[A Case of Duodenum Neuroendocrine Tumor with Multiple Liver Metastasis Treated with Multimodal Therapy].

The patient is a 65-year-old woman with anemia. The multiple liver tumors detected by ultrasonography, it was diagnosed as neuroendocrine tumor(NET), G2 by biopsy. There was an ulcer at the bulb of the duodenum, so we diagnosed liver metastasis of duodenum NET. Because the liver tumors spreaded to both right and left lobes, we carrying out a transcatheter arterial embolization(TAE)twice to liver metastasis, and chemotherapy by octreotide was performed. 20 months after the beginning of treatment, a 4 cm tumor was remained in the left lobe but others were not detected by computed tomography, so we performed cytoreductive surgery. Duodenum bulb resection and left hepatectomy was performed and the specimens were NET, G2 in the pathological findings. We detected a lot of tumors less than 1 cm in the right lobe during the operation, so TAE was carried out for the right lobe after surgery. The disease showed no progression for 28 months after the first admission(post operation5 months).

[A Long-Term Survival Case of Hepatocellular Carcinoma with Lymph Node Metastasis Treated by Multidisciplinary Therapy].

We report a long-term survival case of hepatocellular carcinoma with lymph node metastasis that was successfully treated with multidisciplinary therapy. The patient was a 52-year-old man. He underwent right lobe liver resection with lymph node sampling at the hepatic portal section for hepatocellular carcinoma. Histopathological examination revealed hepatocellular carcinoma with lymph node metastasis. Residual liver recurrences were treated by transcatheter arterial chemoembolization and percutaneous ethanol injection therapy, and lymph node recurrences were treated by radiation therapy and lymph node dissection combined with systemic chemotherapy. The patient has been in good health without recurrence for 10 years and 9 months after the first surgery.

[Effectiveness of Irinotecan, S-1, and Bevacizumab for Rectal Cancer with Lung and Skin Metastases after Adjuvant Chemotherapy].

A 50-year-old woman with a chief complaint of bloody stools was diagnosed with rectal cancer via colonoscopy. Laparoscopic rectal anterior resection with D3 lymph node dissection was performed in June 2014. The pathological diagnosis was pStage III a(Ra, pT3, N1)cancer, and the patient received 8 courses of XELOX as postoperative adjuvant chemotherapy. During follow-up at 12 months after surgery, chest computed tomography revealed a mass in the left lingular segment measuring 25mm in diameter and multiple small nodules in both the lungs, indicating lung metastases. We found several subcutaneous nodules with a maximum diameter of 10mm in her abdomen and the back of head. We removed 3 subcutaneous nodules for the purpose of diagnosis and treatment in June of 2015. The pathological findings were consistent with cutaneous metastases of rectal cancer. The patient received a 1 course of IRIS and 5 courses of IRIS plus bevacizumab. Subsequently, the lung metastases disappeared and no new skin lesions were detected. We suggest that this case could be a good reference in determining the appropriate treatment for rectal cancer having lung or cutaneous metastases.

[Is Adjuvant Chemotherapy Necessary after R0 Resection for pCR or ypStage I Patients with Gastric Cancer ?]

Neoadjuvant chemotherapy(NAC)followed by surgery and palliative chemotherapy for unresectable advanced gastric cancer followed by conversion surgery are currently under investigation in clinical trials and are attractive therapeutic alternatives. We examined the relationship between ypStage and prognosis among patients with gastric cancer who underwent surgery following preoperative chemotherapy and evaluated the necessity of adjuvant chemotherapy in patients with pCR or ypStage I gastric cancer. Sixty-one patients received chemotherapy followed by surgery from 2006 to 2014 in Osaka National Hospital. For preoperative chemotherapy, 41 patients received NAC, and 20 patients received palliative chemotherapy. Five (8.2%)patients with pCR, ypStage I A, and Stage I B disease(n=2, 1, and 2, respectively), 3 of whom received adjuvant chemotherapy and 2 of whom did not, were all alive without recurrence after a median follow-up of 3 years and 6 months. The overall survival for patients from each ypStage in the preoperative chemotherapy group was comparable with that for each ypStage in the surgery without preoperative chemotherapy group during the same period. Discontinuation of adjuvant chemotherapy and intense follow-up is a treatment option after R0 resection for patients with gastric cancer who achieve pCR or downstaging to ypStage I .

[A Patient with HER2-Positive Stage IV Advanced Gastric Cancer Who Received Chemotherapy with Trastuzumab plus XP Followed by Conversion Surgery].

A 68-year-old man presented with type 3 advanced gastric cancer(Circ, tub2>por, HER2 score 3)in the antrum, with skip lesions in the duodenum. The tumor was cT4aN2M1(DUO)CY0, cStage IV . An XP plus trastuzumab regimen(1,000mg/m2 capecitabine[Xeloda®]twice a day on days 1-14, 80mg/m2 CDDP on day 1, 8 mg/m2 trastuzumab on day 1[second course- 6mg/m2])was administered every 3 weeks and repeated for 6 courses without severe adverse events. After 6 courses, the primary tumor and metastatic lymph nodes shrank by 31.7%(a PR according to the RECISTcriteria ), and open distal gastrectomy, D3 lymphadenectomy, and Roux-en-Y reconstruction(ante colic)were performed as conversion surgery(R0). During the administration of adjuvant chemotherapy with S-1, para-aortic, mediastinum, left supraclavicular fossa, and cervical lymph node recurrence developed. Four courses of weekly PTX plus trastuzumab as first-line chemotherapy and 11 courses of biweekly CPT-11 plus CDDP as second-line chemotherapy were administered. Because of prolonged adverse events such as Grade 3 diarrhea, the patient refused continuation of chemotherapy. The patient died 24 months after the start of preoperative chemotherapy.

Survival Impact of Pulmonary Metastasis as Recurrence of Pancreatic Ductal Adenocarcinoma.

AIM: This study aimed at investigating the survival impact of pancreatic ductal adenocarcinoma (PDAC) recurrence as pulmonary metastasis. METHODS: We performed a retrospective case-control study of 142 patients who underwent curative resection for PDAC at our institution between 2003 and 2012. Clinicopathological features were compared among patients stratified according to the recurrence pattern and pulmonary metastasis treatment strategy. RESULTS: Patients underwent pancreaticoduodenectomy (n = 96), distal (n = 42), or total pancreatectomy (n = 4). At the last follow-up, 99 patients had developed recurrent post-resection PDAC, including 14 cases of isolated pulmonary recurrence. The median overall survival was significantly longer for patients with isolated pulmonary recurrence (40.3 months) than with other metastases (20.9 months; HR 5.85; p = 0.0156). Two patients underwent resection for isolated pulmonary recurrence, and both survived for ∼70 months after primary resection. CONCLUSION: Patients with first recurrence of PDAC as pulmonary metastasis had a better prognosis than patients with other types of metastases. Moreover, when isolated pulmonary metastasis is controlled for a certain period, pulmonary resection is likely to improve patient survival.

[Metastasizing Leiomyoma of the Lung Detected on Chest X-ray after Surgery for Breast Cancer；Report of a Case].

A 60-year-old postmenopausal woman presented with a lung nodule, which was detected on a chest X-ray 2 years after surgery for breast cancer. Pulmonary metastasis from the breast cancer was suspected and surgical resection was performed. On histopathological examination, the lung nodule showed a smooth muscle cell tumor, and immunohistochemical staining was positive for estrogen and progesterone receptors. As a mass in the uterine was detected by computed tomography images before surgical resection, benign metastasizing leiomyoma of the lung was suspected. Subsequently, the patient underwent hysterectomy and bilateral salpingo-oophorectomy. The pathological findings revealed that the mass in the uterine was atypical leiomyoma, which was consistent with the primary lesion of the lung metastasis. Atypical leiomyoma is classified as a benign tumor, but in this case, careful follow-up is required because of its clinical course and histological features.

[An Evaluation of Outcome of Surgical Treatment for Recurrence after Curative Pancreatectomy for Pancreatic Ductal Cancer].

The aim of this study was to evaluate the outcome of surgical treatment for recurrence after curative pancreatectomy for pancreatic ductal cancer. Ten cases were enrolled, and the time from initial pancreatectomy to recurrence, location of recurrence, and outcome after surgical treatment for recurrence was evaluated. The time to recurrence was more than 1 year in 4 cases, and the locations of recurrence in these cases were the remnant pancreas and lung in 3 and 1 patients, respectively. Among these 4 cases, a second recurrence was observed in only 1 case, and survival after surgical treatment of the first recurrent site was more than 3 years in the other 3 cases. For the remaining 6 cases, the time to recurrence was less than 1 year and the recurrences were located in the abdomen but not in the remnant pancreas. A second recurrence was observed in all cases, and the survival time was less than 2 years in 4 out of 6 cases. Based on the results of this study, recurrence in the remnant pancreas and lung after curative resection for pancreatic ductal cancer could be a potential indication for surgical treatment.

[A Case of Lateral Lymph Node Recurrence Five-Years after Curative Surgery for Rectal Cancer].

A 62-year-old woman had undergone laparoscopic abdominoperineal resection for rectal cancer in February 2008. The pathological diagnosis was pT2, pN0, M0, pStageⅠ. At her request, she took UFT for 5 years as adjuvant chemotherapy. A CT examination revealed lateral lymph node swelling in January 2014. She was referred to our hospital after a diagnosis of lateral lymph node recurrence. She was administered 6 courses of FOLFIRI plus Cmab as neoadjuvant chemotherapy, after which the tumor size reduced by 62%. The treatment effect was rated as a PR. Laparoscopic right intrapelvic lymph node dissection was performed in July 2014, and the pathological diagnosis was recurrence of rectal cancer in the lateral lymph nodes. We report a case of dissection of lymph node recurrence 5 years after curative surgery for rectal cancer, along with a literature review.

[A Case of Esophageal Cancer with Paraaortic Lymph Node Metastasis Treated with Lymphadenectomy after Esophagectomy].

A 70-year-old woman underwent subtotal esophagectomy with two-field lymph node dissection for squamous cell carcinoma of the middle thoracic esophagus (type 0- /Ⅱa+Ⅱc, pT1bN1 [2/25] M0, pStage Ⅱ). Approximately 1 year and 2 months after surgery, abdominal CT showed a swollen paraaorticlymph node. PET-CT also indicated lymph node metastasis. The lymph node was diagnosed to have metastasis from the esophageal cancer, and the patient began treatment with chemotherapy. However, the treatment plan was changed to lymphadenectomy because of neutropenia. She underwent paraaortic lymph node dissection and right partial adrenalectomy. The lymph node was confirmed to have metastasis from the esophageal cancer. The neutropenia persisted after surgery, so she did not receive adjuvant chemotherapy. The patient remained alive for more than 5 years after surgery without any evidence of recurrence. Isolated paraaortic lymph node metastasis after esophagectomy is rare, and there have been only 2 cases, including our own, of long-term survival after paraaortic lymph node dissection. Lymphadenectomy for isolated lymph node metastasis can improve long-term prognosis but it cannot sufficiently predicate it. Therefore, accumulation of more cases is required.

[Optimal Target Population for Adjuvant Chemotherapy for Pathological T1 Gastric Cancer].

The ACTS-GC trial showed the efficacy of adjuvant treatment with S-1 in patients who had undergone D2 gastrectomy for Stage Ⅱ or Ⅲ(excluding pT1) gastric cancer, classified according to the 13th Japanese Classification of Gastric Carcinoma. We retrospectively analyzed the treatment outcomes of pT1 gastric cancer patients who underwent gastrectomy at our institute to determine the optimal target population for adjuvant treatment among these particular patients. Patients with pT1 gastric cancer who underwent gastrectomy for primary gastric cancer at our institute between 2000 and 2008 without perioperative chemotherapy and mortality were included in the current analysis (n=461). The incidence of lymph node metastasis in M and SM patients were 1.7% (4/240) and 16.7% (37/221), respectively. The 5-year relapse-free survival in M and SM patients was 100% and 96.2%, respectively. On multivariate analysis, the most important risk factor for recurrence in SM patients was 3 or more involved nodes (HR: 6.53, [95%CI: 1.10-31.29], p=0.040). The 5-year relapse-free survival in SM patients with involvement of 3 or more nodes was 66.7% and was comparable with that in stage Ⅱ surgery-only patients in the ACTS-GC trial. Hence, SM patients with 3 or more involved nodes are candidates for effective adjuvant treatment after curative gastrectomy.

[Pulmonary metastasis of an ovarian granulosa cell tumor resected 11 years before].

A 69-year-old female, who had undergone oophorectomy for a left ovarian granulosa cell tumor (OGCT) in November 1999, was referred to our hospital due to rectal infiltration of the tumor detected during the initial surgery. The patient underwent low anterior resection, omentectomy and adnexectomy for the residual lesion at 1 month after the initial operation, and was followed up without postoperative adjuvant chemotherapy. In November 2010, abdominal computed tomography( CT) showed a soft tissue tumor on the surface of the liver. Meanwhile, a solitary nodule in S3 of the left lung was detected on chest CT. Laparotomy was done under suspicion of liver metastasis, but the lesion was revealed to be peritoneal dissemination at surgery. After subsequent 1-year follow-up, the enlargement of the pulmonary nodule was noted, and partial resection of the left lung was performed. The tumor was pathologically diagnosed as a metastasis of the OGCT.

[A case of HER2-positive advanced gastric cancer with extensive lymph node metastasis treated via chemotherapy with a trastuzumab-containing regimen followed by conversion surgery].

A 62-year-old man presented with type 3 gastric cancer (tub1, HER2 positive) in the cardia, with 10-cm direct invasion into the lower esophagus, and extensive lymph node metastasis (Virchow and paraaortic nodes). Trastuzumab (Her), in the XP regimen (capecitabine and cisplatin [CDDP] plus Her; Xeloda®: 2,000 mg/m² on day 1-14, CDDP: 80 mg/m² on day 1, Her: 8(6) mg/kg on day 1), was administered every 3 weeks and repeated for 6 courses. After administering 6 courses of the XP plus Her regimen, without severe adverse events in the patient, computed tomography (CT) revealed shrinkage of both the main tumor and the metastatic sites, by 51%. Esophagectomy and proximal gastrectomy with 3-field lymphadenectomy and gastric tube reconstruction was performed via right thoracotomy and laparotomy (R0). However, Grade 3 pneumonia occurred postoperatively, and the patient was discharged on day 67 after surgery. After treatment, the tumor was histologically evaluated as Grade 1b gastric cancer, and remnant cancer cells also expressed HER2. The patient was too frail to receive adjuvant chemotherapy, and he died of pneumonia 11 months after surgery, without obvious relapse. Perioperative chemotherapy with a regimen containing Her has a possible role in treating advanced HER2-positive gastric cancer. Multiple invasive conversion surgeries might decrease the feasibility of adjuvant chemotherapy and worsen the prognosis.

[A case of resection margin involvement gastric carcinoma that relapsed late after additional gastrectomy].

We report a case of a patient with resection margin involvement gastric carcinoma that recurred 5.5 years after additional resection. A 64-year-old man underwent distal gastrectomy for advanced gastric carcinoma (sig+por2, pSE, pN0, pStage IIB) in January 2008. A total gastrectomy was performed 2 months after the initial gastrectomy because of proximal resection line involvement, and curative resection was obtained. Adjuvant chemotherapy with S-1 was completed, and follow-up surveillance was finished 5 years after the additional surgery. In November 2013, the patient experienced bouts of vomiting, and a computed tomography (CT) scan showed an abdominal abscess that had spread to the liver and communicated with the intestine. Despite abscess drainage and antibiotic therapy, infection control was difficult and the patient died 20 days after hospitalization. An autopsy showed the recurrence lesions had diffusely spread to the peritoneum and was also disseminated around the Roux-Y jejunum. These findings suggest that peritoneal recurrence might lead to penetration of the intestine and abscess formation.

[Micronodular thymoma with lymphoid stroma（MNT）].

We report a surgical case of MNT, which is a rare type of thymoma. A 56-year-old man was referred to our hospital for examination of a mass in the anterior mediastinum. The computed tomography (CT) scan showed a lobulated mass with relatively smooth margins. Also, contrast study indicated homogeneous enhancement. Since these findings suggested the possibility of thymoma, the patient underwent thymothymomectomy. Histological findings showed short spindleshaped tumor cells forming nests of various sizes, and lymphoid stroma with lymphoid follicles. The pathological diagnosis was MNT. The long-term outcome after resection of MNT currently remains unclear, and accumulation of further cases is required.

[A case of squamous cell carcinoma of the anal cancer with associated human immunodeficiency virus].

A 62-year-old man with internal piles tested positive for infection with HIV and was admitted to our hospital. He presented with an anal tumor with bilateral inguinal nodal metastasis and pain in the anus; the tumor was diagnosed as stage IIIb (cA1N2M0). The patient's immune system was unstable. Therefore, he was administered chemoradiotherapy [low dose 5-fluorouracil plus cisplatin (FP) and radiotherapy (RT)] following HAART. Chemoradiotherapy resulted in complete response. However, CT performed 2 years after the diagnosis showed a recurrence in the hilar and mediastinal lymph node. The patient was administered chemotherapy with 5-fluorouracil and cisplatin (5-FU/CDDP) to the metastatic lymph node. However, the treatment response was graded as progressive disease, and the treatment was changed from CDDP to mitomycin C (MMC). The patient developed non-hematologic toxicity and died within 3 years of the diagnosis. We report a case of squamous cell carcinoma of the anus with associated HIV infection.

Malignant hepatic epithelioid angiomyolipoma with recurrence in the lung 7 years after hepatectomy: a case report and literature review.

Angiomyolipoma (AML) arising in the liver is rare and usually benign, but it occasionally has malignant potential. A 58-year-old man with a liver tumor identified by a previous doctor with features suggestive of hepatocellular carcinoma on computed tomography (CT) underwent anterior segmentectomy of the liver in 2006. Microscopically, the tumor was composed of exclusively epithelioid cells that were scatteredly positive for human melanoma black 45 on immunohistochemistry. Accordingly, primary hepatic epithelioid AML (eAML) was diagnosed. The patient was subsequently referred to our hospital for follow-up after hepatectomy. He had event-free survival for nearly 7 years. In 2013, two well-defined round nodules were detected in the right lung field by chest CT, and partial pneumonectomy was performed for diagnosis and treatment. Histological examination of the resected lung tissue showed that it was morphologically and immunohistochemically identical to his primary hepatic eAML, leading to the diagnosis of pulmonary metastasis. This paper demonstrates a rare case of malignant hepatic eAML with late recurrence in the lung after hepatectomy.

New tubular bioabsorbable knitted airway stent: biocompatibility and mechanical strength.

OBJECTIVE: This study examines the biocompatibility and suitability of a new tubular bioabsorbable knitted stent made of poly-L -lactic acid in normal rabbit airways and examines the mechanical strength of this stent in vitro. METHODS: A tubular knitted airway stent (group B, n = 15) made of poly-L -lactic acid wire was implanted operatively in New Zealand White rabbits intratracheally; silicone stents served as controls (group A, n = 8). The cervical trachea was exposed, and the stent was implanted. Up to 40 weeks after stent implantation, the rabbits were killed, at which time bronchoscopy, histologic examination, and scanning electron microscopic study was done. We tested poly-L -lactic acid stents and silicone stents for their mechanical strength in vitro. We subjected stents to area loads and measured their mechanical strengths. RESULTS: In group A, which received silicone stents, 3 (37.5%) rabbits died within 4 weeks of stent implantation as a result of airway obstruction by secretions inside the stent lumen. In group B, poly-L -lactic acid stents, 1 (6.7%) rabbit died 3 weeks after implantation because of weakness caused by anorexia. In the remaining animals, except for 1 animal with stent trouble, the bronchial lumen was fully open until the 40th week after implantation. After 40 weeks of follow-up, the stents disappeared, except for nonabsorbable suture in the bronchial wall. None of the animals in group B died of airway complication. Histologic examination and scanning electron microscopic examination of the group A silicone stents showed marked regression of ciliated cells under the stent. In group B the ciliated epithelium was preserved, and there were numerous capillary blood vessels in the submucosa. In scanning electron microscopy of the group B poly-L -lactic acid stents, the ciliated cells were preserved between the mesh holes of the stent. For diameters between 4 and 6 mm, the mechanical strength of silicone stents was greater than that of poly-L -lactic acid stents. However, the mechanical strength of poly-L -lactic acid stents increased as a function of their diameter. CONCLUSION: A new tubular bioabsorbable stent made of poly-L -lactic acid is biocompatible in normal rabbit airways, indicating that poly-L -lactic acid is a promising material for airway stents for clinical use.

Pulmonary metastasectomy for 165 patients with colorectal carcinoma: A prognostic assessment.

OBJECTIVE: The purpose of this study was to analyze our entire experience with pulmonary resection for metastatic colorectal carcinoma to determine prognostic factors and critically evaluate the potential role of extended metastasectomy. METHODS: We analyzed the postoperative survival of 165 patients who underwent curative pulmonary surgery at eight institutions in the Kansai region of western Japan (Kansai Clinical Oncology Group) from 1990 to 2000. RESULTS: Overall survivals at 5 and 10 years were 39.6% and 37.2%, respectively. Cumulative survival of patients who underwent simultaneous bilateral metastasectomy was significantly lower than that of the patients who underwent unilateral metastasectomy or sequential bilateral metastasectomy (P =.048). Five-year survival was 53.6% for patients without hilar or mediastinal lymph node metastasis, versus 6.2% at 4 years for patients with metastases (P <.001). Five-year survival of patients with a prethoracotomy carcinoembryonic antigen level less than 10 ng/mL was 42.7%, versus 15.1% at 4 years for patients with a carcinoembryonic antigen level 10 ng/mL or greater (P <.0001). Twenty-one patients underwent a second or third thoracotomy for recurrent colorectal carcinoma. Overall 5-year survival from the date of the second thoracotomy was 52.1%. The 34.1% 10-year survival for the 26 patients with hepatic metastasis resected before thoracotomy did not differ significantly from that of patients without hepatic metastases (P =.38). CONCLUSIONS: The status of the hilar or mediastinal lymph nodes and prethoracotomy carcinoembryonic antigen level were significant independent prognostic factors. Patients with pulmonary metastases potentially benefit from pulmonary metastasectomy even when there is a history of solitary liver metastasis. Careful follow-up is warranted, because patients with recurrent pulmonary metastases can undergo repeat thoracotomy with acceptable long-term survival. Simultaneous bilateral metastasectomy confers no survival benefit. Prospective studies may determine the significance of this type of pulmonary metastasectomy.