[Considering Recurrence Prevention Regimen for Colorectal Cancer Patients with Hyperammonemia Caused by Chemotherapy Containing 5-Fluorouracil].

A 64-year-old woman was admitted to our hospital because of severe constipation and was diagnosed with unresectable cStage Ⅳb rectal cancer with multiple lung metastases and liver metastases. Because of obstructive symptoms, a laparoscopic sigmoid colostomy was performed. Because of RAS/BRAF wild type, we started the mFOLFOX6 plus panitumumab (Pmab). Ten days after 10 cycles of chemotherapy, she was admitted because of general fatigue, stoma edema, ascites, and leg edema. She became confused(JCSⅢ-200). The laboratory results revealed that her serum ammonia level was 293µg/ dL. We diagnosed 5-FU-induced hyperammonemic encephalopathy. Treatment with branched-chain amino acid solutions resulted in improvement of his mental status and serum ammonia level decreased. After that, the chemotherapy was changed to 5-FU 80% FOLFIRI plus bevacizumab, but hyperammonemia recurred. After improvement of hyperammonemia, the patient has been treated for 4 cycles without becoming unconscious after switching to FTD/TPI plus bevacizumab therapy. In this case, muscle weakness due to sarcopenia was considered to be one of the causes. We believe that oral drugs containing FTD/TPI can be used relatively safely without causing hyperammonemia.

[Two Cases Suspected of Lynch Syndrome Caused by Juvenile Rectal Cancer].

Case 1: A 28-year-old man was admitted to our hospital because of bloody stools that persisted for several months. Colonoscopy showed a 1/2 circumferential type 2 tumor in the rectum. Laparoscopic high anterior resection(D3)was performed for rectal cancer cT3N0M0, cStage Ⅱa. The final diagnosis was pStage Ⅱa, and MSI-high. XELOX therapy was performed for 3 months to prevent recurrence, and the patient is alive without recurrence. Case 2: A 51-year-old man, father of case 1 patient, was admitted to our hospital because of anemia and dyspnea. Colonoscopy showed a circumferential type 2 tumor in the ascending colon. Laparoscopic right hemicolectomy(D3)was performed for ascending colon cancer cT4b N2aM0, cStage Ⅲc. The final diagnosis was pT3N0M0, pStage Ⅱa, and MSI-high. The patient is alive no recurrence without adjuvant chemotherapy. Both patients had a family history of colorectal cancer, were MSI-high, met the Amsterdam criteria Ⅱ and the revised Bethesda guidelines, and were suspected of having Lynch syndrome. A detailed family history and appropriate information provision were considered useful.

Hard Palate Metastasis from Rectal Adenocarcinoma.

The most common sites of metastasis from colorectal cancer are liver, lungs, and peritoneum. Oral cavity metastasis is extremely rare, accounting for only 1-2% of all oral cancers. We report the case of a 71-year-old male who presented with hard palate metastasis 20 months after his initial diagnosis for T4N1M1 rectal adenocarcinoma according to the UICC TNM classification. To the best of our knowledge, hard palate metastasis from colorectal cancer has never been previously reported in the literature. The hard palate metastasis deteriorates oral function, resulted in unfavorable prognosis. Early detection of oral cavity metastasis could lead to the opportunities for additional treatment and improve outcomes following treatment.

[A Case of Rectal Cancer and Multiple Lung Metastases That Had Complete Response Treated by XELOX plus Bevacizumab after Primary Lesion Resection].

A 54-year-old woman visited our hospital complaining of abdominal distension. Endoscopic examination revealed type 3 tumor in the rectum located 15 cm from the anal edge. Enhanced computed tomography showed multiple ground glass-like shadows in both lungs that were suspected of multiple metastases. We diagnosed as having rectal cancer with multiple lung metastases. After placing the stent transanally to release the intestinal obstruction, we performed laparoscopic high anterior resection. Then, the patient received chemotherapy with 10 courses of XELOX plus bevacizumab and 9 courses of the regimen without oxaliplatin. A whole-body CT revealed complete response. And while taking capecitabine the patient remains well and without recurrence. We describe the present case with reference to the literature.

Cytomegalovirus colitis followed by ischemic colitis in a non-immunocompromised adult: a case report.

We report a rare case of cytomegalovirus (CMV) colitis followed by severe ischemic colitis in a non-immunocompromised patient. An 86-year-old woman was admitted after experiencing episodes of vomiting and diarrhea. The next day, hematochezia was detected without abdominal pain. The initial diagnosis of ischemic colitis was based on colonoscopy and histological findings. The follow-up colonoscopy revealed a prolonged colitis. Immunohistochemical staining detected CMV-positive cells following conservative therapy. Intravenous ganciclovir therapy led to successful healing of ulcers and disappearance of CMV-positive cells. The prevalence of CMV infection is common in adults. CMV colitis is relatively common in immunocompromised patients; however, it is rare in immunocompetent patients. In our case, CMV infection was allowed to be established due to the disruption of the colonic mucosa by the prior severe ischemic colitis. Our experience suggests that biopsies may be necessary to detect CMV and the prompt management of CMV colitis should be instituted when intractable ischemic colitis is observed.

[A case of laparoscopic surgery for a rectal carcinoid after ALTA therapy for an internal hemorrhoid].

We report a case of laparoscopic surgery for a rectal carcinoid after aluminum potassium and tannic acid (ALTA) therapy for an internal hemorrhoid. A 66-year-old man was admitted to our hospital because of bleeding during defecation. He was diagnosed via anoscopy with Goligher grade II internal hemorrhoids. Examination via colonoscopy revealed 2 yellowish submucosal tumors in the lower rectum that were 5mm and 10mm in diameter. A rectal carcinoid tumor was diagnosed based on histopathology. Abdominal computed tomography demonstrated no metastases to the liver or lymph nodes. First, we performed ALTA therapy for the internal hemorrhoids. Two weeks later, we performed laparoscopic-assisted low anterior resection (D2) for the rectal carcinoid. The patient was discharged without complications and has not experienced recurrence during the 2 years of follow-up care.

[A case of emergency resection of a giant gastrointestinal stromal tumor of the stomach associated with hemorrhagic shock].

We report a case of emergency resection of a giant gastrointestinal stromal tumor of the stomach associated with hemorrhagic shock. A 79-year-old woman was admitted to our hospital because of massive hematemesis. Laboratory analysis revealed a hemoglobin level of 6.5 g/dL. Abdominal computed tomography (CT) and upper gastrointestinal endoscopy revealed a submucosal tumor, 12 cm in diameter, in the fornix of the stomach. As a Dieulafoy-like lesion was present, we attempted coagulation hemostasis in the exposed blood vessels. Endoscopic hemostasis was not successful. The patient went into hemorrhagic shock. Emergency surgery was performed: total gastrectomy with distal pancreatosplenectomy. The resected specimen measured 10×12×7 cm and was hard. Immunohistologically, the tumor was positive for c-kit and CD34 and negative for alpha smooth muscle actin (αSMA), desmin, and S-100. Histological examination revealed that the patient had a high-risk gastrointestinal stromal tumor of the stomach with no nodal metastasis. The postoperative course was uneventful and the patient has remained alive without recurrence for 4 years.