Potential for expanding indications and curability criteria of endoscopic resection for early gastric cancer in elderly patients: results from a Japanese multicenter prospective cohort study.

BACKGROUND AND AIMS: Evidence for endoscopic resection (ER) in elderly patients with early gastric cancer (EGC) is limited. We assessed its clinical outcomes, and explored new indications and curability criteria. METHODS: We analyzed data from a Japanese multicenter prospective cohort study. Patients aged ≥75 years with EGC treated with ER were included. We classified "eCuraC-2 (corresponding to noncurative ER, defined in the Japanese gastric cancer treatment guidelines)" into "elderly-high (EL-H)" (>10% estimated metastatic risk) and "elderly-low (EL-L)" (≤10%). RESULTS: In total, 3,371 patients with 3,821 EGCs were included; endoscopic submucosal dissection (ESD) was the prominent treatment choice. Among them, 3,586 lesions met the guidelines' ER indications and 235 did not. The proportions of en bloc and R0 resections and perforations were 98.9%, 94.4%, and 0.8%, respectively, in EGCs within the indications. In EGCs beyond the indications, they were 99.5%, 85.4%, and 5.9%, respectively, for lesions diagnosed as ≤3 cm, and 96.0%, 64.0%, and 18.0% for those >3 cm. Curative ER ("eCuraA/B") and EL-L were observed in 83.6% and 6.2% of lesions within the indications, respectively, and in 44.2% and 16.8% of lesions <3 cm beyond the indications, respectively. The 5-year cumulative gastric cancer death rates following eCuraA/B and EL-H were 0.3% (95% CI, 0.2-0.6) and 3.5% (2.0-5.7), respectively. Following EL-L, the rate was 0.9% (0.2-3.5) even without subsequent treatment. CONCLUSIONS: Usefulness of ESD for elderly EGC patients was confirmed by their clinical outcomes. Lesions ≤3 cm and EL-L emerged as new ER indication and curability criterion, respectively.

Risk factors for intraoperative and delayed perforation related with gastric endoscopic submucosal dissection.

BACKGROUND AND AIM: Perforation is one of the most important complications of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). Several studies have examined risk factors for intraoperative and delayed perforations, but most were retrospective analyses with small numbers of patients. METHODS: This study represents a secondary analysis of a Japanese multicenter prospective cohort study. We investigated the factors associated with each type of perforation using 9015 patients with 9975 EGCs undergoing ESD between July 2010 and June 2012. RESULTS: Intraoperative perforation occurred in 198 patients (2.2%) with 203 lesions (2.0%), necessitating emergency surgery for four lesions (0.04% [2.0%, 4/203]). Delayed perforation occurred in another 37 patients (0.4%) with 42 lesions (0.4%), requiring emergency surgery for 12 lesions (0.12% [28.6%, 12/42]). Factors showing significant independent correlations with intraoperative perforation were upper or middle third of the stomach; remnant stomach or gastric tube; procedure time ≥100 min; tumor size >35 mm; body mass index (BMI) < 18.5 kg/m2; and ≥72 years. Factors showing significant independent correlations with delayed perforation were procedure time ≥60 min; BMI < 18.5 kg/m2; ≥75 years; ulceration; and tumor size >20 mm. Intraoperative perforation occurred most frequently at the greater curvature in the upper third of the stomach (7.9%), whereas delayed perforation occurred most frequently at the greater curvature in the middle third (1.2%). CONCLUSION: This multicenter prospective cohort study clarified the risk and risk factors of intraoperative and delayed perforation related to ESD for EGCs, providing information to help endoscopists reduce perforation.

Long-term Survival After Endoscopic Resection For Gastric Cancer: Real-world Evidence From a Multicenter Prospective Cohort.

BACKGROUND & AIMS: We aimed to clarify the long-term outcomes of endoscopic resection (ER) for early gastric cancers (EGCs) based on pathological curability in a multicenter prospective cohort study. METHODS: We analyzed the long-term outcomes of 9054 patients with 10,021 EGCs undergoing ER between July 2010 and June 2012. Primary endpoint was the 5-year overall survival (OS). The hazard ratio for all-cause mortality was calculated using the Cox proportional hazards model. We also compared the 5-year OS with the expected one calculated for the surgically resected patients with EGC. If the lower limit of the 95% confidence interval (CI) of the 5-year OS exceeded the expected 5-year OS minus a margin of 5% (threshold 5-year OS), ER was considered to be effective. Pathological curability was categorized into en bloc resection, negative margins, and negative lymphovascular invasion: differentiated-type, pT1a, ulcer negative, ≤2 cm (Category A1); differentiated-type, pT1a, ulcer negative, >2 cm or ulcer positive, ≤3 cm (Category A2); undifferentiated-type, pT1a, ulcer negative, ≤2 cm (Category A3); differentiated-type, pT1b (SM1), ≤3 cm (Category B); or noncurative resections (Category C). RESULTS: Overall, the 5-year OS was 89.0% (95% CI, 88.3%-89.6%). In a multivariate analysis, no significant differences were observed when the hazard ratio of Categories A2, A3, and B were compared with that of A1. In all the pathological curability categories, the lower limit of the 95% CI for the 5-year OS exceeded the threshold 5-year OS. CONCLUSION: ER can be recommended as a standard treatment for patients with EGCs fulfilling Category A2, A3, and B, as well as A1 (UMIN Clinical Trial Registry, UMIN000005871).

Survival analysis of a prospective multicenter observational study on surgical palliation among patients receiving treatment for malignant gastric outlet obstruction caused by incurable advanced gastric cancer.

BACKGROUND: We had previously reported that surgical palliation could maintain quality of life (QOL) while improving solid food intake among patients with malignant gastric outlet obstruction (GOO) caused by advanced gastric cancer. The present study aimed to perform a survival analysis according to the patients' QOL to elucidate its impact on survival. METHODS: Patients with GOO who underwent either palliative gastrectomy or gastrojejunostomy were included in this study. A validated QOL instrument (EQ-5D) was used to assess QOL at baseline and 2 weeks, 1 month, and 3 months following surgical palliation. Postoperative improvement in oral intake was also evaluated using the GOO scoring system (GOOSS). Thereafter, univariate and multivariate survival analyses were performed to determine independent prognostic factors. RESULTS: The median survival time of the 104 patients included herein was 11.30 months. Patients who received postoperative chemotherapy, PS 0/1, baseline EQ-5D ≥ 0.75, improved or stable EQ-5D, and improved oral intake expressed as GOOSS = 3 had significantly better survival. Multivariate analysis identified postoperative chemotherapy, a better baseline PS, a better baseline EQ5D, improved or stable EQ5D scores, and improved oral intake 3 months after surgical palliation as independent prognostic factors. CONCLUSION: Apart from preoperative PS and postoperative chemotherapy, the present study identified better baseline QOL, improvement in postoperative QOL, and improvement in oral intake as prognostic factors among patients who underwent palliative surgery for advanced gastric cancer with GOO.

Short-term outcomes of multicenter prospective cohort study of gastric endoscopic resection: 'Real-world evidence' in Japan.

OBJECTIVES: A Japanese multicenter prospective cohort study examining endoscopic resection (ER) for early gastric cancer (EGC) has been conducted using a Web registry developed to determine the short-term and long-term outcomes based on absolute and expanded indications. We hereby present the short-term outcomes of this study. METHODS: All consecutive patients with EGC or suspected EGC undergoing ER at 41 participating institutions between July 2010 and June 2012 were enrolled and prospectively registered into the Web registry. The baseline characteristics were entered before ER, and the short-term outcomes were collected at 6 months following ER. RESULTS: Nine thousand six hundred and sixteen patients with 10 821 lesions underwent ER (endoscopic submucosal dissection [ESD]: 99.4%). The median procedure time was 76 min, and R0 resections were achieved for 91.6% of the lesions. Postoperative bleeding and intraoperative perforation occurred in 4.4% and 2.3% of the patients, respectively. Significant independent factors correlated with a longer procedure time (120 min or longer) were as follows: tumor size >20 mm, upper-third location, middle-third location, local recurrent lesion, ulcer findings, gastric tube, male gender, and submucosa. Histopathologically, 10 031 lesions were identified as common-type gastric cancers. The median tumor size was 15 mm. Noncurative resections were diagnosed for 18.3% of the lesions. Additional surgery was performed for 48.6% (824 lesions) of the 1695 noncurative ER lesions with a possible risk of lymph node (LN) metastasis. Among them, 64 (7.8%) exhibited LN metastasis. CONCLUSIONS: This multicenter prospective study showed favorable short-term outcomes for gastric ESD.

Long-term outcomes of laparoscopy-assisted distal gastrectomy with suprapancreatic nodal dissection for clinical stage I gastric cancer: a multicenter phase II trial (JCOG0703).

BACKGROUND: Laparoscopic gastrectomy has become a common surgical treatment for gastric cancer in eastern Asian countries. However, a large-scale prospective study to investigate the benefit of laparoscopy-assisted distal gastrectomy (LADG) regarding long-term outcomes has never been reported. We have already reported the short-term outcomes of this study. Here we report long-term outcomes as the secondary endpoints of this study after a 5-year follow-up period. METHODS: This study comprised patients with clinical stage I gastric cancer who were able to undergo a distal gastrectomy. LADG with D1 plus suprapancreatic lymph node dissection was performed by credentialed gastric surgeons who had each conducted at least 30 LADG and 30 open gastrectomy procedures. The primary endpoint was the proportion of patients who developed either anastomotic leakage or pancreatic fistula. The secondary endpoints included overall survival and relapse-free survival. RESULTS: From November 2007 to September 2008, 176 eligible patients were enrolled, comprising 140 patients with pathological stage IA disease, 23 patients with pathological stage IB disease, 9 patients with pathological stage II disease, and 4 patients with pathological stage IIIA disease. No patients had recurrent disease, and three of the patients died within the follow-up period. The 5-year overall survival was 98.2% (95% confidence interval 94.4-99.4%) and the 5-year relapse-free survival was 98.2% (95% confidence interval 94.4-99.4%). CONCLUSIONS: The long-term outcomes of stage I gastric cancer patients undergoing LADG seem comparable to those of patients undergoing an open procedure, although this result should be confirmed by a randomized control trial. We have already completed accrual of 921 patients for a multicenter randomized phase III trial (JCOG0912) to confirm the noninferiority of LADG compared with open gastrectomy in terms of relapse-free survival.

[A Case of Advanced Gastric Cancer with Para-Aortic Lymph Node Dissection after Neoadjuvant Chemotherapy].

The patient was a 49-year-old woman with advanced gastric cancer.CT and PET-CT revealed para-aortic lymph node metastases.She was diagnosed with Stage IV T4aN3M1(LYM)and underwent neoadjuvant chemotherapy with S-1 plus CDDP.After 3 courses, both the tumor and para-aortic lymph node metastases decreased in size.Because radical resection was considered possible, she underwent distal gastrectomy with D3(D2+No.1 6a2-b1)dissection and Roux-en-Y reconstruction. Histopathological findings revealed the cancer was Stage I B(yp T1b N1)with the disappearance of cancer cells in the para-aortic lymph nodes.She was discharged on POD 32.She underwent adjuvant chemotherapy with S-1 and was followed up for 3 years with no recurrence.Para -aortic lymph node metastases are factors predicting a poor outcome; however, when neoadjuvant chemotherapy is effective, long-term survival can be expected from gastrectomy with curative PAND.

[A Case of Malignant Obstruction of the Colon Due to Peritoneal Dissemination of Gastric Carcinoma Treated with Colon Stenting and Colectomy after Chemotherapy].

A man in his 60s underwent gastrectomy to treat gastric carcinoma. Approximately 2.5 years after the surgery, he was admitted to the hospital because of abdominal pain. He was diagnosed with obstruction of the transverse colon due to a colon tumor. A stent was placed to treat the obstruction and avoid oncologic emergency. Biopsy results and imaging showed that the patient did not have colon cancer, but his previous gastric cancer had disseminated peritoneally. Chemotherapy was selected as treatment for recurrent gastric cancer. After chemotherapy, the patient underwent colectomy with removal of the stent. His postoperative course was good, and he was discharged from hospital without complications. The patient received additional chemotherapy. We encountered a case of colon obstruction due to peritoneal dissemination of gastric cancer that was successfully treated using a metallic colorectal stent. Colon stenting for malignant bowel obstruction is useful to avoid oncologic emergencies. However, there is no evidence at this time that long-term placement of a stent is safe. The decision to remove or retain the stent should be made upon carefully considering the condition of the patient and progression of the disease.

[A Case of Locally Advanced Pancreatic Cancer Showing R0 Resection after Resection of the Portal Vein Following Preoperative Chemoradiotherapy].

We report a case of pancreatic cancer showing R0 resection after resection of the portal vein(PV)following preoperative chemoradiotherapy. A 71-year-old woman was admitted to our hospital with back pain. We diagnosed the patient with pancreatic cancer using computed tomography scan and fine-needle aspiration biopsy. Because the tumor directly invaded the PV, we diagnosed it as a borderline resectable locally advanced pancreatic cancer. Radiation therapy(40 Gy/20 Fr)was administered with S-1 monotherapy(120 mg/body/day on days 1-5 and days 8-12). After the treatment, the main tumor was stable without distant metastasis. Therefore, we performed pancreaticoduodenectomy with resection of the PV. Pathological examination confirmed negative margin status. The patient was healthy and showed no sign of recurrence eight months after surgery.

[Assessment of Endoscopic Resection and Partial Duodenectomy for Duodenal Mucosal Tumor].

INTRODUCTION: The risk of perforation following endoscopic resection is high. We analyzed the outcome of partial duodenectomy and discussed the therapeutic strategy for duodenal mucosal tumor(DMT). PATIENTS AND METHODS: We analyzed 19 cases who have undergone endoscopic resection, and 11 cases who have undergone partial duodenectomy for DMT in our institute since 2007. We divided them into the first period(ESD actively indicated)and late period(ESD carefully indicated according to the alteration of indication of ESD for DMT in 2013)groups. RESULTS: In the first period, all 17 cases initially underwent endoscopic resection and 4 cases were complicated by perforation. On the other hand, in the late period, 6 of 12 cases initially underwent endoscopic resection and 1 case was complicated by perforation. Emergent partial duodenectomy was performed with additional resection in the perforation cases. There were no complications associated with surgery, and all 29 cases achieved curative resection, based on the histology results. CONCLUSION: We can safely indicate endoscopic resection for DMT with surgical back-up and cooperation with the endoscopic internal department.

[A Long-Surviving Case of Unresectable Gall Bladder Carcinoma Treated with Gemcitabine-Based Chemotherapy].

We report a 5-year surviving patient with unresectable gall bladder carcinoma treated with gemcitabine(GEM)-based chemotherapy. A 64-year-old man was diagnosed with unresectable gall bladder carcinoma with peritoneal dissemination based on laparotomy findings. Two months later, he started to receive GEM chemotherapy. Twelve months after surgery, the patient chose to suspend GEM treatment. One year and 10 months later, multiple lung metastases appeared and GEM was restarted in combination with UFT. Although the primary lesion and lung metastases gradually progressed, the patient maintained a good quality of life. After 3 years and 2 months, chemotherapy was changed to GEM plus S-1 because of progressive disease. Five years and 2 months after surgery, his condition was complicated by a secondary pneumothorax, and the patient received home oxygen therapy. Five years and 8 months after surgery he died of respiratory distress caused by the progression of lung metastases. Even in the case of unresectable advanced gall bladder carcinoma, effective chemotherapy could improve quality of life and prolong survival.

[Outcome of Pulmonary Metastasectomy for Hepatocellular Carcinoma].

Pulmonary metastasis of hepatocellular carcinoma (HCC) is considered a poor prognostic feature of the disease, and the utility of pulmonary resection is unclear. We evaluated clinical outcomes following pulmonary resection in 7 patients. All patients underwent video-assisted thoracic surgery (VATS). The median disease-free interval (DFI) was 14 (6-23) months. During pulmonary resection in 1 of the patients, intrahepatic recurrence was discovered and, 18 months later, this patient died of the recurrence. Of the remaining 6 patients, 2 patients developed intrahepatic recurrence and brain metastasis and died at 66 months and 10 months after pulmonary resection. Three patients are still alive and disease-free to date with a median follow-up duration of 42 (18-55) months. Of these 3 surviving patients, 2 patients had solitary pulmonary metastases and 1 patient had multiple bilateral pulmonary metastases; these patients underwent VATS once. The 7th patient underwent VATS 3 times for pulmonary metastasis and had no evidence of intrahepatic or extrahepatic recurrence. This patient died of an unrelated cause 15 months after the last pulmonary resection (47 months after the primary pulmonary resection). This study indicates that surgical resection of metachronous pulmonary metastases is associated with a favorable outcome in selected patients.

[Efficacy of Neoadjuvant Therapy for Borderline Resectable Pancreatic Cancer Involving the Superior Mesenteric Artery].

Multidisciplinary therapy is essential in the treatment of borderline resectable pancreatic cancer involving the superior mesenteric artery (BR-SMA). We analyzed the outcomes of multidisciplinary treatment for BR-SMA and evaluated the efficacy of neoadjuvant therapy (NAT). We reviewed the clinical courses of 10 patients with BR-SMA. Seven patients were treated with preoperative neoadjuvant therapy (NAT group), and 3 patients underwent radical pancreaticoduodenectomy first (SF group). In the NAT group, the rate of R0 was 7/7 (100%), the induction rate of postoperative adjuvant chemotherapy (AC) was 6/7 (86%), and the first recurrence sites were the lung in 4 patients, and the liver and peritoneum in one patient each, respectively. In the SF group, the rate of R0 was 2/3 (67%) because of a positive pathological dissecting peripancreatic margin in 1 case. The induction rate of AC was 3/3 (100%), and the first recurrence sites were the liver in 2 patients, the peritoneum in 1, and a local site in 1. The disease free survival of the NAT group (median survival time [MST] 19.3 months) was significantly better than that of the SF group (MST 5.7 months) (log rank test, p=0.002). The median overall survival of the NAT and SF groups was 51.6 months and 19.5 months, respectively (p=0.128). An R0 resection could be performed in all cases in the NAT group. The NAT extended disease-free survival. We conclude that NAT is recommended in the treatment of BR-SMA.

[Gastric cancer with liver metastasis and peritoneal dissemination treated with conversion surgery to achieve r0 resection after capecitabine, cisplatin, and trastuzumab chemotherapy-a case report].

Herein, we present a case report suggesting the importance of conversion surgery and the effectiveness of adjuvant chemotherapy with trastuzumab. A 77-year-old woman was diagnosed with gastric cancer complicated by multiple liver metastases and peritoneal dissemination. Owing to a HER2 immunohistochemistry (IHC) tumor score of 3+, we initiated capecitabine plus cisplatin (CDDP) plus trastuzumab chemotherapy. Subsequently, the liver metastases and peritoneal dissemination were absent on computed tomography images, and no new metastatic lesions developed during chemotherapy. After 10 chemotherapy courses, the patient underwent distal gastrectomy and 2 partial liver resection procedures. The liver metastasis remained, and it received a score of 2+ on the HER2 IHC test. We have continued to administer postoperative capecitabine plus trastuzumab chemotherapy because no metastatic lesions have appeared.

[Three cases of surgical resection of peritoneal recurrence of hepatocellular carcinoma following hepatectomy].

Surgical treatment of peritoneal recurrence (PR) of hepatocellular carcinoma (HCC) is still controversial. We report herein 3 cases of PR treated by surgical resection. Firstly, a 55-year-old woman presented with recurrences in the peritoneum and mediastinal lymph nodes 12 months after hepatectomy for ruptured HCC. After the administration of sorafenib, the mediastinal lesions shrank and the PRs were resected. There has been no recurrence 20 months after PR resection. The second case was of a 56-year-old man with recurrences in the remnant liver and the peritoneum 41 months after hepatectomy for ruptured HCC. The remnant liver lesions were controlled by transcatheter arterial chemoembolization (TACE), and the PRs were resected twice. However, multiple bone and lung metastases developed and the patient died of HCC 73 months after peritoneal resection. In the third case, a 63-year-old man had recurrences in the remnant liver and the peritoneum 78 months after hepatectomy. Remnant liver lesions were controlled by radiofrequency ablation (RFA) and TACE, and PRs were resected. However, the hepatic lesions had progressed and he died 102 months after initial hepatectomy. Based on our observations, patients with PRs who have no other distant metastases and whose intrahepatic lesions are controllable and PRs are completely resectable may have relatively long-term survival. Surgical treatment of PR may also improve the quality of life and prognosis.

[Experiences of laparoscopic repeat hepatectomy for recurrent hepatic cancer after open hepatectomy].

We report 3 cases of recurrent hepatic cancer in patients who underwent laparoscopic repeat hepatectomy (LRH). Case 1: A 70-year-old female with ascending colon cancer and liver metastases underwent open right colectomy followed by open S5 resection. Seven months later, the patient experienced a recurrence in the lateral segment and underwent laparoscopy-assisted ( L-A) partial resection. The adhesiolysis around the left liver was performed through a 7-cm upper median incision. Partial resection of the lateral segment was performed by hand-assisted laparoscopic surgery (HALS) using a median incision. Case 2: A 63-year-old female with metachronous liver metastases from rectal cancer underwent open S4a and S5 resection. Nineteen months later, she experienced a recurrence in S4b and underwent an L-A S4b resection. Adhesiolysis around the previous hepatic transection was performed through a small upper median incision. Mobilization of the liver was performed by HALS. A hepatic transection of S4b was also performed in the upper median incision. Case 3: An 80-year-old female with hepatocellular carcinoma (HCC) recurrence in the lateral segment after open S4 resection underwent L-A lateral segmentectomy. An adhesiolysis, mobilization of the liver, and a hepatic transection were performed by HALS and hybrid technique as described in case 2. In a patient with a history of open hepatectomy, LRH may be extensively indicated by utilizing HALS or a hybrid procedure.

[A case of AFP-producing esophagogastric junction cancer with liver metastases with a good response to chemotherapy].

A 62-year-old man was diagnosed with esophagogastric junction cancer following esophagogastroduodenoscopy in response to hematemesis. Although liver metastasis was detected during surgery, a total gastrectomy and lower esophagus resection for local control was performed. Alpha-fetoprotein(AFP)-producing tumor with hepatoid adenocarcinoma was diagnosed on the basis of the pathological examination. Serum AFP levels remained high postoperatively and multiple liver metastases were detected on computed tomography imaging. After 6 courses of chemotherapy with S-1 and cisplatin (CDDP), a significant reduction in the size of the liver metastases and a decrease of serum AFP levels were achieved. Postoperative 2-year tumor control using S-1 single agent chemotherapy was obtained. AFP-producing esophagogastric junction cancer has a poor prognosis. This case raises the possibility that long-term survival can be obtained by combining surgery for local control with systemic chemotherapy.

[An examination of the utility of high-precise radiation therapies for the recurrence of postoperative esophageal cancer].

We analyzed 16 cases (23 therapeutic sites) of post-operative recurrence of esophageal cancers that were treated with high-precise radiation therapies.The recurrence sites were cervical lymph nodes (5 cases), superior mediastinal lymph nodes (5 cases), posterior mediastinal lymph nodes (3 cases), regional lymph nodes with anastomosis (2 cases), abdominal paraaortic lymph node (3 cases), and regions with hematogenous metastasis (5 cases: liver, lung, spleen, and dissemination to the diaphragm bottom).By recurrence number, 10 cases presented with a single lesion, and 6 cases had multiple lesions.The effect of the treatment was complete response (CR) in all cases, and 6 cases maintained CR.The median of the overall survival after radiotherapy was 562 (132-1,231) days.Analysis of the prognostic factors for the overall survival from a recurrence revealed that the metastatic number (single) (p=0.003), and the metastatic pattern(hematogenous metastasis) (p= 0.004), significantly improved prognosis.We conclude that radiotherapy is an option to extend prognosis in some recurrence cases.

[A case of fixing an anastomotic site to the abdominal wall out of the abdominal cavity for a small intestinal perforation during chemotherapy].

A 53-year-old man presented with a continuous high fever and was diagnosed with diffuse large B-cell lymphoma with metastasis to the lung, spleen, and mesenterium. He was treated with cyclophosphamide and prednisolone followed by administration of cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP) chemotherapy 20 days later. Two days after initiation of CHOP therapy, the patient complained of severe abdominal pain. Perforative peritonitis was diagnosed using abdominal computed tomography. A perforation of the small intestine approximately 160 cm distal to the Treitz ligament was uncovered during emergency laparotomy. The risk of leakage was considered too high for anastomosis of the small intestine to be performed. Further, construction of an intestinal stoma could result in a high-output syndrome that could lead to difficulty in resuming chemotherapy. Based on these considerations, we fixed the anastomotic region to the abdominal wall using a technique similar to construction of an intestinal stoma. Post-operative anastomotic leakage did not occur. Nine days later, a perineal hernia was noted near the anastomotic site and a second operation was performed. The anastomotic site was placed back into the abdominal cavity during this operation. CHOP therapy was resumed 16 days after the first operation.

[A case of intrahepatic cholangiocarcinoma with peritoneal dissemination treated successfully with surgical resection and adjuvant chemotherapy].

A 72-year-old woman was diagnosed with liver dysfunction during a medical examination. An abdominal computed tomography (CT) scan showed multiple nodules in the left lobe, anterior segment, andposterior segment of the liver, leading to a diagnosis of intrahepatic cholangiocarcinoma (ICC). Extended left lobectomy and partial hepatectomy in the anterior and posterior segment with lymph node dissection was performed. At the time of the operation, small nodules on the peritoneum near the stomach were resected; these nodules were diagnosed as peritoneal disseminations of ICC. The histopathological diagnosis was moderately differentiated tubular adenocarcinoma (T4N0M1, Stage IVB). Adjuvant chemotherapy with S-1 was administered for 18 months. Thirty months after the operation, multiple lung metastases were detected by using CT, and chemotherapy with gemcitabine was initiated. Thirty-six months after chemotherapy with gemcitabine, the patient is alive and at home despite her lung metastases, which grew slightly in size. Herein, we report a long-term survival case of ICC with peritoneal dissemination that was successfully treated with surgical resection and adjuvant chemotherapy.