[Adjuvant Chemotherapy and the Prognosis of ypStageâ Gastric Cancer].

The efficacy of postoperative chemotherapy for patients with ypStageⅠgastric cancer has not been evaluated. We investigated the characteristics and prognosis of7 patients with ypStage Ⅰgastric cancer. cStages were ⅡA, ⅡB, ⅢB, and Ⅳin 1, 1, 1, and 4 patients, respectively. S-1 plus cisplatin and docetaxel plus cisplatin plus S-1 were administered in 5 and 2 patients, respectively, for 2-8 courses before gastrectomy. Microscopic curative resection was performed for all patients. ypStage was 0, ⅠA, and ⅠB in 1, 2, and 4 patients. All patients received postoperative chemotherapy with S-1 or docetaxel plus S-1(DS). The 5-year recurrence-free survival was 71% and the 5-year overall survival was 68%. Two patients developed recurrence. One patient developed recurrence 1 year and 1 month after gastrectomy in spite of S-1 treatment for 4 months. Another patient developed recurrence 11 months after gastrectomy after DS treatment for 4 months followed by S-1. The other 5 patients received S-1 for 1-5 years and have survived without recurrence. Although the prognosis ofypStage Ⅰgastric cancer was comparatively good, the regimen and courses ofpostoperative chemotherapy should be evaluated in a prospective study.

[A Case Report of Long Survival in Pancreatic Cancer with Superior Mesenteric Arterial Invasion Following Multimodal Therapy].

The prognosis of pancreatic cancer with superior mesenteric arterial invasion is very poor and judgment of surgical indication is very difficult. We report a case that received multimodal therapy for pancreatic cancer with superior mesenteric arterial invasion. A 43-year-old woman consulted a local doctor because of upper abdominal pain. Ultrasonography revealed a nodule in the pancreatic body and elevated CA19-9 values. She was referred to our hospital for evaluation and therapy. Computed tomography showed a low-density area in the pancreatic body and around the superior mesenteric artery. The clinical diagnosis was pancreatic cancer with superior mesenteric arterial invasion. She received chemoradiation therapy(RT, 50.4 Gy, gemcitabine[GEM]plus TS-1)followed by distal pancreatectomy. She received adjuvant chemotherapy(TS-1)for 6 months. However, follow-up CTperformed 10 months after surgery revealed local recurrence. The patient received chemotherapy( GEM)for 8 months and GEM plus nab-PTX for 22 months. She died from the cancer 50 months after the primary operation.

[A Case of Chemotherapy with Abscess Drainage for Pancreatic Cancer Detected Due to Peritonitis].

A 69-year-old woman was admitted to our hospital because of abdominal pain. Abdominal CT revealed free air, so we performed an emergency operation. Although the perforation site could not be confirmed, pancreatic cancer invading the stomach, spleen, and transverse colon was found. As a splenic abscess and peritoneal dissemination were also found, we created a colostomy and placed drains. Although the postoperative course was good, the splenic abscess continuous with the tumor remained. We thought that early removal of the drain would be difficult, so chemotherapy was introduced while continuing drainage. Fortunately, the pancreatic cancer was controlled, and the abscess tended to shrink, so we removed the tube 137 days after the surgery. After that, we continued chemotherapy, but in the second year after the surgery, the liver metastasis acutely exacerbated and DIC also developed, resulting in cancer death. If surgical intervention is difficult, as in this case, chemotherapy may be considered as an option, keeping in mind the possibility of exacerbation of infection.

[A Case of Gastric Cancer with Ramucirumab-Related Colon Perforation after a Subtotal Colectomy].

A 61-year-old man with advanced gastric cancer underwent distal gastrectomy after chemotherapy. Fifteen months later, peritoneal metastasis and colon stenosis were detected. Therefore, subtotal colectomy and ileosigmoidostomy were performed. Three weeks later, paclitaxel(PTX)treatment was initiated, followed by nab-PTX with ramucirumab(Ram)treatment at 7 weeks postoperatively. The patient experienced sudden abdominal pain diagnosed as gastrointestinal perforation 13 weeks postoperatively. Operative findings showed that the anastomosis of the ileosigmoidostomy was perforated, and this was treated using sutures. Angiogenesis inhibitors should be carefully administered even 4 weeks or more after surgery.

[The Experience of the Intensity Modulated Radiation Therapy for Abdominal Lymph Node Metastases from Gastric Cancer].

The recurrence ofgastric cancer has a poor prognosis in spite ofsystemic chemotherapy. We report three cases oflocal control ofdisease after the recurrence owing to intensity modulated radiation therapy(IMRT). The first case was a 66-yearsold man. He was received distal gastrectomy after neoadjuvant chemotherapy for advanced gastric cancer. Abdominal lymph node metastases appeared 1 year and 7 months after the surgery. IMRT was performed and he keeps CR for 1 year and 8 months. The second case was a 72-years-old man. He received proximal gastrectomy for early gastric cancer. Abdominal lymph node metastasis appeared 1 year and 9 months after the surgery. IMRT was performed and he keeps CR for 1 year. The third case was a 71-years-old woman. She received distal gastrectomy for advanced gastric cancer. Abdominal lymph node metastasis appeared 2 years after the surgery. IMRT was performed and she keeps CR for 10 months. We experienced longtime CR after IMRT against abdominal lymph node metastasis. IMRT could be one ofthe strategies ofthe comprehensive treatment for the recurrence of gastric cancer.

Gasless transumbilical laparoscopic-assisted appendectomy as a safe and cost-effective alternative surgical procedure for mild acute appendicitis.

PURPOSE: Several reports have demonstrated the effectiveness and feasibility of single incisional transumbilical laparoscopic-assisted appendectomy (TULAA). We developed a modified TULAA technique, gasless-TULAA, which involves lifting the abdominal wall with a retractor, without pneumoperitoneum or another incision. METHODS: We assessed the surgical outcomes of 257 patients treated for appendicitis in our hospital between 2005 and 2013. In a preoperative comprehensive evaluation, appendicitis without abscess was defined as mild appendicitis (mild appendicitis group: MAG), and appendicitis with abscess was defined as severe appendicitis (severe appendicitis group: SAG). The clinical outcomes were compared with those in other published reports. The cost-effectiveness of gasless-TULAA was compared with that of conventional multiport laparoscopic appendectomy (CMLA) in our hospital. RESULTS: In MAG (n = 228), the operation time and postoperative hospital stay were 46.9 ± 22.7 min and 2.6 ± 1.2 days, respectively. The gasless-TULAA was completed without trocars in 91.2 % of patients. The surgical outcomes of SAG were significantly worse than those of MAG (p < 0.001). The surgical cost of gasless-TULAA was significantly lower than that of CMLA (p < 0.001). CONCLUSION: Gasless-TULAA is a cost-effective, safe, and readily available surgical technique for mild appendicitis, which can obviate the need for specialized equipment.

Safety of early laparoscopic cholecystectomy for patients with acute cholecystitis undergoing antiplatelet or anticoagulation therapy: a single-institution experience.

BACKGROUND/AIMS: Early cholecystectomy is recommended for patients with acute cholecystitis, particularly when less than 72 hours have passed since symptom onset. The safety of early laparoscopic cholecystectomy for patients receiving anticoagulants or antiplatelet agents is unclear. We retrospectively analyzed the safety of early laparoscopic cholecystectomy for patients with acute cholecystitis undergoing antiplatelet or anticoagulation therapy. METHODOLOGY: Between 2005 and 2012, a total of 239 patients were diagnosed with acute cholecystitis, 183 of whom underwent early laparoscopic cholecystectomy. We compared the clinical features and surgical outcomes of 21 patients undergoing antiplatelet or anticoagulation therapy with those of 162 patients not undergoing antiplatelet or anticoagulation therapy. RESULTS: Of the 21 patients, 15 patients took aspirin and four took clopidogrel sulfate. Three patients received dual therapy with two agents. The distributions of the severity of acute cholecystitis, a past history of abdominal operations, body mass index, blood test results, operation time, and blood loss were not significant between the two groups. Neither conversion to open surgery nor bleeding-related complications occurred in the patients undergoing antiplatelet and anticoagulation therapy. CONCLUSIONS: Early laparoscopic cholecystectomy for selected patients with acute cholecystitis undergoing antiplatelet and anticoagulation therapy is feasible and safe.

[Sternomyelitis caused by delayed tracheal necrosis after thyroidectomy;treatment using muscle flap of petoralis major].

We experienced a rare case of delayed tracheal rupture after thyroidectomy for papillary thyroid cancer, and the infection causing sternomyelitis. A 69-year-old man presented subcutaneous emphysema after 6 days of total thyroidectomy with bilateral cervical and mediastinal dissection for lymph node metastases by adverse T sternotomy. He underwent tracheostomy on 10th postoperative day (POD), debridement of sternum on 14th POD, and implantation of skin-muscle flap using pectolaris major on 43th POD. The flap showed good adaptation and no infectious complications recurred, so that he could consequently receive closing procedure of tracheostomy on 94th POD.

[Multidisciplinary therapy for recurrent pancreatic cancer].

We report 2 cases of pancreatic cancer with distant organ metastasis. Case 1: A 67-year-old man with pancreatic cancer (T3N0M0, Stage III) underwent pancreaticoduodenectomy (PD). A follow-up computed tomography (CT) scan performed 48 months after the primary resection detected two masses in his right lung, which were treated by stereotactic body radiotherapy ( SBRT). Twenty-three months after SBRT, the patient is alive. Case 2: A 54-year-old woman with pancreatic cancer (T3N1M0, Stage III) underwent PD. A follow-up CT scan performed 12 months after the primary resection detected 3 masses in her liver, which were treated by SBRT. The patient died because of lymph node metastasis of the pancreatic cancer 32 months after SRT.

[A case of long-term survival after hepatic resection for metastatic gastric cancer].

We report a case of long-term survival of a patient who underwent hepatic resection for metastatic gastric cancer. The patient was a 75-year-old man who underwent distal gastrectomy for gastric cancer in 2004. On pathological examination, the tumor was diagnosed as T4a (SE) N0M0, stage IIB. A metastatic lesion was detected in segment 6 of the liver at 2 years after gastrectomy. With regard to radiological findings, a single metastatic lesion and no lymph node metastasis or peritoneal recurrence was observed. The hepatic lesion was curatively resected. Another metachronous liver metastasis was identified in segment 7 of the liver at 3 years after gastrectomy. We resected the remnant liver metastasis, after which the patient has not exhibited any evidence of tumor recurrence for more than 5 years. This case suggests that patients could survive for a long period after undergoing resection of hepatic metastasis because no lymph node metastasis was observed during the operation of the primary gastric cancer, only a single hepatic metastasis without any metastasis to other organs was observed, and the metastatic lesion of the liver could be curatively resected.

[A case of a patient with giant mucinous cystadenocarcinoma who presented with abdominal pain].

We report a case of a patient in whom a giant mucinous cystadenocarcinoma was treated with distal pancreatectomy. A 37-year-old woman was admitted to the hospital complaining of intermittent epigastric pain. The laboratory data revealed a marked increase in serum levels of carcinoembryonic antigen( CEA 22 ng/mL), cancer antigen( CA) 19-9( 258,129 U/ mL), and CA125 (53 U/mL). A computed tomography (CT) scan revealed a cystic tumor, 15 cm in diameter, in the body of the pancreas. The tumor presented as a multilocular cyst with enhanced nodules. On positron emission tomography (PET)-CT,[ 18F] fluorodeoxyglucose uptake by the nodules of the cyst was noted. Under the diagnosis of malignant mucinous cystic neoplasm, we performed distal pancreatectomy, splenectomy, partial gastrectomy, and left adrenalectomy because the tumor was suspected to be invading the stomach and left adrenal gland. The tumor was histologically diagnosed as invasive mucinous cystadenocarcinoma with ovarian-like stroma. The patient survived for 14 months after surgery without tumor recurrence. Invasive mucinous cystadenocarcinoma of the pancreas has high rates of lymph node metastasis and early recurrence after surgery. We believe that we would have had to perform complete tumor resection equivalent to that of invasive ductal carcinoma of the pancreas if the mucinous cystic neoplasm was found to be malignant preoperatively.

[Abdominal lymph node metastases detected five years after surgery for the lung cancer; report of a case].

A 73-year-old woman who had underwent right lower lobectomy for adenocarcinoma of the lung( S10,pT1aN0M0, stage I A) 5 years before, visited our hospital with back pain. Whole body computed tomography (CT) revealed the enlargement of the abodominal lymph nodes surrounding the celiac artery,which was positive for fluorodeoxyglucose-positron emission tomography( FDG-PET). Open biopsy of the lymph node was performed and histopathological diagnosis was metastases of adenocarcinoma.Additional immunohistological examination showed positive findings for cytokeratin( CK) 7 and thyroid transcription factor( TTF)-1, but negative for CK20, suggesting the lesion to be metastases of lung cancer. Abdominal lymph node should be kept in mind in patients with lower lobe lung cancer.

[A case of intrahepatic recurrence of intrahepatic cholangiocarcinoma treated with repeated hepatectomy].

A 60-year-old man with intrahepatic cholangiocarcinoma (ICC) underwent a left hepatectomy. Following the procedure, S-1 was administered during the period of five months. About two years after the hepatectomy, the patient underwent a hepatic resection again for remunant hepatic recurrences of ICC. Aggressive surgical resection may be the only method to assure a good outcome. An indication of resection for the hepatic recurrence of ICC will be examined in the future.

[A radical resection of non-small cell lung cancer invading chest wall with ipsilateral axillary lymph node metastases].

A 41-year-old man who had non-small cell lung cancer invading his right 3rd, 4th and 5th ribs with hilum lymph node swelling(cT3N1M0, cStage III A), received chemoradiation therapy, cisplatin(CDDP)/docetaxel, and 2 Gy/Fr of irradiation prior to surgery. But the therapy was discontinued due to interstitial pneumonitis on day 24, during 28 Gy of radiation. At that time, a PET-CT scan revealed the accumulation of FDG in the primary tumor, hilar lymph node, and one of the ipsilateral axillar lymph nodes, in which cancer cell presence was proven by aspiration needle cytology. We organized a radical operation even though the node status was classified to cStage IV, because ipsilateral axillary lymph nodes may be regarded as regional nodes for tumors invading the chest wall. Right upper lobectomy and chest wall resection were performed, and the ipsilateral hilar, mediastinal, and axillary lymphnode were dissected. Pathological findings showed no active cancer cell in the primary lesion and hilar lymph nodes(Ef. 3), but obvious metastasis in one of the axillary lymph nodes(pT0N0M1b, pStage IV). The patient received adjuvant chemotherapy(CDDP/vinorelbine), and is alive and tumor-free 10months after the resection.

[Squamous cell carcinoma of the anal canal showing pathological complete response after S-1 plus radiotherapy -a case report].

The patient was a 53-year-old woman who underwent colonoscopy for anal pain and melena. We diagnosed her with Stage I (T2N0M0) anal canal squamous cell carcinoma by biopsy specimen and CT scan. We recommended chemo-radiotherapy because she hoped to keep her anus. For this patient, we planned an S-1 administration at a dose of 120 mg/ body/day for consecutive 14 days followed by 7 days of rest period with whole pelvis and bilateral inguinal radiation (total 45 Gy/25 Fr). Then we added a booster radiation (14 Gy/7 Fr) to a local area for 5 days followed by 2 days of rest period. After 2 weeks of chemo-radiotherapy, we could not detect any tumors by colonoscopy. We diagnosed it as a pathological complete response for biopsy specimen.

[Two case reports-a control of the bleeding from advanced gastric cancer, unable to undergo resection, but was possible by transcatheter arterial embolization (TAE)].

CASE 1: A 61-year-old man having advanced gastric cancer was presented with massive hematemesis. We could not control bleeding by gastrointestinal endoscopic hemostatic therapy, so we performed a transcatheter arterial embolization (TAE). We performed embolization on the left gastric artery. CASE 2: A 58-year-old man having advanced gastric cancer was presented with hematemesis. We could not control bleeding by gastrointestinal endoscopic procedure, so we conducted TAE. We performed embolization on the left gastric artery and right gastric artery. In both cases, hemostasis was achieved by TAE, and effectively controlled the bleeding from advanced gastric cancer.

[Long-term control of sacral metastasis from rectal cancer with S-1 + radiation treatment (RT) and mFOLFOX6 combination therapy--a case report].

Combined chemotherapy including 5-FU plus radiation treatment resulted in a synergistic effect has been reported. S-1 enhances a radiation response of colon cancer cell line xenografts. Also the effectiveness of S-1 + radiation therapy has been reported. A 66-year-old man underwent a low anterior resection for lower rectal cancer. Adjuvant chemotherapy was not performed due to Stage II rectal cancer. Twenty months after the operation, solitary sacral bone metastasis was found during the postoperative work-up. S-1 (120 mg/day) combined with radiotherapy was performed on days 1-14 and 21-35. Radiation (3 Gy) was administered a total of 45 Gy on days 1-5, 7-12 and 35-40. Moreover, the reduction was judged as complete response after 11 courses of mFOLFOX 6. There has been no sign of recurrence for 44 months. It suggested that local control therapy (S-1 + radiation) plus systemic chemotherapy (mFOLFOX6) was one of the promising effective therapies for single sacral bone metastasis of rectal cancer.

[Evaluation of systemic chemotherapy for unresectable gallbladder carcinoma].

We analyzed a treatment outcome and the effect of systemic chemotherapy for patient with unresectable gallbladder carcinoma. Sixteen patients were investigated. Gemcitabine (GEM) was administrated for fifteen patients as the first-line chemotherapy. S-1 was administrated for ten patients as the second-line chemotherapy. The response rate and tumor control rate of the first-line GEM were 14.3% and 78.6%, respectively. The median progression free time of the first-line GEM was 6.0 months. The response rate and tumor control rate of the second-line S-1 were respectively 20.0% and 30.0%. The median progression free time of the second-line S-1 was 1.8 months. The median survival time of all cases was 14.9 months. The outcome of systemic chemotherapy for patients with unresectable gallbladder carcinoma in our hospital was feasible compared with past reports.

[A case report--transarterial embolization for advanced gallbladder carcinoma with hepatic metastasis].

A 75-year-old female presented with appetite and weight loss and epigastralgia. CT revealed a primary gallbladder carcinoma Stage IVb with multiple hepatic metastases. Gastrofiberscopy revealed an invasion to duodenal and bleeding from the tumor. For her poor performance status, it seems to be too difficult to undergo a general chemotherapy. So after gastrojejunostomy, transarterial embolization (TAE) was performed. She underwent 2 times TAE. There was a notable reduction in tumor size. But pulmonary metastases were found in bilateral lung. She died after 8 months. TAE may be useful for advanced gallbladder carcinoma with tumor vascularity.

[Radiofrequency ablation combined with transcatheter arterial chemoembolization for the local recurrent tumor after resection of the adrenal metastasis from hepatocellular carcinoma--a case report].

We report a case of local recurrent tumor after a resection of right adrenal metastasis from hepatocellular carcinoma successfully treated with radiofrequency ablation combined with transcatheter arterial chemoembolization. The case is a man in his 80s who had a curative surgical resection and microwave coagulation therapy (MCT) for multiple hepatocellular carcinomas in February 2003. The lesions were judged to be T4, N0, M0 and Stage IV,then, he was treated as an outpatient on a regular schedule. In July 2003, a right adrenal tumor 2 cm in diameter was detected by computed tomography (CT), but the value of the adrenocortical hormones were normal on blood examination, and he was observed at regular intervals. In February 2005, the adrenal lesion enlarged to 5 cm in diameter and the value of PIVKA-II became high on blood examination, so April 2005, a surgical resection was performed, and it was diagnosed as the metastasis from HCC. In July 2008, the recurrent tumor 3 cm in diameter was observed in the right retroperitoneum. It was considered inoperable because of the past operation, and transcatheter arterial chemoembolization of an inferior adrenal artery and a fine branch through a right sub-phrenic artery was performed for the recurrent tumor, and one week after the embolization, radiofrequency ablation was treated by CT fluoroscopy guidance. Ten months after the tumor embolization combined with radiofrequency ablation, there were no local and distant recurrences observed by CT examination. Transcatheter arterial embolization combined with radiofrequency ablation is considered as a feasible and effective method for not only HCC but also for a local recurrent tumor after resection of the adrenal metastasis from hepatocellular carcinoma.