[Staging Laparoscopy in the Treatment of Advanced Gastric Cancer].

OBJECTIVE: We examined the applicability and safety of staging laparoscopy(SL)in the treatment of advanced gastric cancer. METHODS: We retrospectively reviewed the gastric cancer cases that were examined using SL between January 2015 and December 2019 at our hospital. RESULTS: Within this period, 59 gastric cancer patients underwent SL, of whom 53 were diagnosed with SL at first examination. The rare complications of SL were postoperative nausea and vomiting(1 case). In 47.5%(28/59)of patients, we observed peritoneal dissemination including positive lavage cytology. In 2 cases, peritoneal dissemination was found during curative resection despite not being detected by SL. Thus, the false negative rate of peritoneal dissemination discovery was 6.7%(2/30). Among the individuals who were diagnosed as P1 or CY1 at first, subsequent SLs were performed in 6 cases, and 5 patients were re-assigned as P0CY0, of whom 4 underwent conversion surgery. CONCLUSIONS: SL is an essential and safe examination method for defining the treatment strategy in advanced gastric cancer. However, further improvements are needed to reduce the false negative discovery rate and to advance gastric cancer treatment by increasing reliability of diagnosis.

Frailty is a useful predictive marker of postoperative complications after pancreaticoduodenectomy.

BACKGROUND: Frailty results in a high risk for disability, hospitalization, and mortality. This study aimed to investigate perioperative details of frail patients who underwent pancreatectomy and whether frailty can be a predictive factor of postoperative complications, especially of clinically relevant postoperative pancreatic fistula (CR-POPF). METHODS: This retrospective study included patients who underwent pancreatectomy in our hospital between August 2016 and March 2019. The patients were divided into frail and pre-/non-frail groups. The diagnostic criteria were based on the Japanese version of the Cardiovascular Health Study. RESULTS: Of 93 patients, 11 (11.8%) and 82 (88.2%) were frail and pre-/non-frail patients, with median ages of 82 and 72 years, respectively (p = 0.041). Postoperative complications (Clavien-Dindo ≧ IIIa) were found in 8 and 32 patients (p = 0.034), CR-POPF in 3 and 13 patients (p = 0.346), and postoperative hospital stays were 21 and 17 days (p = 0.041), respectively. On multivariate analysis, frailty was an independent predictive factor (odds ratio [OR] 5.604, 95.0% confidence interval [CI] 1.002-30.734; p = 0.047) of postoperative complications (Clavien-Dindo ≧ IIIa) after pancreaticoduodenectomy. On multivariate analysis, a soft pancreas (OR 5.696, 95.0% CI 1.142-28.149; p = 0.034) was an independent and significant predictive factor of CR-POPF after pancreaticoduodenectomy. CONCLUSIONS: Frailty may be a useful predictive factor of postoperative complications in patients undergoing pancreaticoduodenectomy.

[A Case of DIC Following Mixed Acidosis during Laparoscopic Hepatectomy].

The patient was an 81-year-old man. Laparoscopic sigmoidectomy was performed for a sigmoid colon cancer(S, type 2, pT3[SS], INF a, Ly0, V0, BD1, Pn0, pPM0, pDM0, RM0, pN0, pM0, pStage Ⅲa, R0, Cur A). One year after the surgery, a blood test showed CEA as high as 68.9 ng/mL, and an abdominal enhanced computed tomography revealed a hepatic tumor showing marginal contrast in the 4th liver segment. Positron emission tomography showed an accumulation of SUVmax 19.0 at the same site, and a metastatic liver tumor was diagnosed. A laparoscopic medial hepatectomy was performed. Bleeding from the hepatectomy site increased significantly after completion. Subcutaneous emphysema spreading from the face to the trunk and thigh was observed, and blood tests revealed a pH of 7.172, PaCO2 of 71.0 mmHg, lactate of 67 mg/dL, mixed acidosis, D-dimer of 118 µg/mL, and a disseminated intravascular coagulation(DIC)syndrome was diagnosed. Following the difficulty of hemostasis, the surgery was changed to laparotomy and terminated by gauze packing. We encountered a case of acidosis exacerbated by hypercapnia that progressed to DIC during laparoscopic medial hepatectomy.

The impact of epidural catheter insertion level on pain control after esophagectomy for esophageal cancer.

BACKGROUND: Although the effectiveness of epidural anesthesia on pain control after esophagectomy has been reported, the appropriate insertion level of the epidural catheter remains unclear for adequate postoperative pain control. We investigated the relationship between the epidural catheter insertion level and postoperative pain control after esophagectomy for esophageal cancer. METHODS: We analyzed retrospectively 63 patients who underwent McKeown esophagectomy for esophageal cancer between October 2014 and November 2018. The epidural catheter was inserted at the T4-T10 level before general anesthesia induction, and epidural anesthesia was started during the operation. In the analysis, the epidural catheter insertion level was divided into three groups (over T6/T7, T7/T8, and under T8/T9) and determined. Postoperative pain was evaluated a numeric rating scale (NRS) for at least 7 postoperative days, and the first NRS after extubation was used to evaluate the impact of the epidural catheter insertion level on pain control. RESULTS: Ten patients (15.9%) failed pain control. The χ2 test and a forward stepwise logistic regression analysis revealed that only the epidural catheter insertion level affected pain control (P < 0.05). The T7/T8 insertion level significantly decreased postoperative pain after esophagectomy. In the subgroup analysis, epidural catheter insertion under T8/T9 significantly increased postoperative pain after esophagectomy when thoracoscopy/laparoscopy was assisted. No significant differences were observed in the incidence of postoperative complications among the epidural catheter insertion levels. CONCLUSIONS: The T7/T8 epidural catheter insertion level contributed to postoperative pain relief and could lead to enhanced recovery after esophagectomy for esophageal cancer.

[A Case of Giant Hematogenous Left Quadricep Muscle Metastasis of Hepatocellular Carcinoma].

The patient was a 62-year-old man with no specific medical history. Lateral segmentectomy was performed for hepatocellular carcinoma with a tumor size of approximately 14×13 cm. The histopathological diagnosis was moderately differentiated hepatocellular carcinoma: Fc(-), Fc-Inf(-), Sf(-), S0, N0, Vp2, Vv1, Va0, B0, P0, SM(-), CH. Five years after the first surgery, computed tomography(CT)revealed a left lung tumor in segment 9/10 and left lymph nodes; thus, left pneumonectomy was performed, and these tumors were identified to have metastasized from the primary tumor. Six years after the first surgery, his serum alpha-fetoprotein level was remarkably elevated from 254.9 ng/mL to 3,143.0 ng/mL for three months, and at the same time, he developed left meralgia and swelling of the left femur. Magnetic resonance imaging showed a high-density mass(30×14 cm)in the left quadriceps, and positron emission tomography-CT revealed high uptake in the left quadriceps with a maximum standardized uptake value of 12.3. A needle biopsy of the left femur tumor confirmed metastasis from the primary tumor. Radiotherapy was administered because general anesthesia can prove to be hazardous due to the patient having undergone left pneumonectomy.

[Local Control of Advanced Breast Cancer with Mohs Paste and Systemic Therapy].

Unresectable locally advanced breast cancer results in a decline in patient quality of life because of the presence of bleeding, exudates, and strong odor. The clinical application of supportive care using Mohs paste for improving quality of life has become widespread. We report 2 cases of locally advanced breast cancer treated with systemic therapy and chemosurgery. Case 1 was a Japanese woman in her fifties who had a locally advanced left breast cancer. She had continuous bleeding and exudates, and received Mohs chemosurgery and endocrine therapy. One month later, the surface healed and dried up. The bleeding, exudates, and strong odor disappeared almost completely. Case 2 was a Japanese woman in her forties who had a locally advanced left breast cancer with massive exudates and oozing blood. She underwent Mohs chemosurgery 20 times, but the exudates and bleeding were not controlled. According to pathological findings, we confirmed her breast cancer to be of the triple negative subtype. After 2 courses of therapy with 5-fluorouracil, epirubicin, and cyclophosphamide, the tumor immediately decreased in diameter by 65%. The bleeding, exudates, and strong odor disappeared. Although Mohs chemosurgery is useful for local control of locally advanced breast cancer, this alone is insufficient to treat the disease. Early introduction of systemic therapy is considered essential in breast cancer treatment.

[Stereotactic Body Radiotherapy with CyberKnife®for Liver Metastases from Colorectal Cancer].

For treatment of colorectal liver metastases, liver resection is recommended for resectable cases in the clinical guidelines for colorectal cancer. On the other hand, there are currently no data supporting the efficacy of radiation therapy as a topical treatment, and this treatment can therefore not presently be recommended. With CyberKnife®, it is possible to perform stereotactic radiation therapy using a linear accelerator with high accuracy, even for lesions in the trunk area such as liver metastases. Between December 2009 and September 2014 in our hospital, we performed radiation treatment using CyberKnife® for 14 cases with 22 colorectal liver metastases. As a result, we obtained response and local control rates of 76.2%and 81.0%, respectively. Moreover, no advanced adverse events were observed. Thus, we consider that CyberKnife® treatment for colorectal liver metastases is effective as a topical treatment, with low invasiveness and high safety.

[Nanoparticle albumin-bound Paclitaxel for unresectable or recurrent gastric cancer].

The efficacy and safety of nanoparticle albumin-bound paclitaxel(nab-paclitaxel)administered every 3 weeks for unresectable or recurrent gastric cancer was evaluated retrospectively. Nab-paclitaxel was intravenously administered at 260 mg/ m² on day 1 of each 21-day course without anti-allergic premedication until disease progression or discontinuation. Nine patients received nab-paclitaxel. The overall response rate was 11.1%, and the disease control rate was 55.6%. Grade 3/4 toxicities included neutropenia(44.4%), leukopenia(33.3%), and peripheral sensory neuropathy (33.3%). It is important to manage both neutropenia and peripheral neuropathy. Although only few cases were analyzed, therapeutic effect can be obtained even with the starting dose of 180 mg/m² suggesting management of toxicities will be feasible. In view of the toxicities observed, a reduced starting dose of 180 mg/m² should be considered in the case of poor performance status patients. Nab-paclitaxel is a promising drug because of its convenience and may replace weekly paclitaxel for unresectable or recurrent gastric cancer.

[A case of gastric cancer showing response to first-line XP regimen after lymph node recurrence during the administration of S-1 as postoperative adjuvant chemotherapy].

We report on a patient who underwent total gastrectomy with D2 lymph node dissection for metastatic gastric cancer. We administered S-1 at 60 mg/m² as postoperative adjuvant chemotherapy. Six months after surgery, recurrence was detected in the para-aortic lymph node. As a first-line treatment for the recurrent cancer, the patient underwent capecitabine/CDDP therapy(capecitabine 1,800 mg/m², CDDP 60 mg/m²). A significant reduction in the recurrent lymph nodes was observed by CT after 6 months of administration, resulting in 24 months of progression-free survival. S-1/CDDP therapy is recommended as a first-line chemotherapy for recurrent gastric carcinoma in the Japanese gastric cancer treatment guidelines. Likewise, single agent S-1 administration is recommended as postoperative adjuvant chemotherapy for advanced gastric cancer patients. However, in cases of recurrence after S-1 therapy, there is insufficient evidence on the efficacy of S-1/CDDP; thus, the type of administration and time to recurrence could be considered for optimization. We identified a case of gastric cancer showing response to first-line capecitabine/CDDP therapy after lymph node recurrence following the administration of S-1 as postoperative adjuvant chemotherapy. Since capecitabine and S-1 differ in their mechanisms of action and as predictive factors for therapeutic effect, capecitabine may be an efficient option in cases of S-1 failure. The present case suggests that capecitabine/CDDP therapy may be an effective treatment for S-1 pretreated patients with advanced or metastatic gastric cancer.

[A case of metachronous ovarian metastasis after curative surgery of colon cancer with simultaneous hepatic metastasis].

The patient was a 51-year-old woman who presented with nausea, vomiting, and abdominal pain. Detailed examination revealed a carcinoma of the descending colon with simultaneous hepatic metastasis. Because the carcinoma comprised a circumferential stenotic lesion and resection of the hepatic metastasis was feasible, combined left hemicolectomy and hepatectomy were initially performed. During postoperative adjuvant chemotherapy, the hepatic metastasis was observed to increase in size, and therefore, a second hepatectomy was performed approximately 2 years and 6 months after the initial surgery. Adjuvant chemotherapy was subsequently continued for approximately 1 year. A metastatic ovarian tumor was identified on abdominal computed tomography (CT) approximately 1 year after chemotherapy was discontinued. Bilateral salpingo-oophorectomy was performed approximately 3 years and 6 months after the initial surgery. Histopathological examination revealed the lesion to be a colon carcinoma metastasis.

[A case of liver metastasis from esophageal cancer treated with stereotactic body radiation therapy].

A 70-year-old woman was diagnosed as having advanced lower thoracic esophageal cancer with abdominal lymph node metastases(T3N1M0, Stage III). After administering 2 courses of neoadjuvant chemotherapy with 5-fluorouracil(5- FU)( 800 mg/m2)and cisplatin(80 mg/m2), we performed curative surgery with D2 lymph node dissection. The patient could not receive adjuvant chemotherapy because of her poor performance status. After curative surgery, liver metastasis appeared in segment 8. The liver metastasis(S8)was treated with stereotactic body radiation therapy(SBRT)( 60 Gy/3 Fr). After SBRT, we administered systemic chemotherapy with docetaxel and nedaplatin as second-line chemotherapy. The patient had no recurrence for 12 months after SBRT. SBRT exhibited an excellent local therapeutic effect without any serious complications, suggesting that it is an effective treatment for liver metastasis from esophageal cancer.

Two cases of trastuzumab deruxtecan-induced interstitial lung disease in advanced breast cancer.

Trastuzumab deruxtecan (T-DXd) frequently induces interstitial lung disease (ILD) more than other anti-human epidermal growth factor receptor 2 therapies. We diagnosed two cases of ILD induced by T-DXd in patients with advanced breast cancer. The first case is that of a 57-year-old Japanese woman who complained of dyspnoea and fever after 4 cycles of T-DXd. Chest computed tomography (CT) showed diffuse consolidation and a reticular shadow. The second case was that of a 72-year-old Japanese woman who complained of dyspnoea after 3 cycles of T-DXd. Chest CT showed a reticular shadow predominantly in the left lung. Both patients were treated with corticosteroids, including pulse methylprednisolone; however, their general condition weakened due to ILD, long-term corticosteroid therapy and breast cancer progression. Subsequently, the patients were unable to continue chemotherapy for breast cancer. To the best of our knowledge, this is the first report in a real-world clinical setting.

Laparoscopic total gastrectomy for remnant gastric cancer: A single-institution experience.

INTRODUCTION: The incidence of remnant gastric cancer is increasing because of past use of subtotal gastrectomy to treat peptic ulcer and increased survival rates after radical gastrectomy for gastric cancer. The feasibility and advantages of laparoscopic total gastrectomy (LTG) for remnant gastric cancer remain unclear. Therefore, we aimed to investigate the safety, feasibility, and clinical short-term outcomes of LTG for remnant gastric cancer. METHODS: Patients who underwent completion total gastrectomy for remnant gastric cancer between April 2007 and October 2017 were divided into two groups: the open total gastrectomy (OTG) group and the LTG group. Clinicopathological data and short-term outcomes were analyzed. RESULTS: A total of 31 remnant gastrectomies (23 OTG, 8 LTG) were performed. Blood loss was significantly lower in the LTG group than in the OTG group (135.5 vs 568.3 mL, P = 0.013). However, there was no significant difference in the operation time, days to food intake, or length of hospital stay between the two groups. Additionally, there was no significant difference in the postoperative complications, number of retrieved lymph nodes, or pathological findings. Two LTG patients (25.0%) required conversion to open surgery. There was no mortality in either group. CONCLUSIONS: LTG for remnant gastric cancer can be a safe treatment option and may have an advantage of less blood loss than OTG.

Life-threatening giant esophageal neurofibroma with severe tracheal stenosis: a case report.

BACKGROUND: Benign esophageal tumors are relatively rare, and a neurofibroma in the esophagus is extremely rare. Dysphagia is the most common clinical manifestation in patients with esophageal neurofibroma, and no cases of giant esophageal neurofibroma with severe tracheal stenosis have been reported. CASE PRESENTATION: A 73-year-old woman presented with shortness of breath, and computed tomography scan exhibited a giant mediastinal tumor causing severe tracheal stenosis. An upper gastrointestinal endoscopy revealed a giant submucosal lesion without mucosal changes located 18-23 cm from the incisor teeth. 18F-fluorodeoxyglucose (FDG)-positron emission tomography image revealed an upper mediastinal homogeneous mass and left supraclavicular lymph node with increased FDG accumulation. We performed endoscopic ultrasound-guided fine-needle aspiration biopsy; however, a definitive diagnosis could not be determined. During further investigation, her shortness of breath suddenly worsened and she suffered from wheezing. Because of risk of smothering, we decided to perform quasi-urgent lifesaving surgery. Under the preparation of extracorporeal membrane oxygenation (ECMO) when tracheal intubation fails, bronchial blocker was inserted over the tracheal stenosis and the left-lung ventilation was performed via intubation alone. Under general anesthesia, the patient was placed in the left lateral position and we performed right thoracotomy. The tumor strongly adhered to the trachea; however, the trachea or recurrent laryngeal nerves were not damaged in the surgery. Following esophagectomy, we performed gastric conduit reconstruction through the posterior mediastinum, and hand-sewn anastomosis was performed in the left neck. Immunohistochemical staining was positive for S-100 but negative for c-KIT, CD34, α-SMA, and desmin; these morphological and immunohistochemical characteristics were consistent with the diagnosis of neurofibroma. CONCLUSIONS: It is often difficult to diagnose esophageal neurofibroma preoperatively. The preparation of ECMO could be considered in patients with severe airway obstruction for safe tracheal intubation. This is the first case of life-threatening giant esophageal neurofibroma with severe tracheal stenosis.

Bouveret's syndrome with a concomitant incidental T1 gallbladder cancer.

Bouveret's syndrome, which is a gastric outlet obstruction caused by a gallstone in the duodenum, is a rare complication of gallstone disease. We report a case of Bouveret's syndrome in an 81-year-old woman who also exhibited incidental gallbladder cancer. She was admitted to our hospital complaining of upper abdominal pain and vomiting. A computed tomography examination showed a cholecystoduodenal fistula, a large impacted stone at the gastric outlet, and a dilated stomach. She was diagnosed as having Bouveret's syndrome. The patient underwent an upper gastrointestinal endoscopy and a mechanical lithotripsy was successfully performed for the stone. She then underwent a cholecystectomy with primary closure of the duodenal fistula. An intra-operative histopathology examination revealed severe cholecystitis with an adenocarcinoma in part of the gallbladder. Gallbladder bed resection and regional lymph node dissection were also performed. To the best of our knowledge, this is the first published report of a case in which Bouveret's syndrome and gallbladder cancer co-existed.