[A Resected Case of Intraperitoneal Foreign Body Granuloma Mimicking Peritoneal Dissemination].

Foreign body granuloma(FBG)is a granuloma that occurs due to chronic inflammation caused by various residual foreign objects. In the field of gastrointestinal surgery, intraperitoneal foreign body granulomas(IPFBGs)are often caused by sutures materials or residual gauzes, but those caused by food residue are extremely rare. We present an IPFBG case of food residue caused by anastomotic leakage, which was difficult to be distinguished from peritoneal dissemination. The patient is a 74- year-old male. Anastomotic leakage occurred following low anterior resection for rectal cancer, peritoneal drainage and ileostomy were performed. 1.5 years after rectal resection, liver metastasis was diagnosed by CT and peritoneal dissemination was diagnosed by PET-CT. Both lesions were resected at the same time. The pathological findings were liver metastasis and FBG. It was presumed to be an FBG formed by food residue left behind after anastomotic leakage. It has reported that FBG caused by residual gauzes were shown a ring-shaped uptake by PET-CT, but that was not observed in our case. In addition, since a nodule suspected of liver metastasis was observed simultaneously, we considered no differential diagnosis other than peritoneal dissemination. IPFBG resembling peritoneal dissemination, occurred after anastomotic leakage. A food residue can cause IPFBG, it is necessary to consider IPFBG in decision making treatment strategy for peritoneal nodule.

[A Strategy of Treatment for Perforated Gastric Cancer].

In past reports, the incidence of gastric perforation accounts for 0.08 to 3.6% of all gastric cancers, and the proportion of perforated gastric cancer(PGC)in gastric perforations is 26 to 32%. In the treatment of PGC, critical care for peritonitis, diagnosis of gastric cancer and curability for gastric cancer are required simultaneously, so it is not easy to decide the treatment strategies. Therefore, for the purpose to consider treatment strategies for PGC, we conducted a clinicopathological study on PGC in our hospital for the past 12 years. There were 22 cases of PGC, and we analyzed clinicopathologically 19 cases excluding perforation during endoscopic resection and perforation during chemotherapy. The R0 surgery group tended to have a good prognosis even in PGC cases, and there was surgery-related death in the one-stage gastrectomy group. So it was considered desirable to perform radical surgery after the general condition was stable by the treatment of peritonitis was given priority in the PGC.

[Clinicopathological Examination of 81 Cases Added Gastrectomy for Early Gastric Cancer after ESD].

As a general rule, our department has performed additional gastrectomy with lymph node dissection(radical surgery: RS) for non-curative endoscopic submucosal dissection(ESD)cases. This time, we performed a clinicopathological study on 81 patients who underwent RS after ESD for 10 years from May 2009 to April 2019. Lymph node metastasis(LNM)was observed in 5 cases and local cancer residue(LCR)was observed in 8 cases. Examination of the presence or absence of LNM and LCR by clinicopathological factors(histopathological type, tumor size, lymphatic invasion[ly], venous invasion[v], horizontal margin[HM], vertical margin[VM], submucosal invasion, ulceration[scar])revealed no significant risk factor for LNM, however, tumor size and HM were significant risk factors for LCR. The relationship between the eCura system and the case rate associated with LNM in our hospital was similar to that in the original report. Regarding the prognosis, there was one local recurrence and no death from the primary disease.

[A Case of Primary Gastric Adenocarcinoma with Enteroblastic Differentiation(GAED)].

Gastric adenocarcinoma with enteroblastic differentiation(GAED)is a rare disease that is classified as a special type in the 15th edition Japanese Classification of Gastric Carcinoma. GAED is considered to have a poor prognosis. We report about a 76-year-old man with GAED who presented with complaints of poor appetite and weight loss. He was suspected of having gastric cancer based on ultrasonography and computed tomography findings and was referred to our hospital by his home doctor. Upper gastrointestinal endoscopy revealed a gastric cancer in the lesser curvature of the gastric antrum. Distal gastrectomy was performed. Histopathology showed a moderately differentiated adenocarcinoma with a clear cytoplasm. Immunostaining was positive for Sal-like protein 4(SALL4)and negative for α-fetoprotein(AFP). The patient was diagnosed as having GAED. Vascular and lymphatic invasion were not observed. He was discharged on the 9th day after surgery. At 5 months postoperatively, he was treated with adjuvant chemotherapy, and no recurrence was noted. GAED is a rare disease with a poor prognosis. We report this case and discuss relevant literature.

Prospective Multicenter Study on the Prognostic and Predictive Impact of Tumor Budding in Stage II Colon Cancer: Results From the SACURA Trial.

PURPOSE: The International Union Against Cancer highlighted tumor budding as a tumor-related prognostic factor. International assessment criteria for tumor budding were recently defined by the 2016 International Tumor Budding Consensus Conference (ITBCC2016). This study aimed to clarify the prognostic and predictive values of tumor budding in a randomized controlled trial evaluating the superiority of adjuvant chemotherapy with oral tegafur-uracil over surgery alone for stage II colon cancer (SACURA trial; ClinicalTrials.gov identifier: NCT00392899). PATIENTS AND METHODS: Between 2006 and 2010, we enrolled 991 patients from 123 institutions with stage II colon cancer. Tumor budding was diagnosed by central review on the basis of the criteria adopted in the ITBCC2016. We prospectively recorded all clinical and pathologic data, including the budding grade, and performed prognostic analyses after 5 years of completing the patients' registration. RESULTS: Of 991 tumors, 376, 331, and 284 were classified as BD1, BD2, and BD3, respectively; the 5-year relapse-free survival (RFS) rate was 90.9%, 85.1%, and 74.4%, respectively (P < .001), and ranged widely in T4 tumors (86.6% to 53.3%). The budding grade significantly correlated with recurrence in the liver, lungs, lymph nodes, and peritoneum (P < .001 to .01). Multivariable analysis revealed that budding and T stage exerted an independent impact on RFS, and on the basis of the Harrell concordance index, these two factors substantially contributed to the improvement of the Cox model for predicting RFS. Both the BD2 and BD3 groups demonstrated greater improvement in the 5-year recurrence rate in the adjuvant chemotherapy group than the surgery-alone group by approximately 5%, but the difference was statistically nonsignificant. CONCLUSION: Tumor budding grade on the basis of the ITBCC2016 criteria should be routinely evaluated in pathologic practice and could improve the benefit of adjuvant chemotherapy for stage II colon cancer.

[Cases of Oncologic Emergency Associated with Colorectal Cancer].

The clinical condition of oncologic emergency associated with colorectal cancer includes hemorrhage, perforation and obstruction. Obstructive colorectal cancer is an oncologic emergency commonly observed in our daily clinical practice. Colonic stent placement for obstructive colorectal cancer is relatively easy and safe and may be considered as an effective treatment method that enables favorable intestinal decompression preoperatively and one-stage resection. Colonic stent use can be a bridge to surgery, enabling shorter duration of hospitalization, and reduced postoperative complications, and colostomy rates, as compared to emergency surgery. From January 2009 to December 2016, this study was designed to evaluate the clinical outcomes of 68 patients who underwent surgery for obstructive colorectal cancer. The patients were divided into 2 groups: 32 cases receiving colonic stent placement(the S group), 36 cases receiving ileus tube and emergency surgery(the NS group). There was no significant difference in terms of morbidity or survival rate between the 2 groups. For the S group, 31 out of 32 could one-stage resection(94%). The colostomy rate in the S group was significantly lower than that in the NS group(3% vs 33%). In the S group, number of dissected lymph nodes was significantly larger and the duration of postoperative stay was shorter than that in the NS Group.

[A Case of Early Gastric Cancer with Multiple Lymph Node Metastases Revealed by Additional Surgical Resection after ESD].

A 74-year-old man was referred to our hospital for further investigation of a cystic lesion in the pancreatic body, which had been detected by ultrasonography at a local hospital. He was diagnosed as intraductal papillary mucinous neoplasm(IPMN) and further preoperative examinations were conducted. Upper gastrointestinal endoscopy demonstrated a type 0-II c tumor of the greater curvature in the upper third of the stomach. Endoscopic ultrasonography showed no sign of submucosal invasion. Endoscopic submucosal dissection(ESD)was carried out and pathological examination of a specimen revealed well differentiated adenocarcinoma with submucosal invasion, which fulfilled the indication for additional gastrectomy with lymph node dissection. Laparoscopy-assisted proxymal gastrectomy with D1 plus lymph node dissection and distal pancreatectomy with splenectomy was performed. Pathological examination demonstrated intraductal papillary mucious adenoma(IPMA)in the pancreatic body and no residual gastric cancer in a specimen, however 7lymph node metastases from gastric cancer was confirmed(pN3a), including 3 metastatic lymph nodes incidentally-detected adjacent to the pancreatic parenchyma. We report a rare case of early gastric cancer with N3 lymph node metastases, with a brief literature review.

A Soup Service for Advanced Digestive Cancer Patients with Severe Anorexia in Palliative Care.

BACKGROUND/AIMS: The palliative care team (PCT), nutrition support team (NST), and department of nutrition in our hospital developed a special soup service for patients with terminal cancer. We evaluated the usefulness of this soup service for improving the mood in patients with advanced digestive cancer with severe anorexia. MATERIAL AND METHODS: We retrospectively reviewed the clinical data of 18 patients with advanced cancer originating in digestive organs who received soup service at our institution between 2015 and 2016. Members of the PCT, NST, and a licensed cook visited the bedside of each patient and served them a cup of soup twice a week. RESULTS: Fifteen patients (83%) were able to taste the soup with no adverse events, and 11 (73%) of them enjoyed the taste of the soup. In the five patients who died in our hospital during the service, the time between their last soup intake and death ranged from two to seven days (median three days). CONCLUSION: Even terminally ill patients suffering from advanced digestive cancer with severe anorexia were able to enjoy the taste of the soup served to them. The establishment of special meal service, such as this soup service, may not only relieve their stress but also support the strength of living and help improve their spiritual quality of life.

Surgery and imatinib therapy for liver oligometastasis of GIST: a study of Japanese Study Group on GIST.

We conducted a multicenter prospective study to clarify the efficacy and safety of surgery and imatinib for liver oligometastasis of gastrointestinal stromal tumors. Eligible gastrointestinal stromal tumor patients were enrolled in the surgery trial or the imatinib trial. Primary endpoints were recurrence-free survival and progression-free survival, respectively. The trials were prematurely terminated due to amendment of guidelines for adjuvant imatinib therapy and low patient accrual. In the surgery trial, all the six patients showed hepatic recurrence: median recurrence-free survival was 145 days (range: 62-1366 days). Of the five patients receiving salvage imatinib therapy, two showed progressive disease although no death was observed. Of the five patients enrolled in the imatinib trial, one died of pneumonia after progressive disease, and four had not shown progressive disease as of last visit. The results suggest that liver oligometastasis of gastrointestinal stromal tumor may not be controllable by surgery alone and require concomitant imatinib therapy.

Multiple rectal carcinoid tumors in monozygotic twins.

We report multiple rectal carcinoid tumors in monozygotic twins who, respectively, had 42 and 36 carcinoid tumors in the lower rectum. This is the first report about carcinoid tumors in monozygotic twins. Both twins developed a similar number of rectal carcinoids with a similar distribution. Investigation of their genetic background may provide information about the origin of these tumors.

[A case of advanced gastric cancer found to be remaining by gastrectomy after a clinically complete response to chemotherapy].

The patient was a 72-year-old woman diagnosed with advanced gastric cancer, hepatic portal lymph node and para-aortic lymph node metastases. After five courses of S-1/CDDP combination therapy, both the primary tumor and lymph node metastases disappeared clinically. She wished to continue chemotherapy instead of having a resection. After three more courses of S-1/CDDP therapy, gastric cancer and lymph node metastases were still completely regressed, but complications of carcinoma of the gallbladder were suspected. Gastrectomy was performed with cholecystectomy, and a histopathological examination revealed cancer cells remaining in the gastric submucosa and xanthogranulomatous cholecystitis. We consider surgical therapy for clinically completely disappearing advanced gastric cancer by chemotherapy, in addition to case report.

[Efficacy of the combined use of taurine for hyperbilirubinemia caused by UFT therapy after surgery for colonic cancer].

For postoperative adjuvant chemotherapy, UFT was administered to 69 cases of stage II and III colonic cancer following surgery with a radical curability of A. Among these patients, 8 developed hyperbilirubinemia. UFT administration was discontinued for those who developed overt jaundice or dermatological symptoms, experienced a relapse of an earlier asthmatic respiratory difficulty, or for those who were found with multiple hepatic metastases. For the 4 who had developed subclinical jaundice with a total bilirubin level of 1.6 to 2.2 mg/dl, UFT was combined with taurine. The combination successfully eliminated hyperbilirubinemia. All 4 are currently alive with no recurrence at this writing. Taurine ameliorates one's capacity to excrete bile, blood flow, and augments the actions of hepatocytes. It is effective in treating the hyperbilirubinemia that develops during UFT therapy.