[Surgical Outcomes of the Patients with Gastric Cancer in Aged 85 and Older at Our Hospital].

We investigated the surgical outcomes of the patients with gastric cancer in aged 85 and older. There were 9 males and 8 females, with a median age of 86 years. All had comorbidities and 7 had double cancers. Type of surgery was distal gastrectomy in 14 and total gastrectomy in 3, respectively. Postoperative complications occurred in 8 cases, and case with adhesion ileus or mesenteric bleeding performed reoperation. The postoperative hospital stay was 15 days. The cause of death was recurrent diseases in 2 cases and other diseases in 4. The overall survival rate was 63.9% for 3 years and 42.6% for 5 years, respectively. Elderly patients with gastric cancer may be increase in Japan, but they have large individual differences about tolerance of surgical intervention. Therefore, it is important to evaluate the detail of general condition in such patients.

[A Case Report of an Appendiceal Goblet Cell Carcinoid].

A 56-year-old woman complaining of right lower abdominal pain was admitted to our hospital. An abdominal computed tomography showed the enlarged appendix tip and a high density area around the appendix to retroperitoneum. The patient was diagnosis with acute appendicitis and underwent emergency laparoscopic appendectomy. Histopathological findings of the resected specimens revealed a component with signet ring cell carcinoma morphology that was positive for neuroendocrine markers by immunohistochemical staining, which led to the diagnosis of goblet cell carcinoid(GCC)of appendix. GCC cells were found to infiltrate the surrounding serosa and Ly positive. An additional laparoscopic ileocecal resection with D3 dissection was performed. In the appendix GCC, additional resection is considered because the lymph node metastasis rate increases(SS/13%)as the depth of wall progresses. Appendiceal tumors including GCC may develop acute appendicitis and may be followed by additional resection. Therefore, it is important to consider how to deal with the first surgery.

[A Case of Multiple Small Bowel GIST Complicated with von Recklinghausen's Disease].

The case was a 55-year-old woman. She have been pointed out von Recklinghausen's disease for several years. She was referred to our hospital due to multiple abdominal tumor and severe anemia. Enhanced CT examination revealed multiple intraabdominal tumors with central necrosis. The tumors diagnosed mesenchymal tumors associated with von Recklinghausen's disease, and tumor resection was indicated under laparotomy. Tumors were resected together with small and large bowel. The tumor in the pelvic space was resected together with the uterus and right ureter. She was discharged without any postoperative complications at 15 days after the operation. Because immunostaining was positive for CD34, c-kit and DOG1 and Ki-67-positive cells were 18%, the tumors were diagnosed with high-risk GIST for small bowel.

[Clinical Outcomes of Recurrent Diseases after Esophagectomy According to Time of Recurrence].

We analyzed retrospectively the difference in treatment selection and prognosis according to timing of recurrence after radical resection of esophageal cancer. Of 190 patients who underwent radical esophagectomy for esophageal cancer from April 2010 to December 2017, 56 patients(29.5%)had recurrent diseases during the postoperative periods. These cases were divided into 27 cases with recurrence diagnosed less than 180 days after initial surgery(Group A)and 29 cases with recurrence diagnosed more than 180 days(Group B). Although there was no difference in the pathological staging, preoperative treatment, and type of recurrence between the 2 groups, there were significantly more cases with symptomatic recurrence in Group A. Surgical intervention was possible in 1 case in Group A and 10 cases in Group B, respectively. There was significantly more in Group B. Second-line treatment was possible in only 5 cases in Group B. Survival after recurrence was tend to have better in Group B. There are few cases who indicated surgical intervention and second-line treatment in early recurrence cases after radical esophagectomy for esophageal cancer, and the prognosis is poor in such cases.

Clinical silence of pulmonary lymphoepithelioma-like carcinoma with subcutaneous metastasis: a case report.

BACKGROUND: Dissemination of lung cancer to cutaneous sites usually results in a poor prognosis. Pulmonary lymphoepithelioma-like carcinoma (PLELC) is a rare tumor, and no therapeutic strategy for it has yet been established. We present herein an extremely rare case of a long-term surviving patient with PLELC showing subcutaneous metastasis. CASE PRESENTATION: A 76-year-old woman was diagnosed unexpectedly as having PLELC based on a nodule on her back. After surgical resection of the primary and metastatic lesions, she has remained alive with no recurrence for over 5 years without any additional therapy. CONCLUSION: Even in the case of PLELC with subcutaneous metastasis, surgical management may afford a prognosis of long-term survival.

[Azygos Arch Preserving Thoracoscopic Esophagectomy for Less Invasiveness].

We reported the technique ofthoracoscopic esophagectomy with preservation ofazygos arch for less invasivenesss. Among thoracoscopic esophagectomy, this retchnique indicated for the patients with the tumor located at middle or lower thoracic and don't reach adventitia. Twenty-eight patients was performed this procedure and azygos arch were preserved in all cases. None the cases were converted conventional thoracotomy. The operation time was 133.5 minutes(median), and estimated blood loss was 30 mL(median)in thoracic procedure. As for thoracoscopic esophagectomy, could preserved respiratory function, further less surgical stress can obtain this technique.

[Treatment Outcomes and Prognosis of Patients with Recurrent Diseases after Esophagectomy for Esophageal Cancer].

We retrospectively analyzed the treatment outcomes of 52 patients with recurrent diseases after radical esophagectomy for esophagealcancer. Median time of diagnosis of recurrent diseases was 180 days after surgery, and 90.4%of allpatients were diagnosed with recurrent diseases within 2 years. Twenty-seven patients were diagnosed with single area recurrence, and the remaining 25 were diagnosed with complex recurrence. Among patients with single area recurrence, surgical intervention was indicated in 9, and chemoradiotherapy(CRT)was indicated in 14. Meanwhile, among patients with complex recurrence, surgicaltreatment was indicated in only 2 patients. Median survivaltime was 293 days in allpatients, 611 days in single area recurrence, and 148 days in complex recurrence. Among patients with single area recurrence, those treated with surgical intervention or CRT had significantly better survival than those who underwent other treatment modalities. Although the prognosis of the patients with recurrent diseases after esophagectomy was poor, the patients with single area recurrence or treated with local therapy were expected to survive longer than patients with complex recurrence or those treated with other modalities.

[Three-day-type transdermal fentanyl patch conversion by rapid titration method with short-acting oral oxycodone for cancer pain].

This study compared the efficacy and safety of a 3-day-type transdermal fentanyl patch conversion by the rapid titration method to short-acting oral oxycodone for cancer pain.We evaluated seven hospitalized cancer patients who had moderate to severe cancer pain.Pain intensity was rated using an 11-point(0-10)numerical rating scale(NRS).All 7 patients initially reported their pain intensity at rest as NRS≥4 during treatment by Non-Steroidal Anti-Inflammatory Drugs(NSAIDs).Short - acting oral oxycodone(OxiNorm®)5 mg was administered to all patients.One hour after short-acting oral oxycodone was administered, pain assessment was carried out using NRS by the author.Short -acting oral oxycodone was administered four times a day periodically, and as a rescue dose.If the total daily dose of short-acting oral oxycodone was stable for 2 days, we switched to the 3-day-type transdermal fentanyl patch.The optimal dosage of the 3-day-type transdermal fentanyl patch was determined by titration of short-acting oral oxycodone.All 7 patients reported mild levels(NRS≤2)of cancer pain for 2 days.No serious side effects were reported.The 3-day-type transdermal fentanyl patch conversion by the rapid titration method with short-acting oral oxycodone can be accomplished safely and effectively for patients with moderate cancer pain.

[A case of advanced rectal cancer responding to l-Leucovorin (LV)/5-fluorouracil( 5-FU) therapy as neoadjuvant chemotherapy].

We report a case in which l-Leucovorin/5-fluorouracil (l-LV/5-FU) therapy was remarkably effective for advanced rectal cancer as neoadjuvant chemotherapy (NAC). A 54-year-old man complained of bloody stool and constipation,and was diagnosed as having stage IIIB advanced rectal cancer with N2 lymphnode metastases on July 31, 2003. Two cycles of NAC by l-LV/5-FU therapy were performed. On abdominal computed tomography (micro CT), the primary lesion in the rectum decreased 82% and the metastatic lymphnodes had disappeared. As we established a diagnosis of the downstaging for stage II, a lower anterior resection with D3 lymphnode dissection was performed on December 5, 2003. The pathological examination demonstrated II, mod, 1.8 x 2.2 cm, a1, ly1,v0, ow(-), aw(-), n0, stage II. We could allow curability-A resection. The pathological effect of chemotherapy was grade 2 in which cancer cells became necrotic, suggesting apoptosis. The postoperative course was good. Postoperatively, 3 cycles of l-LV/5-FU therapy were performed. Although the patient had to be followed with internal use of 5-FU 200 mg/day as an outpatient from June 2, 2004, to date, there has been no sign of recurrence during the 12-month follow-up after the operation. Moreover, no adverse by chemotherapy was seen during the treatment. Thus, NAC by this therapy may be useful for patients with advanced rectal cancer.

Sarcoid reaction in the spleen after sigmoid colon cancer resection: a case report.

BACKGROUND: A sarcoid reaction is a phenomenon characterized by histologically proven granulomatous lesions without evidence of sarcoidosis. This pathology is a benign tumor itself, but several reports have described sarcoid reactions accompanying malignant tumors. Sarcoid reactions occur in various cancers, such as skin, lung, ovary, stomach, and breast cancers. However, only a few published reports have described sarcoid reactions in patients with colorectal cancer. CASE PRESENTATION: A 76-year-old woman underwent laparoscopic sigmoidectomy for sigmoid colon cancer. The postoperative follow-up computed tomography and 18-fluorodeoxyglucose positron emission tomography-computed tomography findings were suspicious for splenic metastasis of the sigmoid colon cancer. The patient then underwent laparoscopic splenectomy. Histopathological examination of the resected lymph nodes and spleen showed a non-caseating epithelioid cell granuloma. The patient was diagnosed with a sarcoid reaction. CONCLUSIONS: To our knowledge, this is the first report of a sarcoid reaction in the spleen and regional lymph nodes after colon cancer resection. The effect of a sarcoid reaction on the prognosis in patients with colorectal cancer has not been fully determined because of the small number of such cases. Further analyses involving a larger number of cases are necessary to evaluate the relationship between sarcoid reactions and prognosis in patients with colorectal cancer. We herein present an extremely rare case of a sarcoid reaction in the spleen and regional lymph nodes.

[A case of advanced gastric cancer with direct invasion of the transverse colon responding to paclitaxel/5'-DFUR combined therapy].

A 50-year-old man was diagnosed with non-resectable scirrhous gastric cancer of antrum accompanied with colon ileus due to direct invasion of the transverse colon. As the ileus improved after cecostomy, chemotherapy with TS-1/cisplatin(CDDP) was performed. Because of no response, 4 cycles of paclitaxel (PTX)/doxifluridine (5'-DFUR) therapy was performed as second-line chemotherapy. Since the stenosis of transverse colon dilated completely and the tumor disappeared, we performed total gastrectomy and right hemicolectomy, and could resect completely. Though 2 cycles of PTX/5'-DFUR therapy was performed postoperatively and the patient's postoperative condition was good, he was suffering from carcinomatous peritonitis complicated by ileus and obstructive jaundice 4 months after operation. He died 1 year after the first medical examination, but his QOL was fairly good for 10 months. PTX/5'-DFUR therapy, which has only slight complications, may be useful for patients with recurrent gastric cancer who had been treated with 5-FU administration as first-line chemotherapy. But the future problem was how to control dissemination after surgery in a resectable case after chemotherapy.

[A case of cecal cancer with multiple liver metastases responding to irinotecan (CPT-11)/cisplatin (CDDP) combination therapy for elevation of CA19-9 after complete response (CR) by l-leucovorin(LV)/5-fluorouracil(5-FU) therapy].

A 62-year-old woman complained of abdominal pain and diarrhea from February 2, 2002. She was diagnosed with advanced cecal cancer with simultaneous multiple liver metastases. The serum level of CA 19-9 was 420 U/ ml. Ileoceal resection with D3 lymphnode dissection. The replacement of reservoir for hepatic arterial infusion (HAI) was performed on February 2, 2002. As the dissemination was seen near the mesocolon at laparotomy, we could resect all together. Pathological examination demonstrated II, 5.0 x 2.5 cm, mod, se, INFgamma, ly(1), v(1), n(2), stage IV. Systemic l-leucovorin/5-fluorouracil (l-LV/5-FU) + HAI of weekly high-dose 5-FU combination therapy was initiated at postoperative 14 days. The serum CA 19-9 level decreased immediately but was not within the normal range. On abdominal computed tomography (CT), liver metastatic lesions decreased 9 9% on May 27, 2002 and disappeared on August 26, 2002. Though there were no signs of recurrence, the serum CA 19-9 level elevated as of October, 2002. Since the hepatic artery was occluded, HAI was discontinued on November 28, 2002. The serum CA 19-9 level elevated inspite of the continuation of the l-LV/5-FU therapy which we increased an amount of 5- FU. Thus, we changed low-dose irinotecan (CPT-11)/cisplatin (CDDP) therapy. The serum level of CA 19-9 decreased gradually and got with in normal range on March, 2004. It did not elevate since then. Low-dose CPT-11/CDDP therapy may be useful for patients with advanced colon cancer thought to be resistant to 5-FU as second-line chemotherapy.

The distribution of secretory immunoglobulin A in the liver of patients with hepatolithiasis.

Patients with hepatolithiasis are known to be complicated with bile stasis and bacterial infections in the stone-containing ducts. It has been suspected that a decrease in portal venous flow is important in the progression of hepatolithiasis. This study was done to find if the affected liver in hepatolithiasis is inflamed or has lowered local immunity by an examination of the distribution of secretory immunoglobulin A and proliferating cell nuclear antigen in the intrahepatic biliary tracts in operative specimens of 36 patients with hepatolithiasis. The number of biliary epithelia stained for the immunoglobulin was greater when the cholangitis was more severe up to a point; in advanced cholangitis, with severe parenchymal atrophy or proliferating epithelia, there were fewer cells stained for the immunoglobulin than in mild cholangitis. In hepatolithiasis, secretory immunoglobulin A decreases when inflammatory changes become severe and there is parenchymal atrophy caused by stenosis or obstruction of portal branch.

[Complete response to treatment with low-dose FP therapy in a patient with stage IVB primary hepatocellular carcinoma with multiple lung and bone metastases].

We report a case in which low-dose FP (5-fluorouracil/cisplatin, 5-FU/CDDP) therapy was remarkably effective for stage IVB advanced hepatocellular carcinoma (HCC) with lung and bone metastases. 5-FU of 250 mg/body/day was continuously infused over 24 hours and CDDP of 10 mg/body/day was infused over 30 minutes from day 1 to day 5 in a week. Administration was continued for 4 weeks as 1 cycle. An 81-year-old woman was diagnosed with HCC in S3 and underwent a transcatheter hepatic arterial embolization (TAE) for the tumor in December 2000. The patient complained of lumbago and hip pain in July 2001 and was admitted for dysbasia in September 2001. On admission, the level of serum AFP and PIVKA-II elevated to a remarkable 59,300 ng/ml and 25,700 AU/ml. Chest computed tomography (CT) showed multiple bilateral lung metastases and abdominal CT showed a tumor 12 x 11 x 10 cm in diameter in the right, iliac bone. No recurrent sign was found in the liver except for the accumulation of Lipiodol. Low-dose FP therapy of 2 cycles was performed. The levels of serum AFP and PIVKA-II decreased to 374 ng/ml from 59,300 and to 35 AU/ml from 25,700, respectively, after this therapy. The CT findings revealed that a complete response (CR) was obtained for lung metastases and a partial response (PR) was obtained for bone metastases after completion of course 2, and maintained thereafter. The oral UFT of 600 mg was administered after completion of course 2 in the outpatient setting. The level of AFP and PIVKA-II decreased to 13.2 ng/ml and to 26 AU/ml, respectively, in February 2002. No sign of recurrence was seen during the 13 months of follow-up after low-dose FP therapy. Toxic events consisted of only leukopenia (grade 1). Her quality of life (QOL) was fair during this therapy. Low-dose FP therapy is possibly useful for patients with stage IVB advanced HCC.

[A case of advanced descending colon cancer with peritoneal dissemination responding to weekly high-dose l-leucovorin/5-fluorouracil combination therapy].

We report a case in which l-leucovorin/5-fluorouracil (l-LV/5-FU) combination therapy was remarkably effective for non-resectable advanced descending colon cancer with carcinomatous peritonitis. A 65-year-old man complained of severe abdominal distension, abdominal pain and pulmonary failure, and was diagnosed as having ileus due to descending colon cancer. The patient underwent urgent open laparotomy to release the ileus condition on March 5, 2002. During the laparotomy, we established a diagnosis of nonresectable descending colon cancer accompanied by severe peritoneal dissemination and therefore performed only double-barreled transverse colostomy. The postoperative course was very good. Pathological examination of omental dissemination demonstrated moderately differentiated adenocarcinoma and cytology of ascites was class II. The levels of serum CEA and CA19-9 were within the normal ranges. l-LV/5-FU therapy was initiated postoperatively. Seven cycles of this chemotherapy regimen was performed with no apparent side effect during the treatment. There was no postoperative accumulation of carcinomatous ascites. The patient gained 15 kg compared with body weight admission. On abdominal computed tomography (CT), the primary lesion of the colon decreased 98% and there was no ascites found. To date, there has not been any sign of recurrence during the 19 months of follow-up after this therapy, and we are currently discussing closure of the transverse colostomy. This therapy may be useful for patients with advanced colon cancer accompanied by peritoneal dissemination.

[A case of recurrent stomach cancer treated with 5-fluorouracil responding to weekly paclitaxel therapy].

We report a patient with unresectable stage IV stomach cancer with metastasis to the paraaortic lymph nodes who achieved an effective response to neoajuvant chemotherapy, which allowed curability-B resection, and in whom weekly paclitaxel (TXL) therapy for postoperative recurrence was very effective in improving QOL. The patient was a 65-year-old man. After preoperative PMFE therapy, CEA decreased from 68.1 ng/ml to 0.8 ng/ml, and CA19-9 from 15,000 U/ml to 190 U/ml. The paraaortic lymph nodes disappeared, and stomach wall thickening decreased. The overall response to treatment was evaluated as a partial response (PR). After surgery, the patient was given TS-1, but became unable to take oral medication because of retroperitoneal and lymph node recurrence. Since the cancer appeared to be resistant to 5-fluorouracil (5-FU), the patient was treated by weekly TXL therapy. Increased appetite and weight gain were observed from the middle of the first course of therapy, and CEA decreased from 28.2 ng/ml to 4.9 ng/ml, and CA19-9 from 15,000 U/ml to 2,000 U/ml. Abdominal CT scans demonstrated shrinkage of the tumor. Although the patient died 1 year and 8 months after the initial examination, he was able to take oral medication and maintain good QOL for 10 months after the start of TXL therapy. Only grade 1 side effects (alopecia and leukopenia) were observed throughout the course. These results suggest that TXL therapy is effective also for 5-FU-resistant stomach cancer, and exhibits effects early even in patients in a poor general condition, causing only mild side effects, with early improvements in QOL.