[Ascending Colon Cancer with Radical Resection after Stent Reimplantation Due to Colonic Stent Obstruction for Palliation-A Case Report].

Since the insurance coverage of colorectal stents for bowel obstruction due to colorectal cancer in 2012, the use of colorectal stenting for palliation has rapidly spread. We report a case of ascending colon cancer in which a colorectal stent was placed for palliation, but the stent was reimplanted due to obstruction, followed by radical resection. The patient was a 92- year-old woman who was brought to the emergency room at the age of 90 years with repeated vomiting and abdominal pain, and was diagnosed as colorectal cancer ileus caused by ascending colon cancer, and a colorectal stent was inserted. She received palliative care and had been asymptomatic for 1 year and 3 months, but due to in-stent stenosis, she had bowel obstruction and sent to emergency room, and another stent was installed. The patient had a good course, but 4 months after the second stenting, she was concerned about restenosis and referred to the department of surgery, then performed a radical resection. The indication for colorectal stents for palliative purposes should be considered on a case-by- case basis, including ADL, stage of the disease, and prognosis.

Suspected Immune Thrombocytopenic Purpura Induced by Lenalidomide for the Treatment of Myelodysplastic Syndrome with Deletion of Chromosome 5q: A Case Report.

Lenalidomide (LEN), one of the key drugs in the treatment of myelodysplastic syndromes (MDS) with 5q deletion, as well as multiple myeloma (MM), has various immunomodulatory effects and has been associated with autoimmune diseases, including immune thrombocytopenic purpura (ITP). A 78-year-old man presented with pancytopenia and was diagnosed with MDS with 5q deletion and other chromosomal abnormalities. Two cycles of LEN therapy (one cycle: 10 mg/day for 21 days) resulted in a transient improvement in anemia, followed by MDS progression with severe thrombocytopenia (4 × 109/L) refractory to platelet transfusions. As other non-immune and alloimmune causes of transfusion-refractory thrombocytopenia were excluded, and the level of platelet-associated immunoglobulin G was extremely high compared with the level before treatment with LEN, the diagnosis of ITP was highly suspected. Despite treatment with prednisolone (PSL), eltrombopag, and repeated platelet transfusions, his platelet count did not increase, and he died of a gastrointestinal hemorrhage. Several cases of ITP induced by LEN used to treat MM had been reported, but the platelet count recovered after administration of PSL in these previous cases. However, we should be mindful of using LEN for patients with MDS because its treatment may become extremely difficult if ITP develops.

[A Case of Two-Stage Operation for Esophageal Cancer with Sarcoidosis].

A 69-year-old man with dysphagia was diagnosed with advanced esophageal cancer by upper gastrointestinal endoscopy. He had undergone pancreatic tail and partial transverse colon resection for pancreatic cancer, and right hilar lymph node biopsy and partial lower lobe resection for the diagnosis of pulmonary sarcoidosis. Contrast-enhanced computed tomography(CT)scan showed no change over time in lymph node enlargement in the mediastinum, so metastasis of esophageal cancer was considered to be negative. Therefore, the diagnosis of advanced esophageal cancer, Mt, type 2, T2N0M0, cStage Ⅱ, was made, and surgery was performed after 2 courses of DCF therapy. Because of the adhesions in the thoracic cavity and possible problems with elevation of the gastric tube and blood flow due to resection of the pancreatic tail, it was decided to perform two-stage operation. Although imaging studies over time, as in the present case, can help in the diagnosis, it is difficult to distinguish whether enlarged lymph nodes are reactive changes or metastases. In this study, we experienced a case of thoracic esophageal cancer complicated by sarcoidosis with enlarged mediastinal lymph nodes.

[A Case of Refractory Lymphorrhea after Laparoscopic Distal Gastrectomy].

An 84-year-old man with gastric cancer, cT2N0M0, cStage Ⅰ underwent laparoscopic distal gastrectomy, D1+dissection, and Roux-en-Y reconstruction. We started enteral nutrition on the second postoperative day, but milky drainage appeared from the drain on the fifth postoperative day. The triglyceride in the ascites was markedly elevated, and it was diagnosed as a lymphorrhea. Neither conservative treatment nor lymphangiography were successful. We decided to perform surgical intervention because the lymphorrhea did not improve for about 1 month after gastrectomy. At laparotomy, we detected the lymphatic ducts using enteral nutrition of fat formulas during surgery and successfully closed the lymphatic ducts by suturing and ligation on the 38th postoperative day. Prolonged lymphorrhea causes extreme deterioration of the patient's general condition. Prolonged total parenteral nutrition also increases the risk of infection. It is important to perform surgical treatment for intractable lymphorrhea that does not improve with conservative treatment without hesitation.

[A Case of Solitary Desmoid Tumor after Laparoscopic Sigmoid Colon Cancer Resection].

A 71-year-old man with pathological Stage Ⅰ(pT1bN0M0)underwent laparoscopic sigmoid colon cancer resection. After 18 months postoperatively, follow-up computed tomography(CT)showed a 30 mm enhanced soft tissue tumor near the anastomotic site. Considering the magnetic resonance imaging(MRI)and positron emission tomography(PET)results, we diagnosed sigmoid colon cancer with local recurrence. Laparoscopic radical resection of the colon and intestine, including the tumor, was performed. Pathologically, the tumor comprised spindle-shaped cells with collagen fibers and was diagnosed as a desmoid tumor by immunostaining(ß-catenin+, c-kit-, CD34-, α-SMA-, and DOG-1-). We report a case of intra-abdominal desmoid tumor near the anastomotic site after laparoscopic sigmoid colon cancer resection.

[A Case of Conversion Surgery after Chemotherapy for Advanced Gastric Cancer with Peritoneal Disseminations].

BACKGROUND: Advanced gastric cancer with peritoneal dissemination is difficult to treat, although prognosis has improved with chemotherapy and the introduction of molecular targeted drugs. CASE: A 65-year-old male was diagnosed as type 3 advanced gastric cancer on the posterior wall of antrum by esophagogastroduodenoscopy for anemia screening. When the patient underwent radical surgery, multiple disseminated nodules(P1c)were detected. After chemotherapy(SOX, PTX plus RAM)was administered, the tumor shrank, and staging laparoscopy was performed. Since disseminated nodules have disappeared, distal gastrectomy(R0)was performed as conversion surgery. As postoperative adjuvant chemotherapy, S-1 was administered for about 1 year and 6 months. During repair of incisional hernia at 1 year postoperatively, the patient was confirmed to have no disseminated recurrence. The patient is currently alive with no sign of recurrence for 4 years.

[A Case of Long-Term Survival without Recurrence following Resection of Hepatic and Pulmonary Metastases of Gastric Cancer].

A 78-year-female underwent distal gastrectomy for gastric cancer. The final diagnosis was moderately differentiated tubular adenocarcinoma, T4a, N2, M0, Stage ⅢB. Four years later, S6 hepatic metastasis and S9 pulmonary metastasis were detected. After 10 courses of S-1 plus oxaliplatin therapy, she received partial hepatectomy(S6). One year after hepatectomy, she underwent partial pulmonary resection for lung metastasis in the left lung(S9). Histopathological findings revealed the lung tumor was a pulmonary metastasis from gastric cancer with a small primary lung adenocarcinoma. There has been no recurrence for 30 months since the last operation.

[A Case of Surgical Resection for Solitary Lymph Node Metastasis of Hepatocellular Carcinoma].

A 77-year-old man has undergone 5 times of transcatheter arterial chemoembolization(TACE)and 5 times of radiofrequency ablation(RFA)for hepatocellular carcinoma(HCC)since 2015. In February 2019, serum tumor marker levels extremely increased and CT scan showed a 40 mm mass in hepatoduodenal ligament. Imaging study revealed that intrahepatic lesions of HCC were well controlled and the mass was diagnosed as solitary lymph node metastasis of HCC. We performed surgical resection of the lymph node. The patient discharged 8 days after the surgery. Histopathologicaly, the tumor was diagnosed as lymph node metastasis of HCC. The patient remains free from recurrence 14 months after surgery.

Prognostic impact of postoperative intra-abdominal infections after elective colorectal cancer resection on survival and local recurrence: a propensity score-matched analysis.

PURPOSE: Several authors have reported an association between anastomotic leak and/or intra-abdominal abscess and oncological survival and recurrence. However, no reports have investigated whether combining anastomotic leak/intra-abdominal abscess and positive drainage culture influences long-term oncological outcomes. Therefore, we defined these complications as postoperative intra-abdominal infections. The present study aimed to evaluate the prognostic impact of postoperative intra-abdominal infections on long-term oncological outcomes after curative stage I-III colorectal cancer surgery. METHODS: We performed a retrospective analysis of 755 consecutive patients with stage I-III colorectal cancer undergoing curative surgery between 2010 and 2015 by performing a propensity score-matched analysis to reduce selection bias. RESULTS: Of the 755 patients, 62 were matched for postoperative intra-abdominal infections analyses. The median follow-up was 48 months. Compared with the non-infections group, the postoperative intra-abdominal infections group had a significantly shorter local recurrence-free survival (P = 0.01 prior to matching, and P = 0.05 after matching). No significant difference was found between the groups in terms of overall, cancer-specific free, recurrence-free, or distant recurrence-free survival. However, multivariate analyses identified postoperative intra-abdominal infections as an independent prognostic factor for local recurrence-free survival (P = 0.04 prior to matching, and P = 0.03 after matching). CONCLUSIONS: In this matched-pair analysis comparing stage I-III colorectal cancer patients with and without postoperative intra-abdominal infections, postoperative intra-abdominal infections were associated with poor local recurrence-free survival, but not overall, cancer-specific free, recurrence-free, or distant recurrence-free survival.

Suppression of Malignant Potentials of A549 Human Lung Cancer Cell Line by Downregulation of the ß4-Galactosyltransferase 1 Gene Expression.

Our previous study demonstrated that downregulation of transcription factor Specificity protein (Sp) 1 suppresses the malignant potentials of A549 human lung cancer cell line with the reduced ß4-galactosylation of highly branched N-glycans on cell surface glycoproteins. The reduced ß4-galactosylation was brought about by the decreased expression of the ß4-galactosyltransferase 1 (ß4GalT1) gene. Herein, we examined whether the reduced ß4-galactosylation by decreasing the ß4GalT1 gene expression suppresses the malignant potentials of A549 cells. In the ß4GalT1-downregulated cells, the ß4-galactosylation of highly branched N-glycans was reduced in several glycoproteins such as lysosome-associated membrane protein-1 and E-cadherin. The anchorage-independent growth and migratory ability of the ß4GalT1-downregulated cells decreased when compared with the control cells. Furthermore, the phosphorylation of p44/42 mitogen-activated protein kinase (MAPK) decreased in the ß4GalT1-downregulated cells. These results indicate that downregulation of the ß4GalT1 gene decreases the ß4-galactosylation of highly branched N-glycans and the phosphorylation of p44/42 MAPK, and suppresses the malignant potentials of A549 cells.

[A Case of Unresectable Gallbladder Cancer with Relatively Good Prognosis Treated with Upfront Surgery Followed by Systemic Chemotherapy].

A female patient in her 60s was diagnosed with advanced gallbladder cancer invading the hilar plate. Exploratory laparoscopic examination showed limited peritoneal dissemination. Despite endoscopic nasobiliary drainage, it was difficult to treat infectious cholangitis. To initiate chemotherapy, it was imperative to control the infection; hence, we chose to perform extended right hepatectomy, extrahepatic bile duct resection, lymph node dissection, and cholangiojejunostomy. We have been able to continue systemic chemotherapy for more than 2 years after surgery, and the patient did not experience infectious cholangitis. She has survived for almost 2 years and 8 months post-diagnosis.

[pCR Achievement in Two Cases Treated with XELOXIRI as Neoadjuvant Chemotherapy for Locally Advanced Rectal Cancer].

BACKGROUND: Neoadjuvant chemotherapy is designed to prevent disease recurrence, particularly distant recurrence, and to improve overall patient survival. We present 2 cases where pathological complete response(pCR)was obtained after administering XELOXIRI as neoadjuvant chemotherapy for locally advanced rectal cancer. Case 1: The patient was a 63-year-old man diagnosed with rectal cancer(Ra, cT4aN1M0, cStage Ⅲa)and treated with 6 courses of XELOXIRI as neoadjuvant chemotherapy. After systemic chemotherapy, he underwent laparoscopy-assisted low anterior resection and showed a pCR. Case 2: The patient was a 56-year-old man diagnosed with rectal cancer(Rb, cT3N3M0, cStage Ⅲb)and treated with 6 couses of XELOXIRI as neoadjuvant chemotherapy. After systemic chemotherapy, he underwent low anterior resection and showed a pCR. CONCLUSION: We present 2 cases treated with XELOXIRI as neoadjuvant chemotherapy for locally advanced rectal cancer where pCRwas achieved.

[Clinical Outcome of Radiation Therapy for Solitary Lymph Node Metastasis of Gastric Cancer].

We report the clinical course of 6 gastric cancer patients who received radiation therapy at our hospital for solitary lymph node metastasis. The site of the metastatic lymph node was the clavicle, para-aorta, para-portal vein, common hepatic artery, and diaphragm in 1, 1, 2, 1, and 1 case, respectively. Median irradiation dose was 50[range, 45-50.4]Gy, and combination chemotherapy was administered in 4 cases. The clinical outcome was complete response and partial response in 3 cases each, with no adverse events associated with radiation therapy. The median progression-free survival was 11.3 months. In summary, local treatment by radiation therapy is one of the treatment options for patients with solitary lymph node metastasis of gastric cancer.

[A Case of Colon Cancer with Peritoneal Dissemination and Liver Metastasis That Responded to Comprehensive Treatment by Perioperative Chemotherapy and Cytoreductive Surgery].

A 64-year-old man was referred to our hospital to determine the cause of fecal occult blood. Colonoscopy revealed a type Ⅱtumor located in the ascending colon. Histopathologic analysis of the tumor biopsy specimen revealed moderately differen- tiated, tubular adenocarcinoma with KRAS exon 2(G12V)mutation. FDG-PET/CT revealed high trace accumulation in the S4 of the liver and in multiple sites spread across the abdominal cavity(cT4aN1M1c2[H1, P3], cStage Ⅳc). Chemotherapy using S-1 plus oxaliplatin(SOX)with bevacizumab(Bmab)was administered. After 8 courses of SOX with Bmab, the volume of the ascending colon cancer and liver metastasis reduced, and peritoneal disseminations disappeared. We, therefore, considered that curability B resection was suitable, and performed right hemicolectomy, total omentectomy, and resection of the rectovesical peritoneum. Histopathological examination of surgical specimens revealed extensive fibrosis from the submucosa to subserosal tissue with some tubular adenocarcinoma cells(histological effect: Grade 2). For maintenance therapy, trifluri- dine/tipiracil plus Bmab was administered after cytoreduction. The patient is in remission for 26 months without recurrence. Perioperative chemotherapy and cytoreductive surgery are useful for the treatment of colon cancer with diffuse peritoneal dissemination.

[Two Cases of Esophagogastric Junction Cancer after Subtotal Stomach-Preserving Pancreaticoduodenectomy].

We report 2 cases with esophagogastric junction(EGJ)cancer who underwent remnant gastrectomy preserving Braun anastomosis after subtotal stomach-preserving pancreaticoduodenectomy(SSPPD)with modified Child's reconstruction. In case 1, a 73-year-old man was diagnosed with EGJ cancer 4 years after SSPPD for stenosis of lower bile duct. He underwent remnant gastrectomy with Roux-en-Y(R-Y)reconstruction preserving Braun anastomosis using linear stapler(overlap method). In case 2, a 77-year-old man, who underwent SSPPD for intraductal papillary mucinous neoplasm 1 year ago, was performed endoscopic submucosal dissection for EGJ cancer and planned additional gastrectomy, because of non-curative resection. He was performed remnant gastrectomy with R-Y reconstruction preserving Braun anastomosis using circular stapler. In both patients, the postoperative courses were favorable without complication. Remnant gastrectomy after PD is difficult because of anatomical changes due to adhesions and gastrointestinal reconstruction. R-Y reconstruction preserving Braun anastomosis may be a useful surgical procedure for remnant gastric cancer after SSPPD.

[A Case of Conversion Surgery Following Combined Chemotherapy with Molecular Targeting Agent for Unresectable Colorectal Liver Metastases].

A 76-year-old woman complaining of constipation was diagnosed with advanced rectosigmoid colon cancer with unresectable liver metastases. We performed a laparoscopic high-anterior resection due to the obstruction. The patient then received a capecitabine plus oxaliplatin(CapeOX)plus cetuximab(Cmab)combination chemotherapy. After 7 cycles of CapeOX with Cmab, the multiple liver metastases had reduced remarkably in size. Therefore, a liver metastases resection was performed. The patient underwent 6 cycles of postoperative CapeOX with Cmab therapy and has survived 7 years with no recurrence after the primary surgery.

[A Case of Long-Term Survival without Recurrence following Resection of Hepatic and Pulmonary Metastases of Gastric Cancer].

We report a case of long-term survival without recurrence followingresection of hepatic and pulmonary metastases of gastric cancer. A 64-year-old man underwent distal gastrectomy for gastric cancer. Seventeen months later, he underwent partial hepatectomy for hepatic metastasis in S7. Twenty months after the partial hepatectomy, he underwent hepatectomy for right lobe resection for hepatic metastases in S6/S7 and S7. Six months after the hepatectomy, he underwent partial pulmonary resection for lungmetastasis in the right lung(S3). He has remained tumor-free for 5 years after the pulmonary resection.

[A Case of Scirrhous Gastric Carcinoma Diagnosed by Staging Laparoscopy].

We report a case of scirrhous gastric carcinoma diagnosed by staging laparoscopy and discuss some literature reviews. A 60-year-old man was referred because of a choking sensation and weight loss, and gastroendoscopy revealed thickening of the entire circumference of the wall at the gastric cardia. Scirrhous gastric carcinoma was suspected, and biopsy was performed at many points and times by endoscopic examination, but the histologic findings revealed no malignant features. We performed staging laparoscopy, peritoneal washing cytology, and biopsy of the nodules in the abdominal wall. He was diagnosed with advanced gastric cancer with peritoneal dissemination and has received chemotherapy. Staging laparoscopy is a useful method for diagnosis and determination of the management of scirrhous gastric carcinoma.

[A Case of Rectal Cancer with Multiple Liver Metastases Curatively Resected after Systemic Chemotherapy].

A 61-year-old man complainingof bloody stool was diagnosed with advanced rectal cancer with multiple liver metastases (cT3[A]N1M1a[H2], cStage Ⅳ). We introduced bevacizumab combined systemic chemotherapy prior to radical surgery and confirmed tumor shrinkage in both the primary tumor and liver metastases following systemic chemotherapy. We performed laparoscopic lower-anterior resection, and then the patient underwent liver metastases resection. The histologic evaluation was Grade 2. This was a pathologically curative resection, and the patient has been disease-free since the last operation.

PRIMA-1 induces p53-mediated apoptosis by upregulating Noxa in esophageal squamous cell carcinoma with TP53 missense mutation.

TP53 is associated with the resistance of cytotoxic treatment and patient prognosis, and the mutation rate of TP53 in esophageal squamous cell carcinoma (ESCC) is extraordinarily high, at over 90%. PRIMA-1 (p53 re-activation and induction of massive apoptosis) has recently been reported to restore the function of mutant TP53; however, its antitumor effect and mechanism in ESCC remain unclear. After evaluating the TP53 mutation status of a panel of 11 ESCC cell lines by Sanger sequencing, we assessed the in vitro effect of PRIMA-1 administration on cells with different TP53 status by conducting cell viability and apoptosis assays. The expression levels of proteins in p53-related pathways were examined by Western blotting, while knockdown studies were conducted to investigate the mechanism underlying PRIMA-1's function. An ESCC xenograft model was further used to evaluate the therapeutic effect of PRIMA-1 in vivo. PRIMA-1 markedly inhibited cell growth and induced apoptosis by upregulating Noxa expression in ESCC cell lines with TP53 missense mutations, whereas no apoptosis was induced in ESCC with wild-type TP53 and TP53 with frameshift and nonsense mutations. Importantly, the knockdown of Noxa canceled the apoptosis induced by PRIMA treatment in ESCC cell lines with TP53 missense mutations. PRIMA-1 administration, compared with placebo, showed a significant antitumor effect by inducing Noxa in the xenograft model of an ESCC cell line with a TP53 missense mutation. PRIMA-1 exhibits a significant antitumor effect, inducing massive apoptosis through the upregulation of Noxa in ESCC with TP53 missense mutations.