Different prognostic effect of lymph node metastasis between remnant gastric cancers and primary proximal gastric cancers.

BACKGROUND: Although the dissected lymph node number in remnant gastric cancer (RGC) may be smaller than in primary proximal gastric cancer (PGC), altered lymphatic flow provides different metastatic patterns in lymph nodes, which could potentially give rise to prognostic differences between RGC and PGC with nodal metastasis. METHODS: Between 1993 and 2020, 2546 consecutive patients with gastric cancer underwent gastrectomy. Of these, 53 RGC and 381 PGC patients with pStage I-III gastric cancer underwent curative gastrectomy. We reviewed their hospital records retrospectively. RESULTS: The number of dissected lymph nodes was significantly smaller in RGC patients than in PGC patients (P < 0.001: RGC: 13.0 vs. PGC: 34.5). Although the five-year overall survival (OS) rate did not differ between RGC and PGC in all patients, the prognosis in each pN stage of RGC was worse compared with that of PGC, suggesting that each lymph node metastasis has a greater prognostic effect in RGC. Specifically, even with pN1 (20.0%) or pN2 (40.0%) RGC patients, their five-year OS rates were poor and similar to those of pN3 PGC patients (35.7%). The presence of lymph node metastasis in RGC (HR: 4.41, 95% CI: 1.02-18.9, P = 0.045) was an independent and a similar prognostic impact in pN3 PGC (HR: 2.82, 95% CI: 1.57-5.07, P < 0.001). Lymph node metastasis in RGC more strongly affected peritoneal or lymph node recurrence rather than hematogenous recurrence. CONCLUSION: The presence of lymph node metastasis yielded a poorer prognosis in RGC patients compared with primary PGC patients. RGC patients with lymph node metastasis should be specifically targeted in an effort to improve their prognosis.

Impact of severe postoperative complications on the prognosis of older patients with colorectal cancer: a two-center retrospective study.

BACKGROUND: The occurrence of postoperative complications may affect short-term outcomes and prognosis of patients with various malignancies. However, the prognostic impact of these complications in older patients with colorectal cancer (CRC) remains unclear. Therefore, this study aimed to investigate the impact of severe postoperative complications on the oncological outcomes of older (aged ≥ 80 years) and non-older (aged < 80 years) patients with CRC. METHODS: We retrospectively analyzed 760 patients with stage I-III CRC who underwent curative surgery in two institutions between 2013 and 2019. The patients were categorized into older (aged ≥ 80 years, 191 patients) and non-older (aged < 80 years, 569 patients) groups. Short- and long-term outcomes were compared between the two groups. RESULTS: The incidence of severe postoperative complications did not differ between the two groups (p = 0.981). Cancer-specific survival (CSS) was significantly worse in older patients with severe complications than in those without severe complications (p = 0.007); meanwhile, CSS did not differ between the non-older patients with severe complications and those without severe complications. Survival analysis revealed that the occurrence of severe postoperative complications was an independent prognostic factor for CSS in older patients (hazard ratio = 4.00, 95% confidence interval: 1.27-12.6, p = 0.017). CONCLUSION: CRC surgery can be safely performed in older and non-older patients. Moreover, the occurrence of severe postoperative complications might more strongly affect the prognosis of older patients than that of non-older patients.

[Surgical Outcomes of Colorectal Cancer for Over 90-Year-Old Patients in Our Hospital].

The aim of this study was to investigate the short-term outcomes of surgery for colorectal cancer(CRC)in the elderly aged over 90 years old. We retrospectively analyzed 1,043 patients with stage Ⅰ-Ⅳ CRC who underwent curative surgery in our institutions between 2013 and 2022. The patients were divided into the super older(aged ≥90 years, 20 patients) and non-super older groups(aged 80-89 years, 243 patients). The short-term outcomes were compared between the 2 groups. There were no significant differences in tumor location, stage, surgical approach, duration of operation and blood loss. The incidence of severe postoperative complications did not differ between the 2 groups. In conclusion, our study suggested that surgery for colorectal cancer could be as safely performed in super elderly patients as in non-super elderly patients.

[Laparoscopic Surgery for Delayed Chylous Ascites in Unresectable Gastric Cancer Patient-A Case Report].

Chylous ascites is a rare post operative complication after gastrectomy, which commonly occurs in early postoperative period. Here, we successfully treated a patient with unresectable gastric cancer who occurred chylous ascites 9 months after first surgery and underwent laparoscopic surgery for chylous ascites. Since prolonged chylous ascites may cause malnutrition, surgical treatment should be considered for refractory chylous ascites.

Laparoscopic Surgery for Elderly Colorectal Cancer Patients With High American Society of Anesthesiologists Scores.

BACKGROUND/AIM: To evaluate the safety of colorectomy in elderly colorectal cancer patients with high American Society of Anesthesiologists (ASA) scores compared to those with low scores. PATIENTS AND METHODS: Two hundred patients with stage I-IV colorectal cancer aged ≥80 years were retrospectively analyzed. Short- and long-term outcomes were compared between 136 patients with ASA scores ≤2 (low ASA group) and 64 patients with scores ≥3 (high ASA group). RESULTS: The incidence of postoperative complications, duration of postoperative hospital stay, and 5-year overall and cancer-specific survival rates did not differ significantly between the groups. Laparoscopic surgery was significantly associated with a lower incidence of postoperative complications than open surgery in the high ASA score group (p=0.041), whereas no difference was observed in the low ASA score group (p=0.639). In the high ASA group, open surgery (p=0.024) and higher body mass index (p=0.040) were independent risk factors for postoperative complications. CONCLUSION: Colorectal cancer resection can be safely performed in elderly patients with high ASA scores. Moreover, laparoscopic surgery may have a stronger contribution to the reduction of postoperative complications in elderly patients with colorectal cancer with high ASA scores than in those with low ASA scores.

[A Case in Which a Distal Pancreatectomy Was Performed for Pancreatic Metastasis of Renal Cell Carcinoma after Nephrectomy, and a Total Pancreatectomy Was Performed for Residual Pancreatic Recurrence].

We reported a case in which a pancreatic resection was performed for pancreatic metastasis of renal cell carcinoma 24 years after nephrectomy, and a residual pancreatectomy was performed 4 years later for residual pancreatic recurrence. The patient was a 72-year-old. In 1991, he underwent right nephrectomy for right renal cell carcinoma. During follow-up, in 2015, mass lesions were noted in the pancreatic tail and distal pancreatectomy was performed on suspicion of pancreatic neuroendocrine tumor(NET). Pathological examination diagnosed metastasis of renal cell carcinoma. In 2019, mass lesions were noted in the residual pancreas and total pancreatectomy was performed. Pathological examination diagnosed metastasis of renal cell carcinoma. There was 5 cases in Japan, including an our case, in which pancreatectomy was performed again after pancreatectomy for pancreatic metastasis of renal cancer, and the average time until the first pancreatic metastasis was pointed out was 11.8 years, and the average time until pancreatic recurrence was 9.4 years. Pancreatic metastasis of renal cell carcinoma shows heterochronic and multiple metastasis occurs, requiring long-team follow-up. When determining the extent of resection, it was suggested that the minimum number of repetitions necessary may lead to a long-term prognosis, taking into account the patient's age, background.

[A Case of an Advanced Gastric Cancer Patient with Outlet Obstruction and Malnutrition Who Successfully Underwent Neoadjuvant Chemotherapy with Enteral Nutrition].

We reported a case of an advanced gastric cancer patient with gastric outlet obstruction and malnutrition who successfully underwent neoadjuvant chemotherapy with enteral feeding. The patient is a 72-year-old man. The diagnosis was advanced gastric cancer with pyloric stenosis. Both decompression and enteral nutrition was performed with a W-ED®. Chemotherapy was markedly effective and nutritional status improved. He underwent robot-assisted distal gastrectomy(D2)and Billroth Ⅱ reconstruction under good nutritional status after neoadjuvant chemotherapy with intragastric decompression and nutritional management using a W-ED® tube. W-ED® tube is a useful tool for the proper nutritional management of patients with advanced gastric cancer who have pyloric stenosis by adequate decompression and enteral feeding.

[Safety and Efficacy of Neoadjuvant Chemotherapy(UDON: 5-FU, Docetaxel, and Nedaplatin)for Esophageal Cancer].

We investigated the safety and efficacy of UDON(5-FU, docetaxel and nedaplatin), a similar DCF therapy, as neoadjuvant chemotherapy for advanced esophageal cancer. Twelve patients who underwent radical esophagectomy after neoadjuvant chemotherapy for esophageal cancer at our department from June 2021 to December 2022 were retrospectively evaluated. One patient had Grade Ⅲ or higher neutropenia(8%)and 2 patients had anorexia(15%)as adverse events, but they could be safely treated. Nutritional status and ADL were maintained in all patients, and surgery was performed after 2-3 courses of neoadjuvant chemotherapy. The median postoperative hospital stay was 14 days, and no severe postoperative complications were observed. The histological effect to chemotherapy was Grade 3 in 3 patients(23%). UDON therapy is a safe and effective treatment.

[A Case of Pembrolizumab Therapy Markedly Effective for Advanced Recurrent Colorectal Cancer].

We report a case of pembrolizumab therapy as the fourth-line therapy for colorectal cancer and multiple lymph node recurrence with high-frequency microsatellite instability(MSI-High). The patient was a 75-year-old woman diagnosed with ascending colon cancer(pT4aN2bM0, Stage Ⅲc)and underwent laparoscopic right hemicolectomy, D3 dissection, and functional end-to-end anastomosis after inserting a self-expandable metallic stent. Postoperative adjuvant chemotherapy was performed, and the patient was followed. Postoperative 1 year 8 months, lymph node recurrence was indicated, and FOLFOX plus panitumumab therapy was introduced. FOLFIRI plus ramucirumab therapy and FTD/TPI were introduced as the second-line and third-line treatments, respectively; however, recurrent lymph nodes were further exacerbated and showed treatment resistance. Lymph node biopsy confirmed MSI-High, and pembrolizumab therapy was initiated as the fourth-line treatment. After the therapy, the lymph nodes reduced markedly. The patient remains undergoing chemotherapy without any adverse events.

[Patient with Epstein-Barr Virus-Positive Esophagogastric Junctional Cancer with Splenic Metastasis and Underwent Metastasectomy following Immune Checkpoint Therapy].

Recurrent gastric cancer(GC)with splenic metastasis showed poor prognosis, and its treatment strategy remains unclear. Recently, studies identified the considerable prognostic effect of metastasectomy in GC following intensive chemotherapy. Here, we successfully treated a patient with Epstein-Barr virus-positive esophagogastric junctional cancer with splenic metastasis who underwent metastasectomy and obtained pathological complete response following immune checkpoint therapy and had long-term survival. We reviewed the literature to discuss the clinical significance of our treatment strategy.

Continuous Recurrent Laryngeal Nerve Monitoring During Single-Port Mediastinoscopic Radical Esophagectomy for Esophageal Cancer.

BACKGROUND: Although single-port mediastinoscopic radical esophagectomy is ultimate minimally invasive surgery for esophageal cancer without thoracotomy or the thoracoscopic approach, the high incidence of recurrent laryngeal nerve (RLN) palsy remains a pivotal clinical issue. METHODS: This study included 41 patients who underwent single-port mediastinoscopic radical esophagectomy with mediastinal lymphadenectomy between September 2014 and March 2022. Among these, continuous nerve monitoring (CNM) for RLN was done in 25 patients (CNM group), while the remaining 16 patients underwent without CNM (non-CNM group). Clinical benefits of CNM for RLN were evaluated. RESULTS: The overall incidence of postoperative RLN palsy was 14.6% (6/41). The CNM group showed a significantly lower incidence of postoperative RLN palsy as compared to the non-CNM group (P = 0.026: CNM vs. non-CRNM: 4.0% (1/25) vs. 31.2% (5/16)). The CNM group had a lower incidence of postoperative pneumoniae (CNM vs. non-CNM: 4.0% (1/25) vs. 18.8% (3/16)) and shorter days of postoperative hospital stay (CNM vs. non-CNM: 13 days vs. 41 days). Multivariate analysis revealed that the CNM use (odds ratio 0.07; 95% CI 0.05-0.98) was an independent factor avoiding postoperative RLN palsy. CONCLUSION: The CNM for RLN contributes to a remarkable reduction in the risk of postoperative RLN palsy and improvement in outcomes in single-port mediastinoscopic radical esophagectomy.

Night home enteral nutrition as a novel enforced and physiologically effective nutrition therapy following total gastrectomy for gastric cancer.

Enteral nutrition has been reported to be safe and effective in malnourished patients undergoing upper gastrointestinal surgery. In this study, we devised night home enteral nutrition (N-HEN) as a novel nutritional strategy and evaluated the efficacy in gastric cancer patients following total gastrectomy. Between January 2017 and March 2021, 24 patients were prospectively included in the protocol and supported by N-HEN for three postoperative months through a jejunostomy during the night (Elental:1200 kcal/day), and 22 patients without N-HEN were followed as a control group (CG). Body weight loss, nutritional indicators and tolerance to chemotherapy were evaluated. After 3 and 6 months, patients with N-HEN had significantly less body weight loss than CG (3 months P < 0.0001: N-HEN 4.0% vs. CG 15.2%, 6 months P < 0.0001: N-HEN 7.7% vs. CG 17.7%). Prealbumin was significantly higher in patients with N-HEN than CG after 3 and 6 months (3 months P < 0.0001, 6 months P = 0.0037). Albumin, total protein and hemoglobin, tended to be higher after 3 and 6 months in patients with N-HEN than CG, and total cholesterol after 6 months. Concerning the tolerance to adjuvant chemotherapy in Stage II-III patients, patients with N-HEN significantly had a higher completion rate (P = 0.0420: N-HEN 70% vs. CG 29%) and longer duration (P = 0.0313: N-HEN 458 days vs. CG 261 days) as planned. Continuous monitoring of blood glucose concentration in patients with N-HEN did not show nocturnal hypoglycemia or hyperglycemia. N-HEN could be a novel enforced and physiologically effective nutritional strategy to support potentially malnourished patients following total gastrectomy.

[Novel Treatment Strategy Using Trafermin® Consisting of bFGF for Intractable Pancreatic Fistula-A Case Report].

Pancreatic fistula is one of the most critical complication following distal pancreatectomy. We report here a successfully treated case with intractable pancreatic fistula using Trafermin® consisting of basic fibroblast growth factor(bFGF). A 60- year-old man underwent laparoscopic distal pancreatectomy. After surgery, pancreatic fistula was occurred. Pancreatic fistula persisted for 3 months despite of several conservative treatments. After obtaining informed consent, we started to inject 50µg/day of Trafermin® through a drainage tube into the dehiscence of pancreas. Consequently, pancreatic fistula was successfully closed within a week. This technique could be one of the treatment choices for intractable pancreatic fistula following distal pancreatectomy.

[Long-Term Elderly Survivor with Recurrent MSI-High Gastric Cancer Using Pembrolizumab as a Second-Line Chemotherapy].

KEYNOTE-158 and 061 trials revealed the efficacy and safety of pembrolizumab(KEYTRUDA®)treatment in patients with recurrent high microsatellite instability(MSI-high)gastric cancer following gastrectomy. Here, we successfully treated an elderly case with recurrences following radical gastrectomy for advanced gastric cancer using pembrolizumab as a second- line chemotherapy. Even in elderly patients, pembrolizumab might contribute to effective and safe treatment in late-line chemotherapy for recurrent MSI-high gastric cancer.

[Mediastinoscopic Radical Esophagectomy for Esophageal Cancer in a Patient with Chronic Pulmonary Infection].

Mediastinoscopic esophagectomy(ME)is a minimally invasive approach without thoracotomy and pulmonary atelectasis during surgery. Here, we report the case of a 67-year-old patient who was successfully treated with thoracic esophageal cancer and severe chronic pulmonary infection using ME and home enteral nutrition therapy. Esophageal cancer patients with severe lung dysfunction have a risk of postoperative pneumoniae. ME could be a promising procedure for patients with severe lung dysfunction. We highlight the usefulness of ME as a safe approach to avoid pulmonary complications.

[A Case of G-CSF Producing Esophageal Carcinosarcoma Treated Effectively with Nivolumab for Recurrences following Two-Stage Surgery].

G-CSF producing esophageal carcinosarcoma is extremely rare, and its effective treatment strategy remains undefined. Here, we report the case of a 69-year-old woman who underwent successful two-stage surgery using mediastinoscopic esophagectomy and laparoscopic reconstruction for the management of severe anemia, malnutrition, and inflammation due to G-CSF producing esophageal carcinosarcoma(G-CSF 265 pg/mL). Chemoradiotherapy could not manage lymph node recurrences in the patient; however, nivolumab was found to be effective and helped achieved a prolonged partial response.

[Conversion Surgery for Advanced Gastric Cancer with Ovarian Metastasis-A Case Report with Review of the Literatures].

Stage Ⅳ gastric cancer(GC)with ovarian metastasis showed poor prognosis and its treatment strategy remains unclear. Recent studies identified the favorable prognostic effect of conversion surgery in Stage Ⅳ GC following intensive chemotherapy. We report here a case with advanced GC and ovarian metastasis, who underwent conversion surgery for them followed by chemotherapy and had a long-term survival. We reviewed the literatures in order to discuss clinical significance of our treatment strategy.

[Clinical Evaluation of the Efficacy and Adverse Effects of Nivolumab Treatment for Patients with Advanced Gastric Cancer].

BACKGROUND: Nivolumab, a fully human IgG4 monoclonal antibody inhibitor of programmed death-1(PD-1), was approved for use in the treatment of patients with advanced gastric or gastroesophageal junction cancer who had been previously treated with B2 chemotherapy regimens in Japan. METHODS: We investigated the efficacy of nivolumab therapy in 15 consecutive patients with advanced gastric cancer between October 2017 and December 2018 in our facility. RESULTS: In our study, the 6-month overall survival rate was 67.7%, and the median survival time(MST)was 6.3 months. Immune-related adverse events(irAEs)occurred in the following patients: 2 patients, interstitial pneumonia(13%); 1 patient, myocarditis (6.7%); 1 patient, hypothyroidism(6.7%); and 1 patient, liver dysfunction(6.7%). Of the patients with an absolute lym- phocyte count(ALC)of C2,000/mL at baseline, 33%(4/12)experienced irAEs, while of those with an ALC of >2,000/mL, 67% had irAEs. The 6-month overall survival rate was better in patients with an ALC >1,600/mL(100%, 4/4)than in those with an ALC of C1,600/mL(35%, 4/11). The 6-month overall survival rate of the patients with a neutrophil-to-lymphocyte ratio(NLR)of <4 was 63%, which was better than the 33% rate in those with an NLR of B4. CONCLUSIONS: Nivolumab therapy was a safe and feasible treatment option. The cutoff values of ALC of 2,000/mL for irAEs and of ALC of 1,600/mL and NLR of 4 for prognosis might be effective surrogate markers in nivolumab treatment.

[Better Effect of Home Night Enteral Nutrition in an Elderly Patient Following Laparoscopic Total Gastrectomy for Advanced Gastric Cancer].

Postoperative low nutrition, body weight loss and poor QOL are pivotal clinical issues for elderly patients following total gastrectomy for advanced gastric cancer. Here, we report a successfully treated high-risk elderly case using home night enteral nutrition and adjuvant chemotherapy following laparoscopic total gastrectomy for advanced gastric cancer. Home night enteral nutrition might not impair oral intake and daily QOL, and could be a useful treatment strategy for elderly patients following total gastrectomy.

[Long-Term Survivor with Recurrent Gastric Cancer Using Trifluridine/Tipiracil as a Late-Line Chemotherapy].

TAGS trial revealed the efficacy and safety of trifluridine/tipiracil(Lonsurf®)treatment in patients with metastatic gastric cancer following gastrectomy. Here, we successfully treated 38 months survival case after recurrences following radical gastrectomy for advanced adenocarcinoma of esophago-gastric junction using historical recommended chemotherapy regimens and trifluridine/tipiracil as a fifth-line chemotherapy. Trifluridine/tipiracil therapy contributed to effective and safety treatment even in late-line chemotherapy for recurrent gastric cancer.