[Descending Colon Cancer with Synchronous Solitary Small Intestinal Metastasis-A Case Report].

A 77-year-old man presented with biliary colic and was diagnosed with descending colon cancer and cholelithiasis.During the surgery, a mass was detected in the upper jejunum, located 5 cm from the Treitz ligament on the anal side.Open left hemicolectomy with partial jejunal resection was performed.The mass in the small intestine was diagnosed as solitary small intestinal metastasis of colon cancer through immunohistopathological examination.Isolated intestinal metastases of colorectal cancers are rare.Furthermore, synchronous metastases are rare among these cases.A previous study reported poor prognosis in patients with small intestinal metastasis; therefore, more studies on the small intestinal metastasis of colorectal cancer are necessary.

[A Resected Case of Retroperitoneal Metastasis and Small Bowel Metastasis from HCC].

A 71-year-old man underwent right hemi-hepatectomyfor a hepatocellular carcinoma(HCC)measuring 18 cm in diameter. The pathological diagnosis was poorlydifferentiated HCC. Ten months after the surgery, computed tomographyrevealed a nodule 12mm in diameter in the right lung as well as 2 nodules measuring 19 and 11mm in diameter in the retroperitoneum at the cranial aspect of the left kidney. Four months later, the nodule in the right lung had enlarged to 44 mm, while the 2 nodules in the retroperitoneum had enlarged to 68mm and 34 mm. These nodules were resected and histopathologicallydiagnosed as metastasis from HCC. Twenty-one months after liver resection, computed tomographyrevealed nodules 16 and 25mm in diameter in the retroperitoneum around the urinarybladder and jejunum, respectively. One month later, intussusception resulted from the jejunal tumor. Laparoscopic surgerywas performed for both tumors, which were diagnosed as metastases from HCC. Twenty-five months after liver resection, metastasis from the HCC appeared in the left adrenal grand, at the site of the jejunal anastomosis, and in the fattytissue around the right scapula. Twenty-nine months after liver resection, the patient died of respiratoryfailure from multiple metastases in the left lung.

[A Case of Rupture of Esophageal Varices during a Course of CAPOX with Bevacizumab Therapy for Sigmoid Colon Cancer with Multiple Liver Metastases].

The patient was a 67-year-old man with multiple liver metastases from sigmoid colon cancer and had received capecitabine, oxaliplatin, and bevacizumab(CAPOX plus Bev)combination chemotherapy. After 11 courses of this therapy, he had a rupture of esophageal varices and was treated with endoscopic variceal ligation(EVL). Esophageal varices are rare during the course of oxaliplatin-based chemotherapy. More studies are necessary for early detection of esophageal varices during this therapy.

[A Case of Treated with Laparoscopic Surgery for Intussusception Up to the Splenic Flexion Region Due to Cecum Cancer].

A 93-year-old woman was admitted to the hospital because of respiratorydiscomfort. A chest CT scan indicated aspiration pneumonitis and, simultaneously, intussusception was observed in the splenic flexure region. Abdominal enhance CT scan revealed a tumor in the advanced region of intussusception. Laparoscopy-assisted ileocecal resection was performed. Since the intussusception was difficult to reduce laparoscopically, the ileocecum was mobilized and the intussusception was reduced manually. In the resected specimen, a type 1 tumor was observed in the cecum and histopathologic ally diagnosed as cercal cancer. We report a case with intussusception due to colorectal cancer treated bylaparoscopic surgery.

[A Case of Paget-Type Recurrence 20 Years after Breast Conserving Surgery for Invasive Ductal Carcinoma].

We report an 85-year-old female suffered Paget-type recurrence at right remnant breast. The patient had undergone breast conserving surgery(BCS)20 years ago in another hospital for invasive ductal carcinoma of the right breast(pT1N0M0, Stage I ). Her chief complain was a skin ulcer of the right nipple. The pathological diagnosis for biopsy specimen from the areola was Paget's disease. She underwent total mastectomy. Paget cells were detected pathologically in the epidermis of the nipple and nearby mammary duct connected with fibrous tissue after BCS, suggesting Paget-type recurrence of invasive breast carcinoma.

Additional surgical resection after endoscopic mucosal dissection for early gastric cancer: A medium-sized hospital's experience.

PURPOSE: In Japan, the majority of early gastric cancers (EGCs) are now treated with endoscopic submucosal dissection (ESD). Patients with non-curative lesions treated by ESD are advised to undergo additional surgical resection (ASR) based on guidelines from the Japan Gastroenterological Endoscopy Society (JGES) and Japanese Gastric Cancer Association (JGCA). However, many studies have demonstrated that residual cancer and lymph node metastasis are only rarely found in ASR specimens. Here we retrospectively analyzed the conditions that could enable the avoidance of unnecessary ASR. METHODS: The ESD data for 114 absolute indication lesions and 26 lesions of expanded indication lesions were analyzed. The indications and the curability were evaluated according to the JGES/JGCA guidelines. RESULTS: The rates of non-curative resection and ASR were significantly higher in the expanded indication group compared to the absolute indication group (26.9% and 19.2% vs. 7.9% and 0.9%, respectively). ASR was performed for six patients. Three of their ARS specimens contained neither residual cancer nor lymph node metastasis, and the pathological findings of the preceding ESD specimens deviated slightly from the curative criteria defined by the guidelines. The conditions of the lesions that did not meet the curative criteria were as follows: (1) sm1 invasion of undifferentiated-type lesion <10 mm dia., (2) 21-25 mm dia. mucosal undifferentiated-type lesion, or (3) peacemeal resection with a horizontal margin positive for the mucosal differentiated-type. CONCLUSIONS: These data suggest that a close follow-up without ASR might be appropriate for patients in the above-mentioned three categories after non-curative ESD for EGC.

Regulation of neutrophil infiltration into peritoneal cavity by laparoscopic gastrectomy.

BACKGROUND/AIMS: Laparoscopic surgery is a minimally invasive operation developed for treating gastrointestinal malignancies. We aimed to characterize the differences in the intra-abdominal environment following open and laparoscopic surgeries. METHODOLOGY: We investigated data of 48 patients who underwent gastrectomy between 2010 and 2012. We analyzed the mRNA expression of chemokines, indoleamine 2, 3-dioxygenase (IDO), and so on in peritoneal lavage fluid with real-time RT-PCR. We also determined the leukocyte population and calculated the granulocyte/lymphocyte (G/L) ratio in peritoneal lavage fluid using flow cytometry. RESULTS: CCL3 mRNA was significantly upregulated, whereas IDO mRNA was significantly downregulated, in the open group compared to the laparoscopic surgery group. Flow cytometry revealed that the G/L ratio was significantly higher in the open group. CONCLUSIONS: We suggest that the production of chemokines and neutrophil infiltration into the abdominal cavity may be suppressed in the laparoscopic surgery. Thus, laparoscopic surgery may be beneficial in preserving local immunity.

[Complete Response to Chemotherapy after Resection of Rectal Cancer with Virchow's Lymph Node Metastasis].

A 62-year-old woman was admitted to our hospital because of bloody stool. Colonoscopy revealed stenosis by a type 2 tumor of the recto-sigmoid colon. A biopsy specimen contained moderately differentiated adenocarcinoma. Thoraco-abdominal computed tomography (CT) showed liver metastasis (S7, 10 mm) and enlargement of Virchow's lymph node (17 mm) and several para-aortic lymph nodes (15 mm on average). Because of oozing from the tumor and severe stenosis of the recto-sigmoid colon, we performed laparoscopic-assisted high anterior resection of the primary lesion. After surgery, 3 courses of mFOLFOX6, 20 courses of mFOLFOX6 plus bevacizumab, and 5 courses of infusional 5-FU plus Leucovorin plus bevacizumab were administered. Thoraco-abdominal CT demonstrated complete response to the 1 year 2 months of chemotherapy. The patient has been alive without relapse for 2 years after surgery.

Intranodal cytokeratin particles is a predictive marker of efficacy for neoadjuvant therapies in patients with squamous cell carcinoma of the esophagus.

BACKGROUND/AIMS: Lymph node metastasis is one of the most important prognostic factors in patients with esophageal squamous cell carcinoma (ESCC). Neoadjuvant treatment can reduce micrometastasis in lymph nodes to enable curative resection by down staging. The aim of this study was to evaluate the histological effect of neoadjuvant therapy on lymph node metastasis of ESCC by performing immunohistochemistry for cytokeratin staining. METHODOLOGY: A total of 3061 lymph nodes were examined from 62 patients who received neoadjuvant treatment followed by esophagectomy with lymphadenectomy. RESULTS: We observed positive staining for cytokeratin in 276 (9.0%) lymph nodes, which included overt metastasis, micrometastasis and hyalinized cytokeratin particles (HCP). Patients with HCPs in lymph nodes had better outcomes than patients without HCPs in lymph node. A significant prognostic difference between the patients with HCPs and without HCPs was observed in a subgroup of patients with nodal metastasis. CONCLUSIONS: Our findings suggest that HCP might reflect a degenerative change of cancer cells in lymph nodes and can predict the response to neoadjuvant therapy.

Clinical impact of the extent of lymph node micrometastasis in undifferentiated-type early gastric cancer.

OBJECTIVE: Lymph node (LN) metastasis is one of the most important prognostic factors for undifferentiated-type early gastric cancer (EGC). The aim of this study was to examine expansion of micrometastasis in regional LNs to clarify the importance of lymphadenectomy for undifferentiated-type EGC. METHODS: Clinicopathological features of 307 patients with undifferentiated-type EGC who underwent gastrectomy with lymphadenectomy between 1997 and 2010 at the Department of Surgical Oncology, Osaka City University, were retrospectively reviewed. Micrometastasis in LNs was detected by immunohistochemistry using anticytokeratin antibody. RESULTS: The incidence of LN metastasis was 1.8% in patients with mucosal (pT1a) tumors and 17.3% in those with submucosal (pT1b) tumors. Multivariate analysis revealed that lymphatic invasion and tumor depth were independently related to LN metastasis. Micrometastasis was found in 41 (13.3%) patients. Twenty-two patients with pN0 had micrometastasis in the perigastric region. Micrometastasis had spread to the area along the left gastric or common hepatic artery in 12 patients. Patients with an upgraded stage by micrometastasis had significantly worse disease-free survival. CONCLUSIONS: LN micrometastasis was observed beyond the perigastric LNs and correlated with poor outcomes in patients with undifferentiated-type EGC. These data underscore the importance of adequate lymphadenectomy for patients with undifferentiated-type EGC. © 2014 S. Karger AG, Basel.

Thoracoscopic esophagectomy in the prone position versus in the lateral position for patients with esophageal cancer: a comparison of short-term surgical results.

AIM: Thoracoscopic esophagectomy (TE) in the prone position for patients with esophageal cancer has received a great deal of attention. We retrospectively compared clinical outcomes and surgical stress of TE in the prone position (TE-P) and in the lateral position (TE-L) at our institution. METHODS: A total of 58 consecutive patients (28 in the TE-L group and 30 in the TE-P group) were studied. Between the 2 groups, clinical outcomes and various parameters were compared. RESULTS: There were no hospital deaths in both TEL and TEP groups. Blood loss during the thoracoscopic part of the surgery were significantly (P<0.01) lower in the TE-P group (118±72 mL) compared with the TE-L (245±203 mL) group. The incidence of respiratory complications tended to be lower (P=0.07) in the TE-P group (3.3%) than in the TE-L (17.8%) group. The duration of systemic inflammatory response syndrome condition was significantly (P=0.02) shorter in the TE-P group (1.5±2.5 d) than in TE-L (3.6±3.5 d) group. The levels of serum C-reactive protein on postoperative days 1 and 2 were significantly (P<0.01) lower in the TE-P group than in the TE-L group. CONCLUSIONS: TE-P for patients with esophageal cancer was safe and feasible. TE-P might be a potentially less invasive procedure than TE-L.

Port site metastasis after laparoscopic-assisted distal gastrectomy (LADG).

This report describes a case of port site metastasis after laparoscopic gastrectomy for gastric cancer. A 57-year-old man with clinical cTNM stage II (T2 N0 M0) gastric cancer was admitted to our hospital. After administration of an oral fluoropyrimidine drug (S-1) for 2 weeks, he underwent laparoscopy-assisted distal gastrectomy (LADG). On hematoxylin and eosin staining, the pTNM stage was IA (T1b N0 M0). Eighteen months later, the patient developed a subcutaneous metastasis at the trocar site. A second operation was performed, and the abdominal wall mass was resected. The histological finding confirmed a diagnosis of metastatic gastric carcinoma. Immunohistochemical analysis revealed micrometastasis in fat tissue adjacent to the lymph node near the left gastric artery. Surgeons should be aware that port site metastasis can occur in patients undergoing LADG for gastric cancer with lymphatic micrometastasis, which is undetectable on routine hematoxylin and eosin staining.

Successful resection of esophageal cancer with right aortic arch by video-assisted thoracoscopic surgery: a case report.

The right aortic arch (RAA) forms a vascular ring, encircling both the esophagus and trachea. We herein report a case of thoracic esophageal cancer with RAA successfully resected using video-assisted thoracoscopic surgery (VATS). A 64-year-old man who presented with a complaint of abdominal pain, was admitted to our hospital. Further examinations revealed gall stones and multiple superficial esophageal carcinomas. Three-dimensional computed tomographic images showed RAA and aortic diverticulum. The trachea and esophagus were completely encircled by the RAA, the aortic diverticulum and the pulmonary artery. We successfully and safely performed VATS esophagectomy for esophageal cancer accompanied with RAA. To the best of our knowledge, this report is the first case for which VATS esophagectomy for esophageal cancer, accompanied with RAA, was carried out. Marking of the left recurrent laryngeal nerve with colored tape at the cervical part of the surgery made it easy to identify it during the thoracoscopic part of the surgery.

[Successful treatment of locally advanced squamous cell carcinoma of the esophagus by combination chemotherapy with 5-fluorouracil plus nedaplatin following tracheal stent tube placement-a case report].

The patient was a 68-year-old man who complained of hoarseness and dyspnea. Upper gastrointestinal endoscopy revealed a type 3 tumor located in the middle thoracic esophagus at 30 cm from the incisor tooth that involved one-fourth of the circumference of the esophagus. Histopathological examination revealed moderately differentiated squamous cell carcinoma. Chest computed tomography( CT) revealed severe tracheal stenosis due to compression by a metastatic lymph node along the left recurrent laryngeal nerve. The patient was diagnosed as having cT4( 106recL-trachea), N2( 101L, 106recL, 106recR), M0, Stage IVa unresectable esophageal carcinoma. After insertion of a tracheal stent tube( spiral Z stent: diameter, 18 mm; length, 80 mm) to improve dyspnea, combination chemotherapy with 5-fluorouracil( 5-FU) plus nedaplatin was administered. Subsequent CT and endoscopy showed that the main tumor and the metastatic lymph node had significantly reduced in size and that complete response (CR) had been achieved. Thirty months after the initial treatment, the patient showed no sign of disease recurrence, after completion of 19 cycles of chemotherapy. The patient did not experience any severe adverse events. We report a case of a patient with locally advanced squamous cell carcinoma of the esophagus successfully treated with 5-FU/nedaplatin combination chemotherapy following tracheal stent tube placement.

[A case of metastatic gastric cancer from breast cancer treated with proximal gastrectomy].

We report a case of a 72-year-old woman with breast cancer who developed significant stenosis due to gastric cardia metastasis. The patient had undergone radical mastectomy for breast cancer when she was 53 years old and had developed postoperative recurrent diseases in the sternum and lung when she was 62 years old. Nineteen years after mastectomy, computed tomography (CT) scans showed gastric cardia metastasis. As symptoms of cardiac stenosis gradually developed, we performed proximal gastrectomy. The specimen was histologically diagnosed as estrogen receptor( ER)-positive scirrhous carcinoma that had metastasized from the breast cancer. The patient resumed oral intake of food after surgery. Surgical treatment might be useful to improve the quality of life of patients with metastatic gastric tumor.

[A case of emphysematous cholecystitis during the course of chemotherapy for gastric cancer].

A 77-year-old woman with Stage IV gastric cancer was admitted to our hospital because of high fever, poor appetite, and abdominal pain during combined chemotherapy with S-1 and cisplatin( CDDP). Abdominal computed tomography (CT) revealed the presence of gas in the submucosal layer on the basis of which emphysematous cholecystitis (EC) was diagnosed. We performed cholecystectomy and were able to proceed with the chemotherapy 1 month after surgery. Destruction of the gallbladder mucosa by ischemia has been reported to be a possible cause of emphysematous cholecystitis. Moreover, underlying systemic diseases such as arterial sclerosis and diabetes mellitus could be risk factors for EC. Our case suggested that chemotherapeutic agents might trigger ischemic changes in the gallbladder and thus result in EC.

[A case report of a stage IV gastric cancer patient with rapid progression of liver metastases induced by postoperative anastomotic leakage].

The patient was a 39-year-old man with type 3 gastric cancer with synchronous multiple liver and lung metastases, who was diagnosed as cStage IV(cT4aN1M1H1). He received induction chemotherapy with S-1 and CDDP. After chemotherapy, the liver and lung metastases had disappeared completely. He underwent total gastrectomy and splenectomy, with D2 nodal dissection. Anastomotic leakage occurred on postoperative day 6, and substantial inflammatory conditions continued for 2 weeks. He died 6 weeks after surgery with multiple liver metastases. This case suggests that elevated inflammatory conditions may cause tumor progression.

[Clinical experience of chemotherapy with S-1/CDDP for highly-advanced gastric cancer].

BACKGROUND: We evaluated the efficacy and safety of chemotherapy with S-1/CDDP for advanced and recurrent gastric cancer at Fuchu Hospital. METHODS: The participants were 24 patients treated at our hospital. S-1 was given orally at 80 mg/m/2 for days 1-21, and 60 mg/m2 of CDDP was administered on day 8, followed by a 2-week rest period, within a 5-week course. RESULTS: Results were rated as a partial response in 12 cases and a stable response in 4 cases. The response rate was 50% (12/24), and median survival time was 273 days. The total incidence of grade 3 or greater adverse reactions including leucopenia, neutropenia, anemia, general fatigue, and eruption, was 25% (6/24). CONCLUSION: The combination of S-1/CDDP therapy appears to be highly efficacious and safe and showed promise as a useful treatment strategy, even in an outpatient clinic.

[Two cases of the primary small intestine cancer successfully treated with S-1 and UFT/LV therapy].

The primary small intestinal cancer is rare in gastrointestinal cancer, and there are much advanced/recurrent cases. However, there were a few case reports about chemotherapy for advanced or recurrent small intestinal cancer, and a treatment resume was inconsistent. We reported that S-1 and UFT/LV therapy was effective with the two cases as an oral chemotherapy for the primary small intestinal cancer.