[A Case of Self-Expandable Metallic Stent Placement to Treat Colon Obstruction Due to Metastatic Gastric Cancer].

A66 -year-old woman presented with abdominal pain and nausea. She was diagnosed with wall thickening of the gastric antrum and bowel obstruction caused by tumors of the splenic flexure on computed tomography. Aself -expandable metallic stent(SEMS)was placed in the splenic flexure of the colon 4 days after transanal ileus tube replacement. No complication was observed, and she could ingest a normal diet, permitting her discharge from the hospital 12 days after SEMS placement. She was diagnosed with gastric cancer(Type 4, cT4a[SE], N2, H0, P1, M1[LYM], cStage IV )on upper gastrointestinal endoscopy and computed tomography, and administration of S-1 plus oxaliplatin(SOX)was started. Nab-paclitaxel as the second-line chemotherapy was administered after 8 courses of SOX therapy because of an increase in the amount of ascites. No late complication associated with stent placement was recognized. SEMS placement was suggested to be effective for treating colon obstruction due to metastatic gastric cancer.

[Examination of Patients with Malignant Obstruction Treated with Chemotherapy after Ileo/Coleostomy].

Management for obstructive cancer of the colon diverges into many ways. The aim of this study was to evaluate the treatment course of patients with malignant obstruction after ileo/coleostomy. Thirty-six patients with malignant obstruction who underwent ileo/coleostomy in our hospital from May 2012 to January 2016were enrolled in the study. Clinical outcomes were the period before treatment initiation, chemotherapy, radiotherapy, primary lesion resection, and death, and these were retrospectively analyzed. Although 9 stomal complications occurred, no case experienced a delayed treatment start. However, patients with perioperative complications, sepsis due to the tumor, pneumonia, cerebral infractions, and ileus needed a long recovery period before treatment initiation. Patients who need ileo/coleostomy must be considered for performance status and ways to decrease perioperative complications to prevent stomal complications from chemo/radiotherapy.

[A Case of an Elderly Patient with Unresectable Gastric Cancer Treated by Paclitaxel and Ramucirumab].

An 80-year-old man was admitted to our hospital with appetite loss in December 2014. Gastroduodenal scope, abdominal computed tomography(CT), and laparoscopy revealed type 4 advanced gastric cancer(poorly differentiated adenocarcinoma) with multiple lymph node(LN)involvement and multiple peritoneal metastasis. S-1(80mg/body)was administrated between January 2015 and September 2015 in the outpatient clinic. A partial response was obtained, but a gastric tumor, ascites, and LN re-growth were observed. Since October 2015, paclitaxel(PTX)(70mg/m2; day 1, 8, and 15)and ramucir- umab(RAM)(8mg/kg; day 1 and 15)have been administered. After 2 courses, bi-weekly PTX plus RAM were continued for grade 3 neutropenia and grade 2 anorexia. The tumor and LNs partially responded, and the ascites disappeared. With this dosage and administration schedule, the partial response(PR)was maintained for approximately 8 months without any severe adverse reactions. This successful case might indicate that it is important for elderly patients with gastric cancer that progressed with prior chemotherapy regimens to consider appropriate reduction of the PTX dosage, schedule, and continuation of RAM.

[Clinical Experience of Ramucirumab for Treating Advanced Gastric Cancer].

BACKGROUND: The REGARD and RAINBOW trials showed that ramucirumab(RAM)alone and RAM plus paclitaxel(PTX) were effective therapies for advanced gastric cancer patients previously treated with chemotherapy. In this retrospective study, we evaluated the safety and efficacy of RAM alone and PTX plus RAM in such patients. METHODS: Patients who were received RAM at 8mg/kg or RAM plus PTX at 80mg/m2(on days 1, 8, and 15 of a 28-day cycle)between June 2015 and March 2016 were enrolled in this study. We compared the clinical outcome of RAM alone(RAM group, n=10)with that of RAM plus PTX(PTX+RAM group, n=13). RESULTS: The RAM group contained many more patients with poor performance status or prior chemotherapy of 2 or more regimens than the PTX+RAM group. All patients in both groups received chemotherapy on an outpatient basis. One case of grade 3 or 4 hematological adverse events was found in the RAM group and 6 cases were found in the PTX+RAM group. The overall response rate was 10% in the RAM group and 30% in the PTX+RAM group. Progression-free survival was 54 days in the RAM group and 187 days in the PTX+RAM group(p=0.0374). Overall survival was 158 days in the RAM group and was not reached in the PTX+RAM group(p=0.1091). CONCLUSIONS: RAM alone and RAM plus PTX can be administered safely on an outpatient basis and are beneficial for advanced gastric cancer patients previously treated with chemotherapy.

[Efficacy and Safety of Pertuzumab for HER2-Positive Metastatic Breast Cancer].

The CLEOPATRA trial showed a significant improvement in the progression-free survival (PFS) and overall survival of patients with HER2-positive first-line metastatic breast cancer (MBC) who were treated with pertuzumab (PER), trastuzumab (TRA), and docetaxel (DTX), compared to those treated with placebo, TRA, and DTX. PER was approved in 2013 for treating HER2-positive MBC in Japan. Herein, we present the retrospective review of data from 10 HER2-positive MBC patients who received PER in our hospital between September 2013 and August 2014.T he median age was 52 years (range, 45-66 years), and 7 patients were positive for ER.Six patients had not received any previous chemotherapy for their metastatic disease, while the others had received comparatively heavy pretreatment doses of chemotherapy.Our patients received the PER, TRA, and DTX regimen, although 2 patients were treated without DTX. Four patients experienced a partial response, 6 patients experienced stable disease (SD), and 3 patients experienced SD for ≥6 months. The response rate was 40%, and the clinical benefit rate was 70%.The median PFS was 7.3 months (range, 2.5-11.5 months). Grade 3 neutropenia and allergic reactions were observed in 1 and 2 patients, respectively; no Grade 4 adverse events were observed, and thus, the regimen was well tolerated. Further clinical research seems to be warranted for developing new treatment strategies involving PER for HER2-positive MBC.

[Examination of the Usefulness of Palliative Self-Expanding Metallic Stents in Patients with Malignant Colorectal Obstruction].

Self-expanding metallic stents (SEMS) are a useful palliative option in malignant colorectal obstruction. The aim of this study was to evaluate the clinical outcomes of SEMS used for palliation. Patients with malignant colorectal obstruction who underwent SEMS insertion in our hospital from April 2014 to March 2015 were enrolled in the study. Clinical outcomes and complications of palliative SEMS insertion were retrospectively analyzed. Nine patients were enrolled in the palliative SEMS group. The success rate was 100%, while the complication rate was 11%. Successful SEMS insertion may enable oral intake in a few days, but 3 patients required up to several weeks to resume oral intake. Palliative SEMS are effective and beneficial for malignant colorectal obstruction.

[A Case of Bone Metastasis from Early Gastric Cancer after a Five-Year Disease-Free Interval Following Gastrectomy].

A woman in her 50s underwent distal gastrectomy and D1+b dissection in December 2005 for early gastric cancer that was diagnosed as a signet-ring-cell carcinoma, fStage Ⅱ (T1a, N2, H0, P0, CY0, M0) with 12 lymph node metastases in the second field. Multiple bone metastases were diagnosed on the basis of CT and bone scintigraphy findings and serum ALP elevation (2,743 IU/L) I n December 2010. Fourteen courses of S-1 plus CDDP and 4 mg of zoledronate were administered from January to September in 2011. Pancytopenia, D-dimmer elevation, myelocytes, and metamyelocytes were observed in October 2012, indicating she had bone marrow metastasis. She was treated with a transfusion, anti-DIC therapy, and paclitaxel. She died from gastric cancer in December 2012. We report a rare case of recurrence with bone metastasis from early gastric cancer. S-1 plus CDDP chemotherapy and zoledronate therapy is an effective treatments for multiple bone metastases from gastric cancer.

[Two Cases of Bleeding Advanced Gastric Cancer Treated with Palliative Radiation Therapy].

Case 1: A man in his 70's was being treated with chemotherapy for unresectable advanced gastric cancer. Blood transfusion, endoscopic intervention including argon plasma coagulation, and transcatheter arterial embolization (TAE) were all used to treat repeated tumor bleeding causing anemia, but controlling the bleeding was difficult. In order to control the hemorrhage, radiation therapy of 31 Gy/10 Fr to the cancer was administered. After receiving radiation therapy, the anemia stopped. Case 2: A man in his 70's considered an operation for advanced gastric cancer, but his cardiac performance was poor and it was impossible to perform an operation. We conducted radiation therapy of 39 Gy/13 Fr for the purpose of preventing bleeding from gastric cancer. After receiving radiation therapy, the anemia stopped. We believe that radiation therapy is effective to stop bleeding from gastric cancer.

[Three Cases of Bleeding from Advanced Gastric Cancer Treated by Transcatheter Arterial Embolization(TAE)and Continued Chemotherapy].

Case 1: A man in his 70s was underwent transcatheter arterial embolization (TAE) because of progressive anemia, and the gastroduodenal artery and left gastric artery were embolized. Two weeks later, he started chemotherapy (S-1, Tmab). Case 2: A man in his 60s was underwent TAE because of anemia. The left gastric artery and right gastroepiploic artery were embolized. Bleeding was controlled and he continued chemotherapy. Case 3: A man in his 70s was who vomited blood during the course of chemotherapy underwent TAE, during which contrast dye extravasated from the anterior gastric artery. The splenic artery was embolized. After TAE, abdominal pain and splenic infarction appeared, but could be treated by conservative therapy. Chemotherapy was started 4 weeks later. TAE is an effective method for controlling bleeding from advanced gastric cancer.

[A Case of Disseminated Carcinomatosis of the Bone Marrow with Disseminated Intravascular Coagulation Caused by Cecal Cancer Successfully Treated with mFOLFOX6].

Disseminated carcinomatosis of the bone marrow is often accompanied by disseminated intravascular coagulation syndrome (DIC). This condition is rarely caused by colorectal cancer, and there are no established therapies. OUR CASE: A 66-year-old woman was admitted to our hospital because of DIC. She had been diagnosed with cecal cancer and multiple metastases of the lymph nodes, liver, and bone. She was diagnosed with disseminated carcinomatosis of the bone marrow and treated with systemic chemotherapy by modified FOLFOX6 (mFOLFOX6). Subsequently, the DIC rapidly resolved, and she was discharged from the hospital.

[A Case of Invasive Ductal Carcinoma in the Fat Replacement of the Pancreatic Body and Tail].

A 56 year-old woman with obesity (BMI3 2) and diabetes mellitus was diagnosed with right renal cell carcinoma. She underwent right nephrectomy 1 year ago. Seven months after surgery, CT revealed a rapidly growing mass near the spleen. The mass showed slight accumulation of FDG (SUVmax=2.4) on PET-CT. Since the lesion grew rapidly and was not enhanced in the early phase of enhanced CT, we diagnosed pancreatic cancer. Distal pancreatectomy and splenectomy were performed. The final pathological diagnosis was invasive ductal carcinoma in the fat replacement of the pancreatic body and tail. Postoperatively, the patient had no complications such as pancreatic fistula or aggravation of glucose intolerance. She received postoperative chemotherapy with gemcitabine. Since she developed pulmonary artery thrombosis, postoperative chemotherapy was interrupted after 8 courses. Thirty-two months after the surgery, she was still living without any recurrence. Acinar cells were absent in the fat replacement of the pancreas, but the pancreatic duct cells were still present. There was carcinoma in situ in the main pancreatic duct surrounding chronic inflammation. Fat replacement itself could be potentially precursor of the pancreatic cancer.

[A case of rectal GIST treated by perineal partial rectal resection using laparoscopic surgery].

A 60-year-old man presented to our hospital with melena. A submucosal tumor (24 mm) was found via magnetic resonance imaging between the prostate and the rectum (Rb). A gastrointestinal stromal tumor (GIST) that displaced the prostate ventrally was diagnosed via histopathology. Preoperative imatinib treatment was initiated to reduce the tumor size and prevent extensive surgery. Approximately 33% of the tumor was reduced using chemotherapy. First, laparoscopic rectal dissection and mobilization were performed reaching the pelvic floor. Then, we performed perineal partial rectal resection. There has been no recurrence.

[A case of metastatic colorectal cancer that reduced in size after re-challenging with an anti-EGFR monoclonal antibody].

A 58-year-old woman was confirmed as having multiple liver metastases after undergoing a high anterior resection for a sigmoid colon tumor. She was administered bevacizumab+FOLFOX as the first regimen and bevacizumab+FOLFIRI and S-1 and irinotecan (IRIS)therapy as the second regimen. During this treatment she also underwent hepatectomy 3 times and radiofrequency ablation once. She was administered panitumumab+irinotecan as the third regimen and, due to the presence of multiple pulmonary metastases, was subsequently considered to have had a partial response (PR). Because she subsequently developed progressive disease (PD), she received the fourth regimen as part of a clinical trial (TAS102) in another hospital. Cetuximab+irinotecan was administered as the fifth regimen after PD and the tumor was found to have reduced in size by 23%upon computed tomography (CT) 2 months later. Although stable disease (SD) was achieved, she was subsequently administered regorafenib for 8 months as a sixth regimen after the disease progressed a second time. In some cases of KRAS wild type metastatic colorectal cancer, re-challenging with an anti-epidermal growth factor receptor (EGFR) monoclonal antibody seems to be an effective strategy for reducing tumor mass.

[A case of Stage IV sigmoid colon cancer cured with radical combined modality therapy].

The patient was a 54-year-old man who had undergone resection of the sigmoid colon for unresectable sigmoid colon cancer with multiple liver( H1), lymph node, and lung metastases at the previous hospital. Chemotherapy with 5-fuorouracil, Leucovorin, and oxaliplatin (mFOLFOX6) plus bevacizumab was initiated after surgery. The outcome was partial response. The patient was introduced to our hospital because he had relocated. Based on the findings of the patient's computed tomography( CT) and positron emission tomography( PET)-CT scans, we decided to perform radical resection. We performed partial hepatectomy( S7 and S8) and pancreatoduodenectomy for metastases to the hepatoduodenal ligament lymph node. After confirming that there was no recurrence, he underwent right partial pneumonectomy. Currently, the patient shows no signs of recurrence. The therapy for colon cancer should include aggressive radical surgery to control metastasis.

[A case of early colorectal cancer with synchronous multiple liver metastases].

We report the case of a 64-year-old man who had early submucosal invasive colorectal cancer with synchronous multiple liver metastases. The patient underwent endoscopic resection for a type Isp polyp of the sigmoid colon. The pathological diagnosis was well-differentiated adenocarcinoma with submucosal layer( sm3) invasion and lymphatic infiltration (ly2). A positive vertical margin was suspected. Abdominal computed tomography revealed multiple tumors at the S2/3, S5, and S8 segments of the liver and a small gastric submucosal tumor. The patient underwent sigmoid colon resection with D3 lymphadenectomy, left lateral hepatic segmentectomy, partial hepatectomy in the S5 and S8 segments, and partial gastrectomy. Histological examination showed lymph node metastasis but no residual cancer in the sigmoid colon. The histological findings from the liver were similar to those found in primary colorectal carcinoma. The gastric submucosal tumor was confirmed to be a gastrointestinal stromal tumor with a low risk grade. As the present case is considered rare, we herein review our previous report on a case of early colorectal cancer with synchronous multiple liver metastases.

[Long-term efficacy of chemotherapy for unresectable gastric cancer with multiple bone metastases-a case report].

A 49-year-old man was admitted to our hospital with back pain, appetite loss, and body weight loss in January 2009. Gastroduodenal endoscopy, abdominal computed tomography( CT), and magnetic resonance imaging( MRI) revealed type 4 advanced gastric cancer( signet-ring cell carcinoma) with multiple lymph node( No. 16 LNs), right adrenal gland, and multiple bone metastases. Between February 2009 and April 2011, 20 courses of S-1( 80 mg/m2) plus CDDP( 60 mg/m2) and zoledronic acid hydrate (4 mg/body) were administrated. Since May 2011, S-1 (70 mg/m2) and zoledronic acid hydrate( 4 mg/body) have been continued. The lymph node and adrenal gland metastases showed a complete response( CR), and the gastric tumor showed a partial response; however, the bone metastases did not show CR or progressive disease (PD) for 4 years after initiation of therapy. Chemotherapy with zoledronic acid hydrate is considered as a useful therapeutic option for advanced unresectable gastric cancer with multiple bone metastases.

[A study of laparoscopic stoma creation for patients with malignant bowel obstruction].

UNLABELLED: We evaluated the efficacy of laparoscopic palliative stoma creation for patients with malignant bowel obstruction (MBO). PATIENTS AND METHODS: Twenty-four patients with MBO who underwent laparoscopic stoma creation between January 2009 and December 2012 were studied and their clinical outcome was evaluated retrospectively. RESULTS: Compared to the open approach, the laparoscopic approach led to significantly shorter operation times and a significantly lower incidence of surgical site infection( SSI). The rate of removal of the intestinal tube and intravenous drip after surgery was 100% and 88%, respectively, and the rate of oral intake was 100% after palliative stoma creation. The prognosis was 58% in 3 months and 29% in 1 year, and the median survival time was approximately 4 months. DISCUSSION: The quality of surgery by the laparoscopic approach was better than that by the open approach, and the quality of life( QOL) after stoma creation was better than that before surgery. Given the shorter operation time, lower incidence of SSI, and better QOL, laparoscopic stoma creation is a beneficial choice for palliative treatment in patients with MBO.

Acinar cell carcinoma of the pancreas: a possible role of S-1 as chemotherapy for acinar cell carcinoma. A case report.

CONTEXT: Acinar cell carcinoma of the pancreas is a rare malignancy, accounting for 1-2% of pancreatic exocrine malignancies. This rarity makes it difficult to standardize a protocol of treatment for acinar cell carcinoma. CASE REPORT: A 71-year-old male without any particular past history was referred to our institute with abdominal distention and mild liver dysfunction. Computed tomography (CT) revealed a cystic lesion with a diameter of 3.5 cm, which originated from the neck of pancreas and had solid nodules inside. Several nodules were demonstrated surrounding the cystic tumor. Laparotomy and histological study demonstrated peritoneal dissemination of acinar cell carcinoma. The patient was treated with S-1 monotherapy (80 mg/m2 for four weeks with a two-week interval as one cycle). After one cycle of S-1 monotherapy, CT demonstrated remarkable shrinkage of the main tumor and disappearance of the nodules on the peritoneum. The patient underwent a radical distal pancreatectomy. The patient was then treated with 16 cycles of S-1 monotherapy after the radical pancreatectomy and remains without any recurrence of the disease two years later. CONCLUSION: Initially inoperable acinar cell carcinoma was treated by monotherapy using S-1, resulting in curative operation and two years disease free survival post operation. S-1 might be more effective on acinar cell carcinoma, rather than gemcitabine.

[A case report of locally recurrent rectal cancer after low anterior resection that led to a pathological complete response to neoadjuvant chemoradiotherapy].

We report a case of low anterior resection that led to a pathological complete response of locally recurrent rectal cancer to neoadjuvant chemoradiotherapy. A 57-year-old male patient underwent low anterior resection for rectal cancer pathologically diagnosed as type 2, tub2>tub1,pSS,INF b,int,ly2,v2,pPM0,pDM0,no,M0,H0,P0, and fStage II. After 2 years and 11 months, local recurrence of his rectal cancer was identified by colon fiberscopy. Neoadjuvant chemoradiotherapy was conducted with CPT-11, UFT/LV, and radiation(50 Gy),and this recurrent lesion exhibited a partial response to the chemoradiotherapy regimen according to magnetic resonance imaging findings. Then, we performed total pelvic exenteration, and the pathological examination revealed a pathological complete response.

[A case of refractory deep incisional surgical site infection due to methicillin-resistant Staphylococcus aureus (MRSA) and successfully treated with oral linezolid].

We report a case of methicillin-resistant Staphylococcus aureus(MRSA) surgical site infection successfully treated with linezolid. A 66-year-old man had undergone total gastrectomy for gastric cancer after neoadjuvant chemotherapy. Three days after the operation, he was diagnosed with deep incisional surgical site infection due to MRSA, and wound care was started. After discharge, he received adjuvant chemotherapy and wound care, but the wound had not healed in 10 months. We started treatment with oral linezolid and nutritional support, and the wound was fully healed 12 months after the operation. Antibiotic treatment with oral linezolid may be effective for refractory deep incisional surgical site infection due to MRSA in outpatients.