[A Case of Type 4 Ascending Colon Cancer Showing Early Postoperative Lymphangitis Carcinomatosa].

A 56-year-old man was admitted to our hospital because abdominal CT showed wall thickening of the ascending colon. Colonoscopyshowed type 4 colon cancer, diagnosed as poorlydifferentiated adenocarcinoma bybiopsy , with circumferential stenosis. Enhanced CT after admission also showed obstructive ileus and lymphadenopathy leading to a paraaortic lesion, but no other distant metastases were seen. Right hemicolectomywas performed. Histological examination showed poorlydifferentiated adenocarcinoma extending from the hepatic flexure to the terminal ileum, with marked invaded vessels and stromal fibrosis, which was diagnosed as type 4 colon cancer of scirrhous and lymphangiosis types. On the 10th postoperative day, he developed lymphangitis carcinomatosa. Intensive treatment including steroid therapy was not effective, and he died of respiratory failure on the 26th day. Type 4 colon cancer is rare and has very poor prognosis. We report a case and literature review.

[A Case of Type 4 Gastric Cancer with Esophageal Invasion That Responded to Neoadjuvant Chemotherapy Containing S-1 and Oxaliplatin followed by Surgery].

We encountered a case of type 4 gastric cancer with esophageal invasion that responded to neoadjuvant chemotherapy containing S-1 and oxaliplatin(SOX)followed by surgery, which could be curative resection. A 46-year-old man was referred to our hospital because of abnormal upper gastrointestinal series findings. He was diagnosed with type 4 advanced gastric cancer with esophageal invasion, cT4b(diaphragm)N2M0, Stage ⅢC, and 3 courses of neoadjuvant SOX therapy were administered. Adverse events were minor. After NAC, the primary lesion and lymph nodes showed marked reductions on CT; total gastrectomy and subtotal thoracic esophagectomy were performed. The pathological response to NAC was evaluated as Grade 2 in the primary tumor and Grade 3 in the lymph node; overall, NAC showed considerable antitumor effects. The final diagnosis was ypT3N0M0P0CY0H0, StageⅡA, and was judged as curatively resected. Currently, we are continuing to administer adjuvant chemotherapy containing S-1.

[Experience of Ramucirumab plus FOLFIRI as Second-Line Treatment for Metastatic Colorectal Cancer in Our Hospital].

We experienced 2 cases in which ramucirumab plus FOLFIRI as second-line treatment was beneficial. Case 1 was a 67-yearold man, underwent panitumumab plus mFOLFOX6 as first-line treatment for unresectable rectal cancer with ureteral invasion and multiple liver metastases, but the disease became worse at 9.3 months. We changed to ramucirumab plus FOLFIRI as second-line treatment. After 2 courses, a grade 3 febrile neutropenia was observed, but treatment was beneficial and continued administration for 9 months or more. Case 2 was a 73-year-old man who underwent panitumumab plus mFOLFOX6 as first-line treatment after cytoreductive surgery of the primary lesion for sigmoid colon cancer with intestinal obstruction and liver metastasis, but the disease became worse at 4.7 months. Upon entering ramucirumab plus FOLFIRI therapy, the metastatic lesions shrinked remarkably. Adverse events of grade 3 or higher were not observed and finally continued administration for 7.9 months. It was suggested that ramucirumab plus FOLFIRI combination therapy for metastatic colorectal cancer could be an effective as second-line treatment.

[Experience with Gemcitabine plus Nab-Paclitaxel Therapy for Advanced Metastatic Pancreatic Cancer in Our Hospital].

A 71-year-old-man was referred to our hospital because of jaundice of the skin. On biochemical examination of blood, we identified an elevation in the levels of AST and ALT, the serum level of biliary enzymes, and the serum levels of tumor markers. We found pancreatic head cancer with invasion to the main blood vessels and duodenum, with liver metastases, on abdominal CT. We made a diagnosis of unresectable advanced pancreatic head cancer with distant metastasis, and we initiated gemcitabine plus nab-paclitaxel therapy as first-line chemotherapy. The serum CA19-9 level decreased gradually after initiating therapy; both the primary tumor and liver metastases slightly reduced in size after 3 courses of first-line therapy, as assessed on abdominal CT. Hair loss, peripheral neuropathy, and neutropenia were observed as adverse events, but treatment continued as it was tolerable. Finally, because his disease condition worsened after 7 courses of the therapy, we switched to TS-1 as second-line therapy. Eleven months have elapsed since treatment was initiated, and the patient is continuing secondline therapy while maintaining PS.

[A Case of Multiple Bevacizumab-Related Colonic Perforations during Opioid Use].

We present the case ofa 54-year-old man who had been treated with bevacizumab-containing chemotherapy for a postoperative recurrence of lung cancer for 5 months; he had used opioids for cancer pain in his right lateral chest for 2 months. He was admitted to the hospital because his chest pain had worsened 5 days earlier and he was experiencing a dull pain in his lower abdomen. His condition was recognized as an aggravation of the cancer pain and his opioid dose was increased. He presented with intense abdominal pain 6 days after admission, and we diagnosed gastrointestinal perforations from an abdominal CT scan. Therefore, we undertook an emergency operation. Multiple perforations were seen on the transverse and descending colon; an extensive colectomy and a colostomy were performed. Histopathological findings showed that multiple ulcer perforations and normal mucosa coexisted throughout the resected specimen. Bevacizumab-induced ischemic changes were the suspected cause. When pain control becomes variable during opioid use, conditions such as bevacizumab-related gastrointestinal perforations should be considered, in addition to progression of the cancer pain itself, and the appropriate treatment should be administered.

[Examination of outcomes after conversion surgery for Stage IVGastric cancer in our hospital].

PURPOSE: We examined the outcomes of conversion surgery (CS) for Stage IV gastric cancer performed in our hospital. OBJECTIVE AND METHOD: We retrospectively examined the outcomes of 5 Stage IV gastric cancer patients, for whom surgical excision was possible and CS was performed after induction chemotherapy between January 2010 and December 2013. RESULTS: The median age of the patients who underwent CS was 62 years, and non-recovering factors were as follows: M1 (LYM) for 3 patients, H1 for 1 patient, and P1 for 1 patient. For all patients, the induction chemotherapy regimen consisted only of TS-1+cisplatin (CDDP). Using diagnostic imaging to determine treatment effect, we found that 2 patients showed a partial response(PR)as a result of the induction chemotherapy. As a result of CS, R0 surgery could be enforced to 3 cases and postoperative complications accepted neither. Ef-grade which of the histopathological judging of the chemotherapy were 1a: 4 cases, 2: 1 case. After adjuvant chemotherapy treatment in 3 patients, the median survival time (MST) of the CS patients was 22.5 months. In contrast, the MST of non-CS patients, who received treatments other than CS, was 4 months. These results indicate that the MST for CS patients was substantially longer compared to patients who did not receive CS (p=0.046). CONCLUSION: Although CS in response to Stage IV gastric cancer fully needed to examine selection of a case, the timing of operation introduction, etc. to be successful, a possibility of contributing to a prognosis improvement in a multidisciplinary treatment was suggested.

[Protocol for the administration of modified FOLFOX6 (mFOLFOX6) in patients with unresectable/recurrent colorectal cancer].

In patients undergoing FOLFOX6 therapy for the treatment of unresectable/recurrent colorectal cancer, control of cumulative peripheral neuropathy is problematic. In our department, we stop using mFOLFOX6 as a primary therapy after 6 to 8 courses. Instead, we use mFOLFOX6 as a secondary therapy, and re-introduce mFOLFOX6 as a tertiary therapy; the patients undergoing this treatment protocol were included in Group A. We have studied the degree of neurotoxicity and the time of its occurrence in these patients compared to those undergoing the standard method (Group B; 12 cases). Grade 3 peripheral neuropathy was observed in both the groups. In Group B, peripheral neuropathy occurred in the primary treatment period, whereas in Group A, it appeared in the tertiary treatment period. Moreover, in Group A, we observed Grade 2 peripheral neuropathy in the primary treatment period in 3 cases, but this was promptly resolved after the therapy was shifted to the secondary treatment period. The period with neurological toxicities was shorter in Group A compared to Group B. When treating colorectal cancer with chemotherapy, it is important to elucidate how the prognosis can be improved while maintaining the quality of life( QOL). In our department, we place a greater emphasis on the QOL of the patient.

[A case of recurrent breast cancer that responded to bevacizumab].

We report a case of a 59-year-old woman who was forced to undergo mastectomy of the right breast (Rt Bt) plus axillary lymph node (Ax) dissection for right breast cancer at another hospital. The pathological diagnosis was invasive ductal carcinoma( scirrhou[s sci], pT2N2M0, Stage IIIA, estrogen recepto[r ER[]+], progesterone recepto[r PgR[]+], human epidermal growth factor receptor-2[HER2][2+]). Although no recurrence was observed after postoperative adjuvant chemotherapy and endocrine therapy, skin metastasis on the left back and pleuritis carcinomatosa were detected at our hospital 9 years and 6 months after the operation. Thereafter, bone metastasis, contralateral lymph node metastasis, and frequent occurrence of hepatic metastasis were sequentially detected. The patient was treated with chemotherapy (a total of 4 regimens) and endocrine therapy in addition to radiation therapy for lymph node metastasis over a period of approximately 2 years and 3 months; however, disease control was poor. Therefore, combined chemotherapy with paclitaxel and bevacizumab was initiated from February 2012. Soon after the initiation of combination therapy, the serum carcinoembryonic antigen (CEA) level gradually reduced and computed tomography (CT) revealed that the multiple-organ metastases had remarkably reduced in size. The response was classified as a clinical partial response (cPR). Although adverse events such as peripheral neuropathy, nose bleeding, and high blood pressure were observed, these were all of lesser that Grade 2 severity. The efficacy of chemotherapy was noted for 11 months.