[A Case of Concentrated Ascites Reinfusion Therapy(CART)for Abundant Refractory Ascites in Cecal Cancer with Peritoneal Dissemination Followed by the Readministration of Chemotherapy].

A 66-year-old man underwent laparoscopic ileocecal resection for cecal cancer with liver metastasis(cT3N1M1a, cStage Ⅳa). One month later, combination chemotherapy with capecitabine, oxaliplatin, and bevacizumab was administered for liver metastasis. However, during the treatment, peritoneal dissemination and abundant diuretic-resistant ascites was revealed, resulting in poor dietary intake. One year and 11 months after the surgery, the chemotherapy was interrupted and cell-free and concentrated ascites reinfusion therapy(CART)was undergone as palliative care. The initial volume of retrieved ascites was 6,500 mL, and the volume was increased gradually to a maximum of 14,020 mL without hemodynamic instability. Totally CART was administered 10 times during 7 months without any complications: mean volume of retrieved ascites; 9,780 mL/unit, the interval between therapies; 2-3 weeks. Serum albumin level did not decrease since CART administration. His oral intake and daily activities were improved by CART. These clinical outcomes contributed to the readministration of chemotherapy. We present a recent case of safe and periodical CART for abundant refractory ascites in cecal cancer with peritoneal dissemination, resulting in the improvement of QOL and the readministration of chemotherapy.

[A Long-Term Survival Case of HER2-Positive Gastric Cancer with Distant Lymph Node Metastasis Receiving Multidisciplinary Therapy].

An 82-year-old man presented with right cervical swelling. Cervical ultrasonography revealed several swollen lymph nodes which were diagnosed with adenocarcinoma by fine needle aspiration cytology. Computed tomography showed right axillary lymph nodes were also swelling. Upper and lower gastrointestinal endoscopy found type 0-Ⅱa gastric cancer located at the posterior wall of the middle region. Pathology was HER2-positive moderately differentiated tubular adenocarcinoma. Doublet chemotherapy with S-1 and cisplatin was administered for unresectable gastric cancer(cT1bN0M1, cStage Ⅳb). One month later, doublet chemotherapy was changed to triplet chemotherapy with trastuzumab, capecitabine, and cisplatin. A month later, complete response(CR)was achieved. After 8 courses of triplet chemotherapy, we changed to doublet chemotherapy with trastuzumab and capecitabine due to impaired kidney function 8 months. Two months later from that, endoscopic mucosal dissection was performed for gastric cancer as local therapy(pathology: well differentiated tubular adenocarcinoma, pT1a, ly0, v0). Two years and 2 months after the beginning of chemotherapy, the right axillary lymph nodes were enlarged again and surgically resected(pathology: HER2-positive poorly differentiated adenocarcinoma). He had CR for 8 years and 2 months, and chemotherapy was canceled due to his decision. During 1 year and 7 months, disease progression was not observed. We present a long-term survival case of HER2-positive gastric cancer with distant lymph node metastasis receiving multidisciplinary therapy.

[A Case of Palliative Laparoscopic Surgery in an Older Woman with Advanced Gastric Cancer and a Large Hiatal Hernia].

A 94-year-old woman presented with anorexia, persisting for several months, and marked anemia. An upper gastrointestinal endoscopy revealed type 3 advanced gastric cancer in the antrum. CT imaging indicated a large esophageal hiatus hernia and the elevation of the gastric fornix to the level of the bronchus. Wall thickening in the antrum, surrounded by increased fat tissue density, and swollen lymph nodes along the common hepatic artery, were detected. She was diagnosed with advanced gastric cancer(cT3N1M0, cStage Ⅲ)and a large hiatal hernia. A laparoscopic hiatal hernia repair and distal gastrectomy were performed. The cancer was exposed outside the serosa in the antrum, yet there was no indication of ascites, liver metastasis or peritoneal dissemination. The esophageal hiatus was sutured, and a distal gastrectomy(Billroth-Ⅱ reconstruction)was conducted. To avert hernia recurrence, sutures were applied to the posterior wall of the abdominal esophagus and the crus of the diaphragm, as well as the fornix of the remnant stomach and the diaphragm. Her postoperative course was uneventful, and she was discharged on POD13. There were no instances of gastric cancer recurrence or hiatal hernia 7 months post-operation.

[A Case of Cardiodiaphragmatic Corner Lymph Node Recurrence after Surgery for Ascending Colon Cancer].

The case is a female, 50s. She presented to our hospital because of her intestinal obstruction. A CT scan at her visit showed wall thickening of her ascending colon. Colonoscopy revealed type 2 advanced cancer in the ascending colon. The pathological examination was a diagnosis of adenocarcinoma. Laparoscopic right hemicolectomy was performed for cT3N1M0, cStage Ⅲb ascending colon cancer. The pathological result was pT3N1M0, Stage Ⅲb. Contrast-enhanced CT was performed 10 months after the operation. As a result, she was found to have recurrent multiple liver metastases. A laparoscopic partial hepatectomy was performed at the site of recurrence. The pathological result was adenocarcinoma. It was a diagnosis of metastasis recurrence from colorectal cancer. A CT scan 16 months after primary surgery revealed enlarged cardiodiaphragmatic lymph nodes. A PET-CT scan revealed an accumulation of SUVmax 3.0 in the same area. She was diagnosed with lymph node recurrence of colorectal cancer and underwent resection. Histopathological result was adenocarcinoma. It was diagnosed as metastasis from ascending colon cancer.

[A Case of Descending Colon Cancer with Long-Term Maintenance of QOL by Multidisciplinary Treatment Approach for Locally Recurrent Lesion with Hydronephrosis].

We report a case of recurrent descending colon cancer in which QOL was maintained for a long period by performing resection with intestinal reconstruction, chemotherapy, and radiotherapy for local recurrence with hydronephrosis. A man in his 60s with good ADL underwent laparoscopic left hemicolectomy for descending colon cancer. After 4.5 years postoperatively, computed tomography and positron emission tomography showed a local recurrence of 32 mm contacting with the left external iliac artery and sigmoid colon, and CAPOX plus BEV was started. When cholecystitis developed after 5 chemotherapy courses, the recurrent lesion was resected simultaneously. After 8 months, repeated recurrent lesion with a major axis of 13 mm with left hydronephrosis was observed at the same site. After 3 years of chemotherapy after placing the left ureteral stent, CEA level gradually increased, and tumor growth was observed. Because of the aggressive chemotherapy limitation due to high proteinuria, 66 Gy/22 Fr radiotherapy was performed. After 1 month of radiotherapy, the CEA level decreased and proteinuria improved in that period. Radiotherapy for local recurrence can be a useful interval for chemotherapy and effective local control.

[Postoperative Severe Dysphagia Due to Hypophosphatemia in a Patient with Peritoneal Dissemination of Gastric Cancer].

An 83-year-old man presented with melena and weight loss. Upper gastrointestinal endoscopy showed type 3 advanced gastric cancer with pyloric stenosis. Surgical findings revealed numerous peritoneal dissemination, then gastro-jejunum anastomosis was performed. The oral diet was resumed on POD4, however severe dysphagia occurred immediately on POD6. There were no specific findings on MRI/MRA and nasal endoscopy. Serum antibodies related to neuromuscular diseases and connective tissue diseases were also negative. Despite the rehabilitation, the dysphagia remained. Before total parenteral nutrition on POD16, hypophosphatemia was discovered(1.4 mg/dL). His dysphagia disappeared with the improvement in the serum phosphate level. Hypophosphatemia might be caused by an inadequate intake as urine phosphate, serum calcium and serum PTH levels were normal. We present a recent case of severe dysphagia due to hypophosphatemia in a patient with peritoneal dissemination of gastric cancer.

[Disseminated Bone Marrow Carcinomatosis from Colon Cancer-A Case Report].

A 77‒year‒old man came to our hospital with complaints of abdominal pain and difficulty to defecate. Abdominal CT scan showed an abnormal region in the ascending colon, which was suspected to be an ascending colon cancer. D‒dimer was remarkably high, and the platelet count was 63,000/µL; these results suggested disseminated intravascular coagulation caused by tumor activation. After he was admitted, we performed a contrast enhanced CT, and found no signs of remote metastasis. We decided to resect the tumor without colonoscopy examination in order to release the DIC state. After the surgery, the platelet count did not increase, and leukopenia was observed. We conducted a bone marrow biopsy, and made a diagnosis of disseminated carcinomatosis from colon cancer. The patient's condition did not improve, and he died on day 42 after admission. Pathological autopsy was performed and several minimal remote metastases were found throughout the body.

[A Case of Transverse Colon Cancer with Metastatic Recurrence in Bilateral Inguinal Lymph Nodes].

A woman in the 60s. She was referred to our hospital because the fecal occult blood test was positive. Colonoscopy was performed. Cancer is found in the transverse colon. There were no metastases in the lungs and liver. Laparoscopic left hemicolectomy was performed. Histopathological examination was adenocarcinoma(tub1>tub2>muc), pT1b, pN2, ly2, v1, pPM0, pDM0, pRM0, budding(0, Grade 1), fStage Ⅲb. After postoperative adjuvant chemotherapy, she visited an outpatient clinic 8 months after surgery with a complaint of swelling of both inguinal lymph nodes. The swollen inguinal lymph node was relatively soft and there was no evidence of infection. A biopsy of the bilateral lymph nodes was performed. Histopathological examination revealed adenocarcinoma containing mucus components. These findings were consistent with histological findings in transverse colon cancer. Based on these results, we diagnosed metastatic recurrence from transverse colon cancer to both inguinal lymph nodes.

[Primary Biliary Cholangitis Diagnosed with Spontaneous Bacterial Peritonitis after Gastrectomy for Gastric Cancer-A Case Report].

Spontaneous bacterial peritonitis is defined as an ascitic fluid infection without an evident intra-abdominal surgically treatable source. The diagnosis is established by a positive ascitic fluid bacterial culture and an ascitic fluid absolute polymorphonuclear leukocyte(PMN)count≥250 cells/µL. Here we report the case of 81-year-old female patient who was diagnosed with spontaneous bacterial peritonitis after gastrectomy for gastric cancer. The laparoscopic distal gastrectomy and D1+ lymph node dissection were performed for Stage Ⅰ gastric cancer, and the postoperative course was uneventful. The patient presented with abdominal pain and was hospitalized again on the third day from the discharge. Computed tomography showed an accumulation of ascites, and the ascitic fluid polymorphonuclear leukocyte count was 9,973 cells/µL. The patient was diagnosed with spontaneous bacterial peritonitis, and antibacterial agent was performed. Abdominal pain and accumulation of ascites had been improved, and the ascitic fluid polymorphonuclear leukocyte count had decreased clearly. The patient discharged on the 57th day from the operation. Spontaneous bacterial peritonitis after gastrectomy for gastric cancer was rare. We report this rare case, along with a discussion of the literature.

[A Case of Portal Vein Thrombosis Found during Postoperative Adjuvant Chemotherapy(CAPOX)after Laparoscopic Surgery for Rectal Cancer].

Portal vein thrombosis after laparoscopic colorectal cancer surgery is rare and sometimes lethal. We report a case of asymptomatic portal vein thrombosis found during postoperative adjuvant chemotherapy(CAPOX)after laparoscopic surgery for rectal cancer. A male patient in his 60s underwent postoperative adjuvant chemotherapy( CAPOX). The elevation of liver enzyme before the chemotherapy was moderate enough to start. The liver enzyme was increased mildly during the chemotherapy. Computed tomography 27 weeks after the operation revealed the thrombus from the main portal vein to the right branch and posterior branch, and atrophy of the lateral segment with narrowed left branch. Blood flow was confirmed to be maintained by ultrasonic Doppler. We decided to discontinue the chemotherapy and started anticoagulant therapy with Warfarin. Thrombosis was disappeared 2 weeks later, and liver function went back to normal range after 8 weeks. Liver dysfunction during chemotherapy should be noted not only for drug-induced liver damage, but also for the possibility of postoperative asymptomatic portal vein thrombosis.

[Tumor Embolisms from Colon Cancer Detected on Transcatheter Examination-A Case Report].

A 58-year-old woman underwent surgery and systemic chemotherapy(FOLFIRI plus panitumumab)for ascending colon cancer with multiple lymph node and liver metastases; the preoperative Virchow lymph node aspiration cytology showed adenocarcinoma.After 4 courses of chemotherapy, contrast-enhanced CT showed an embolus in the left subclavian vein.An anticoagulation therapy was started, but the embolus tended to increase.Three months later, the patient developed dyspnea and was diagnosed with pulmonary artery thromboembolism and superior vena cava thrombosis.Transcatheter examination was performed because of the anticoagulation-resistant embolism, and the biopsy revealed tumor embolism due to colon cancer.She died of respiratory failure 10 days after the biopsy.The tumor directly infiltrating the vein because of left subclavian lymph node metastases might have resulted from increased tumor emboli.Although cases of tumor emboli infiltrating the veins and developing from lymph node metastases are rare, a transcatheter biopsy may help to detect them.

[A Case of Stevens-Johnson Syndrome Induced by Chemotherapy for Metastatic Colon Cancer].

A 78-year-old woman had a semicircular ulcerative lesion of AV 7 cm, as detected using colonoscopy, and pathologic examination based on a biopsy showed well-differentiated adenocarcinoma. On contrast-enhanced CT of the liver, a number of nodular lesions that seemed to be liver metastases were observed. It was decided to administer chemotherapy containing mFOLFOX6 plus panitumumab. Bilateral hemorrhage of the ocular conjunctiva and eyelid edema were observed from the 4th day of chemotherapy. Edema of the lips, epidermolysis, and erythema appeared in addition to vision impairment. We diagnosed her with SJS based on these symptoms. We also administered steroid pulse therapy. Eyelid edema improved, and vision impairment improved 24 hours after the initiation of treatment. For severe cases with visual impairment, systemic administration of corticosteroids is recommended. In this case, administering steroid pulse therapy from an early stage resulted in improvement without sequelae.

[A Case of Nephrotic Syndrome Induced by FOLFIRI plus Ramucirumab for Metastatic Descending Colon Cancer].

We report a case of multiple lung metastases of RAS mutant type descending colon cancer with development of nephrotic syndrome after the introduction of FOLFIRI plus ramucirumab(RAM). A female patient in her 50s underwent adjuvant chemotherapy with capecitabine and oxaliplatin after primary tumor and partial lung resection. For recurrent multiple lung metastases, 4 years of capecitabine and bevacizumab therapy was administered. FOLFIRI plus RAM therapy was introduced because of tumor progression. After treatment, the patient showed increased urine protein content, decreased serum albumin levels, marked hypertension, and increased edema, and was diagnosed with nephrotic syndrome. The patient's condition improved with prednisolone, additional doses of antihypertensive, and diuretics. Even in cases where it is possible to control proteinuria during bevacizumab administration, it is necessary to keep in mind that RAM administration as second-line therapy may cause nephrotic syndrome.

[A Case of Cecal Cancer Complicated with Intussusception Treated Laparoscopically].

A 75-year-old woman presented with the chief complaint of right lower abdominal pain. There was mild tenderness in the lower right abdomen and a mass was palpated. There were no peritoneal irritation symptoms. A CT examination was performed. The ascending colon was invaginated with a part of the cecum and ileum. Wall thickening was observed in the advanced part. Colon cancer was suspected. The preoperative diagnosis was considered to be an intussusception with cecal cancer at the advanced part. A laparoscopic ileocecal resection was performed. The intraoperative findings were as follows. The tumor was invading the ascending colon, but it was possible to restore it by pressing on the developed part with forceps. The pathological diagnosis was Type 2, muc>tub1, pT4aN0M0, pStageⅡb. The postoperative course was good. Water intake was started on the next day, meals were started from the second day, and the patient was discharged on the 9th day after the operation. Cecal cancer complicated with intussusception is a relatively rare disease. We report a case that was laparoscopically operable.

[A Case of an Elderly with Locoregional Recurrence of ER-Negative HER2-Positive Breast Cancer Successfully Treated with Local Therapy].

An 80-year-old woman who received on anticoagulant therapy for atrial fibrillation was diagnosed with ER-negative HER2-positive breast cancer(cT4bcN1M0, Stage ⅢB). She underwent mastectomy with skin graft and lymphadenectomy, but was evaluated to be too old for standard chemotherapy and HER2-directed therapy. Four months after the operation, she was diagnosed with regional lymph node metastasis and underwent radiotherapy. Moreover, 9 months later, other recurrent sites were revealed in the parasternal lymph node and thoracic wall without distant metastasis. Radiotherapy could be performed around these secondary recurrent sites while avoiding overlap. After 2 years, solitary contralateral axillary lymph node metastasis was diagnosed by PET-CT. She underwent Lt axillary lymphadenectomy. The intrinsic breast cancer subtype did not change. Patient performance status was kept to achieve a good quality of daily life. Eight months later, she diagnosed with primary pancreatic cancer and received 13 cycles of chemotherapy until her death from pancreatic cancer 14 months later. During chemotherapy, no recurrence of breast cancer was observed.

[A Case of Extended Mediastinal and Retroperitoneal Emphysema after Transanal Local Excision of an Early Lower Rectal Adenocarcinoma].

We observed a case of a large collection of mediastinal and retroperitoneal emphysema, which developed after a transanal local excision for an early lower rectal carcinoma and was treated conservatively. An 80's female patient presented with a chief complaint of bowel difficulty, which was diagnosed as mucosal prolapse syndrome with anal sphincter dysfunction. Endoscopic colonoscopy showed full circumferential proliferation of the mucosal membrane including a semicircular protruding lesion, on the upper side of the dentate line. Biopsy revealed findings indicative of an adenocarcinoma(tub1/pap), Group 4. After a sufficient informed consent was taken, a transanal local excision under spinal anesthesia was conducted discontinuously over half of the circumference. The patient underwent partial-thickness excision, partially full-thickness, and the defects are closed as much as possible. A fever of 38 degrees Celsius was recognized on the 1st postoperative day, and a CT scan, on the 2nd postoperative day, showed a large collection of retroperitoneal and mediastinal emphysema tracking upwards to the nasopharynx. Since fever was the only subjective symptom present, antibiotic therapy under fasting was chosen. The mediastinal emphysema had mostly resolved by the 10th postoperative day. Even though standard transanal excision is not a treatment under air supply there is a risk leading mediastinal and retroperitoneal emphysema.

[A Case of Inflammatory Breast Cancer with Very Severe Obesity].

A 39-year-old woman with very sever obesity was admitted to our hospital for a right breast redness and hardness. Her height, weight and BMI were 166 cm, 145 kg and 52.6 kg/m2. Her breast had peau d'orange. CT scan showed swelling of whole right breast and Level I , II lymph node. We performed core needle biopsy and diagnosed as the inflammatory breast cancer with ER and HER2 positive. We introduced chemotherapy(pertuzumab, trastuzumab and paclitaxel)and nutrition counseling in order to reduce her body weight. After 4 courses of chemotherapy, the clinical complete response was obtained and her body weight decreased to 125 kg. We performed mastectomy and axillary node resection and confirmed pathological complete response. Adjuvant chemotherapy(5-FU, epirubicin and cyclophosphamide), adjuvant trastuzumab therapy, postmastectomy radiation therapy and adjuvant hormonal therapy were administered. There have been no signs of recurrence as of 2 years after the operation.

[A Case of Advanced Transverse Colon Cancer with Relapse behind the Rectum after Laparoscopic-Assisted Resection].

A 60's male patient underwent laparoscopic left hemicolectomy with D3 lymph node dissection for transverse colon cancer. Adjuvant chemotherapy with tegafur-uracil and leucovorin was administered.Thirty -four months later, MRI scan revealed a mass with sacrum invasion.Radiation therapy(39 Gy/13 Fr)was performed followed by chemotherapy(modified oxaliplatin, leucovorin, and 5-fluorouracil plus bevacizumab).Two weeks after the completion of radiation therapy, staging laparoscopy and tissue biopsy was performed in the hard tumor, which was located at the caudal end of the incisional scar of the retroperitoneum, in front of the sacrum.The pathological diagnosis revealed metastasis from transverse colon cancer.Radiographic examination showed partial response to radiochemotherapy, and buttock pain decreased.CT review before pain developed showed a small tumor located mainly in the mesorectum slightly adjacent to the sacrum, suggesting the implantation of cancer cells to the stripped plane behind the mesorectum during the surgery.

[Two cases of radiotherapy-induced sarcoma after breast cancer surgery].

We report 2 cases of radiotherapy-induced sarcoma of the residual breast after breast cancer surgery. In 1 case, the patient was a 64-year-old woman. She underwent breast-conserving surgery and axillary lymph node dissection followed by irradiation to the residual breast in July 2001. A 1.1 × 1.0-cm tumor was noted in the residual breast 7 years 5 months after radiotherapy. An excisional biopsy was performed, and a histological diagnosis of angiosarcoma was made. She died of lung and peritoneal metastases 3 years 2 months after the diagnosis. In the other case, the patient was also 64 years old. She underwent breast-conserving surgery and sentinel lymph node biopsy followed by irradiation to the residual breast in October 2006. A 5.7 × 3.9-cm induration was noted in the residual breast 3 years 5 months after radiotherapy. A core needle biopsy was performed, and a histological diagnosis of sarcoma was made. Mastectomy was performed, and the histological diagnosis was malignant fibrous histiocytoma. She died of chest wall and intrapleural tumor recurrence 3 months after the mastectomy. Although radiotherapy-induced sarcoma is rare, early detection of the tumor in the irradiation area is important, as radiotherapy is often performed for breast cancer patients.

[Locoregional recurrence of HER2-positive breast cancer - treatment after complete remission and long-term clinical benefits].

We report 7 cases of locoregional recurrence in human epidermal growth factor receptor 2 (HER2)-positive breast cancer that we treated. An early complete response (CR) and long-term response was achieved in 5 cases. There were 4 HER2- subtype and 3 Luminal HER2-type cases. Metastasis and recurrence were detected in the residual breast tissue and the supraclavicular, axillary, and parasternal lymph nodes. Chemotherapy consisting of trastuzumab was administered as first-line treatment. A CR was observed 3-4 months after the initiation of therapy in 4 cases, and the time to progression was 27.6- 65.8 months. After achieving a CR, 3 patients terminated treatment and 2 patients continued to take trastuzumab. However, due to adverse effects associated with the chemotherapy, 1 patient changed to endocrine therapy. A second, long-term, CR was achieved in 2 relapsed CR patients by re-challenging with the same chemotherapy regimen. Two patients did not achieve CR and died due to distant metastases. For a better quality of life, it is advisable to continue treatment after a clinical CR for solitary or more complex locoregional recurrences. Following the first-line therapy and a so-called chemoholiday, the patient's disease can be re-challenged using the previously sensitive regimen with careful observation.