[Ascending Colon Cancer with Radical Resection after Stent Reimplantation Due to Colonic Stent Obstruction for Palliation-A Case Report].

Since the insurance coverage of colorectal stents for bowel obstruction due to colorectal cancer in 2012, the use of colorectal stenting for palliation has rapidly spread. We report a case of ascending colon cancer in which a colorectal stent was placed for palliation, but the stent was reimplanted due to obstruction, followed by radical resection. The patient was a 92- year-old woman who was brought to the emergency room at the age of 90 years with repeated vomiting and abdominal pain, and was diagnosed as colorectal cancer ileus caused by ascending colon cancer, and a colorectal stent was inserted. She received palliative care and had been asymptomatic for 1 year and 3 months, but due to in-stent stenosis, she had bowel obstruction and sent to emergency room, and another stent was installed. The patient had a good course, but 4 months after the second stenting, she was concerned about restenosis and referred to the department of surgery, then performed a radical resection. The indication for colorectal stents for palliative purposes should be considered on a case-by- case basis, including ADL, stage of the disease, and prognosis.

[A Case of Two-Stage Operation for Esophageal Cancer with Sarcoidosis].

A 69-year-old man with dysphagia was diagnosed with advanced esophageal cancer by upper gastrointestinal endoscopy. He had undergone pancreatic tail and partial transverse colon resection for pancreatic cancer, and right hilar lymph node biopsy and partial lower lobe resection for the diagnosis of pulmonary sarcoidosis. Contrast-enhanced computed tomography(CT)scan showed no change over time in lymph node enlargement in the mediastinum, so metastasis of esophageal cancer was considered to be negative. Therefore, the diagnosis of advanced esophageal cancer, Mt, type 2, T2N0M0, cStage Ⅱ, was made, and surgery was performed after 2 courses of DCF therapy. Because of the adhesions in the thoracic cavity and possible problems with elevation of the gastric tube and blood flow due to resection of the pancreatic tail, it was decided to perform two-stage operation. Although imaging studies over time, as in the present case, can help in the diagnosis, it is difficult to distinguish whether enlarged lymph nodes are reactive changes or metastases. In this study, we experienced a case of thoracic esophageal cancer complicated by sarcoidosis with enlarged mediastinal lymph nodes.

[A Case of Refractory Lymphorrhea after Laparoscopic Distal Gastrectomy].

An 84-year-old man with gastric cancer, cT2N0M0, cStage Ⅰ underwent laparoscopic distal gastrectomy, D1+dissection, and Roux-en-Y reconstruction. We started enteral nutrition on the second postoperative day, but milky drainage appeared from the drain on the fifth postoperative day. The triglyceride in the ascites was markedly elevated, and it was diagnosed as a lymphorrhea. Neither conservative treatment nor lymphangiography were successful. We decided to perform surgical intervention because the lymphorrhea did not improve for about 1 month after gastrectomy. At laparotomy, we detected the lymphatic ducts using enteral nutrition of fat formulas during surgery and successfully closed the lymphatic ducts by suturing and ligation on the 38th postoperative day. Prolonged lymphorrhea causes extreme deterioration of the patient's general condition. Prolonged total parenteral nutrition also increases the risk of infection. It is important to perform surgical treatment for intractable lymphorrhea that does not improve with conservative treatment without hesitation.

[A Case of Conversion Surgery after Chemotherapy for Advanced Gastric Cancer with Peritoneal Disseminations].

BACKGROUND: Advanced gastric cancer with peritoneal dissemination is difficult to treat, although prognosis has improved with chemotherapy and the introduction of molecular targeted drugs. CASE: A 65-year-old male was diagnosed as type 3 advanced gastric cancer on the posterior wall of antrum by esophagogastroduodenoscopy for anemia screening. When the patient underwent radical surgery, multiple disseminated nodules(P1c)were detected. After chemotherapy(SOX, PTX plus RAM)was administered, the tumor shrank, and staging laparoscopy was performed. Since disseminated nodules have disappeared, distal gastrectomy(R0)was performed as conversion surgery. As postoperative adjuvant chemotherapy, S-1 was administered for about 1 year and 6 months. During repair of incisional hernia at 1 year postoperatively, the patient was confirmed to have no disseminated recurrence. The patient is currently alive with no sign of recurrence for 4 years.

A Prospective, Open-Label, Multicenter Phase 2 Trial of Neoadjuvant Therapy Using Full-Dose Gemcitabine and S-1 Concurrent with Radiation for Resectable Pancreatic Ductal Adenocarcinoma.

BACKGROUND: Neoadjuvant therapy reportedly shows only marginal clinical benefit in pancreatic ductal adenocarcinoma (PDAC), especially in resectable cases. However, with more effective regimens, neoadjuvant therapy may become a standard of care for resectable cases. A prospective, open-label, multicenter phases 1 and 2 trial of neoadjuvant therapy was conducted using full-dose gemcitabine and S-1 concurrently with 50.4 Gy of radiation therapy (GSRT) for resectable PDAC. This report describes the phase 2 results. METHODS: The phase 2 part of this study enrolled 57 patients with cytologically or histologically proven PDAC deemed resectable based on imaging before neoadjuvant therapy. These patients received GSRT. After reevaluation by computed tomography scan, surgical exploration was performed, followed by adjuvant therapy. According to the prescribed protocol of the clinical trial, statistical analyses included 57 phase 2 patients and 6 phase 1 patients who received the same dosage as in phase 2. RESULTS: This trial enrolled 63 patients (42 men and 21 women) with a median age of 70 years. Leukopenia or neutropenia of grade 3 or higher occurred for 79% of the patients, but no other severe adverse events were observed. Among the 63 patients, 54 underwent surgical resection. Intention-to-treat analysis of the 63 patients showed an excellent median survival time lasting as long as 55.3 months. The patients who completed neoadjuvant therapy, surgery, and adjuvant therapy had a 5-year survival rate of 56.6%. CONCLUSIONS: This regimen showed outstanding clinical efficacy with acceptable tolerability for patients with resectable PDAC.

[A Case of Adenosquamous Carcinoma of Pancreas Treated with Conversion Surgery after Systemic Chemotherapy].

CASE: A man in his 60s reported upper abdominal pain; close examination revealed a tumor in the body-tail of the pancreas that was suspected to be infiltrating the stomach. Multiple liver lesions(S3, S4)were also detected. Histological examination by EUS-FNA showed poorly-differentiated carcinoma; thus, this case was diagnosed with unresectable pancreatic cancer with liver metastases(cT3, cN1[No. 7], cM1[P0, H1], cStage Ⅳ: JPS 7th). After 2 kinds of systemic chemotherapy(9 courses of GEM plus nab-PTX and 9 courses of modified FOLFIRINOX), obvious distant metastases or local progression did not appear and conversion surgery was scheduled. Although a metastatic lesion was identified at S5 of the liver just before the surgery, it was assumed that an R0 resection could be achieved; therefore, the operation(distal pancreatectomy with combined proximal gastrectomy, left adrenalectomy, lymph node dissection, partial hepatectomy of S5, and cholecystectomy)was performed. Histopathological examination showed squamous metaplasia of the epithelial tissue combined with glandular formation. This case was, thus, diagnosed as adenosquamous carcinoma of pancreas. This patient was discharged 90 days after the operation. The patient is still alive 2 years and 2 months since the first diagnosis.

Skeletal Muscle Loss during Neoadjuvant Chemotherapy Is an Independent Risk Factor for Postoperative Infectious Complications in Patients with Advanced Esophageal Cancer.

OBJECTIVE: Neoadjuvant therapy followed by surgery has been the standard treatment for advanced esophageal cancer. Severe toxicities may influence body composition, including skeletal muscle mass, and increase postoperative complications. The purpose of this study was to evaluate the influence of sarcopenia, changes in body composition, and adverse events during neoadjuvant chemotherapy (NACT) on postoperative complications in esophageal cancer patients. METHODS: A total of 83 patients with esophageal cancer undergoing NACT followed by esophagectomy were included. Body composition was assessed before chemotherapy and before esophagectomy. The relationships between postoperative infectious complications and sarcopenia, changes in body composition, and adverse events during NACT were investigated. RESULTS: Univariate analysis revealed that skeletal muscle loss during NACT, but not preoperative sarcopenia, was significantly higher in the complication (+) group. Febrile neutropenia tended to occur frequently in the complication (+) group. Multivariate analysis demonstrated that skeletal muscle loss was the only factor significantly associated with infectious complications (p = 0.029). Among adverse events, febrile neutropenia was significantly associated with a decrease in skeletal muscle mass. CONCLUSION: Loss of skeletal muscle mass during NACT was a significant risk factor for postoperative infectious complications in patients with esophageal cancer. Prevention of severe adverse events may reduce postoperative infectious complications.

[Two Cases of Locally Recurrent Rectal Cancer Undergoing Preoperative Chemoradiationtherapy].

Case 1 is a 68-year-old woman with locally recurrent rectal cancer(LRRC)developed 5 years after resection of primary rectal cancer. The tumor seized right lateral side in pelvic. We performed tumor excision after preoperative chemoradiation comprised external beam radiation with oral S-1(tegafur/gimeracil/oteracil). He has been relapse-free for 3 years 3months after surgery. Case 2 is a 74-year-old man with LRRC developed 2 years after resection of primary rectal cancer. The tumor was located dorsal to anastomosis site in pelvic. We performed abdominoperineal resection for LRRC after preoperative chemoradiation with oral S-1. He has been relapse-free for 2 years. It was suggested that preoperative radiotherapy combined with oral FU for local recurrence after rectal cancer may contribute to distant and local control.

[A Case of Diaphragmatic Metastasis from Adenocarcinoma of the Rectum Treated via Surgical Resection].

A 67-year-oldman underwent lower anterior resection for rectal cancer andresection of liver metastatic tumor 5 years later. Seven years and 2 months after the initial surgery, a soft tissue mass was detected in the left diaphragm. Further retrospective review of CT scan images showedthat the diaphragmatic tumor was present just before the hepatectomy. Partial resection of the left diaphragm was performed, and no relapse has occurred since then for 2 years. Most cases of diaphragmatic metastasis are considered to arise from dissemination, but we considered this case as more likely to be hematogenous. When surgery is chosen to treat metastatic tumors of colorectal cancer, checking for other metastasis via preoperative imaging andperforming curative resection is important.

A case report of a 19-week gravid patient with a dehisced abdominal wound and treated with V.A.C. ATS(®) Therapy System.

Negative pressure wound therapy (NPWT) is an effective treatment for various non-healing wounds, and V.A.C.(®) Therapy was the first-approved NPWT device by the Japanese government in 2009. We report the case of a 19-week pregnant patient where V.A.C.(®) Therapy was applied to her dehisced laparotomy wound with satisfactory results. The patient was a 30-year-old female who was referred to our hospital from her previous doctor because of the presence of an ovarian cyst on the left ovary. The patient presented at 14 weeks into her pregnancy, and surgery was considered because of no reduction in the size of the cyst. An oophorocystectomy was performed, and then the surgical incision was re-opened at postoperative day (POD) 10 due to a surgical site infection. V.A.C.(®) Therapy was initiated on POD 26 (20 weeks of pregnancy) and continued for 28 days. After 28 days of V.A.C.(®) Therapy (POD 54), the wound was sutured for complete closure. The foetus did not experience any adverse affects from the surgery and, subsequently, normal vaginal delivery was achieved. This case is the first report of the use of V.A.C.(®) Therapy over a dehisced abdominal wound on a pregnant patient in our country.

[Examination of the Usefulness of Laparoscopic Resection for Primary Lesions of Stage â £ Colorectal Cancer].

For patients with Stage Ⅳ colorectal cancer, primary site resection improves survival and relieves symptoms of bleeding and obstruction by the primary lesion. Laparoscopic surgery is thought to be useful for Stage Ⅳ colorectal cancer because of its low aggressiveness and the short recovery time. We examined the usefulness of laparoscopic resection of primary lesions for Stage Ⅳ colon cancer patients. Forty-one cases of Stage Ⅳ colorectal cancer treated by resection of the primary lesion were investigated, and we compared the group of patients with laparoscopic surgery (LAC) to the group of patients with open laparotomy (OP). The LAC Group was superior to the OP Group from the viewpoint of blood loss, days of hospitalization, and length of time from operation to start of chemotherapy. For Stage Ⅳ colorectal cancer, laparoscopic resection of the primary lesion is thought to be a useful method to reduce the invasiveness of treatment.

[Two Effective Cases of Re-Insertion of Self-Expanding Metallic Stent(SEMS)for Re-Obstruction of Colon Cancer after SEMS Treatment].

Recently, self-expanding metallic stent (SEMS) have been found to be useful for treatment of intestinal obstruction by colorectal cancer, either as a bridge to surgery or terminal treatment. When SEMS are used for patients in the terminal stage with obstruction due to colorectal cancer, re-obstruction is a severe problem. We report 2 cases of re-insertion of SEMS for obstruction of colon cancer after the first insertion of SEMS. No major problems occurred in either the 2 cases. In the first case, the patient suffered from re-obstruction of colon cancer 6 months after the first SEMS treatment and died 9 months after the second SEMS treatment. In the second case, the patient suffered from re-obstruction of colon cancer 5 months after the first SEMS treatment and died 7 months after the second SEMS treatment. Re-insertion of SEMS for a second obstruction due to colorectal cancer after SEMS treatment is useful for terminal treatment for maintaining QOL.

[A Case of Liposarcoma Occurring in the Retroperitoneum Treated by Laparoscopic Excision].

We experienced a rare case of liposarcoma that we were able to remove laparoscopically based on a preoperative diagnosis. The patient in this case was a 67-year-old woman. Abdominal CT and pelvic MRI showed a mass of 15 cm in diameter on the left side of the pelvis. Well-differentiated liposarcoma was diagnosed based on these images. Based on imaging findings, the possibility of permeation to the neighboring organs was considered to be low, and so the operation was performed laparoscopically. The location of the tumor was similar to that seen during preoperative imaging diagnosis, and we were able to remove it laparoscopically without resecting the organ. The postoperative progress was good, and the patient left the hospital on the fourth postoperative day. This case shows how with detailed preoperative imaging, a minimally invasive approach is possible for the treatment of liposarcoma.

[Examination of the usefulness of the self-expanding metallic stent for ileus due to colorectal cancer].

Ileus due to colon cancer often develops from a timing and the method of the operation and perioperative care, comparing with ordinary cases. The use of self-expanding metallic stent (SEMS) was first authorized by insurance and became available nationwide in Japan in 2012. Insertion of SEMS for ileus due to colorectal cancer is useful as a bridge to surgery (BTS) approach and releases stenosis as palliative care. Here we report 5 successful cases of anastomosis performed during a laparoscopic operation for ileus due to colorectal cancer after BTS using SEMS. Successful SEMS insertion for colon cancer ileus enables observation of the proximal side. Because the decompression efficiency with SEMS is high, laparoscopic surgery becomes possible. SEMS insertion as a BTS is useful for ileus due to colorectal cancer.

Influence of Percutaneous Transhepatic Gallbladder Aspiration and Drainage for Severe Acute Cholecystitis on the Surgical Outcomes of Subsequent Laparoscopic Cholecystectomy: Post Hoc Analysis of the CSGO-HBP-017 (CSGO-HBP-017C).

OBJECTIVE: Percutaneous transhepatic gallbladder aspiration (PTGBA) and/or drainage (PTGBD) are useful approaches in the management of acute cholecystitis in patients who cannot tolerate surgery because of poor general condition or severe inflammation. However, reports regarding its effect on the surgical outcomes of subsequent laparoscopic cholecystectomy (LC) are sparse. The aim of this retrospective study was to investigate the influence of PTGBA on surgical outcomes of subsequent LC by comparing the only-PTGBA group, including patients who did not need the additional-PTGBD, versus the additional-PTGBD group, including those who needed the additional-PTGBD after PTGBA. PATIENTS AND METHODS: We conducted a post hoc analysis of our multi-institutional data. This study included 63 patients who underwent LC after PTGBA, and we compared the surgical outcomes between the only-PTGBA group (n = 56) and the additional-PTGBD group (n = 7). RESULTS: No postoperative complications occurred among the 63 patients, and the postoperative hospital stay was 11 ± 12 days. Fourteen patients (22.2%) had a recurrence of cholecystitis, of whom 7 patients (11.1%) needed the additional-PTGBD after PTGBA. Significantly longer operative time (245 ± 74 vs 159 ± 65 min, P = 0.0017) and postoperative hospital stay (22 ± 27 vs 10 ± 9 d, P = 0.0118) and greater intraoperative blood loss (279 ± 385 vs 70 ± 208 mL, P = 0.0283) were observed among patients in the additional-PTGBD group compared with the only-PTGBA group, whereas the rates of postoperative complications (Clavien-Dindo grade ≥3: 0% each) and conversion to open surgery (28.6% vs 8.9%, P = 0.1705) were comparable. CONCLUSION: PTGBA for acute cholecystitis could result in good surgical outcomes of subsequent LC, especially regarding postoperative complications. However, we should keep in mind that the additional-PTGBD after PTGBA failure, which sometimes happened, would be associated with increased operative difficulty and longer recovery.

[Resection and postoperative multidisciplinary treatment for hepatocellular carcinoma with massive portal venous tumor thrombus-a single-center experience].

BACKGROUND: Patients with advanced hepatocellular carcinoma( HCC) with massive portal venous tumor thrombus (PVTT) face a dismal prognosis as no standard therapy has been defined. A cancer board was established at our hospital 5 years ago. OBJECTIVE: The aim of this retrospective study was to evaluate our surgical and multidisciplinary treatment for HCC with massive PVTT. PATIENTS AND METHODS: From July 2007 to June 2012, 8 patients with HCC with PVTT extending into the main portal trunk were treated. Hemihepatectomy and PVTT removal were performed in 4 patients. Postoperative multidisciplinary treatment included transarterial chemoembolization, hepatic arterial infusion therapy, and administration of sorafenib. In 1 patient, intrahepatic recurrence and bilateral adrenal metastases were resected. RESULTS: There was no in- hospital mortality. The median postoperative hospital stay was 30 days. The overall median survival for patients who underwent surgery and who did not undergo surgery was 344.5 days and 67 days, respectively. CONCLUSIONS: Resection for HCC with PVTT extending into the main portal trunk is acceptable at medium-scale teaching hospitals in Japan. Surgery and postoperative multidisciplinary therapy may improve the outcome of patients with HCC with massive PVTT.

[Clinical significance of neutrophil to lymphocyte ratio in colorectal cancer patients receiving adjuvant chemotherapy combined with polysaccharide-K].

The neutrophil to lymphocyte ratio (N/L ratio) has been reported to be related to the prognosis of various types of cancer. In particular, a high N/L ratio has been suggested to be associated with poor outcome. We investigated the changes in N/L ratio during treatment in 12 patients who had undergone surgery for colorectal cancer and were receiving postoperative adjuvant therapy with a combination of chemotherapy and polysaccharide-K (PSK). The patients were stratified into 2 groups according to the preoperative N/L ratio (cut-off ratio was 2.5): high N/L (≥2.5) and low N/L (<2.5). The changes in N/L ratio and other clinical parameters over time were investigated. In patients with a high preoperative N/L ratio, the use of postoperative PSK-chemotherapy controlled the N/L ratio at low levels. The N/L ratio tended to remain low in patients with low preoperative N/L ratios. No difference in outcome was observed between patients with high and low N/L ratios. In patients who underwent colorectal cancer surgery, postoperative adjuvant therapy with a combination of chemotherapy and PSK succeeded in controlling the N/L ratio at low levels. Further studies with more patients are required to explore the outcomes associated with changing N/L ratios.

[Response to neoadjuvant chemotherapy in breast cancer as assessed by subtype].

The aim of this study was to investigate the responses to neoadjuvant chemotherapy (NAC) in breast cancer according to subtype. The study included 69 women who received NAC at our hospital between January 2004 and January 2013. Complete response( CR) was achieved in 14 patients( 20.3%) and partial response( PR) was achieved in 37 patients (53.6%).CR and PR rates according to subtype were as follows: 0% and 57.1% for the luminal type, 0% and 66.7% for the luminal-human epidermal growth factor receptor (HER)-2 type, 16% and 56% for the triple negative type, and 58.8% and 41.2% for the HER2 type, respectively. The CR rate was the highest among patients with HER2-type breast cancer. Trastuzumab was additionally administered to 12 patients with HER2-type breast cancer, and the CR rate among these patients was significantly higher after trastuzumab treatment( 75%).Thus, it is important to select a treatment strategy for breast cancer on the basis of the subtype diagnosed.

[Two long-term survival cases of Stage IV colon cancer through multidisciplinary treatment].

We report the long-term survival in two cases of colon cancer through multidisciplinary treatment, including surgery. Case 1: A 67-year-old male patient underwent anterior rectal resection, partial hepatectomy(S4, S5, S5/8) and cholecystectomy for rectal cancer with liver metastasis in July 2006(pSS, pN0, sH1, sP0, sM0, Stage IV, Cur B). Liver metastasis, lung metastasis, and metastatic colon cancer occurred 5 times during the 59 months following the first operation. We performed surgery and adjuvant chemotherapy to treat each recurrence. Case 2: A 42-year-old male patient underwent sigmoidectomy for sigmoid colon cancer with multiple liver metastasis in May 2007 (pSS, pN0, sH2, sP0, sM0, Stage IV, Cur C). Recurrence occurred 7 times at the liver and lung during the 58 months after the first operation. We performed surgery and adjuvant chemotherapy to treat each recurrence.

[Three cases of sigmoid colon cancer accompanied by invagination].

Invagination in adults is rare compared to children. We experienced 3 sigmoid colon cancers in which symptoms of invagination were discovered. Because the tumors in 2 of the 3 cases could be reduced, operations were electively performed. The tumor in the remaining case could not be reduced and an urgent operation was required. Because all cases responded in the early stage, their postoperative progress was good. Invagination in adults is typically caused by an organic disease, particularly cancer. It is necessary to consider not only reduction of the invagination but also treatment of the primary disease causing invagination. It is important that the malignant symptoms be detected promptly in order to develop a suitable treatment strategy.