medical examination. An abdominal computed tomography (CT) scan showed multiple nodules in the left lobe, anterior segment, andposterior segment of the liver, leading to a diagnosis of intrahepatic cholangiocarcinoma (ICC). Extended left lobectomy and partial hepatectomy in the anterior and posterior segment with lymph node dissection was performed. At the time of the operation, small nodules on the peritoneum near the stomach were resected; these nodules were diagnosed as peritoneal disseminations of ICC. The histopathological diagnosis was moderately differentiated tubular adenocarcinoma (T4N0M1, Stage IVB). Adjuvant chemotherapy with S-1 was administered for 18 months. Thirty months after the operation, multiple lung metastases were detected by using CT, and chemotherapy with gemcitabine was initiated. Thirty-six months after chemotherapy with gemcitabine, the patient is alive and at home despite her lung metastases, which grew slightly in size. Herein, we report a long-term survival case of ICC with peritoneal dissemination that was successfully treated with surgical resection and adjuvant chemotherapy.

Wiskott-Aldrich syndrome presenting with a clinical picture mimicking juvenile myelomonocytic leukaemia.

BACKGROUND: Wiskott-Aldrich syndrome (WAS) is a rare X-linked immunodeficiency caused by defects of the WAS protein (WASP) gene. Patients with WAS typically demonstrate micro-thrombocytopenia. PROCEDURES: The report describes seven male infants with WAS that initially presented with leukocytosis, monocytosis, and myeloid and erythroid precursors in the peripheral blood (PB) and dysplasia in the bone marrow (BM), which was initially indistinguishable from juvenile myelomonocytic leukaemia (JMML). RESULTS: The median age of affected patients was 1 month (range, 1-4 months). Splenomegaly was absent in four of these patients, which was unusual for JMML. A mutation analysis of genes in the RAS-signalling pathway did not support a diagnosis of JMML. Non-haematological features, such as eczema (n = 7) and bloody stools (n = 6), ultimately led to the diagnosis of WAS at a median age of 4 months (range, 3-8 months), which was confirmed by absent (n = 6) or reduced (n = 1) WASP expression in lymphocytes by flow cytometry (FCM) and a WASP gene mutation. Interestingly, mean platelet volume (MPV) was normal in three of five patients and six of seven patients demonstrated occasional giant platelets, which was not compatible with WAS. CONCLUSIONS: These data suggest that WAS should be considered in male infants presenting with JMML-like features if no molecular markers of JMML can be detected.

[Two cases of long-term survival after treatment of recurrent intrahepatic cholangiocarcinoma and intrahepatic metastasis in the remnant liver with repeated hepatectomy].

We report 2 cases of recurrent intrahepatic cholangiocarcinoma (ICC) with intrahepatic metastasis in the remnant liver in patients who underwent repeated hepatectomy and are currently alive and free of the disease. Case 1 involves a 53-year- old woman who underwent extended right hepatectomy for mass-forming type ICC (7-cm in diameter) in the right lobe. After 7 months, she experienced tumor recurrence, and exhibited a 3.8-cm solitary intrahepatic metastasis in the remnant left lateral segment. The patient underwent partial resection of the lateral segment and is currently disease-free at 2 years and 9 months after the recurrence. Case 2 involves a 59-year-old woman who underwent extended left hepatectomy for combined mass-forming and periductal-infiltrating-type ICC( 5-cm in diameter) in the left lobe. After 2 years and 3 months, she experienced tumor recurrence, and exhibited a 3-cm solitary intrahepatic metastasis in the remnant right anterior segment 8. She underwent partial resection of segment 8 and is currently disease-free at 2 years and 11 months after the recurrence. Most of the recurrences of ICC in the remnant liver exhibit multiple lesions or concomitant extrahepatic metastases; therefore, the indication of repeated hepatectomy for intrahepatic recurrence in the remnant liver is restrictive. However, most of the reported cases on repeated hepatectomy for intrahepatic recurrence involved a solitary metastasis in the remnant liver, and revealed a relatively favorable prognosis. Thus, we believe that a solitary recurrence of ICC in the remnant liver could be an indication for repeated hepatectomy.

[A case of superficial primary malignant melanoma of the esophagus].

A 71-year-old man who was being followed-up for esophagus melanosis in the middle thoracic esophagus for 2 years was found to have a black semipedunculated tumor at the same site. Radical subtotal esophagectomy with 2-field lymph node dissection was performed. Histopathological examination indicated a malignant melanoma (pT1b [SM1], N0, Stage I). Adjuvant chemotherapy with DAC-tam (dacarbazine, nimustine, cisplatin, and tamoxifen) was administrated for a diagnosis of primary cutaneous malignant melanoma. After 2 courses of chemotherapy, no recurrence was observed for 10 months. Combined radical surgery with lymph node dissection and systemic chemotherapy is recommended for primary malignant melanoma of the esophagus with submucosal tumor invasion. This treatment is necessary because of the risk of high local recurrence and distant metastasis based on the malignant potential predicted by histopathological examination.