Impact of gastrectomy for incurable advanced gastric cancer in urgent situations in the elderly.

BACKGROUND: Chemotherapy is the standard treatment for incurable advanced gastric cancer; however, its indications are limited in elderly patients. Furthermore, the efficacy of chemotherapy and surgery as well as the treatment strategy for incurable gastric cancer in elderly patients with urgent conditions are unclear. In these situations, palliative gastrectomy or gastrojejunostomy is often performed. Less invasive surgical procedures should be performed on elderly patients in consideration of their condition; however, gastrectomy may be preferable if it can improve the prognosis. Therefore, we investigated the significance of palliative gastrectomy in elderly patients with incurable advanced gastric cancer who underwent surgery due to stenosis or bleeding. METHODS: Fifty-six patients aged >80 years with stage IV incurable advanced gastric cancer who underwent surgery at our department between February 1992 and July 2021 were included in the study. The patients underwent gastrectomy (distal and total gastrectomy) or gastrojejunostomy. We examined the association between the clinicopathological factors and overall survival after surgery. RESULTS: The subjects included 43 men and 13 women. Twenty-nine patients underwent distal gastrectomy or total gastrectomy, and 27 underwent gastrojejunostomy. The median follow-up duration for all patients was 297 days. The univariate analysis indicated significant differences in the surgical procedure and blood loss. Multivariate analysis showed a significant difference only in the surgical procedure (hazard ratio, 5.32; 95% confidence interval, 2.43-11.6; P < 0.001). CONCLUSIONS: Gastrectomy as a palliative surgery for incurable advanced gastric cancer in elderly patients may improve their prognosis.

Multicenter phase II clinical study of the efficiency and safety of capecitabine plus intermittent oxaliplatin with bevacizumab as first-line therapy in patients with metastatic colorectal cancer (VOICE trial).

PURPOSE: The aim of this phase II study was to evaluate the efficacy and safety of combination therapy with five-cycle CAPOX (capecitabine plus oxaliplatin) plus bevacizumab, followed by five-cycle maintenance therapy with capecitabine plus bevacizumab and reintroduction of CAPOX plus bevacizumab for five cycles, with a preplanned intermittent oxaliplatin strategy in metastatic colorectal cancer (mCRC). METHODS: Patients with untreated mCRC were administered CAPOX (130 mg/m2 oxaliplatin on day 1, 2000 mg/m2/day capecitabine on days 1-14, every 21 days) + bevacizumab (7.5 mg/kg) every 3 weeks for five cycles, maintenance treatment without oxaliplatin for five cycles, and CAPOX + bevacizumab reintroduction for five cycles or upon tumor progression. The primary endpoint was progression-free survival (PFS), and the secondary endpoints were the time to treatment failure (TTF), overall survival, response rate (RR), and safety. RESULTS: Forty-seven patients who fulfilled the inclusion criteria were enrolled in the evaluation of efficacy and safety. Median PFS was 14.1 months (95% confidence interval [CI], 8.6-19.5), and median TTF was 12.3 months (95% CI, 10.3-14.3). The objective RRs were 51.1% (24/47) during induction therapy, 58.3% (21/36) during maintenance therapy, and 63.6% (14/22) during reintroduction therapy. The frequency of patients with neutropenia, diarrhea, peripheral sensory neuropathy, venous thromboembolism, or grade ≥ 3 allergic reactions was 2.1%. CONCLUSION: CAPOX plus bevacizumab therapy with a preplanned intermittent oxaliplatin strategy consisting of brief five-cycle induction therapy, five-cycle maintenance therapy with capecitabine plus bevacizumab, and five-cycle reintroduction therapy consisting of CAPOX plus bevacizumab is safe and effective for mCRC patients. TRIAL REGISTRATION: UMIN ID: 000,005,732, date of registration: June 7, 2011.  https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000006695.

[Recurrence-Free Survival after Repeated Resections for Metastatic Inguinal Tumor in Colorectal Mucinous Adenocarcinoma-A Case Report].

A 79-year-old male presented with right inguinal mass and right leg pain. Laparoscopic right hemicolectomy was performed for transverse colon cancer(type 1, muc, pSS, pN1a, pStage Ⅲa)3 years and 6 months ago. We resected the mass located in the spermatic cord and reconstructed it using the Direct Kugel Patch. Histopathological examination revealed mucinous carcinoma and was diagnosed as a metastatic lesion. Local recurrence was detected in the spermatic cord 1 year after resection, and radical inguinal orchiectomy was performed. Six months after the surgery performed for local recurrence, repeated recurrence was detected in the mesh used for reconstruction. Because this recurrence time was short, the patient opted for chemotherapy; however, this resulted in tumor growth, and surgery had to be scheduled. We performed extended resection of the abdominal wall and reconstruction using the fascia lata tensor muscle flap. Although intestinal obstruction, aspiration pneumonia, and skin flap necrosis were observed, the patient was discharged on the 85th postoperative day and remained alive without recurrence for 17 months. Mucinous carcinoma tends to cause local recurrence and requires adequate surgical margin resection. Extended excision should be considered in such cases of repeated local recurrence without distant metastases.

[A Case of Boderline Resectable Pancreatic Cancer Curatively Resected after Chemotherapy with Gemcitabine and Nab-Paclitaxel].

Combination therapy containingnab -paclitaxel(nab-PTX)and gemcitabine(GEM)is widely administered for metastatic pancreatic cancer. Recently, this regimen is likely to be applied for treatment in patients with locally advanced disease or for neoadjuvant chemotherapy(NAC)in patients with borderline resectable(BR)pancreatic cancer. We report a case of BR pancreatic cancer in a patient who was eligible for comparison of the imaging findings with the microscopic findings of the resected specimen. A 72-year-old woman was admitted to our hospital with a complaint of jaundice. Enhanced CT showed a 35mm tumor at the head of the pancreas involvingthe portal vein and in contact with the superior mesenteric artery(SMA). After 4 courses of chemotherapy containinga combination of nab-PTX and GEM, the tumor reduced in size, but was still in contact with the portal vein and SMA on imaging. The level of tumor marker CA19-9 was remarkably reduced. Subtotal stomach-preservingpancreaticoduodenectomy with portal vein reconstruction was performed. Macroscopic findings of the cut surface of the resected specimen showed that a white nodule at the pancreas head involved the portal vein and was in contact with the close-cut margin from the SMA; however, microscopic findings revealed that tumor cells had disappeared in the plexus around the SMA. R0 resection was achieved. The histological treatment effect based on Evans' classification and TNM classification were GradeⅡ and pT3N1aM0(pStage ⅡB), respectively. There has been no recurrence 15 months after the surgery. Based on the abovementioned findings, chemotherapy containing a combination of nab-PTX and GEM can be an effective option of NAC for BR-A pancreatic cancer. Even if the tumor is in contact with the SMA on imaging, when the CA19- 9 level is markedly reduced, there is a possibility of achievingR0 surgery.

[A Case of Pathologically Complete Response of a Rectal Cancer after Preoperative Treatment with mFOLFOX6 and Radiation Therapy].

A 60-year-old man who had bloody stools after sigmoid colonoscopy was admitted to our hospital. A digital examination and sigmoid colonoscopy showed a type 2 circular tumor at location Rb with incomplete mobility and tumor hemorrhage, and the result of a biopsy was moderately differentiated adenocarcinoma (tub2). Computed tomography and magnetic resonance imaging suggested a possibility of invasion of the primary rectal tumor to the sacrum. The clinical stage was cT4bN0M0H0P0, cStage Ⅱ, which is generally not treatable by surgery. Sigmoid colostomy was performed, and a central venous port was implanted. After a preoperative treatment consisting of 3 courses of mFOLFOX6 and radiation therapy, the clinical stage changed to ycT2N0M0H0P0, ycStageⅠ. Super-low anterior resection and covering ileostomy were performed 46 days after the preoperative treatment. A pathological examination revealed no residual cancer cells in the primary lesion and lymph node (Grade 3, pCR). The patient has been disease-free for 4 years and 9 months after the operation.

[A Case of Locally-Advanced Breast Cancer with Liver Metastasis, Treated with Mastectomy of the Primary Tumor after Chemotherapy].

The patient was a 39-year-old woman who was referred to our hospital with suspicion of locally-advanced breast cancer. After several tests, she received a diagnosis of cT4bN1M1 (liver), Stage Ⅳbreast cancer. The liver metastasis was located in S4, and was 1 cm in size. Core needle biopsy was performed on the breast tumor; the pathological diagnosis was invasive ductal carcinoma (scirrhous carcinoma), nuclear Grade (NG) 3, and HER2-positive. She received epirubicin plus cyclophosphamide (EC) followed by docetaxel (DOC) plus pertuzumab (PER) plus trastuzumab (HER). After chemotherapy, the liver metastasis and axillary lymph node metastases had disappeared on imaging findings, showing a complete response (CR), but the primary breast tumor remained, showing a partial response (PR). She underwent mastectomy and axillary lymph node dissection for local control. After surgery, no metastases including liver metastases were seen on CT. The patient is currently receiving tamoxifen and anti-HER2 therapy.

[Clinical evaluation of eribulin mesylate for the treatment of metastatic breast cancer].

BACKGROUND: Eribulin mesylate, a novel non-taxane inhibitor of microtubule dynamics, results in a significant improvement in the overall survival of heavily pretreated patients with metastatic breast cancer(MBC). In the present study, we aimed to clarify the efficacy and safety of eribulin mesylate for the treatment of MBC. PATIENTS AND METHODS: We examined 18 patients with MBC who received eribulin mesylate in our hospital from October 2011 to May 2013. The patients were assessed for therapeutic response and adverse events with this treatment; in addition, these parameters were assessed in patients undergoing a combination treatment of eribulin mesylate and trastuzumab. RESULTS: The mean age of the patients in this study was 68.7 years(range, 60-85 years). All patients exhibited metastases to lymph nodes and distant sites. The mean number of prior regimens was 4.4(range, 2-9). The mean number of cycles of eribulin mesylate treatment administered was 7.2(range, 2- 17). The objective response rate and clinical benefit rate(PR+long SD)were 33.3%(6/18)and 50.0%(9/18), respectively, and the median progression-free survival was 6 months. The Grade 3/4 adverse events occurring in the patients included neutropenia in 13 patients(72.2%), anemia in 1 patient(5.6%), anorexia in 1 patient(5.6%), stomatitis in 1 patient(5.6%), and peripheral neuropathy in 1 patient(5.6%). However, 3 elderly patients who received the combination treatment of trastuzumab and eribulin mesylate experienced no adverse events. CONCLUSIONS: eribulin mesylate appears to demonstrate an acceptable tumor response in patients with MBC, and it can be safely administered to elderly patients if myelosuppression is carefully managed.

[A case of adenosquamous carcinoma of the sigmoid colon with inferior mesenteric vein thrombosis].

A 63-year-old man who had been admitted to another institute with sepsis and renal failure was referred to our hospital after computed tomography (CT) findings showed thickening of the walls in the sigmoid colon and a defect in contrast enhancement in the portal and inferior mesenteric veins. Emergency sigmoid colon resection with D2 lymphadenectomy was performed after detection of perforation due to sigmoid colon cancer. The histopathological diagnosis was adenosquamous carcinoma, pSS, int, INF b, ly1, v0, pN2, pStage IIIband inferior mesenteric vein thrombosis. He was discharged on day 12, and we administered anticoagulant warfarin therapy.

[A case of sigmoid colon cancer with abdominal wall abscess].

A 63-year-old man was admitted for an abdominal mass. Computed tomography revealed an abscess (21 × 20 cm) in the abdominal wall and a tumor in the sigmoid colon. Thus, cancer of the sigmoid colon complicated by an abscess of the abdominal wall was diagnosed. The abscess was drained and transverse colostomy was performed with curative intent. After the intervention, chemotherapy (XELOX×3) was administered. Three months later, sigmoidectomy was performed and the stoma was closed. Macroscopic and microscopic examination of the resected specimen detected no remnants of cancer. In patients with advanced colon cancer and abdominal wall involvement, a two-stage operation and preoperative chemotherapy may be considered essential when curative resection is performed.

[Long-term survival of a patient with esophageal cancer with brain metastasis after multidisciplinary therapy - a case report].

A 70-year-old woman was admitted for difficulty in swallowing. Esophageal cancer (MtLt, type 3, T4N3M0, cStage IVa) was diagnosed in May 2010. The cancer was unresectable, and chemoradiotherapy (CRT) with TS-1 was initiated in June 2010, and a partial response (PR) was observed. After CRT, TS-1 was continued, but a brain metastasis was detected owing to the development of right hemiplegia in April 2012. Craniotomy and tumorectomy were performed, and the right hemiplegia improved. Pathological examination of the brain tumor indicated squamous cell carcinoma. Because of a recurrence of brain metastasis, a gamma knife procedure was performed in May 2012. Subsequently, several recurrences of brain metastases were diagnosed, and a total of 7 gamma knife procedures were performed up to January 2014. Although systemic chemotherapy (5-fluorouracil and cisplatin [FP], 5 courses)was administered, the patient showed progressive lung metastases in February 2013. The chemotherapy regimen was changed from FP to docetaxel (TXT), but the lung metastases continued to progress up to June 2013. The patient died in March 2014. Patients with esophageal cancer and metastases to the brain have poor prognosis, but the present patient survived approximately 2 years after first diagnosis of metastases to the brain after multidisciplinary therapy.

Ductal branch-oriented pancreatic resection for an intraductal papillary mucinous neoplasm in the uncinate process that caused recurrent acute pancreatitis: a case report of successful treatment.

Acute pancreatitis reportedly occurs in about 15 % of cases of branch duct (BD)-intraductal papillary mucinous neoplasms (IPMNs), with two-thirds of BD-IPMNs being located in the head or uncinate process of the pancreas. However, the surgical indications and optimal treatment methods for BD-IPMNs have not been established. A 59-year-old Japanese male with epigastralgia was admitted to our hospital. A multidetector row computed tomography (MDCT) scan disclosed grade I acute pancreatitis. Magnetic resonance cholangiopancreatography disclosed a 1.5-cm BD-IPMN in the uncinate process. Two months after discharge, the epigastralgia recurred, and MDCT again revealed grade I pancreatitis. Due to the repeated episodes of pancreatitis, we performed ductal branch-oriented pancreatic resection. To detect the inferior branch of the Wirsung duct and avoid the development of a pancreatic fistula, we injected indigo carmine into the tumor which confirmed ligation of the inferior branch. Histopathologically, the tumor proved to be an adenoma. The postoperative course was uneventful in both the short- and long-term follow-up and, to date, there has been no recurrence of pancreatitis, or diabetes mellitus during the 6 years since pancreatectomy. This procedure is one of the methods that can be used for the successful resection of a BD-IPMN in the uncinate process that caused recurrent acute pancreatitis.

[A case of a patient with gastric cancer and liver metastasis -a long-term survival of 10 years].

We report a case of patient who is alive 10 years after total gastrectomy and partial liver resection for gastric cancer and liver metastasis, respectively. The patient is 69-year-old man who was examined in another hospital for nausea, tarry stool, and weight loss. Diagnosis by stomach fluoroscopy revealed gastric cancer and he was admitted to our hospital in September 2002. Computed tomography (CT) scan and ultrasonography (US) revealed liver metastasis in S7. Distant metastases were not detected. The patient underwent distal gastrectomy, transverse colon partial resection, and a hepatic partial resection in October 2002. Pathological findings showed SI, N1, and M1. Though adjuvant chemotherapy was given, a local recurrence was detected in the liver in February 2003. Hepatic arterial infusion (HAI) was started in April 2003. After 8 courses, HAI was discontinued because of hepatic artery obstruction. No additional distant metastases were found. Therefore, transdiaphragmatic radiofrequency ablation (RFA) was performed by thoracotomy. Currently, the patient is treatment free and remains alive after 10 years with no recurrence.

Mandibular bone metastasis of rectal cancer: Report of a case.

A 56-year-old man was referred with lower rectal cancer showing anal canal invasion and liver metastasis. He underwent an abdominoperineal resection and a partial hepatectomy. Adjuvant therapy with tegafur-uracil and leucovorin was administered postoperatively. Lung metastasis was detected 2 years later and was resected. Right mandibular metastasis was diagnosed 2 months after the resection of the lung metastasis. A partial mandibular resection was performed after chemoradiotherapy, followed by reconstruction with a titanium frame and oral cavity reconstruction with a greater pectoral musculocutaneous flap. The pathological diagnosis was metastatic rectal cancer, and the therapeutic effect chemoradiotherapy was Grade 2. He is presently alive without any evidence of cancer, and has maintained a good quality of life 3 years after the mandibular resection and more than 5 years after his first operation. Mandibular metastasis from rectal cancer is very rare and the prognosis is poor according to the literature, so this case is considered to be very unusual.

High preoperative neutrophil-lymphocyte ratio predicts poor survival in patients with gastric cancer.

BACKGROUND: The neutrophil-lymphocyte ratio (NLR) reflects inflammatory status. An elevated NLR has been reported to be a prognostic indicator in some malignant tumors. The aim of this study was to evaluate the clinical significance of the preoperative NLR in patients with primary gastric cancer. METHODS: A total of 709 men and 319 women, with a mean age of 64.4 years, who underwent gastrectomy were included. The numbers of patients in each pathological stage were as follows: stage I, 584; stage II, 132; stage III, 153; and stage IV, 159. The mean NLR was 2.62 +/- 1.68. A total of 127 patients (12.4%) with an NLR of 4.0 or more were classified as high NLR individuals in this study. The prognostic significance of a high NLR, together with various clinicopathological factors, was evaluated by multivariate analysis. RESULTS: The 5-year survival of patients with a high NLR was significantly worse than that of patients with a low NLR (57% vs 82%, P < 0.001). Univariate and multivariate analyses of clinicopathological factors affecting survival revealed that high NLR, depth of tumor, positive lymph nodes, distant metastasis, peritoneal metastasis, poorly differentiated type, and high platelet count were significant risk factors for reduced survival. On multivariate analysis, after adjusting for tumor stage, a high NLR was an independent risk factor for reduced survival (P = 0.003; adjusted hazard ratio, 1.845; 95% confidence interval, 1.236-2.747). CONCLUSION: A high preoperative NLR may be a convenient biomarker to identify patients with a poor prognosis after resection for primary gastric cancer.

Extended left hepatectomy of the left and middle hepatic venous drainage areas along the anterior fissure.

BACKGROUND: Extended left hepatectomy including the middle hepatic vein (MHV) may potentially induce right paramedian sector congestion of the remnant liver. METHODS: To prevent venous congestion in the right paramedian sector, we performed extended left hepatectomy including the left hemiliver and anterior segment, which drain into the MHV and left hepatic vein (LHV), for 15 patients. RESULTS: In 11 of 15 patients (73%), temporary clamping of the common trunk of the MHV and LHV and the proper hepatic artery provided the anterior fissure. Regeneration rate of the middle segment was similar to that of the right lateral sector (10.8% vs 11.2%) on postoperative computed tomography (CT) after 3 months. CONCLUSIONS: This procedure could represent a useful method for preventing postoperative venous congestion.

Portal vein branching pattern in anomalous right-sided round ligament.

OBJECTIVE: To study the relationship of anomalous right-sided round ligament with respect to branches of the portal vein. METHODS: We studied four patients of right-sided round ligament diagnosed radiologically in the last 5 years. 3-D volume rendered CECT abdominal images were analyzed for attachment of the round ligament in the liver in relation to portal venous anatomy and position of gallbladder. RESULTS: In all cases, a trifurcate pattern of portal venous branching was observed. Right-sided round ligament was attached at the point of divergence of the right anterior portal vein. The region to the left of the point of its attachment drained into the middle hepatic vein while the region to the right of the point of attachment drained into the right hepatic vein. The left portal vein branched into posterior and paramedian branches. Right, middle, and left hepatic veins were visualized having normal course in all cases. In all, the gallbladder was present to the left of the round ligament. CONCLUSIONS: Trifurcate pattern of portal vein branching in all four cases. Right-sided round ligament was attached to the bifurcation of the right anterior portal vein in all the cases. The left portal vein branched into posterior and paramedian branches.

Giant intrapelvic solitary fibrous tumor arising from mesorectum.

We report a patient who had a giant pelvic solitary fibrous tumor (SFT) that was excised with the aid of aortic balloon occlusion. A 27-year-old woman was diagnosed, at another hospital, as having an inoperable intrapelvic tumor. On admission, computed tomography showed that the uterus, urinary bladder, and rectum were compressed anteriorly by a pelvic tumor with a maximum diameter of 16 cm. On magnetic resonance imaging, the tumor contained mesh-like structures showing strong intensity. Transanal needle biopsy was performed, and SFT was diagnosed by immunostaining. The tumor was supplied by feeding vessels from the inferior mesenteric artery and bilateral internal iliac arteries. Despite massive intraoperative hemorrhage, this giant tumor was excised with the help of aortic balloon occlusion. An intrapelvic SFT should be resected after careful preparation of countermeasures for hemorrhage.

Laparoscopic major hepato-biliary-pancreatic surgery: formidable challenge to standardization.

INTRODUCTION: Although laparoscopic colorectal or gastric surgery has become widely accepted as a superior alternative to conventional open surgery, the surgical management of hepato-biliary-pancreatic disease has traditionally involved open surgery. Recently, many reports have described laparoscopic partial liver resection, lateral segmentectomy, and distal pancreatectomy. However, laparoscopic major hepato-biliary-pancreatic surgery, such as hepatic lobectomy and pancreaticoduodenectomy, has not been widely developed because of technical difficulties. METHODS: We describe our experience with laparoscopic major hepato-biliary-pancreatic surgery, including right hepatectomy using hilar Glissonean pedicle transaction, and pylorus-preserving pancreaticoduodenectomy. CONCLUSION: Although our experience is limited, and randomized study is necessary to elucidate the appropriate indications for and effects of the present procedures, we believe that laparoscopic major hepato-biliary-pancreatic surgery can be feasible, safe, and effective in highly selected patients, and that it will be one of the standard therapeutic options for carefully selected patients with hepato-biliary-pancreatic disease.

Comparison of laparoscopy-assisted and open pylorus-preserving pancreaticoduodenectomy for periampullary disease.

BACKGROUND: Although many reports have described laparoscopic pancreatic surgery, pancreaticoduodenectomy (PD) has not been widely accepted. The present study aimed to compare laparoscopy-assisted and open pylorus-preserving pancreaticoduodenectomy (PPPD) to investigate the feasibility, safety, and tumor clearance. METHODS: Fifteen patients with periampullary disease underwent laparoscopy-assisted PPPD, in which resection was performed laparoscopically and the reconstruction was performed through a small midline incision. These patients were compared with 15 patients who, during the same period, underwent conventional open PPPD. RESULTS: Mean operative time and mean blood loss were similar between groups. No significant differences in the incidence of complications or hospital stay were noted between groups. Surgical margin and number of lymph nodes found in the resected specimen did not differ between groups. CONCLUSIONS: Laparoscopy-assisted PPPD is on the same level with conventional open surgery in terms of perioperative outcomes or treatment efficacy.