[Laparoscopic Colectomy for a Patient with Transverse Colon Cancer in Situs Inversus Totalis].

A 74-year-old man with situs inversus totalis visited our hospital for a positive fecal occult blood. He was diagnosed with transverse colon cancer by total colonoscopy. We performed laparoscopic partial colectomy. He was discharged on the 8th postoperative day, without postoperative complications. Histopathological examination revealed well differentiated adenocarcinoma, pT1aN0M0, pStage Ⅰ. Preoperative assessment of the anatomical position and vascular malformations, using 3- dimensional computed tomography, was essential for our safe surgical conduct.

Occlusion of a Vortex Vein After Treatment With Half-Fluence Photodynamic Therapy Combined With Intravitreal Aflibercept Injection for Pachychoroid Neovasculopathy.

Photodynamic therapy (PDT) is a treatment option for pachychoroid diseases such as central serous chorioretinopathy (CSC), pachychoroid neovasculopathy (PNV), polypoidal choroidal vasculopathy (PCV), and peripapillary pachychoroid syndrome (PPS). On the other hand, morphological changes of choroidal vessels in the irradiated field after PDT have also been discussed, with occlusion of choriocapillaris and stenosis of choroidal middle and large vessels being reported. Here, we report a case of vortex vein occlusion after half-fluence PDT (HF-PDT) combined with an anti-vascular endothelial growth factor (VEGF) agent for PNV. In this case, HF-PDT achieved complete occlusion of PNV; in addition, a vortex vein that flowed in PNV but was located outside the PDT irradiation field was fully occluded three months post-treatment. At the occluded site of the vortex vein, indocyanine green video angiography revealed pulsation downstream of the vortex vein. Such occlusion of a large vessel by HF-PDT has not been reported previously. Occlusion could be induced by two factors: the potentiality of PDT and risk factors for thromboembolism, such as older age, smoking, and arrhythmia. Further studies are required to determine the mechanisms of these large vessel occlusions.

[A Case of Small Cell Carcinoma of the Esophagus with Complete Response to Chemoradiotherapy in an Elderly Patient].

Small cell carcinoma of the esophagus is a rare malignancy with a perceived poor prognosis. We report a case of long-term survival using chemoradiotherapy. An 80-year-old man visited our hospital complaining of hiccup. Endoscopic examination showed type 2 lesions in the lower esophagus with a pathological diagnosis of small cell carcinoma. Based on the diagnosis of cStage Ⅲ disease and the patient's age, chemoradiotherapy comprising 3 courses of CDDP and CPT-11 and 45 Gy of irradiation was administered. After treatment completion, the therapeutic effect was evaluated as a complete response through CT, PET-CT, and endoscopic examination. No recurrence has been identified more than 5 years after achieving the complete response.

[A Case of Perforative Peritonitis Due to Intestinal Metastasis from Lung Cancer].

We here describe a case of an acute peritonitis due to perforation of a small intestine tumor metastasized from a lung cancer. A 66-year-old man who had undergone a bladder cancer procedure 2 years ago and was hospitalized for the second operation, complained sudden abdominal pain. An enhanced abdominal CTrevealed a small amount of free gas and ascites in the abdominal cavity. On the same day, emergency exploratory surgery was performed with the diagnosis of perforative peritonitis. A laparotomy revealed a jejunal tumor with perforation 40 cm distal from the Treitz ligament. After surgery, the patient confessed that he had got a notice of the recurrence of lung cancer which had been treated 9 years ago. The pathological result indicated the lesion was metastasis from lung cancer. Although small intestinal metastatic tumor from lung cancer is rare, it should be considered when acute abdomen is observed.

[Repeated Insertion of Self-Expandable Metallic Stents as a Palliative Therapy for Unresectable Colorectal Cancer].

A 62-year-old man was admitted to our hospital for malignant rectal stricture due to metastatic rectal cancer. He underwent placement of a self-expandable metallic stent (SEMS). After the administration of 5 courses of FOLFOX4 with bevacizumab, chemotherapy-induced tumor shrinkage led to migration of the SEMS, which was removed immediately without complication. After 10 courses of chemotherapy, he had to discontinue the treatment due to liver failure resulting from tumor progression. Another SEMS was successfully inserted for the progression of rectal stenosis. The patient's QOL was maintained to the end with the SEMS. This case suggests that although it is essential to pay attention to possible complications, SEMS insertion is a very useful procedure for palliative therapy.

[Conversion Therapy of Initially Unresectable Rectal Cancer with Perforation via FOLFOX4 Chemotherapy].

We describe a case of perforated rectal cancer that became curatively resectable after FOLFOX4 chemotherapy. An 81- year-old woman was transferred to our hospital with a diagnosis of bowel perforation. She underwent emergency transverse colostomy, peritoneal lavage, and the insertion of indwelling drainage tubes, because the perforated rectal cancer was considered unresectable. After recuperation, she received chemotherapy consisting of FOLFOX4 and bevacizumab. Owing to a good response to the treatment after 4 months, rectal resection was achieved curatively. Wound dehiscence occurred as a postoperative complication. The patient chose not to receive adjuvant chemotherapy. Currently, she has been alive for more than 1 year 3 months after resection without recurrence.

[Long-term control of stage IV breast and gastric cancer with combination therapy of S-1 and paclitaxel].

We here describe a case of Stage IV breast and gastric cancer in which S-1/paclitaxel therapy was effective in maintaining the patient's QOL. A 50-year-old woman visited our hospital with complaints of her right breast tumor and right brachialgia. She was diagnosed with breast cancer with multiple bone metastases including cervical vertebrae. Accordingly, local radiation therapy and tamoxifen(TAM)administration was started immediately. Gastrointestinal endoscopy revealed gastric cancer, but laparotomy disclosed the gastric cancer was unresectable. At that time, the complaints of pain, nausea, and fatigue had increased and S-1/paclitaxel therapy was started immediately. The treatment reduced the size of the lesions in the breast and stomach and improved the QOL without serious adverse events. We have been maintaining partial response(PR)in this patient for 28 months.

[Three cases of endoscopic gastroduodenal stenting for gastric outlet obstruction caused by unresectable gastric cancer].

Gastroduodenal stenting for gastric outlet obstruction (GOO) caused by malignant disease has been covered by health insurance in Japan since April 2010. We have inserted WallFlex™ duodenal stents (WDS) in 3 patients with GOO caused by unresectable advanced gastric cancer. WDS placement was successful with no complications in all cases. Mean treatment time was 44.7 (35-50) minutes, and mean survival time after WDS placement was 34.7 (19-51) days. Oral food intake was improved in all patients but 1. Enteroparalysis due to peritoneal metastasis supposedly voided WDS placement in 1 patient. WDS placement for GOO caused by advanced gastric cancer is expected to be a safe and effective palliative treatment but sometimes yields no benefit in the patient with peritoneal metastasis.

[Four cases of operations for malignant disease in elderly patients].

The management of elderly patients with malignant disease is determined by their condition, complications, and living environment. Sometimes it is difficult to judge surgical indications for elderly patients. We report 4 cases of patients, 80 years or older, who underwent an operation for malignancy. In the first case we performed a bile duct excision for bile duct cancer, and in the second case we performed distal pancreatectomy for pancreatic cancer. Both operations were non-curative, and the patients were alive and maintained quality of life for 12 months after the operation. In the third non-curative operation, we performed total gastrectomy for remnant gastric cancer. The patient died of cancer 4 months after the surgery. In the fourth case we performed pancreaticoduodenectomy for bile duct cancer; it was a curative operation. The patient was in very good condition 4 months post-operation, but died suddenly due to acute myocardial infarction. In operations treating malignancy in elderly patients, it is important for the patients and their families to fully understand the significance of the operations.

RUNX3 modulates DNA damage-mediated phosphorylation of tumor suppressor p53 at Ser-15 and acts as a co-activator for p53.

Although it has been shown that the gastric tumor suppressor RUNX3 has a growth inhibitory activity, the precise molecular mechanisms behind RUNX3-mediated tumor suppression remained unclear. In this study, we found that RUNX3 is closely involved in DNA damage-dependent phosphorylation of tumor suppressor p53 at Ser-15 and acts as a co-activator for p53. The small interference RNA-mediated knockdown of RUNX3 inhibited adriamycin (ADR)-dependent apoptosis in p53-proficient cells but not in p53-deficient cells in association with a significant reduction of p53-target gene expression as well as phosphorylation of p53 at Ser-15. In response to ADR, RUNX3 was induced to accumulate in the cell nucleus and co-localized with p53. Immunoprecipitation experiments demonstrated that RUNX3 forms a complex with p53 in cells. In vitro pulldown assays revealed that the COOH-terminal portion of p53 is required for the interaction with RUNX3. Forced expression of RUNX3 enhanced p53-mediated transcriptional activation. Additionally, RUNX3 had an ability to induce the phosphorylation of p53 at Ser-15, thereby promoting p53-dependent apoptosis. Intriguingly, RUNX3 interacted with phosphorylated forms of ataxia telangiectasia-mutated in response to ADR; however, it did not affect the extent of DNA damage. From the clinical point of view, coordinated p53 mutation and decreased expression of RUNX3 in 105 human lung adenocarcinomas were significantly associated with the poor outcome of patients (p = 0.0203). Thus, our present results strongly suggest that RUNX3 acts as a novel co-activator for p53 through regulating its DNA damage-induced phosphorylation at Ser-15 and also provide a clue to understanding the molecular mechanisms underlying RUNX3-mediated tumor suppression.