[A case of metastatic colorectal cancer with hyperammonemic encephalopathy induced by 5-FU in a patient continuously treated with XELOX therapy].

We report a rare case of a patient with metastatic colorectal cancer who experienced hyperammonemic encephalopathy induced by 5 -fluorouracil(5-FU)and was continuously treated with capecitabine plus oxaliplatin(XELOX)therapy. A 60 years man with anorexia and weight loss was diagnosed with Stage IV rectal cancer, and chemotherapy with XELOX was initiated. When the second course of XELOX therapy was administered, the patient found it difficult to take oral capecitabine. Subsequently, modified FOLFOX6 was administered. Complications such as nausea and vomiting were observed on day 2, with confusion and cognitive disturbances on day 3 . Laboratory examination revealed hyperammonemia, and therefore, branched-chain amino acid solutions were administered as treatment. The patient's symptoms disappeared entirely on day 4. He is currently receiving XELOX therapy.

[An autopsy case of retroperitoneal paraganglioma that had presented with pheochromocytoma multisystem crisis].

A 40's woman was seen at the emergency room because of severe back pain and vomiting. Abdominal CT scan revealed a tumor about 7cm in diameter located on the retroperitoneum. For 6 hours after admission, her body temperature was 39°C and respiratory failure occurred. After 30 hours, the patient died because of a complication in circulatory failure. From the abnormally high level of catecholamines in the blood and autopsy results, we determined that pheochromocytoma multisystem crisis had been caused by the retroperitoneal paraganglioma.

[Successful management with partial splenic embolization (PSE) of splenomegaly and thrombocytopenia caused by oxaliplatin-based chemotherapy for advanced colorectal cancer].

We report here two cases of advanced colorectal cancer which received chemotherapy, in which partial splenic embolization (PSE) had been effective for controlling splenomegaly and thrombocytopenia. Case 1: A 50-year-old man presented with bloody urine and bloody stool. Computed tomography (CT) showed rectosigmoid cancer with urinary bladder invasion. He underwent colostomy and received chemotherapy. After 3 courses of FOLFOX and 6 courses of bevacizumab/FOLFOX, he suffered from thrombocytopenia with splenomegaly, which led to discontinuation of the therapy. PSE improved thrombocyte counts and enabled him to resume therapy. Case 2: A 72-year-old man presented with bloody stool. Endoscopy and CT showed an advanced rectosigmoid cancer with multiple liver metastases. He underwent low anterior resection and received chemotherapy with FOLFOX and FOLFIRI, together with bevacizumab. After 13 courses of chemotherapy, he also suffered from splenomegaly and thrombocytopenia. PSE produced an increase in thrombocyte count and allowed for a restart of chemotherapy. Oxaliplatin-based chemotherapy may possibly produce hepatic sinusoidal dilation and induce splenomegaly owing to portal hypertension. PSE seemed to be useful for treating thrombocytopenia with splenomagaly, and allowed continuation of the chemotherapy.

[Endoscopic pancreatic stenting was effective in a case of pancreatic duct disruption and leakage due to pancreatic cancer].

A 79-year-old man was admitted on the suspicion of acute pancreatitis. Computed tomography showed acute fluid collection but not typical acute pancreatitis; it formed pseudocysts gradually around the pancreas. Endoscopic retrograde pancreatography (ERP) revealed pancreatic disruption and leakage. Endoscopic nasopancreatic drainage (ENPD) and endoscopic pancreatic stenting (EPS) resulted in collapse of pseudocysts, improvement of symptoms and laboratory data, and a mass in the pancreatic body became distinct. The specimens obtained with endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) showed pancreatic cancer. In conclusion, ENPD and EPS are effective for pancreatic leakage with disruption of the pancreatic duct, and we should take into consideration the possibility of pancreatic cancer when we see patients with pancreatic disruption.

An enucleated duodenal gastrinoma with multiple type 1 endocrine neoplasia located by selective arterial calcium injection.

We report a duodenal gastrinoma in a 50-year-old man who was admitted to our hospital with tarry stools. Esophagogastroduodenoscopy revealed multiple ulcers in the duodenal bulb and a submucosal tumor in the descending duodenum. His serum gastrin level was 1400pg/ml. We suspected Zollinger-Ellison syndrome and performed selective arterial calcium injection to locate the gastrinoma. Increase in the hepatic venous gastrin level was seen only in the gastroduodenal artery area. We diagnosed a gastrinoma located in the pancreaticoduodenal area. Genetic examination showed a single-base deletion in the MEN-1 gene. At operation, the tumor was found in the submucosal layer of the descending duodenum and was extirpated. He is alive without recurrence 3 years after surgery.

[A case of metastatic colorectal cancer suffering from hyperammonemic encephalopathy induced by 5-FU, continuously treated with FOLFOX therapy].

We report a rare case of metastatic colorectal cancer who suffered from hyperammonemic encephalopathy induced by 5- FU and was continuously treated with FOLFOX therapy. A 50-year-old man with ileus was diagnosed with ascending colon cancer Stage IV, and a right hemicolectomy was performed. Postoperative chemotherapy with modified FOLFOX6 was performed. Complications of nausea and vomiting were seen on day 2 , with confusion and cognitive disturbances on day 3 . None of the other radiographic examinations provided an explanation for his symptoms. Laboratory examination revealed hyperammonemia, so branched-chain amino acid solutions and high-volume drip infusion were started for its treatment. His symptoms entirely disappeared on day 4. We changed to chemotherapy for FOLFOX4 using branched-chain amino acid solutions and drip infusion. The tumor marker level normalized following two courses, and CT following ten courses showed that the size of the lung metastasis and abdominal lymph node had reduced significantly. The patient is currently receiving FOLFOX4.

[A case of primary hepato-biliary malignant lymphoma effectively treated with R-CHOP chemotherapy].

A 65-year-old man was admitted to our hospital because of obstructive jaundice caused by a mass extending in the porta hepatis, neck of gall bladder and extrahepatic bile duct. The specimens obtained with ultrasound-guided needle biopsy showed malignant lymphoma (diffuse large B-cell lymphoma: DLBCL). CHOP with Rituximab therapy (R-CHOP therapy) was performed. The treatment resulted in remarkable reduction of the tumor size and improvement of the biliary stenosis. We should take into consideration malignant lymphoma when we see a patient with a tumor of the hepato-biliary system.

A case of serous cystic tumor, which recurred with severe acute pancreatitis.

A 76-year-old woman with serous cystic tumor (SCT) was admitted to our hospital with abdominal pain and was given a diagnosis of severe acute pancreatitis. Infusion of intravenous protein inhibitor and continuous hemodiafiltration (CHDF) were started and she was placed on a respirator, but she died on the 6th day after diagnosis. On autopsy, each SCT cyst showed evidence of hemorrhage. We supposed that the growth of the SCT after hemorrhage compressed the main pancreatic duct and caused severe acute pancreatitis. SCT is benign, and there are no standard treatments. During follow-up of patients with SCT, we should consider the risk of severe acute pancreatitis.