Induction of a pathological complete response by four courses of neoadjuvant chemotherapy for gastric cancer: early results of the randomized phase II COMPASS trial.

BACKGROUND: The prognosis for stage 3 gastric cancer is not satisfactory, even with S-1 adjuvant chemotherapy. A randomized phase II trial was conducted to compare two and four courses of neoadjuvant S-1/cisplatin (SC) and paclitaxel/cisplatin (PC) using a two-by-two factorial design for locally advanced gastric cancer. The primary endpoint was overall survival. We clarified the impact of these regimens on the secondary endpoints, including the clinical and pathological responses, chemotherapy-related toxicities, and surgical results. METHODS: Patients received S-1 (80 mg/m(2) for 21 days with 1 week's rest)/cisplatin (60 mg/m(2) at day 8) or paclitaxel/cisplatin (80 and 25 mg/m(2), respectively, on days 1, 8, and 15 with 1 week's rest) as neoadjuvant chemotherapy. RESULTS: Eighty-three patients were assigned to arm A (two courses of SC, n = 21), arm B (four courses of SC, n = 20), arm C (two courses of PC, n = 21), and arm D (four courses of PC, n = 21). Pathological response rate was 43 % in arm A, 40 % in arm B, 29 % in arm C, and 38 % in arm D. Pathological complete response was only observed in arms B (10 %) and D (10 %). Most bone marrow toxicities, nausea, vomiting, alopecia, and fatigue were slightly higher but acceptable in arms B and D. Grade 3/4 surgical morbidities were not commonly observed in all four arms. CONCLUSIONS: Pathological complete response could be induced by four courses of neoadjuvant chemotherapy without a marked increase of toxicities, regardless of a SC or PC regimen.

[Analysis of portal vein resection during pancreaticoduodenectomy in patients with pancreatic cancer].

The feasibility of portal vein resection (PVR) during pancreaticoduodenectomy (PD) for cancer of the pancreatic head is controversial. We retrospectively evaluate the surgical results and prognosis of 26 patients with pancreatic cancer who received PD with PVR (PVR group, n=14) or without PVR (non-PVR group, n=12). The operation time was significantly greater in the PVR group, with a mean time of 13.6 ± 2.4 minutes. There were no differences between the PVR and non-PVR groups in the incidence of complications or the number of days in hospital. In the PVR group, 7 patients were histopathologically diagnosed with portal vein invasion (PV), but there was no difference in the postoperative survival between PV negative and positive patients. PVR during PD appears to be a safe and feasible treatment for appropriate stage pancreatic cancer patients receiving adjuvant chemotherapy.

[A case of long-term survival in rectal cancer with late lung and kidney metastases treated with combined multimodality therapy].

A 59-year-old man was diagnosed with rectal cancer and a low anterior resection was performed. Bilateral lung metastases appeared 4 years and 4 months after the primary surgery. The lung metastases were resected and FOLFOX6 neoadjuvant chemotherapy was administered. An abdominal computed tomography (CT) scan 7 years and 11 months after the primary surgery revealed bilateral multiple lung metastases, a left renal tumor, and swelling in the surrounding lymph node. A left nephrectomy and lymph node dissection were performed. A diagnosis of renal tumor from rectal cancer metastasis was made. For the lung metastases, chemotherapy (sLV/5FU2+Bmab) was administered in 26 courses and stable disease was achieved. It is important to combine adequate surgical resection and systemic chemotherapy for long survival.

[A case of partial hepatectomy and gastrectomy for hepatocellular carcinoma with direct invasion to the stomach].

An 81-year-old man treated with chronic hepatitis C virus (HCV)-related hepatitis and hepatocellular carcinoma (HCC) was diagnosed in 2010 with HCC recurrence (subclass S2) on computed tomography (CT). He refused surgery and was followed up without treatment. In 2012, he was admitted to our hospital because of hematemesis. Gastrointestinal endoscopy revealed a large tumor in the upper gastric corpus, and pathological examination of the tumor revealed HCC; hence, we diagnosed the patient with direct HCC invasion to the stomach. Although active bleeding from the tumor was controlled, he experienced repeated episodes of hematemesis, and the tumor increased in size. Therefore, partial hepatectomy and gastrectomy were performed. It was confirmed that the tumor invaded the stomach wall. Although surgery was effective for gastrointestinal bleeding caused by HCC invasion, the patient died 12 months after surgery because of multiple liver metastases and exacerbated liver failure.

Pattern of abdominal nodal spread and optimal abdominal lymphadenectomy for advanced Siewert type II adenocarcinoma of the cardia: results of a multicenter study.

BACKGROUND: It remains uncertain whether radical lymphadenectomy combined with total gastrectomy actually contributes to long-term survival for Siewert type II adenocarcinoma of the cardia. We identified the pattern of abdominal nodal spread in advanced type II adenocarcinoma and defined the optimal extent of abdominal lymphadenectomy. METHODS: Eighty-six patients undergoing R0 total gastrectomy for advanced type II adenocarcinoma were identified from the gastric cancer database of 4,884 patients. Prognostic factors were investigated by multivariate analysis. The therapeutic value of lymph node dissection for each station was estimated by multiplying the incidence of metastasis by the 5-year survival rate of patients with positive nodes in each station. RESULTS: The overall 5-year survival rate was 37.1%. Age less than 65 years [hazard ratio, 0.455 (95% confidence interval (CI), 0.261-0.793)] and nodal involvement with pN3 as referent [hazard ratio for pN0, 0.129 (95% CI, 0.048-0.344); for pN1, 0.209 (95% CI, 0.097-0.448); and for pN2, 0.376 (95% CI, 0.189-0.746)] were identified as significant prognosticators for longer survival. Perigastric nodes of the lower half of the stomach in positions 4d-6 were considered not beneficial to dissect, whereas there were substantial therapeutic benefits to dissecting the perigastric nodes of the upper half of the stomach in positions 1-3 and the second-tier nodes in positions 7 and 11. CONCLUSIONS: Limited lymphadenectomy attained by proximal gastrectomy might suffice as an alternative to extended lymphadenectomy with total gastrectomy for obtaining potential therapeutic benefit in abdominal lymphadenectomy for advanced Siewert type II adenocarcinoma.

Ultrasound-guided infraclavicular axillary vein puncture is effective to avoid pinch-off syndrome: a long-term follow-up study.

PURPOSE: Pinch-off syndrome (POS) is a serious complication encountered during the long-term management of totally implantable access ports (TIAPs). The aim of this study was to examine the effect of ultrasound-guided infraclavicular axillary vein puncture to avoid POS in patients with long-term use of a TIAP. METHODS: This was a retrospective review of 207 consecutive TIAPs: one hundred devices implanted using an anatomical landmark technique were used as historical controls (Landmark group), while 107 devices were implanted using an ultrasound (US)-guided puncture method (US group). The pinch-off grade (POG) was determined using chest X-ray findings following the definition of Hinke, and the progression of POG during the follow-up period of the Landmark and US groups was compared. RESULTS: Sixteen cases in the Landmark group were POG-1 and 3 were POG-2, while all cases in the US group were POG-0 at the time of venipuncture (p < 0.001). Eleven patients in the Landmark group showed some degree of progression of the POG during the follow-up period. In contrast, there were no cases showing progression of the POG in the US group (p = 0.002). CONCLUSIONS: US-guided infraclavicular axillary vein puncture was found to effectively make it possible to avoid POS for the long-term management of TIAPs, as well as at the time of implantation.

[Bypass surgery or stent placement for biliary obstruction in patients with unresectable pancreatic cancer].

The therapeutic strategy for biliary obstruction in patients with unresectable pancreatic cancer is controversial. We compared complications and prognosis between 2 groups: the B group, 8 patients who were diagnosed as having inoperable pancreatic cancer at laparotomy and underwent bypass surgery, and the S group, 7 patients who underwent endoscopic stent placement for biliary obstruction due to clinically unresectable pancreatic cancer. Although 1 patient developed cholangitis and surgical site infection in the B group, there was no difference in the duration of hospital stay between the 2 groups. In terms of long-term complications, re-drainage was performed in 1 patient because of stent deviation and gastrointestinal bypass surgery was performed in 2 patients because of duodenum stenosis in the S group. There was no difference in postoperative survival between the 2 groups. Stent placement is less invasive and is recommended for the treatment of biliary obstruction in patients with clinically unresectable pancreatic cancer. However, bypass surgery is acceptable for the treatment of patients diagnosed as having inoperable pancreatic cancer at laparotomy.

[A case of partial pancreatectomy for recurrent metastatic renal cell carcinoma in the remnant pancreas after subtotal stomach-preserving pancreaticoduodenectomy].

We report a case in which recurrent pancreatic metastasis of renal cell carcinoma( RCC) in the remnant pancreas was resected 6 years after subtotal stomach-preserving pancreaticoduodenectomy (SSPPD). A 74-year-old man underwent right nephrectomy for RCC in 1991, left partial nephrectomy for left renal RCC metastasis in 1996, and SSPPD for pancreatic RCC metastasis in 2007. In November 2012, he was referred to our hospital with a tumor in the remnant pancreas, as seen on abdominal computed tomography (CT). Partial pancreatectomy for the recurrent metastatic RCC in the remnant pancreas was performed in January 2013. The tumor was histologically diagnosed as metastasis from clear cell RCC in the remnant pancreas. The postoperative course was uneventful, and the blood glucose level after surgery was well controlled using an oral hypoglycemic agent.

[Two cases of human epidermal growth factor receptor 2-positive advanced gastric cancer successfully treated with S-1, cisplatin, and trastuzumab combination therapy followed by curative resection].

We report 2 cases of human epidermal growth factor receptor 2 (HER2)-positive advanced gastric cancer successfully treated with a combination therapy of S-1, cisplatin( CDDP), and trastuzumab followed by curative resection. Case 1 involved a 62-year-old man with type 3 HER2-positive gastric cancer spanning the antrum of the stomach to the duodenal bulb and directly invading the pancreatic head( cT4b[ Panc] N3H0P0M0, Stage IIIC). We diagnosed it as an unresectable cancer, and selected S-1, CDDP, and trastuzumab for combination chemotherapy. S-1 (120 mg/body/day) was administered orally for 2 weeks, followed by 1 drug-free week as a course, and CDDP (60 mg/m2) and trastuzumab (8 mg/kg loading dose and 6 mg/kg maintenance) were administered by intravenous infusion on day 1. After the third course, significant tumor and lymph node reduction was observed; however, pyloric stenosis developed. Distal gastrectomy with D2 lymphadenectomy was performed. Case 2 involved a 62-year-old woman with type 4 HER2-positive gastric cancer from the angle of the stomach to the duodenal bulb and directly invading the pancreatic head (cT4b [Panc] N2H0P0M0, Stage IIIC). After the third course of combination therapy, significant tumor reduction and disappearance of lymph nodes metastasis was observed. We diagnosed the patient as having a resectable cancer, and performed distal gastrectomy with D2 lymphadenectomy.

[A case of sigmoid colon cancer with Virchow's lymph node metastasis successfully treated with chemotherapy].

We report the case of a 71-year-old woman suffering from advanced sigmoid colon cancer with Virchow's and para- aortic lymph node metastasis. Sigmoidectomy was performed for sigmoid colon cancer in January 2008, and pathological analysis revealed that it was Stage II(pT3, pN0, pM0, Cur A). The patient received capecitabine regimen as adjuvant chemotherapy from February 2008 to July 2008. However, in August 2008, a left cervical mass was detected associated with swelling, which was partially resected. Microscopic findings revealed lymph node metastasis from sigmoid colon cancer, and Virchow's and para-aortic lymph node metastasis were diagnosed. Therapy with FOLFOX and bevacizumab (Bmab) was started and continued for 8 cycles. Virchow's and para-aortic lymph node metastasis could no longer be detected in June 2009. FOLFOX+Bmab treatment was administered for 33 cycles and oxaliplatin was temporarily stopped due to adverse reactions, including neutropenia, peripheral neuropathy, and appetite loss. She had no recurrence for almost 3 years after stopping chemotherapy for Virchow's and para-aortic lymph node metastasis.

[Peritoneal dissemination from gastrointestinal stromal tumor of small intestine responding completely to imatinib mesylate (STI 571)].

The prognosis of metastatic or recurrent GISTs is poor, because these tumors resist chemotherapy and radiotherapy. We report a patient with recurrent GIST who underwent molecularly targeted therapy with imatinib, a novel oral tyrosine kinase inhibitor. A 64-year-old man presented with large intra-abdominal mass. The patient had a history of jejunostomy with colostomy for intestinal GIST. The abdominal mass was phi3 x 3.5 cm in size with ascites at Douglas, as determined by computed tomography, and was diagnosed as a peritoneal relapse of GIST. Treatment with imatinib daily was started. After 1 month of treatment with imatinib, reduction of the abdominal tumor began to be recognized on palpation. Computed tomographic scanning at 11 months revealed that the tumor had completely disappeared. The major side effect was drug eruption,which was easily manageable with 2 weeks drug holidays. Imatinib shows promise as a safe and effective drug for the treatment of patients with recurrent GISTs.

Effects of daikenchuto, a Japanese herb, on intestinal motility after total gastrectomy: a prospective randomized trial.

PURPOSE: This study aimed to assess the efficacy of daikenchuto (DKT), a commonly prescribed, traditional Japanese herbal medicine, on postoperative intestinal dysfunction after gastric cancer surgery. METHODS: Patients with gastric cancer scheduled for a total gastrectomy were randomly assigned before surgery to receive either no treatment (n = 40; control group) or DKT (7.5 g/day, t.i.d.) for 3 months (n = 41) postoperatively. We examined gastrointestinal motility, stool attributes, the quantity of bowel gas, the quality of life, and the incidence of postoperative ileus. RESULTS: During the hospital stay, significant differences were observed between the DKT group and controls in the number of stools per day (1.1 ± 0.6 vs 0.8 ± 0.4, respectively; P = 0.037) and stool consistencies (Bristol scale ratings were 3.7 ± 0.8 vs 3.1 ± 0.8, respectively; P = 0.041). The DKT group showed significant reductions in gas volume scores, calculated from abdominal radiographs, at 7 days, 1 month, and 3 months after surgery. The groups did not show significant differences in quality of life scores (based on the Gastrointestinal Symptom Rating Scale) or in the incidence of postoperative ileus. CONCLUSION: DKT improved bowel movements, stool properties, and bowel gas. These results suggested that DKT promoted early postoperative bowel functions after total gastrectomy.

Laparoscopic resection of intra-abdominal esophageal duplication cyst.

Esophageal duplication cysts are frequently encountered in the mediastinum and rarely in the abdomen. A case of laparoscopic resection of an intra-abdominal esophageal duplication cyst is reported. An incidental 4.5 x 4.0 x 3.5-cm, well-circumscribed, homogenous mass anterior to the intra-abdominal esophagus was detected on staging CT examinations for breast cancer in a 51-year-old woman. Laparoscopic resection of the lesion was performed after completion of breast-conserving surgery and whole breast irradiation. The defect of the muscular layer of the esophagus caused by the complete removal of the lesion required repair with muscular sutures. It was helpful to inspect the integrity of the esophageal wall repair by examining the exterior wall of the esophagus laparoscopically while insufflating air into the esophageal lumen through a fiberoptic esophagoscope. A laparoscopic approach utilizing intraoperative esophagoscopy is easy and safe for removal of intra-abdominal esophageal duplication cysts.

Splenic artery embolization using contour emboli before laparoscopic or laparoscopically assisted splenectomy.

The present study assessed preoperative splenic artery embolization using spherical embolic material, super absorbent polymer microspheres (SAP-MS), before laparoscopic or laparoscopically assisted splenectomy. Distal splenic artery embolization using 250 to 400 microm SAP-MS was performed in nine cases with ITP and in seven cases with the other diseases with splenomegaly. Laparoscopic or laparoscopically assisted splenectomies, including a hand-assisted procedure and the procedure involving left upper minilaparotomy, were done 2 to 4 hours after embolization. Conversion to traditional laparotomy was not required in any of the 16 cases, while conversion to 12-cm laparotomy was required in one case with massive splenomegaly. Mean operating time was 161 minutes, and mean intraoperative blood loss was 290 mL. No major postoperative complications were identified, and only one patient reported postembolic pain before surgery. Preoperative splenic artery embolization using painless embolic material, SAP-MS, would be effective for easy and safe laparoscopic or laparoscopically assisted splenectomy.

[A case of advanced colon cancer responding completely to systemic 5-fluorouracil/l-leucovorin therapy].

A 79-year-old man was admitted for advanced transverse colon cancer with large bowel obstruction. Twelve years earlier he underwent a total gastrectomy with Roux-en Y reconstruction for gastric cancer. No metastasis was detected preoperatively. Exploratory laparotomy revealed massive direct invasion of the mesenterium of the jejunum for Roux-en Y reconstruction. The primary lesion was unresected and transverse colostomy was made. Systemic chemotherapy with 5-fluorouracil and l-leucovorin was scheduled for a total of 4 courses postoperatively. After completion of this chemotherapeutic regimen, a CT scan and colonofiberscopy revealed the primary lesions had disappeared, and a histological examination of biopsy confirmed that the patient had achieved a complete remission (CR). There was no severe side effect during chemotherapy. The patient is presently enjoying a good general condition and has been free from any sign of recurrence.

[TS-1 was prescribed for a patient with stomach cancer with peritoneal dissemination who survived for 3 years and 2 months].

A 42-year-old female patient underwent total gastrectomy for gastric cancer (Borrmann's Type 3). Many rice-grain sized peritoneal metastases were observed in the transverse colon and mesenterium. The lesion was diagnosed as stage IV cancer and the degree of radical cure was determined to be C. Chemotherapy with TS-1 was administered postoperatively. In each cycle, the drug was administered at a daily dose of 100 mg for 4 weeks, followed by a drug-free period of 2 weeks. The adverse reactions were mild, and she underwent the 2nd and further courses of therapy on an outpatient basis. Since she had acute cholecystitis during the 12th course, the drug was withdrawn for 2 months. Thereafter, the drug was started again after resolution of the cholecystitis. At present, ie, 3 years and 2 months after the surgery, the patient is receiving the 23rd course of chemotherapy on an outpatient basis, and abdominal CT shows no evidence of increase in the peritoneal metastases, enlargement of the intraperitoneal lymph nodes, or ascites.

Cosmetic evaluation following volume replacement using lateral tissue flap in breast-conserving surgery.

BACKGROUND: We examined the effectiveness of volume replacement using a lateral tissue flap (LTF) in breast-conserving surgery for a good cosmetic outcome. METHODS: We analyzed the results of 130 patients with breast cancer who underwent breast-conserving surgery with replacement using an LTF from 2006 to 2010 with cosmetic evaluations performed according to the criteria of the Japanese Breast Cancer Society. We examined scores with regard to the following possible contributing factors: partial resection (Bp) or quadrantectomy (Bq), diameter of the specimen, body mass index (BMI), axillary lymphadenectomy, postoperative irradiation, and position of the tumor. RESULTS: The scores for cases with Bp and non-postoperative irradiation were higher than those for Bq and postoperative irradiation cases, though they were not significant factors in multivariate analysis. A negative correlation was seen between score and diameter of the specimen, whereas there was no significant correlation with BMI. There was no significant difference between scores of cases with or without an axillary lymphadenectomy. However, the score for the extended upper-outer area including the upper and outer borders was significantly higher than scores for other portions. In multiple regression analysis, cases with a tumor diameter less than 4 cm in the extended upper-outer area or less than 2 cm in other areas showed good adaptation. CONCLUSION: Tumor location and diameter are important factors for cosmetic evaluation of volume replacement using an LTF.

Single-incision laparoscopic stoma creation: experience with 31 consecutive cases.

INTRODUCTION: Fecal diversion may be performed using various techniques. Each technique has advantages that affect patient selection. In this report, we report our experience with 31 patients who underwent single-incision laparoscopic stoma creation using only a pre-selected stoma site as the point of port access. METHODS: A 2.5-cm skin incision was made at a previously marked stoma site, and two 5-mm trocars were placed into the abdomen through the stoma site. An optional third trocar was inserted at the stoma site only if the bowel needed to be mobilized or if adhesions needed to be divided. After full intra-abdominal exploration, a selected intestinal loop was brought up to the stoma site, and the ostomy was then matured using standard techniques. RESULTS: Between April 2009 and March 2012, 31 patients (19 men) with a mean age of 68 years (range, 46-87 years) underwent single-incision laparoscopic stoma creation. Fecal diversion included ileostomy (n = 18) and colostomy (n = 13). There were no intraoperative complications. Two patients (6.5%) required additional port placement in the midline suprapubic area. Conversion to open laparotomy was required in two patients (6.5%) because of the presence of extensive adhesions. Postoperative complications were observed in two patients and included peristomal ileus and dehydration due to high ileostomy output. CONCLUSIONS: Single-incision laparoscopic stoma creation is an effective technique that allows full intra-abdominal visualization and bowel mobilization, while reducing the need for additional skin incisions beyond that of the stoma site.

Reduced thiamine (vitamin B1) levels following gastrectomy for gastric cancer.

BACKGROUND: Vitamin B1 deficiency is well known as a possible complication following gastric restrictive surgery for morbid obesity; however, reduced vitamin B1 levels in patients who have undergone gastrectomy for gastric cancer have not been discussed previously. METHODS: Serum vitamin B1 levels were determined after the return to normal daily activity in 54 patients with distal gastrectomy for gastric cancer, 32 patients with total gastrectomy for gastric cancer, and 30 patients with radical surgery for colorectal cancer. Changes from serum vitamin B1 levels before operation to those after return to normal daily activity, without nutritional support, were investigated in 25 patients with gastrectomy for gastric cancer and 26 patients with radical surgery for colorectal cancer. RESULTS: Decreased serum vitamin B1 levels, below the normal range, were recognized in 7 of the 54 distally gastrectomized patients and in 5 of the 32 totally gastrectomized patients, whereas no such decrease was recognized in any patient after colorectal surgery. Decreased serum vitamin B1 level was recognized within 6 months after the operation in 6 of the 7 distally gastrectomized patients showing a decreased vitamin B1 level and in 3 of the 5 totally gastrectomized patients showing a decreased vitamin B1 level. Postoperative serum vitamin B1 levels were significantly lower than those before operation in patients with gastrectomies, whereas there was no significant difference in serum vitamin B1 levels before and after the surgeries in patients with surgery for colorectal cancer. CONCLUSION: Vitamin B1 levels may be reduced in gastrectomized patients, especially within 6 months after operation, even after their return to normal daily activity without nutritional support.

Manganese deposition in basal ganglia due to perioperative parenteral nutrition following gastrointestinal surgeries.

BACKGROUND/AIMS: Serial changes in blood manganese (Mn) levels and brain MRI examinations following perioperative parenteral nutrition (PN) were investigated. METHODS: Six cases undergoing pancreatoduodenectomy (PD), 4 cases undergoing thoracic esophagectomy (TE), 18 cases undergoing total gastrectomy (TG) and 20 cases undergoing colorectal surgeries (CR) with daily administration of 20 micromol of Mn per day were studied. Cases undergoing PD, TE, TG or CR without Mn administration served as controls. RESULTS: Hyperintense lesions in the basal ganglia on T1-weighted MRI and elevated blood Mn levels were recognized after PN in 4 of 6 cases in the PD group, in 3 of 4 cases in the TE group, in 1 of 18 cases in the TG group and in 2 of 20 cases in the CR group. No abnormalities were recognized in the control groups. CONCLUSION: The possible Mn deposition in the basal ganglia caused by perioperative PN should be especially noted in cases undergoing PD or TE.