[Situation and Problems of Activities for Cancer Cooperative Treatment in Kumamoto].

The Consultation Support and Information Providing Committee, which is a subsidiary organization of the Kumamoto Cancer Medical Cooperation Council, created a critical path called"my medical chart,"which is used in Kumamoto prefecture jointly. The path was implemented in 2009 at designated cancer hospitals. For promoting cancer consultation support centers and nurturing cancer counselors, the Cancer Special Counselor Working Group was formed, and activities were initiated. These activities of the Committee resulted in an increased number of patients visiting the designated cancer hospitals. The number of medical cooperations using"my medical chart"exceeded 4,800. A disparity was also observed in cancer treatment, such as surgery, radiotherapy, and chemotherapy. We investigate the situation of cancer treatment and report current problems and future issues.

[Consideration of Surgical Treatment for Ileus Symptoms Associated with Progressing Cancer in Our Hospital].

INTRODUCTION: Many cases of terminal cancer develop ileus symptoms such as vomiting and abdominal distension. The causes of ileus symptoms include peritoneal dissemination, localized recurrence, etc. The treatments include octreotide acetate, decompression measures such as ileus tube, and surgical treatment. We evaluated the results of cases that underwent surgical methods to reduce ileus symptoms. METHODS: The subjects were 31 patients comprising 38 cases with ileus symptoms between January 2013 and January 2018. The surgical procedures included bypass(17 cases), tumor extirpation(7 cases), stoma(11 cases), and other(3 cases). RESULTS: Dietary intake information was available for 27 of the 38 cases; in cases that underwent tumor excision, all meals were able to be ingested and there were many cases of long-term survival. DISCUSSION: Surgical procedures can allow patients to eat food and should be considered as dietary intake after treatment is associated with survival duration.

[A Case of Advanced Cardia Gastric Cancer with Pernicious Anemia].

A 70s male was referred to our hospital with anemia that was detected during a medical checkup. Upper gastrointestinal endoscopy showed advanced cardia gastric cancer. A diagnosis of pernicious anemia was made due to the macrocytic hyperchromic anemia and detection of intrinsic factor antibody. A CT scan showed fundic wall thickening and regional lymph node metastasis. After anemia improved following vitamin B12 injection, total gastrectomy with lymphadenectomy was performed. The histopathological findings showed adenocarcinoma(tub1>tub2), Type2 , pT3(SS), pN1(2/24), Stage ⅡB, INF b, ly1, v2, PM0, DM0, EW(+), pR1. He was administered systematic chemotherapy using S-1 for one year after surgery and has been followed up without recurrence for 5 years.

[A Case of Hepatocellular Carcinoma with Portal Vein Tumor Thrombus Successfully Treated by Three-Dimensional Conformal Radiotherapy].

A man in his 50s was referred to our hospital with a liver tumor detected by ultrasonography during a medical checkup. Enhanced CT scan and MRI showed hepatocellular carcinoma(HCC)in S8 of the liver. Laparoscopic partial hepatectomy was performed. The histopathological findings showed well differentiated HCC. Two years later, his serum PIVKA-Ⅱ levels were slightly elevated. A new lesion was detected by US, CT, and MRI at S5 of the liver. A second laparoscopic partial hepatectomy was performed. The histopathological findings showed moderately differentiated HCC. After 1 year, MRI detected 2 new HCCs(S4, S8). The tumor at S8 had invaded the right branch of the portal vein. There was no indication for right hepatectomy because of liver dysfunction. Lipiodol-TACE followed by DEB-TACE was not effective on the tumor. The HCC at S8 had enlarged and formed a portal vein tumor thrombus. PIVKA- / Ⅱ levels increased to 3,596 mAU/mL. The patient was adminis- tered Three-dimensional conformal radiotherapy(45 Gy/15 Fr)and his PIVKA-Ⅱ levels decreased to the normal range. He has been followed-up without recurrences for 2 years and 9 months.

[Endoscopic Topical Therapy Using Mesh for Refractory Suture Failure after Rectal Cancer Surgery].

We reported a case that could be cured with endoscopic topical therapyusing mesh for refractorysuture failure after rectal cancer surgery. The patient was a 73-year-old man. He was diagnosed as lower rectal cancer, and underwent laparoscopic super law anterior rectum resection. On the 13th postoperative day, abdominal pain appeared, suspected ileal necrosis, emergencylaparoscopic examination laparotomywas performed. Upper gastrointestinal perforation was suspected from pus and food on the whole intraperitoneal cavity, and we moved laparotomy. But any perforations were not found, we resected ileum and inserted a drain tube to Douglas fossa. After second surgerydischarge of the juice from the drain was confirmed, diagnosis was made of suture failure of the anastomosis of the rectal cancer. He rejected artificial stomy, we chose conservative therapy. On 114th day after second surgerywe put a mesh for inguinal hernia in the puncture under the endoscope. On the next dayafter the treatment discharge of the juice from the drain was stopped. And finallyhe was discharged. This endoscopic treatment is considered to be useful for refractorysuture failure.

[Jejunal Interposition after Totally Laparoscopic Proximal Gastrectomy Using Overlap Method].

There are several reconstruction methods in laparoscopic proximal gastrectomy(LPG)for earlygastric cancer at the upper part of the stomach. To prevent the esophageal reflux after gastrectomy, we chose jejunal interposition(JI)via the retrocolic route for LPG. We performed totallyLPG with JI using overlap method. METHODS: Five ports were placed. After the lymph nodes dissection bythe standard procedure, the esophagus and the proximal side of the stomach were transected byliner staplers. The jejunum was moved to the upper abdomen through the small hole of the mesocolon. The interposing jejunum was made, and the esophagojejunostomyand jejunogastrostomywere done byusing overlap method. At the end, the jujunum was pulled under the mosocolon escluding the interposing jejunum. The JI reconstruction via a retrocolic route after LPG was completed. DISCUSSION: Following LPG, the JI reconstruction is not so popular because the surgical procedure is complicated. In our technique, the JI reconstruction accomplished easier byoverlap method. CONCLUSION: Our procedure is a considerable operation of reconstruction following LPG.

[Two Cases of Stage IV Pancreatic Cancer Has Gained Relatively Long Free Survival in Multimodality Therapy].

We experienced 2 cases in which Stage IV pancreatic cancer(General rules for the study of pancreatic cancer, The 6th edition, Japanese Pancreas Society)underwent chemotherapy and radiotherapy after surgical operation and had relatively long term relapse-free survival. Local control by adding radiation therapy to surgical resection and suppressing the distant metastases in adjuvant chemotherapy may improve the prognosis.

[A Case of Long-Term Survival of Breast Cancer with Lymph Node and Liver Metastases Treated with Sequential Anti-HER2 Drugs, Chemotherapy, and Endocrine Therapy].

A 50s-year-old woman underwent left partial mastectomy with axillary lymphadenectomy for breast cancer. Histological examination indicated invasive ductal carcinoma, pT1c, pN0, Stage I , ly(+), ER(+), PgR(+). She received adjuvant therapy with tamoxifen and 50 Gy of irradiation to the residual breast. Four years after mastectomy, she was found to have left Rotter lymph node metastasis; then, anastrozole was administered instead of tamoxifen. Nine months later, she was found to have liver metastasis. Immunohistostaining revealed that the breast cancer was HER2-positive; she received AC followed by paclitaxel(PTX)with trastuzumab(T), and achieved complete response(CR). Subsequently, abdominal, cervical lymph node, and liver metastases appeared. Letrozole followed by lapatinib with capecitabine, FEC100, PTX with T, eribulin, S-1, docetaxel with pertuzumab and T, everolimus with exemestane, bevacizumab, and PTX were then administered, resulting in long-term disease control. Sixteen years after mastectomy, she receives outpatient chemotherapy in performance status 1 state.

[A Case of Recurrent Inflammatory Breast Cancer Treated Using Multidisciplinary Therapy].

The patient was a 65-year-old woman who underwent segmental mastectomy for left breast cancer 5 years ago. The pathological diagnosis ofthe tumor was noninvasive ductal carcinoma, TisN0M0 and Stage 0. Postoperative radiation therapy was performed, but chemotherapy and hormone therapy were not administered. The patient presented with redness of the residual left breast. Skin biopsy showed lymphatic invasion of adenocarcinoma, and the patient was diagnosed with inflammatory carcinoma ofthe breast. After 4 cycles ofAC followed by 4 cycles ofdocetaxel, the mass was diminished and the redness disappeared. Total mastectomy with wide skin resection and axillary lymph node dissection was performed. The pathological diagnosis revealed scirrhous carcinoma ofthe left residual breast(T3N0, Stage II B, s, f, g, margin[-], ly0, v0, ER[+], PgR[+], HER2[1+]). She received treatment with an aromatase inhibitor, and 2 years after the operation is alive with no recurrence.

[A Case of Small Intestinal Gastrointestinal Stromal Tumor(GIST)with Synchronous Colonic Cancer and Gastric Cancer at a Different Time].

The patient was a 70-year-old woman with a gastrointestinalstromaltumor (GIST)of the small intestine and synchronous colonic cancer, who underwent laparoscopic right colectomy and resection of the small intestine. We started imatinib therapy because GIST belongs to a high-risk group, according to the modified Fletcher classification. Gastric cancer was diagnosed 2 years after the start of imatinib therapy. Only 4 of the 12 GIST cases seen at our institution over the last 5 years were complicated by another cancer. This is the first case of GIST in which 2 other cancers occurred at both the same and different times. We suggest that imatinib might be a factor in the development of gastric cancer.

[A Case of Laparoscopic Gastrectomy for Gastric GIST after Neoadjuvant Chemotherapy with Imatinib Mesylate].

We report the case of a 68-year-old woman who underwent laparoscopic gastrectomy for a gastric gastrointestinal stromal tumor (GIST) after neoadjuvant chemotherapy with imatinib mesylate. After conducting gastroscopy because of weight loss and anemia, we identified a submucosal tumor in the cardia. A GIST of 8 cm in diameter invaded the pancreatic tail and excluded the splenic vein. We administered imatinib 400 mg/day as neoadjuvant chemotherapy. We performed laparoscopic partial gastrectomy 5 months after the initiation of chemotherapy. According to the histopathological diagnosis, the surgical margin was positive. As an additional excision, we performed laparoscopic proximal gastrectomy. Without postoperative complications, it passes smoothly as of 5 months after surgery.

[Lymphadenectomy performed along the left recurrent laryngeal nerve after anterior detachment of the esophagus via thoracoscopic esophagectomy in the prone position under artificial pneumothorax].

Thoracoscopic esophagectomy was performed in the prone position under artificial pneumothorax and did not affect the surgical area during lung ventilation; tracheal mobility was also improved. Lymphadenectomy around the left recurrent laryngeal nerve was performed by separating the left main bronchus and trachea between the esophagus and pericardium before detaching the dorsal side of the esophagus.

[A case of rectal cancer treated with aggressive surgery for liver and anal metastases].

A 64-year-old man underwent laparoscopic surgery for rectal cancer and lateral lymph node dissection. The histopathological findings indicated adenocarcinoma (moderate>well), pA, pN3(4/25No 263 1/1), pM0, Stage IIIb. After the surgery, he received 12 courses of adjuvant chemotherapy with modified 5-fluorouracil Leucovorin oxaliplatin (mFOLFOX6). Liver metastasis( S8)was present, and open hepatectomy was performed 1 year after the first surgery. Three months after the second surgery, the carcinoembryonic antigen (CEA) level increased and chemotherapy TS-1 was started. However, the CEA level continued to increase, and positron emission tomography-computed tomography revealed peritoneal dissemination, and multiple lymph node, bone, and local metastases(in the liver and rectum). Accordingly, 11 courses of chemotherapy with 5- fluorouracil Leucovorin irinotecan (FOLFIRI) and bevacizumab was administered. The patient recently experienced anal bleeding during each bowel evacuation, which developed owing to the recurrence of the cancer in the anus. To improve his quality of life, the anal tumor was excised 2 years 6 months after the first surgery. Chemotherapy with FOLFIRI and bevacizumab was restarted. The CEA level stopped increasing. We think that the anal surgery did not affect our patient's prognosis but helped improve his quality of life.

[A case report of scirrhous gastric cancer with peritoneal dissemination treated effectively with various chemotherapy regimens after laparoscopic distal subtotal gastrectomy].

We report a 44-year-old male patient who was diagnosed with scirrhous gastric cancer with peritoneal dissemination using laparoscopy. The patient underwent a non-curative resection with laparoscopic distal subtotal gastrectomy. In addition, we placed a port into the patient's abdomen for intraperitoneal chemotherapy administration. Postoperatively, we administered capecitabine (per os)+ paclitaxel (intraperitoneally) and, after 2 cycles, the oral anticancer agent 5-FU was given. The patient died of peritonitis carcinomatosa 25 months after the operation. The combined therapies contributed to improve the quality of life, specifically oral ingestion, for 2 years.

[Present status and future perspectives of the regional referral clinical pathway of cancer in Kumamoto].

Preparation of a system of community cooperation clinical pathway is called for by The Basic Act on Anti-Cancer Measures and The Basic Plans for National Cancer Strategy. Designated cancer care hospitals should play a very important role in constructing a local communication system among hospitals, clinics and nursing homes. In order to cooperate for seamless care of cancer, a notebook for patients with cancer has been made in Kumamoto by launching the Kumamoto Prefecture Regional Cooperation Conference of cancer management with the assistance of Kumamoto Prefectural government and the designated cancer care hospitals. This notebook consists of case information, treatment history, treatment goals, time schedule for cancer treatment, harmful phenomena due to cancer chemotherapy and counterplans for such side effects. This notebook will serve to improve comprehension and the attitude not only of patients, but also of co-medicals to cancer status and treatment. A physician approach and medical system are needed so that each patient can receive cooperative cancer treatment and care between hospitals and clinics.