Efficacy and safety of 5-aminolevulinic acid in adult-onset Still's disease: A preclinical study in mice and a pilot study in humans.

The study aimed to investigate the therapeutic effects of 5-aminolevulinic acid/sodium ferrous citrate (5-ALA/SFC) on adult-onset Still's disease (AOSD), specifically focusing on arthritis and macrophage activation syndrome (MAS). We used mouse models to assess the impact of 5-ALA/SFC on collagen-induced arthritis (CIA) and MAS induced by synthetic oligonucleotides containing CpG motifs (CpG-S-ODN). Additionally, we conducted a pilot study with AOSD patients receiving prednisolone (PSL) treatment and 5-ALA/SFC administration to evaluate its efficacy and safety. The 5-ALA/SFC group exhibited significantly lower joint scores in CIA mice. In CpG-S-ODN-treated mice, 5-ALA/SFC administration led to reduced hemophagocytosis and splenomegaly. The anti-inflammatory properties of 5-ALA/SFC were attributed to the suppression of CCL4 and CXCL10 production in monocytes and the induction of M2 macrophages. AOSD patients treated with 5-ALA/SFC demonstrated successful PSL tapering without adverse events. Collectively, the administration of 5-ALA/SFC showed promising potential in ameliorating arthritis and MAS in AOSD patients.

Outcomes of surgical resection for pulmonary metastasis from pancreatic cancer.

PURPOSE: As the number of long-term survivors of pancreatic cancer is expected to increase thanks to recent advances in multidisciplinary treatment and earlier diagnoses of pancreatic cancer, we are likely to encounter more cases of postoperative pulmonary nodules. We analyzed the clinical course and prognosis of resection of pulmonary metastases from pancreatic cancer to clarify the prognostic implication of pulmonary metastasectomy for pancreatic cancer. METHOD: We retrospectively analyzed 35 patients who underwent resection of lung metastases after pancreatic cancer surgery. Short- and long-term outcomes and factors associated with the prognosis were analyzed. RESULTS: The observation period was 20 (range, 1-101) months, with 3- and 5-year survival rates of 88.3% and 64.5% from pancreatectomy and 44.1% and 28.3% from lung resection, respectively. A univariate analysis revealed that a period from pancreatic cancer resection to pulmonary nodule shadow detection of < 15 months was associated with a significantly lower overall survival from pancreatic resection than a longer period. Conversely, histological type, stage, size of lung metastases, and resection technique were not associated with the overall survival. CONCLUSION: A long-term prognosis may be expected in some cases with a disease-free interval of ≥ 15 months. Our findings suggest that the disease-free interval may influence the prognosis.

Heterozygous disruption of ALAS1 in mice causes an accelerated age-dependent reduction in free heme, but not total heme, in skeletal muscle and liver.

5-Aminolevulinic acid (ALA) is the rate-limiting intermediate in heme biosynthesis in vertebrate species; a reaction catalyzed by the mitochondrial ALA synthase 1 (ALAS1) enzyme. Previously we reported that knockdown of the ubiquitously expressed ALAS1 gene in mice disrupts normal glucose metabolism, attenuates mitochondrial function and results in a prediabetic like phenotype when animals pass 20-weeks of age (Saitoh et al., 2018). Contrary to our expectations, the cytosolic and mitochondrial heme content of ALAS1 heterozygous (A1+/-) mice were similar to WT animals. Therefore, we speculated that regulatory "free heme" may be reduced in an age dependent manner in A1+/- mice, but not total heme. Here, we examine free and total heme from the skeletal muscle and liver of WT and A1+/- mice using a modified acetone extraction method and examine the effects of aging on free heme by comparing the amounts at 8-12 weeks and 30-36 weeks of age, in addition to the mRNA abundance of ALAS1. We found an age-dependent reduction in free heme in the skeletal muscle and liver of A1+/- mice, while WT mice showed only a slight decrease in the liver. Total heme levels showed no significant difference between young and aged WT and A1+/- mice. ALAS1 mRNA levels showed an age-dependent reduction similar to that of free heme levels, indicating that ALAS1 mRNA expression levels are a major determinant for free heme levels. The free heme pools in skeletal muscle tissue were almost 2-fold larger than that of liver tissue, suggesting that the heme pool varies across different tissue types. The expression of heme oxygenase 1 (HO-1) mRNA, which is expressed proportionally to the amount of free heme, were similar to those of free heme levels. Taken together, this study demonstrates that the free heme pool differs across tissues, and that an age-dependent reduction in free heme levels is accelerated in mice heterozygous for ALAS1, which could account for the prediabetic phenotype and mitochondrial abnormality observed in these animals.

Long-Term Outcomes of Pulmonary Metastasectomy for Uterine Malignancies: A Multi-institutional Study in the Current Era.

BACKGROUND: Information on pulmonary metastasectomy (PM) for uterine malignancies in the current era is limited. In the present study, we analyzed the clinical course and results of PM for uterine malignancies in the era of modern imaging diagnostics to clarify the role of PM in the current era in a multi-institutional setting. METHODS: Fifty-seven patients who underwent PM for uterine malignancies between 2006 and 2015 were retrospectively reviewed. The short- and long-term outcomes, along with factors associated with the prognosis, were analyzed. Details of the clinical course after PM were described. RESULTS: The mean age of patients was 59.4 years. The primary tumor was located in the uterus corpus in 34 cases (60%) and in the uterus cervix in 23 cases (40%). The median disease-free interval (DFI) was 32 months. Forty patients (70%) received fluorine-18-2-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography before PM, and complete resection was achieved in 52 patients (91%). Postoperative complications occurred in 4 patients (7%). Of the 52 patients who underwent complete resection of pulmonary metastases, 28 experienced recurrence, and among these, 17 (60%) underwent local therapy, including six repeat PMs. Among the 52 patients who underwent complete resection, the 5-year relapse-free survival rate was 40.7% and the 5-year overall survival (OS) rate was 68.8%. The univariate analysis revealed that a DFI of ≤ 24 months was associated with significantly poorer OS. CONCLUSIONS: PM for uterine malignancies is safe and provides favorable long-term outcomes in selected patients. Patients with a DFI of > 24 months have better OS and are good candidates for PM.

[A Case of Pulmonary Metastases of Colon Cancer with Submucosal Invasion].

In general, distant metastasis is uncommon in colorectal submucosal(SM)invasion without lymph node metastasis. We experienced an extremely rare case of synchronous pulmonary metastases for colon cancer in SM invasion. A man in his 70s was seen at the hospital for a positive fecal occult blood test. Colonoscopy revealed 3 lesions in the sigmoid colon and endoscopic mucosalresection revealed 2,000 mm SM invasion in all 3 lesions. Computed tomography showed no signs of distant lymph node or liver metastasis but showed small nodules in both lungs. Radical treatment included laparoscopic anterior resection with lymph node dissection. Histological examination showed no residual tumor in the colon and no lymph node metastasis. Two years after surgery, the number of lung nodules gradually increased and we performed partial resection of the left lung, which was diagnosed as pulmonary metastasis from colon cancer by histological examination. Therefore, we resected the opposite-side pulmonary metastases. The patient has exhibited no other signs of recurrence in the 2 years since the last operation.

Fulminant onset of insulin-dependent diabetes with positive anti-GAD antibody titers during treatment with nivolumab in a patient with NSCLC.

Programmed cell death-1 (PD-1) and programmed cell death-ligand-1 (PD-L1) inhibitors have been highlighted in the field of cancer treatment. The interaction between PD-1 and PD-L1 is thought to play an important role in the regulation of the self-immune tolerance mechanism, so blocking these molecules may cause serious immune-related adverse events (IrAE), including fulminant insulin-dependent (type 1) diabetes. Here, we describe a patient with fulminant type 1 diabetes induced by nivolumab, an anti-PD-1 antibody. The patient, a 78-year-old man, was being treated with nivolumab as a third-line treatment for squamous cell carcinoma of the lung. After three cycles, he experienced an abrupt flare-up of the blood glucose within half a day. His blood glucose further increased without clinical symptoms until his hospital visit. Laboratory data showed the complete exhaustion of intrinsic insulin and the elevation of serum antibody titer to glutamic acid decarboxylase (GAD). Although the patient was previously diagnosed with non-insulin-dependent (type 2) diabetes, his disease activity had been well controlled with oral medication and low-dose insulin therapy until just before the flare-up. Because of the laboratory findings and the extremely rapid onset of hyperglycemia, a diagnosis of fulminant, rather than the rapid onset, type 1 diabetes related to nivolumab therapy was strongly suspected. Our case study indicates that fulminant hyperglycemia can occur extremely rapidly. The blood glucose of patients receiving PD-1 antibody therapy should be closely monitored.

[A Case of Synchronous Double Cancers of the Liver and Pancreas Treated Using Pancreaticoduodenectomy and Liver Resection].

A 50-year-old woman had a 12mm liver tumor at segment 4 and was diagnosed with hemangioma. Two years later, the liver tumor had grown to 27mm in diameter, and a new pancreatic tumor was detected using CT examination. The pancreatic tumor was suspected of being pancreatic carcinoma, based on the results of endoscopic-ultrasound-guided fine-needlebiopsy( EUS-FNA)of the pancreas. The liver tumor was diagnosed as adenocarcinoma using liver biopsy. Because of its slow growth and the solitary liver tumor, synchronous pancreatic cancer and intrahepatic cancer were suspected. We therefore performed pancreaticoduodenectomy with portal vein resection and partial liver resection of segment 4. Upon histological analysis, carcinoma in situ was detected in the liver tumor and the patient was diagnosed with synchronous double cancers of the liver(cholangiocellular carcinoma)and pancreas(invasive ductal carcinoma). Our case indicated that it is very difficult to distinguish cholangiocellular carcinoma from metastatic liver tumor using diagnostic images. We should therefore consider the possibility of cholangiocellular carcinoma when a solitary tumor in the liver is detected at the same time as pancreatic cancer.

Stereotactic body radiotherapy for second pulmonary nodules after operation for an initial lung cancer.

OBJECTIVE: A second lung cancer is occasionally observed in patients who underwent surgical resection of the index lung cancer. The purpose of this study is to evaluate stereotactic body radiation therapy for second lung cancer. METHODS: Fifty-one medically inoperable patients who underwent stereotactic body radiation therapy for second lung cancer were the subjects: 31 cases of multiple primary lung cancer and 20 of pulmonary metastasis from the index cancer. Clinical stage was T1a in 27 patients, T1b in 13 patients and T2a in 11 patients, and 70% of subjects had impaired respiratory function. Histology of second lung cancer was adenocarcinoma in 16 patients, squamous cell carcinoma in 9 patients and not assessed in 25 patients. The interval between index cancer operation and stereotactic body radiation therapy was 31 months (range: 4-171). The total stereotactic body radiation therapy doses were 48 Gy in 4 fractions or 60 Gy in 10 fractions. RESULTS: With the median follow-up of 36 months, 3-year overall survival rates were 62% with the median survival time of 46 months. Cause-specific survival was 73% at 3 years. Overall survival for multiple primary lung cancer and pulmonary metastasis was quite similar: 62 and 61% at 3 years, respectively. Three-year overall survival was 77% for T1a and 43% for T1b or T2a. Grade 2 pulmonary toxicities occurred in five patients and one patient died of Grade 5 pneumonitis. CONCLUSIONS: Even though the subjects were medically inoperable, the survival outcomes of stereotactic body radiation therapy were favorable. Furthermore, having acceptable toxicity, stereotactic body radiation therapy is feasible and could be an option for multiple primary lung cancer and pulmonary metastasis after surgical resection for the index cancer.

Adjuvant chemotherapy for resected early-stage non-small cell lung cancer.

BACKGROUND: To evaluate the effects of administering chemotherapy following surgery, or following surgery plus radiotherapy (known as adjuvant chemotherapy) in patients with early stage non-small cell lung cancer (NSCLC),we performed two systematic reviews and meta-analyses of all randomised controlled trials using individual participant data. Results were first published in The Lancet in 2010. OBJECTIVES: To compare, in terms of overall survival, time to locoregional recurrence, time to distant recurrence and recurrence-free survival:A. Surgery versus surgery plus adjuvant chemotherapyB. Surgery plus radiotherapy versus surgery plus radiotherapy plus adjuvant chemotherapyin patients with histologically diagnosed early stage NSCLC.(2)To investigate whether or not predefined patient subgroups benefit more or less from cisplatin-based chemotherapy in terms of survival. SEARCH METHODS: We supplemented MEDLINE and CANCERLIT searches (1995 to December 2013) with information from trial registers, handsearching relevant meeting proceedings and by discussion with trialists and organisations. SELECTION CRITERIA: We included trials of a) surgery versus surgery plus adjuvant chemotherapy; and b) surgery plus radiotherapy versus surgery plus radiotherapy plus adjuvant chemotherapy, provided that they randomised NSCLC patients using a method which precluded prior knowledge of treatment assignment. DATA COLLECTION AND ANALYSIS: We carried out a quantitative meta-analysis using updated information from individual participants from all randomised trials. Data from all patients were sought from those responsible for the trial. We obtained updated individual participant data (IPD) on survival, and date of last follow-up, as well as details of treatment allocated, date of randomisation, age, sex, histological cell type, stage, and performance status. To avoid potential bias, we requested information for all randomised patients, including those excluded from the investigators' original analyses. We conducted all analyses on intention-to-treat on the endpoint of survival. For trials using cisplatin-based regimens, we carried out subgroup analyses by age, sex, histological cell type, tumour stage, and performance status. MAIN RESULTS: We identified 35 trials evaluating surgery plus adjuvant chemotherapy versus surgery alone. IPD were available for 26 of these trials and our analyses are based on 8447 participants (3323 deaths) in 34 trial comparisons. There was clear evidence of a benefit of adding chemotherapy after surgery (hazard ratio (HR)= 0.86, 95% confidence interval (CI)= 0.81 to 0.92, p< 0.0001), with an absolute increase in survival of 4% at five years.We identified 15 trials evaluating surgery plus radiotherapy plus chemotherapy versus surgery plus radiotherapy alone. IPD were available for 12 of these trials and our analyses are based on 2660 participants (1909 deaths) in 13 trial comparisons. There was also evidence of a benefit of adding chemotherapy to surgery plus radiotherapy (HR= 0.88, 95% CI= 0.81 to 0.97, p= 0.009). This represents an absolute improvement in survival of 4% at five years.For both meta-analyses, we found similar benefits for recurrence outcomes and there was little variation in effect according to the type of chemotherapy, other trial characteristics or patient subgroup.We did not undertake analysis of the effects of adjuvant chemotherapy on quality of life and adverse events. Quality of life information was not routinely collected during the trials, but where toxicity was assessed and mentioned in the publications, it was thought to be manageable. We considered the risk of bias in the included trials to be low. AUTHORS' CONCLUSIONS: Results from 47 trial comparisons and 11,107 patients demonstrate the clear benefit of adjuvant chemotherapy for these patients, irrespective of whether chemotherapy was given in addition to surgery or surgery plus radiotherapy. This is the most up-to-date and complete systematic review and individual participant data (IPD) meta-analysis that has been carried out.

[Clinical Significance of Placing a PEG during Chemoradiotherapy for Advanced Esophageal Cancer].

BACKGROUND: Unresectable advanced esophageal cancer is often treated with chemotherapy or chemoradiotherapy(CRT). Nutritional disorders caused by dysphagia may lead to a poor prognosis. Placing a PEG before starting CRT for advanced esophageal cancer may maintain better nutritional status. PURPOSE: The purpose of this study is to evaluate the clinical significance of placing a PEG before starting CRT for advanced esophageal cancer. RESULTS: Fifty-one cases were evaluated, 22 PEG (+) and 29 PEG (-). The rate of a CRT was better in PEG (+) than PEG (-) cases (91% vs 79%). Infection around the PEG was the only type of complication, affecting 5%. CONCLUSION: PEG feeding during CRT is important in the development of effective treatments for unresectable advanced esophageal cancer.

[A case of synchronous sigmoid cancer and ureter cancer].

A 78-year-old-man visited a nearby doctor for treatment of hepatitis C and high blood pressure.He was diagnosed with right hydronephrosis by abdominal echography conducted in follow-up of hepatitis C treatment in November 2011; he was then introduced to our hospital for close inspection and medical treatment.We observed wall hyperplasia and narrowing of the lumen in the central sigmoid part by contrast-enhanced computed tomography (CT).The right ureter at the L4/5 level showed wall hyperplasia and a deep color, and the right ureter, renal pelvis, and calix were expanded on the head side. By examination for CF, we observed a type 2 lesion in the sigmoid colon, and a biopsy showed well-differentiated adenocarcinoma. Based upon these findings, he was diagnosed with synchronous sigmoid colon cancer (cT4aN0M0, cStage II) and ureter cancer (cT2N0M0, cStage II); we performed laparotomy sigmoidectomy(D3 dissection)and full extraction of the right kidney urinary tract (lymph node dissection in front of the vena cava, the latter outside and between the aorta and vena cava). The postoperative course was particularly uneventful, and the patient was discharged from the hospital on day 38 after the operation. More than 2 years after the surgery, the patient exhibits no sign of sigmoid colon cancer or ureter cancer recurrence.

Development of a dendritic cell-targeting lipopeptide as an immunoadjuvant that inhibits tumor growth without inducing local inflammation.

Materials used for the past 30 years as immunoadjuvants induce suboptimal antitumor immune responses and often cause undesirable local inflammation. Some bacterial lipopeptides that act as Toll-like receptor (TLR) 2 ligands activate immune cells as immunoadjuvants and induce antitumor effects. Here, we developed a new dendritic cell (DC)-targeting lipopeptide, h11c (P2C-ATPEDNGRSFS), which uses the CD11c-binding sequence of intracellular adhesion molecule-1 to selectively and efficiently activate DCs but not other immune cells. Although the h11c lipopeptide activated DCs similarly to an artificial lipopeptide, P2C-SKKKK (P2CSK4), via TLR2 in vitro, h11c induced more effective tumor inhibition than P2CSK4 at low doses in vivo with tumor antigens. Even without tumor antigens, h11c lipopeptide significantly inhibited tumor growth and induced tumor-specific cytotoxic T cells. P2CSK4 was retained subcutaneously at the vaccination site and induced severe local inflammation in in vivo experiments. In contrast, h11c was not retained at the vaccination site and was transported into the tumor within 24 hr. The recruitment of DCs into the tumor was induced by h11c more effectively, while P2CSK4 induced the accumulation of neutrophils leading to severe inflammation at the vaccination site. Because CD11b+ cells, but not CD11c+ cells, produced neutrophil chemotactic factors such as macrophage inflammatory protein (MIP)-2 in response to stimulation with TLR2 ligands, the DC-targeting lipopeptide h11c induced less MIP-2 production by splenocytes than P2CSK4. In this study, we succeeded in developing a novel immunoadjuvant, h11c, which effectively induces antitumor activity without adverse effects such as local inflammation via the selective activation of DCs.

[Sternomyelitis caused by delayed tracheal necrosis after thyroidectomy;treatment using muscle flap of petoralis major].

We experienced a rare case of delayed tracheal rupture after thyroidectomy for papillary thyroid cancer, and the infection causing sternomyelitis. A 69-year-old man presented subcutaneous emphysema after 6 days of total thyroidectomy with bilateral cervical and mediastinal dissection for lymph node metastases by adverse T sternotomy. He underwent tracheostomy on 10th postoperative day (POD), debridement of sternum on 14th POD, and implantation of skin-muscle flap using pectolaris major on 43th POD. The flap showed good adaptation and no infectious complications recurred, so that he could consequently receive closing procedure of tracheostomy on 94th POD.

[Occurrence of squamous cell lung carcinoma in the irradiated field after radiotherapy for breast cancer].

Radiotherapy for breast cancer reduces the incidence of disease recurrence and breast cancer mortality.However, it has also been associated with an increased risk of developing secondary cancers in exposed sites.Recently, we observed a 64-year-old woman who developed squamous cell lung carcinoma in the field irradiated with a total dose of 55 Gy after conservative breast surgery for left breast cancer 16 years previously.The patient underwent left upper lobectomy combined with chest wall resection.She had no recurrence of the breast cancer for 16 years.The secondary lung cancer tumor was of a different histological type than the primary breast cancer, and it appeared in the irradiated field.In conclusion, we regarded her lung cancer as a radiation-induced cancer, although it is difficult to clearly define radiation-induced cancer.In addition, the patient 's lung cancer may not only be a result of the late effect of irradiation, but might also be due to her smoking habit.

[A long-term survivor of a rectal carcinoid treated by use of repeat TACE for multiple intrahepatic recurrences after liver resection and MCT].

A woman between 50 and 60 years of age was diagnosed with a rectal carcinoid tumor and synchronal multiple liver metastases. We performed a transanal local resection of the rectal tumor, which was 10mm in diameter. During surgery, ultrasonography revealed 8 hypoechoic masses in the liver, and we performed a partial hepatectomy (S5/6, S8) and administered microwave coagulation therapy. Thirty-seven months after surgery, abdominal computed tomography revealed multiple low-density tumors in the bilateral lobe of the liver. We diagnosed these tumors as a recurrence of the liver metastases of the rectal carcinoid and performed trans-arterial chemo-embolization (TACE). After repeated TACE treatments, the liver metastases were controlled favorably. The patient is alive more than 50 months after diagnosis of the recurrent liver metastases. TACE appears to be effective for treating non-resectable multiple liver metastases of rectal carcinoids.

Disseminated Penicillin-Resistant Streptococcus pneumoniae Infection: A Case Report.

An invasive pneumococcal disease involving sternoclavicular joint arthritis, lumbar spondylodiscitis, and muscular abscesses caused by penicillin-resistant Streptococcus pneumoniae has not been reported previously. We successfully treated a 57-year-old man with this condition using surgical drainage and debridement, and laminectomy/fenestration, in combination with the administration of two IV antimicrobial drugs based on blood culture results. Clinical resolution was obtained after decompression of the lumbar spine, with minimal restriction of the left lower limb. This treatment approach should be considered depending on the pathogen, underlying host factors, and the severity of the disease.

Malignant involvement of the iliopsoas muscle associated with non-small cell lung cancer: Two case reports.

Under the current progression of molecular targeting or immune therapy, early detection and radiation therapy of iliopsoas metastasis will not only improve performance status but also enable the continuation of effective systemic cancer treatment.

Cytoreductive surgery and post-operative heated pleural chemotherapy for the management of pleural surface malignancy.

PURPOSE: We retrospectively analysed the long-term outcomes of cytoreductive surgery and post-operative heated pleural chemotherapy (HPC) for thoracic malignancies with pleural spread. MATERIALS AND METHODS: Between 1987 and 2010, 160 patients were enrolled. There were 101 patients with non-small cell lung cancer (NSCLC), 25 with malignant pleural mesothelioma (MPM), 12 with thymoma, and 22 with tumours metastatic to the lung and pleura. Immediately after intra-thoracic administration of cisplatin or carboplatin, hyperthermia was performed by using an 8.00 MHz radiofrequency capacitive heating device for 1 to 4 courses in each patient. RESULTS: There was no systemic toxicity or treatment-related mortality. Five-year overall survival rates were 37.4% in NSCLC, 15.9% in MPM, 91.7% in thymoma, and 25.8% in metastatic lung tumour. Five-year local relapse-free survival (RFS) rates were 55.2% in NSCLC, 24.4% in MPM, 64.8% in thymoma, and 27.2% in tumours metastatic to the lung and pleura. When 101 NSCLCs were categorised into pleural lavage cytology positive (grade 1: n = 37), limited extent of carcinomatous pleuritis (grade 2: n = 21), and extensive carcinomatous pleuritis (grade 3: n = 43), 5-year overall survival rates were 62.5%, 49.2%, and 13.6%, respectively. The local RFS was significantly better in group 1/2 than in group 3. CONCLUSIONS: Although our study has some of the usual weaknesses of a single institution retrospective study, cytoreductive surgery and HPC are feasible and safe. It is suggested that HPC may have a potential role for local control as adjuvant treatment for cytoreductive surgery in patients with minor pleural spread.

[Jejunostomy catheter feeding during postoperative chemotherapy for Stage IV gastric cancer].

Chemotherapy followed by surgery for Stage IV gastric cancer with passage obstruction poses a problem in terms of poor postoperative nutritional status. By maintaining an adequate postoperative nutrition status with jejunostomy catheter feeding, chemotherapy may possibly be continued. We treated 40 cases of Stage IV gastric cancer with passage obstruction from January 2008 to December 2011. In every case, jejunostomy catheter feeding tubes were placed during gastric cancer surgery. We performed 13 total gastrectomies, 20 distal gastrectomies, and 7 gastrojejunal bypass surgeries. Tube obstruction in 4 cases( 10%) and tube deviation in 1 case( 2.5%) occurred during the tube feeding period. Chemotherapy could be resumed in 37 cases( 92.5%), and the duration of chemotherapy was 330 days( range, 41-721). In cases of Stage IV gastric cancer, patients are obliged to start postoperative chemotherapy at an unstable period. By starting jejunal catheter feeding at an early stage after surgery, improved results could be expected in terms of shortening of the hospital stay or continuation of chemotherapy.

[A case of primary undifferentiated carcinoma of the duodenum].

We report a case of undifferentiated carcinoma of the duodenum. A 40-year-old man was referred to our hospital as he experienced upper abdominal pain that had persisted for half a year. Gastrointestinal endoscopy revealed a semicircular tumor in the duodenum. Enhanced computed tomography( CT) revealed that the tumor had not invaded the adjacent tissues, and lymph node metastases were not detected. Biopsy indicated a diagnosis of Group V cancer. Because the tumor was diagnosed as primary duodenal cancer, pancreatoduodenectomy and lymphadenectomy were performed. Histopathological examination revealed the presence of variant cells with irregular cores; we then diagnosed the tumor as undifferentiated cancer of the duodenum. No lymph node metastasis was detected microscopically. This patient has remained well without recurrence for 17 months since the operation. Undifferentiated carcinoma of the duodenum is rare, as only 9 cases have been reported in the Japanese literature.