[A Case of Conversion Surgery for Unresectable Advanced Gastric Cancer of Which Metastatic Site Was Disappear by Chemotherapy but the Primary Site Was Enlarged after Five Years].

A 77-year-old man presented to our hospital with a chief complaint of stomachache. He received a diagnosis of unresectable advanced gastric cancer classified as cT3, N+, M1(LYM, HEP, OSS), Stage ⅣB. He underwent first-line chemotherapy with SOX, second-line treatment with PTX plus Ram, and third-line treatment with nivolumab. The primary tumor showed a reduction in size, and liver and lymph node metastases were not detectable. However, after 5 years of chemotherapy, a re- enlargement was observed in the primary gastric lesion without progression of liver and lymph node metastases. Subsequently, conversion surgery was performed. Based on the pathological analysis, the diagnosis was ypT1b2(SM2), N0(0/17), M0, ypStage ⅠA, R0. After nivolumab administration postoperatively for 5 months, chemotherapy was discontinued as there was no recurrence.

[A Case of Lymphoepithelial Cyst of the Pancreas for Which Malignancy Could Not Be Ruled Out Difficult Preoperative Diagnosis].

Lymphoepithelial cyst(LEC)of the pancreas is a relatively rare benign cystic disease of the pancreas. In this report, we describe a case of LEC in which a malignant tumor could not be ruled out by preoperative diagnosis and surgery was performed. The patient was a 72-year-old man. A simple CT scan of the chest and abdomen performed as a follow-up for another disease incidentally revealed a mass in the pancreatic tail. Enhanced CT of the abdomen showed a tumor approximately 3 cm in size at the pancreatic tail with no contrast effect. MRCP showed moderate signal on T2WI, high signal on T1WI, and high signal on T2WI on some cysts inside the pancreas. PET-CT showed slight uptake of FDG. Both tumor markers CEA and CA19-9 were normal. Therefore, malignant disease such as pancreatic IPMC could not be ruled out, and laparoscopic distal pancreatectomy plus splenectomy was performed. The pathology results showed a diagnosis of pancreatic lymphoepithelial cyst with slight differentiation into sebaceous gland.

Three-year progression-free survival of a patient with concomitant mucinous adenocarcinoma of the colon with peritoneal dissemination and multiple myeloma who received lenalidomide: a case report.

BACKGROUND: Concomitant multiple myeloma (MM) and other primary malignancies is rare. Therefore, the treatment outcomes of patients with these conditions have not been well discussed. Lenalidomide is an oral thalidomide analog drug used for MM. Recently, the antitumor effect of lenalidomide has been gaining attention, and lenalidomide has been applied for managing solid tumors. The current case showed the treatment course of a patient treated with lenalidomide for concomitant MM and colon cancer with peritoneal dissemination. CASE PRESENTATION: A 74-year-old female patient receiving treatment for MM was diagnosed with mucinous adenocarcinoma of the transverse colon. The patient was clinically diagnosed with stage IIIC T4aN2M0 disease. Subsequently, laparoscopic colectomy with lymph node dissection was planned. However, intraperitoneal observation revealed peritoneal dissemination that had sporadically and widely spread. Therefore, palliative partial colectomy was performed to prevent future hemorrhage or obstruction. The patient was discharged on the 10th postoperative day without postoperative complication. Based on the patient's preference, lenalidomide was continually administered for MM without systemic chemotherapy. The patient survived for > 36 months without any signs of tumor progression. CONCLUSION: The current case first showed the treatment course of concomitant MM and colon cancer. The antitumor effect of lenalidomide can possibly contribute to 3-year progression-free survival in patients with mucinous adenocarcinoma of the colon with peritoneal dissemination.

Prognostic Value of C-reactive Protein-to-albumin Ratio after Curative Resection in Patients with Colorectal Cancer.

Objectives: The current retrospective study aimed to evaluate the association between combined preoperative and postoperative C-reactive protein-to-albumin ratio, which is correlated with prognosis in different types of malignancies, and prognosis after curative resection in patients with colorectal cancer. Methods: This study enrolled 263 patients who underwent curative resection for stage II/III colorectal cancer. C-reactive protein-to-albumin ratio was calculated within 30 days before and 7 days after surgery. Receiver operating characteristic curve analyses were performed to determine the optimal cutoff values of preoperative and postoperative C-reactive protein-to-albumin ratio. The correlations between combined preoperative and postoperative C-reactive protein-to-albumin ratio and prognosis were analyzed. Results: The cutoff values of preoperative and postoperative C-reactive protein-to-albumin ratio were 0.223 and 0.813, respectively; higher ratios were significantly associated with poor overall survival, based on the Kaplan-Meier curves (p < 0.001, p = 0.003, respectively). Further, preoperative and postoperative C-reactive protein-to-albumin ratios were correlated with poor progression-free survival (p < 0.001, p = 0.064, respectively). In the multivariate analysis, combined preoperative and postoperative C-reactive protein-to-albumin ratio was an independent predictor of overall survival and progression-free survival (p = 0.012, p = 0.044, respectively). Compared with low preoperative and postoperative C-reactive protein-to-albumin ratio, high ratios of that were significantly associated with poor overall survival (hazard ratio = 3.897, p = 0.006) and progression-free survival (hazard ratio = 2.130, p = 0.029). Conclusions: Combined preoperative and postoperative C-reactive protein-to-albumin ratio, useful for prognostic prediction, can be a promising prognostic marker after curative resection in patients with colorectal cancer.

Aggressive surgical intervention may improve prognosis in patients with ovarian metastasis from colorectal cancer.

PURPOSE: The current study aimed to investigate the prognostic clinicopathological factors of synchronous and metachronous ovarian metastasis (OM) from colorectal cancer (CRC) in patients with and without oophorectomy. METHODS: Female patients with OM from CRC who underwent primary tumor resection at our institution from January 2013 to December 2020 were evaluated. RESULTS: Of 661 female patients, 22 (3.3%) were diagnosed with OM. Among 22 patients with OM, 12 underwent OM resection. Twenty (91%) patients had extra OM upon diagnosis. Thirteen (59%) patients in the non-surgery group had peritoneal dissemination at surgery or on computed tomography scan or positron emission tomography-computed tomography. Two patients in the OM surgery group had emergency surgery because of abdominal pain. Four patients had postoperative complications, and the median duration of hospital admission was 16.5 days. The median survival time from OM diagnosis to mortality was 20.9 months. Then, the association between the clinicopathological factors and overall survival (OS) was investigated. Tumor location and surgery were found to be related to OS (p = 0.03, 0.006, respectively) in the univariate analysis. However, only surgery was associated with OS (p = 0.02) in the multivariate analysis. CONCLUSION: Surgery is an important prognostic clinicopathological factor of OM from CRC. OM tumors should be resected because OM surgery is less likely to cause complications and symptoms.

[A Case of Schwannoma in the Ascending Colon].

A 69-year-old man who was diagnosed with a submucosal tumor in the ascending colon by colonoscopy in X-7 year was presented. The endoscopic biopsy showed normal mucosa, and he had been followed up. During follow-up, computed tomography and colonoscopy performed in X year showed an enlargement of the tumor. Positron emission tomography-computed tomography showed intense FDG uptake. Malignant tumor was suspected, and laparoscopic-assisted right hemicolectomy was performed. The histopathological diagnosis showed spindle-shaped tumor cells proliferating in a fascicular manner. Immunohistochemical staining was positive for S-100 protein and negative for CD34, c-kit, and desmin, and schwannoma was diagnosed. Schwannomas are tumors derived from Schwann cells and therefore rarely develop in the gastrointestinal tract. Careful preoperative diagnosis is important because they do not normally metastasize or undergo malignant transformation.

[A Case of Retroperitoneal Leiomyosarcoma Treated with Repeated Surgical Resection].

A 55-year-old male revealed with a 5 cm-diameter mass in the lower abdomen on ultrasonography incidentally. Computed tomography showed a mass of 7 cm in size on the left side of the bladder. A malignant tumor was suspected, and surgically excised for purpose of diagnosis and treatment. Pathological examination confirmed retroperitoneal leiomyosarcoma, and the resection margins were negative. Follow-up computed tomography scan was performed every 3 months. Repeated resections were performed for twice recurrences within a year after surgery. A year after the first surgery, lung metastasis was detected and chemotherapy was started. Although retroperitoneal leiomyosarcoma is considered to have a poor prognosis, the present case had relatively good prognosis. This may be due to early detection and repeated surgical resection.

High Lymphocyte Count as a Significant Risk Factor for Incisional Hernia After Laparoscopic Colorectal Surgery.

BACKGROUND: In the era of laparoscopic surgery, incisional hernia (IH) remains a common complication of colorectal surgery. Various risk factors for IH have been evaluated to reduce the incidence, but the impact of nutrition on IH has not been well discussed. The aim of this study is to evaluate the relationship between nutritional status and the development of IH after laparoscopic colorectal surgery. MATERIALS AND METHODS: We retrospectively evaluated 342 colorectal cancer patients undergoing laparoscopic colectomy or proctectomy between January 2012 and December 2018. Postoperative computed tomography was used to diagnose the IH. Patient characteristics, including preoperative albumin and lymphocyte counts, were evaluated for the risk of development of IH. Further investigations were conducted regarding the impact of nutritional status on the development of IH in each patient of body mass index (BMI) under and over 25.0 kg/m 2 . RESULTS: IH was observed in 37 patients (10.8%), with a median follow-up period of 48.5 months. Female [odds ratio (OR)=3.43, P <0.01], BMI ≥25 kg/m 2 (OR=2.9, P <0.01), lymphocyte count ≥1798/µL (OR=3.37, P <0.01), and operative time ≥254 minutes (OR=3.90, P <0.01) had statistically significant relationships to IH in multivariate analysis. Low albumin was related to IH in BMI ≥25 kg/m 2 ( P =0.02), but was not in BMI<25 kg/m 2 ( P =0.21). On the other hand, a high lymphocyte count was related to IH regardless of BMI (BMI ≥25 kg/m 2 : P =0.01, BMI<25 kg/m 2 : P =0.04). CONCLUSIONS: A high preoperative lymphocyte count is an independent risk factor for IH, whereas a low albumin count is limited regarding predicting IH.

C-reactive protein/albumin ratio predicts survival after curative surgery in elderly patients with colorectal cancer.

Inflammation-based markers, including the C-reactive protein/albumin ratio (CAR), lymphocyte/monocyte ratio (LMR), neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), Onodera's prognostic nutritional index (PNI), and Glasgow Prognostic Score (GPS), have been demonstrated to serve as prognostic indicators in various malignancies. This study aimed to evaluate their potential predictive value for colorectal cancer (CRC) in the elderly. We retrospectively evaluated 163 patients with CRC, aged 80 years and older, who had undergone curative surgery. The receiver operating characteristic curve analyses and the corresponding areas under the curve (AUCs) were used to determine and compare the discriminatory ability of the inflammation-based markers. Besides, the associations of inflammatory markers and clinical characteristics with overall survival (OS), relapse-free survival (RFS), and cancer-specific survival (CSS) were analyzed. The CAR had a significantly larger AUC than the GPS, PLR, NLR, and LMR (p = 0.006, 0.012, 0.018, and 0.002, respectively), except for the PNI (p = 0.052). The optimal cut-off value was 0.106 for the CAR and 44.894 for the PNI. Moreover, a CAR ≥ 0.106 turned out to be significantly associated with worse 5-year OS, RFS, and CSS compared with a CAR < 0.106. The multivariate analysis indicated that the CAR ≥ 0.106 was an independent prognostic factor for poor OS (HR = 3.596, p = 0.0006), RFS (HR = 2.945, p = 0.003), and CSS (HR = 4.411, p = 0.02). CAR is a useful and promising prognostic marker in elderly patients undergoing curative surgery for CRC.

[A Case of Medullary Carcinoma of the Colon with Poor Prognosis].

An 87-year-oldwoman was referredowing to lightheadedness. Severe anemia(Hb 3.9 g/dL)was detected, and colonoscopy revealeda circumferential elevatedlesion at the transverse colon(Group 5, por). The patient was diagnosed with colon cancer(cT4a, N0, M0, Stage Ⅱ), andright hemicolectomy was performed. Immunochemical analysis showedthat the lesion was MLH1- andPMS2- and confirmed a diagnosis of medullary carcinoma. Although the patient was discharged 48 days after surgery without any incident, she was readmitted because of lower leg edema. Liver metastasis and peritoneal dissemination were suspectedon performing computedtomography, andthe patient died3 5 days after readmission. Medullary carcinoma has molecular pathological features such as methylation of the promoter region andassociatedattenuation of MLH1 protein expression, as well as microsatellite instability. The prognosis for medullary carcinoma is relatively good comparedto that for poorly differentiatedad enocarcinoma, though the present case hada poor prognosis. Herein, we report a literature review.

Laparoscopic colectomy after transcatheter aortic valve implantation in an elderly patient with obstructive descending colon cancer and severe aortic stenosis: a case report.

BACKGROUND: The demand for laparoscopic colectomy is increasing due to greater number of elderly colon cancer patients, and it is important to evaluate existing comorbidities to ensure perioperative safety. Aortic stenosis (AS) is one of the most common heart diseases in the elderly, and elderly cancer patients with severe AS may be considered ineligible for optimal cancer treatment if they cannot endure surgical aortic valve replacement (SAVR). Recently, transcatheter aortic valve implantation (TAVI) has become a valid option in patients who are high risk for SAVR. We herein present the first case of an elderly cancer patient with severe AS who underwent laparoscopic colectomy after TAVI. CASE PRESENTATION: An 87-year-old woman with a history of multiple cardiovascular diseases was diagnosed with obstructive descending colon cancer and initially underwent colonic stenting. However, as preoperative echocardiography revealed severe AS, she underwent TAVI prior to the colectomy to reduce perioperative risk. TAVI was chosen instead of SAVR due to high SAVR mortality risk, and laparoscopic colectomy was performed 22 days after TAVI. Her postoperative course was uneventful, and she was discharged 14 days later without any deterioration in general condition. No recurrence was observed at more than 1 year, even without adjuvant therapy. CONCLUSION: TAVI facilitated subsequent laparoscopic colectomy in an elderly cancer patient with severe AS. Our case report shows that TAVI may enable further cancer treatment even in patients with severe AS, who may otherwise be considered not suitable for such treatments.

[Role of Palliative Chemotherapy for Peritonitis Carcinomatosa of Inoperable Advanced Gastric Cancer].

We report a case of peritoneal dissemination of gastric cancer in which the QOL was maintained with a less-than-optimum dose of anticancer agent. A 64-year-old man underwent total gastrectomy for corpus gastric cancer without distant metastasis performedas an open-laparotomy. Peritoneum disseminations were observed in the left sub-diaphragmatic space and back side of the mesocolon, andthe tumor passedd irectly to the superior mesenteric vein of transverse mesocolon. As a first- line chemotherapy, G-SOX therapy(S-1 80mg/day/body and oxaliplatin 100mg/m2)was administered for 15 courses. After these courses, the disease was categorized as PD. Next, RAM/PTX(ramucirumab 8mg/kg andpaclitaxel 80mg/m2) were administered as second-line chemotherapy. However, the PTX, especially causedprolongedad verse effects such as G4- leveledbloodtoxicity andsevere general fatigue. Therefore, we administereda lower dose of PTX than the original optimal minimum dose. This lower dose chemotherapy resulted in effective changes such as decreased pain and general fatigue and resolution of the bloodtoxicity. As a result, the patient's QOL improved, and his condition has been maintained as SD for 2 years after the operation. For these reasons, this ordinary chemotherapy may be used as a palliative chemotherapy.

[A Case of Hepatocellular Carcinoma Complicated with Idiopathic Thrombocytopenic Purpura].

The patient was a 72-year-oldwoman. She had been diagnosed with idiopathic thrombocytopenic purpura(ITP), hepatitis B, and diabetes mellitus. She was admitted to our hospital because of anemia andvomiting of blood vomiting and was diagnosed with hepatocellular carcinoma at S6. A splenectomy was performed, with a temporary improvement of her platelet count. We tried to control the platelet count with medication and performed transcatheter arterial embolization(TACE)3 times. However, the tumor size decreased only slightly anda new tumor was observed on S2. Therefore, we increased the patient's platelet count to 109×10 4/mL and performed a partial hepatectomy of 4 lesions. The postoperative complications included intraabdominal abscess, but there was no bleeding and the patient was discharged on POD 114. Platelet count is often difficult to maintain in patients diagnosed with ITP. We report our experiences and also provide a discussion of a case of operated hepatocellular carcinoma complicated with refractory ITP.

[Follicular lymphoma with nodular lesions mimicking gallbladder carcinoma].

A 68-year-old female was diagnosed with follicular lymphoma (FL) grade 2, based on the excisional biopsy of her enlarged left cervical lymph node. Positron-emission tomography/computed tomography (PET/CT) revealed the 18F-fluoro-deoxyglucose-avid lesions in the sigmoid colon and at the fundus of the gallbladder, besides those in the left neck. A sigmoid colon polyp, which was endoscopically resected, proved histologically to be a well- to moderately-differentiated tubular adenocarcinoma with deep invasion into the submucosa. In addition, nodular lesions of the gallbladder were enhanced on dynamic CT, markedly suggesting gallbladder carcinoma. Among FL, colorectal cancer, and presumed gallbladder adenocarcinoma, FL was considered having the lowest priority of treatment because of its indolent nature and low tumor burden. We performed laparoscopic-assisted sigmoid colectomy, followed by gallbladder bed resection on the same day. Unpredictably, gallbladder lesions were histologically revealed to be FL. Often, FL involves extranodal sites such as the gastrointestinal tracts. However, the gallbladder involvement is extremely rare, and preoperative distinction from gallbladder adenocarcinoma remains challenging to date; this report discusses its characteristics along with the literature review. Furthermore, our case, in which another malignant neoplasm coexisted, needed histological identification of the gallbladder lesions to ascertain the therapeutic strategy.

[A Case of a Duodenal GIST Observed as a Non-Functional Pancreatic Neuroendocrine Tumor].

A 67-year-oldman was referredto our hospital because his CEA level was increasing. In March 2007, abdominal computed tomography(CT)showedthe presence of a tumor(30mm in diameter)in the pancreatic head. Upon close inspection, the patient was diagnosed with a non-functional pancreatic neuroendocrine tumor and was observed. In September 2016, the patient showedhyperglycemia, liver dysfunction, andelevation of tumor markers. CT revealeda tumor(42mm in diameter) in the pancreatic head. It hadincreasedmore than before. We diagnosedhim with a gastrointestinal stromal tumor(GIST)of the duodenum based on endoscopic ultrasound-guided fine-needle aspiration biopsy and performed pancreaticoduodenectomy. Immunohistochemical staining showedpositive c-kit, andmore than 10%positive MIB-1. Currently, the patient is alive after the surgery.

[A Case of Extramedullary Plasmacytoma of the Stomach Detected Due to Severe Anemia].

A 78-year-oldwoman was referredfor exertional dyspnea. Severe anemia(Hb 4.2 g/dL)was detected, and upper endoscopy revealeda giant ulcer at the posterior wall of the gastric body. Computedtomography showeda mass protruding from the gastric wall, suggestive of a submucosal tumor. Although biopsy did not confirm a diagnosis, we performed distal gastrectomy to control the bleeding. The pathological findings and systemic examination confirmed a diagnosis of extramedullary plasmacytoma of the stomach. Plasmacytoma is a tumor of the bone marrow derived from plasma cells that mature from B cells. The frequency of extramedullary plasmacytoma for all plasmacytoma is about 5% and plasmacytoma derived from the stomach occurs in approximately 2%of these cases. Complete resection with lymph node dissection according to the surgical treatment of gastric cancer is recommended. Large tumors, such as that in the present case, may have a poor prognosis; thus, careful follow-up is required for the early detection of recurrence. We report a case of extramedullary plasmacytoma of the stomach with a literature review.

[A Case of Long-Term Control of Stage â £ Gastric Cancer by Multimodal Therapy].

An 82-year-oldwoman was admittedto our hospital because of appetite loss andwas diagnosedwith a Type 3 tumor in the lower gastric body. Pathological examination suggested moderately differentiated adenocarcinoma with negative staining for HER2 by immunohistochemistry. An abdominal CT revealedthickening of the gastric wall andparaaortic lymph node metastases. The clinical findings suggested Stage Ⅳ disease(T4aN3M1). Chemotherapy was administered with a combination of S-1 plus oxaliplatin(SOX). After 2 courses of the SOX regimen, an abdominal CT showed a reduction of the paraaor- tic lymph node metastases, and the CEA level hadd ecreasedto 6.2 ng/mL. After 7 courses of the SOX regimen, the CEA level hadincreasedto 10.1 ng/mL, and the treatment schedule was changed to a regimen of paclitaxel plus ramucirumab(PTX/ RAM). However, grade 4 neutropenia was observed after the first treatment. Distal gastrectomy with D1+lymph node dissection was performedfor local control in September 2016. The post-operative pathological findings were ypT1b2ypN2M1, ypStage Ⅳ and the chemotherapeutic effect was grade 1a. A CT scan revealedregrowth of the paraaortic lymph node 3 months after the operation. Chemotherapy was administered with a combination of capecitabine plus oxaliplatin(CapeOX). At present, the patient is being treatedwith capecitabine monotherapy in the outpatient department with no signs of tumor regrowth.

[Curative Resection for Liver Metastasis Ten Years after Surgery for Rectosigmoid Cancer-A Case Report].

Here, we report the case of a 73-year-oldfemale patient, who previously underwent high anterior resection for rectosigmoidcancer at the age of 63. Her scheduled5 years of follow-up after colorectal surgery hadbeen finished, but she kept undergoing endoscopic mucosal resection for colorectal polyps every 1 or 2 years since then. Blood examination 10 years 6 months after surgery for rectosigmoidcancer revealedthat the value of her serum CEA was 5.5 ng/mL, which was slightly higher than the normal range. Contrast-enhancedCT showedan irregular-shapedtumor with a diameter of 3 cm in which the contrast of the peripheral area was mainly emphasized. When combining the results of MRI and PET-CT examinations, the liver tumor was clinically diagnosed as either intrahepatic cholangiocarcinoma or metastatic liver cancer. Since the first choice of therapy was tumor resection for both diagnoses, S8 subsegmental hepatectomy was performed 10 years 8 months after surgery for rectosigmoidcancer. HE staining of the resectedspecimen showedwell or moderately differentiatedad enocarcinoma, andits immunostaining findings were as follows: CDX-2: positive, CK20: positive, CK7: negative. It was pathologically diagnosed as liver metastasis from rectal cancer. It is rare for colorectal cancer to have metachronous liver metastasis more than 10 years after surgery. However, in any case where a tumor marker for colorectal cancer increases, it is necessary to examine carefully with the possibility of any metastasis in mind.

[Pregnancy-Associated Stage â £ Gastric Cancer with No Recurrence for a Long Time-A Case Report].

A 28-year-oldwoman visiteda clinic with a complaint of epigastralgia 3 months after delivery. She was diagnosedwith gastritis andtreatedwith medication. Two months later, in January 2006, she was admittedto our hospital with a complaint of dysphagia. Upper gastrointestinal endoscopy revealed type 3 gastric cancer in the lesser curvature of the cardia, and abdominal CT scan showed wall thickening of the upper gastric body. No apparent distant metastases were found. The patient underwent total gastrectomy with D2 lymph node dissection in February 2006. Although there was no peritoneal dissemination, the patient testedpositive in peritoneal lavage cytology. The postoperative pathological diagnosis was gastric cancer pT4aN2M1(P0CY1H0), Stage Ⅳ. She was discharged on postoperative day 22. S-1 monotherapy(100mg/day, day 1- 28q6wks)was performedfor 1 year on an outpatient basis. For 13 years and1 0 months after the surgery, no apparent recurrences of gastric cancer have been observed. In gastric cancers associated with pregnancy, it is difficult to distinguish between perinatal symptoms andsymptoms of gastric disease. Therefore, endoscopic examination shouldbe performedfor perinatal patients presenting with persistent gastrointestinal symptoms.

[A Case of Locally Advanced and Metastatic Breast Cancer Treated with Preoperative Bevacizumab Combination Chemotherapy That Attained Local Control].

We report a case of a 74-year-old woman with a left breast tumor with skin infiltration. Luminal type breast cancer with lung, bone, and parasternal lymph node metastases was diagnosed. She received paclitaxel and bevacizumab treatment. After chemotherapy, the lung metastasis and parasternal lymph node metastasis had disappeared, and the breast tumor had shrunk. Mastectomy and axillary lymph node dissection were performed. She has been receiving post-operative endocrine therapy. Paclitaxel and bevacizumab combination therapy is one of the useful treatments for metastatic breast cancer with skin infiltration.