A case of gastric adenocarcinoma with pyloric gland-type infiltrating submucosa.

BACKGROUND: The development of immunohistochemical staining has revealed that gastric adenocarcinoma with the gastric phenotype can be divided into the foveolar, fundic gland, and pyloric gland phenotypes. Gastric adenocarcinoma of the pyloric gland type is difficult to diagnose using biopsy because of its low atypia and rarity. Herein, we describe a case of gastric adenocarcinoma of the pyloric gland type that was diagnosed immunohistochemically after endoscopic resection. CASE PRESENTATION: A 67-year-old man was referred to our hospital for the diagnosis and treatment of a 30-mm elevated lesion on the lesser curvature side of the middle of the gastric body. Although four biopsies were performed, it was difficult to determine whether the lesion was benign or malignant. Therefore, endoscopic submucosal dissection was performed, and the presence of tumor cells infiltrating the submucosa with venous invasions was identified. Immunohistochemical staining revealed that the tumor cells were positive for MUC5AC and MUC6 and negative for Pepsinogen I and H + /K + -ATPase. From the above findings, he was diagnosed as having gastric adenocarcinoma with pyloric gland type. The patient underwent a laparoscopic distal gastrectomy and was discharged without any adverse events. CONCLUSIONS: Gastric adenocarcinoma of the pyloric gland type is a rare disease, and endoscopic resection can serve as a viable diagnostic option for this condition when it is difficult to diagnose using biopsy. Immunohistochemical pathology images can aid in the diagnosis of gastric adenocarcinoma of the pyloric gland type.

Refractory gastrocutaneous fistula treated by two-stage surgery: a case report.

BACKGROUND: Gastrocutaneous fistulas are a rare complication of enterocutaneous fistulas and can be caused by intestinal injury, infection, and anastomotic leakage. They are typically treated conservatively or endoscopically; however, for large or difficult-to-treat gastrocutaneous fistulas, surgical intervention is required. Herein, we present a case of a huge gastrocutaneous fistula that was successfully treated with a two-stage surgery performed using open abdomen management. CASE PRESENTATION: A 61-year-old man with a perforated gastric ulcer underwent omental filling as an emergency surgery. Post-operative leakage led the development of a 10-cm gastrocutaneous fistula. He was transferred to our hospital for the treatment of gastrocutaneous fistula. Furthermore, nutritional therapy was administered for dehydration, electrolyte abnormalities, metabolic acidosis, and acute kidney injury due to the high-output nature of the fistula. Moreover, owing to the intraperitoneal severe adhesion and poor nutritional status, two-stage surgery was planned. In the first stage, extensive dissection of the adhesions, distal gastrectomy reconstruction with Roux-en-Y anastomosis, and jejunostomy were performed. Furthermore, open abdomen management was conducted to check for the presence of unexpected complications due to extensive dissection of the adhesion and anastomotic leakage. Subsequently, in the second stage of the surgery, abdominal closure was performed on the 9th day after gastrectomy. CONCLUSION: Open abdomen management may be effective for huge gastrocutaneous fistulas with extensive adhesions that require surgical intervention.

Usefulness of indocyanine green fluorescence-guided small intestinal bleeding site identification in small bowel resection: a report of two cases and literature review.

Small bowel bleeding that does not respond to conservative therapy requires surgical resection. However, identifying the bleeding sites intraoperatively is challenging. Indocyanine green (ICG) fluorescence imaging improves diagnosis of small bowel bleeding and surgical decision-making by visualizing blood flow. Herein, we reported two cases of small bowel bleeding that were successfully treated by using ICG to identify the bleeding sites and determine the extent of small bowel resection. The patients were a 46-year-old and a 75-year-old woman, both of whom presented with melena. Contrast-enhanced computed tomography and arteriography confirmed small bowel bleeding, and rebleeding occurred in both patients after transcatheter arterial embolization. Emergent surgeries were performed, and intraoperative selective angiography with ICG injections was conducted to identify obscure bleeding sites. ICG fluorescence identified all bleeding sites in both cases, and small bowel resections were successfully performed. The postoperative courses were uneventful, and both patients had a favorable postoperative course without recurrence of bleeding. ICG fluorescence imaging can safely identify the sites of intestinal bleeding and determine the appropriate extent of bowel resection.

Gastric cancer with a giant lymph node metastasis: a case report and review of the literature.

A 78-year-old man presented with a large abdominal mass detected by ultrasonography during a regular checkup. Even if the mass was > 10 cm in diameter, he was asymptomatic. Computed tomography detected an oval-shaped mass, with a maximum diameter of 12 cm, adjacent to the greater curvature of the stomach. Esophagogastroduodenoscopy revealed a 20 mm slightly depressed (type 0-IIc) lesion on the posterior wall of the gastric antrum, which was confirmed to be adenocarcinoma. Three cycles of combination chemotherapy with S-1 and oxaliplatin were administered as neoadjuvant chemotherapy. After neoadjuvant chemotherapy, the patient underwent distal gastrectomy, and a histopathological study identified the 12 cm giant mass as a lymph node metastasis. The postoperative course was uneventful, and thus far, the patient has completed adjuvant chemotherapy without relapse. Cases of gastric cancer with a giant lymph node metastasis are extremely rare. In this study, we report the present case and review the previous literature.

False-positive 123I-metaiodobenzylguanidine scintigraphy in a patient with a gastrointestinal stromal tumor presenting as a left adrenal incidentaloma.

Summary: A 47-year-old man was diagnosed with a left adrenal incidentaloma at 40 years of age. The tumor had irregular margins and grew from 18 mm to 30 mm in maximum diameter over 7 years. On computed tomography scan, the mass appeared to localize within the tip of the lateral limb of the left adrenal gland, and between the left adrenal gland and the posterior wall of the stomach. The plasma corticotropin and cortisol concentrations and the 24-h urine fractionated metanephrine levels were normal. 123I-metaiodobenzylguanidine scintigraphy showed tumor avidity consistent with a hormonally inactive pheochromocytoma. A laparoscopic left adrenalectomy was performed; however, no tumor was present in the resected specimen. Abdominal computed tomography postoperatively showed that the tumor remained intact and appeared to connect to the posterior wall of the stomach. A laparotomy was performed and the tumor was removed. The tumor was localized to the intraperitoneal space and isolated from the posterior wall of the stomach. The pathological diagnosis was a gastrointestinal stromal tumor. Clinicians need to be aware of the limitations of diagnostic imaging studies in diagnosing non-functioning adrenal incidentalomas, which require a pathological analysis for the final diagnosis. Moreover, clinicians need to provide patients with sufficient informed consent when deciding on treatment strategies. Learning points: Anatomic structures and tumors that develop in neighboring tissues to the adrenal glands may be confused with primary adrenal tumors. 123I- metaiodobenzylguanidine (MIBG) scintigraphy is specific for diagnosing pheochromocytomas and paragangliomas; however, it has been reported that 123I-MIBG may accumulate in neuroendocrine tumors as well as other tumors. Clinicians should recognize the limitations of imaging studies and the uncertainty of an imaging-based preoperative diagnosis.

Hemothorax due to a ruptured esophageal gastrointestinal stromal tumor: case report.

BACKGROUND: Esophageal gastrointestinal stromal tumors (GISTs) are rare tumors of the gastrointestinal interstitium, and comprise less than 0.7% of all GISTs. The presentation of esophageal GIST is relatively benign, commonly characterized by symptoms of dysphagia and gastrointestinal bleed. On the contrary, it is highly unusual for these tumors to present as surgical emergencies. CASE PRESENTATION: Here, we describe a case of hemothorax secondary to the rupture of a massive (19 cm) esophageal GIST in a 79-year-old male. The patient presented with mild back pain, vomiting, and hypotension. A CT scan revealed significant mediastinal enlargement and left hemothorax. We conducted an emergency thoracotomy which revealed a 19 × 15 × 7 cm ruptured esophageal tumor that was bleeding profusely into the left thoracic cavity. Piecemeal resection without esophagectomy was performed to achieve hemostasis. Pathological evaluation of resected tissue confirmed the diagnosis of GIST. The patient was provided adjuvant imatinib therapy and remains progression-free at the 10-month follow-up. CONCLUSIONS: To the best of our knowledge, this is the first reported case of life-threatening hemothorax caused by a ruptured esophageal GIST. Findings from this case may aid in the diagnosis and management of these rare tumors.

Bowel perfusion demonstrated using indocyanine green fluorescence imaging in two cases of strangulated ileus.

We report the use of indocyanine green (ICG) fluorescence for intraoperative diagnosis in two cases of strangulated ileus. We successfully preserved the bowel and avoided postoperative complications by detecting adequate perfusion and no necrosis in the intestine's strangulated regions. In the first case, enhanced computed tomography (CT) revealed a closed loop intestine, which showed poor contrast, and we performed laparotomy with ICG fluorescence. In the second case, the CT scan revealed bowel obstruction without ascites. We conservatively treated the patient with the insertion of a long tube. The patient's condition did not improve, and we performed laparotomy using ICG fluorescence. In both of these cases, the visual observation during laparotomy showed that the ileum had dark-red discoloration. We demonstrated perfusion and preserved the ileum by injecting 2.5 mg of ICG intravenously; fluorescence was observed in the dark-red ileum using the PINPOINT system (Novadaq, Kalamazoo, MI, US). Both patients recovered successfully after the surgery with no adverse events. Our data suggest that ICG fluorescence imaging can be one of the decision-making modalities in patients with strangulated ileus.

Proposal of new treatment algorithm for gastric cancer liver metastases: Up-front surgery or conversion surgery?

Hepatectomy for gastric cancer liver metastases (GCLM) has a 5-year survival rate of 9-42%; however, indications for hepatectomy remain unclear. Many researchers have reported prognostic factors for GCLM after hepatectomy, but surgical indications vary according to the literature. Furthermore, the indication for optimal candidates for neoadjuvant chemotherapy and intensive chemotherapy is also unclear. To understand the indications for surgery and chemotherapy intended for hepatectomy for GCLM, a new treatment algorithm was created based on previously reported evidence from the viewpoint of hepatic surgeons.

Infection control of COVID-19 in operating theaters in a designated hospital for specified infectious diseases in Japan.

At the beginning of the COVID-19 pandemic in 2020, many hospitals around the world recommended stopping elective surgery as a precaution to stop the spread of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The number of elective surgeries was reduced in Japan due to several waves of the pandemic. This work describes the management of COVID-19 and actual polymerase chain reaction (PCR) screening in operating theaters at the National Center for Global Health and Medicine (NCGM), a designated hospital for specified infectious diseases in Japan. The following three steps for COVID-19 infection control were taken to maintain the operating theater: i) Do not bring COVID-19 into the operating theater, ii) Infection control for all medical staff, and iii) Surgical management of surgical patients with COVID-19. We introduced checklists for surgical patients, simulations of surgery on infected patients, screening PCR tests for all surgical patients, and use of a negative pressure room for infective or suspected cases. We determined the flow and timing of surgery for patients with COVID-19. However, many aspects of COVID-19 infection control measures in the operating theater are still unclear. Therefore, infection control measures require further advances in the future to manage new infections.

Computed tomography-guided lymphangiography from the para-aortic lymph node: a useful approach for chylothorax after esophagectomy.

BACKGROUND: Chylothorax is a relatively rare complication of esophagectomy but can lead to fatal conditions. The aim of this report was to present a case of lymphangiography from the para-aortic lymph node (PALN) under computed tomography (CT) guidance, which could be an alternative modality to ultrasound sonography from the groin. CASE PRESENTATION: A 58-year-old man was diagnosed as having postoperative chylothorax after esophagectomy following neoadjuvant chemotherapy. As the pleural effusion did not improve, intranodal lipiodol lymphangiography from the inguinal lymph node was performed but was unsuccessful. Therefore, CT-guided lymphangiography from the left PALN was performed, and the pleural effusion drainage significantly disappeared. CONCLUSIONS: CT-guided lipiodol lymphangiography from the PALN for chylothorax after esophagectomy was safe and thus can be considered an alternative treatment option to ultrasonography-guided intranodal lymphangiography. The flexible use of CT and ultrasonography for lymphangiography may improve the treatment outcomes of chylothorax after esophagectomy.

Right-sided Bochdalek hernia in an adult with hepatic malformation and intestinal malrotation.

BACKGROUND: Bochdalek hernia is a common congenital diaphragmatic defect that usually manifests with cardiopulmonary insufficiency in neonates. It is very rare in adults, and symptomatic cases are mostly left-sided. Diaphragmatic defects generally warrant immediate surgical intervention to reduce the risk of incarceration or strangulation of the displaced viscera. CASE PRESENTATION: A 47-year-old woman presented with dyspnea on exertion. Computed tomography revealed that a large part of the intestinal loop with superior mesenteric vessels and the right kidney were displaced into the right thoracic cavity. Preoperative three-dimensional (3D) simulation software visualized detailed anatomy of displaced viscera and the precise location and size of the diaphragmatic defect. She underwent elective surgery after concomitant pulmonary hypertension was stabilized preoperatively. The laparotomic approach was adopted. Malformation of the liver and the presence of intestinal malrotation were confirmed during the operation. The distal part of the duodenum, jejunum, ileum, colon, and right kidney were reduced into the abdominal cavity consecutively. A large-sized oval defect was closed with monofilament polypropylene mesh. No complications occurred postoperatively. CONCLUSION: Symptomatic right-sided Bochdalek hernia in adults is exceedingly rare and is frequently accompanied by various visceral anomalies. Accurate diagnosis and appropriate surgical repair are crucial to prevent possible incarceration or strangulation. The preoperative 3D simulation provided comprehensive information on anatomy and concomitant anomalies and helped surgeons plan the operation meticulously and perform procedures safely.

Prolonged survival of a patient with aortogastric fistula treated with combined surgery and endovascular stent placement: A case report.

INTRODUCTION: Aortogastric tube fistula is a rare and fatal complication of esophagectomy. The treatment for aortogastric tube fistula with active infection is challenging, wherein a contamination around the fistula can cause a high risk of aneurysm and recurrence of bleeding, even if large amount of bleeding is controlled immediately. PRESENTATION OF CASE: We present a case of a 54-year-old male patient who underwent lower esophagectomy for esophageal squamous cell carcinoma 22 years ago. He developed aortogastric tube fistula on postoperative day 46. The patient underwent two surgeries and stenting for aortogastric tube fistula and pseudoaneurysm between days 46 and 120 following the first surgery, and digestive reconstruction was performed 6 months after the first surgery. Computed tomography and esophagogastroduodenoscopy were performed periodically, and the postoperative course was uneventful for 22 years. However, the patient died from pneumonia at the age of 76 years. Autopsy findings revealed no recurrence of esophageal cancer, anastomotic complications, or stent issues. The fistula between the aorta and gastric tube was closed with a stent and connective tissue. Intrathoracic findings revealed that the cause of death was severe bilateral pneumonia. DISCUSSION: Immediate hemodynamics stabilization and interval infection control enabled successful disease management. CONCLUSION: Tenting for aneurysm was performed under aseptic conditions, and the patient did not experience recurrence of esophageal cancer and stent issues, which contributed to the long-term survival of 22 years.

Current status of doublet combinations of platinum and fluoropyrimidines using oxaliplatin for advanced gastric cancer.

The most common treatment for advanced gastric cancer (AGC) is systemic chemotherapy. The standard treatment for advanced gastric cancer differs worldwide. In Japan, two phase III clinical trials demonstrated the non-inferiority of S-1 compared with 5-fluorouracil (5-FU) and superiority of cisplatin plus S-1 (CS), compared with S-1, with respect to overall survival (SPIRITS trial). Oxaliplatin (L-OHP) has a favorable toxicity profile compared with cisplatin; hence, a phase III clinical trial (G-SOX trial) demonstrated the progression-free survival (PFS) and overall survival in CS was 5.4 and 13.1 months and those in SOX was 5.5 and 14.1 months, respectively. Serious adverse events were more frequently seen in CS than in SOX. So, SOX is as effective as CS for advanced gastric cancer with favorable safety profile. After the publication of this G-SOX trial, the combination of oral or intravenous 5-FU and various doses of L-OHP have been reported. And FOLFOX6 regimen (FOLFOX: a combination of 1-LV and FU with L-OHP) was approved for the treatment of AGC in Japan in 2017. FOLFOX was promising for patients with severe peritoneal metastasis from AGC, because the FOLFOX regimen does not require hydration and does not include oral agents. This review summarizes the efficacy and safety of doublet combinations of platinum and fluoropyrimidines using L-OHP for advanced gastric cancer.

Surgical strategies for treatment of clinical T4 esophageal cancer in Japan.

Definitive chemoradiation (dCRT) is the mainstay treatment for cStage IVa esophageal squamous cell carcinoma (ESCC) with good performance status (PS), according to standard practice guidelines. Salvage surgery may incur operation complications and risk of mortality. According to the esophageal cancer practice guidelines outlined by the Japan Esophageal Society, when a tumor is residual and recurrent, chemotherapy and palliative symptomatic treatment is continued. However, salvage operation has been selected as a therapeutic option for recurrent or residual tumors after dCRT. There is weak evidence for not recommending surgery for cStage IVa ESCC exhibiting residual disease following dCRT. It has been reported that during salvage surgery the only prognostic factor that is thought to be performed is complete resection (R0), but at the same time, salvage esophagectomy increases the incidence of postoperative complications and mortality. The phase II chemoselection study by Yokota T et al. in Japan showed that multidisciplinary treatment initiated by induction therapy, in which docetaxel is added to cisplatin and 5-fluorouracil, resulted in a good prognosis in the short term. In this review, we discuss the surgical strategy and future of unresectable clinical T4 (cT4) ESCC.

Current status of immune checkpoint inhibitor therapy for advanced esophageal squamous cell carcinoma.

Esophageal cancer is the seventh most common cancer, with an estimated 572,000 new cases, and the sixth most common cause of cancer-related deaths in 2018 with 509,000 annual worldwide deaths. Advanced esophageal squamous cell carcinoma (ESCC) is one of devastating tumors with a 5-year survival rate of less than 5% in patients with metastatic disease. Treatment options for patients with advanced ESCC are limited. Current guidelines recommend chemotherapy containing a platinum and a fluoropyrimidine agent as a first-line treatment. Recently, immune checkpoint inhibitors (ICIs), including nivolumab and pembrolizumab, have demonstrated antitumor activity and clinical efficacy in patients with advanced ESCC that is refractory or intolerant to first-line chemotherapy. ICIs are game-changers that not only transformed oncological strategy but also have a wide range of clinical potential in combination with conventional cytotoxic chemotherapy and radiotherapy. There is still an urgent, unmet need for reliable treatment options to conquer this intractable disease.

Billroth-I vs Roux-en-Y after distal gastrectomy: A comparison of long-term nutritional status and survival rates from a large-scale multicenter cohort study.

BACKGROUND: The optimal standard reconstruction procedure after distal gastrectomy is controversial. No large-scale persuasive clinical studies from long-term perspectives on this topic have yet been conducted. STUDY DESIGN: This retrospective multicenter study analyzed a database of 2510 consecutive patients with clinical stage I gastric cancer who underwent distal gastrectomy followed by Billroth-I (B-I) or Roux-en-Y (R-Y) anastomosis from 2006 to 2012. After adjusting for 30 potential confounding factors using propensity score matching, we compared the body weight loss and other nutritional status for 5 years as primary outcomes between the two groups. We also investigated surgical outcomes, endoscopic findings, and long-term survival rates as secondary outcomes. RESULTS: After matching the inclusion criteria, 940 patients (470 in each group) were enrolled. There was no marked difference in the body weight loss and other nutritional indicators. The incidence of grade ≥3 postoperative complications (Clavien-Dindo classification) or the incidence of gallstone formation was not markedly different between the two groups. The postoperative hospital stay after surgery was significantly longer, and the readmission rate was significantly higher in the R-Y group than in the B-I group. An endoscopic examination revealed no trends regarding the incidence and severity of gastritis or residual food in the remnant stomach. The 5-year overall survival rate was 92.6% in the B-I group and 91.8% in the R-Y group, with no significant difference (P = .379, log-rank test). CONCLUSIONS: Roux-en-Y reconstruction may be nearly equal to Billroth-I with regard to the long-term nutritional perspectives.

[A Case of Gallbladder Carcinoma Producing Alpha-Fetoprotein(AFP)with Metastatic Liver Tumor].

Gallbladder carcinoma producing alpha-fetoprotein(AFP)is rare.We report a case of AFP producing carcinoma of the gallbladder with huge metastatic hepatic tumor.A 81-year-old female with a hepatitis B virus(HBV)had a fever and right hypochondralgia.Abdominal CT showed an enlarged gallbladder with gallbladder stones, a huge tumor in the right lobe of liver, and swelling paraaortic lymph nodes.Acute cholecystitis was treated by percutaneous transhepatic gallbladder drainage (PTGBD).The hepatic tumor was diagnosed as hepatocellular carcinoma for HBV carrier and the high level of AFP and PIVKA- II .We performed right lobectomy, cholecystectomy and the resection of paraaortic lymph nodes.In the resected gallbladder, the papillary tumor was detected.Histopathological diagnosis was moderately to poorly differentiated adenocarcinoma of the gallbladder.The liver tumor and paraaortic lymph nodes were metastases of the gallbladder carcinoma.The both of gallbladder and liver tumor immunohistochemically stained positive to AFP.It was difficult to diagnose the hepatic tumor because of HBV carrier, the high level of AFP and the unnoticed gallbladder tumor.Gallbladder carcinoma with the high level of AFP might have relation to liver metastases.

Clinical Significance of Splenic Hilar Dissection with Splenectomy in Advanced Proximal Gastric Cancer: An Analysis at a Single Institution in Japan.

BACKGROUND: Significance of splenic hilar node dissection with splenectomy is now denied for advanced gastric cancer of upper one-third of the stomach without invasion to the greater curvature by the Japan Clinical Oncology Group 0110, a pivotal randomized study from Japan. However, a question remains for tumors which involve the greater curvature, as this study excluded such tumors. METHODS: We retrospectively analyzed 421 consecutive patients with gastric cancer who underwent curative total gastrectomy with splenectomy from 1992 to 2009. The survival curves, state of lymph node (LN) metastasis, and index of the estimated benefit from LN dissection of each station were evaluated according to the tumor location. RESULTS: The incidence of No. 10 metastasis was 9.3 % (39/421), with 15.9 % in patients with tumors involving the greater curvature (Gre group, n = 132) and 6.2 % in those without (non-Gre group, n = 289) (P = 0.032). The 5-year overall survival (OS) of patients with and without No. 10 metastasis was 35.4 and 43.1 % (P = 0.135) in the Gre group and 32.8 and 66.5 % (P = 0.0006) in the non-Gre group, respectively. The index of No. 10 LN dissection was 5.6 and 2.0 in the Gre and non-Gre groups, respectively. In the Gre group, the index was relatively higher in patients aged < 65 years, within pT3, and with Borrmann type 4 tumors. CONCLUSIONS: Splenectomy may have a survival benefit when a tumor shows involvement with the greater curvature, especially in relatively young patients and those without serosal exposure.

Laparoscopic splenic hilar lymph node dissection for proximal gastric cancer using integrated three-dimensional anatomic simulation software.

BACKGROUND: Laparoscopic lymph node (LN) dissection along the distal splenic artery (Station No. 11d) and around the splenic hilum (Station No. 10) remains challenging even for skilled surgeons. The major reason for the difficulty is the complex, multifarious anatomy of the splenic vessels. The latest integrated three-dimensional (3D) simulations may facilitate this procedure. METHODS: Usefulness of 3D simulation was investigated during 20 laparoscopic total gastrectomies with splenic hilar LN dissection while preserving the spleen and pancreas (LTG + PSP) or with splenectomy (LTG + S). Clinical information acquired by 3D simulation and the consistency of the virtual and real images were evaluated. Furthermore, clinical data of these patients were compared with that of the patients who underwent the same surgery before the introduction of 3D simulation (n = 10), to clarify its efficacy. RESULTS: The vascular architecture and morphologic characteristics were clearly demonstrated in 3D simulation, with sufficient consistency. The median durations of 14 LTG + PSP and 6 LTG + S operations were 318 and 322 min, respectively. The estimated blood losses were 18 and 38 g, respectively. There were no deaths. One postoperative peritoneal abscess (grade II according to Clavien-Dindo) was recorded. A comparison of clinical parameters between surgeries without or with 3D simulation showed no differences in operation time, blood loss, or complication rate; however, the number of retrieved No. 10 LNs has significantly increased in cases with the use of 3D simulation (p = 0.006). CONCLUSIONS: This kind of surgery is not easy to perform, but the latest 3D computed tomography simulation technology has made it possible to reduce the degree of difficulty and also to enhance the quality of surgery, potentially leading to widespread use of these techniques.

[Pancreatoduodenectomy for locally advanced ascending colon cancer after neoadjuvant chemotherapy (mFOLFOX6)].

A 69-year-old man was referred to our hospital with the chief complaint of a palpable abdominal mass. Computed tomography and colonofiberscopy revealed that a large type 2 ascending colon cancer had invaded the duodenum and pancreas. To down-size the tumor, chemotherapy was planned and a FOLFOX regimen was effective; we therefore decided to perform a radical operation. The patient is still alive and disease-free 1 year and 8 months after the surgery.