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A 73-year-old woman underwent a descending colectomy for descending colon cancer. The tumor was graded as pStage Ⅲb(pT3[SS], pN1b, pM0, Cur A), according to the 9th edition of the Japanese Classification of Colorectal, Appendiceal, and Anal Carcinoma. Postoperative treatment of adjuvant chemotherapy comprised oral tegafur/uracil and Leucovorin for 6 months with no evident recurrence. However, contrast-enhanced CT and FDG-PET/CT examination 8 years and 7 months after surgery revealed a 30 mm irregular recurrent tumor in the left iliac fossa. Since the tumor was adjacent to the left psoas muscle, it was considered that RM0(no tumor identified at the radial margin)could not be achieved in that region. Owing to the patient's good general condition, systemic chemotherapy with CAPOX+bevacizumab was administered. Although adverse events prompted discontinuation of the treatment during the first course, the recurrent tumor had significantly regressed. Systemic chemotherapy with mFOLFOX6+bevacizumab as selected subsequent treatment achieved a significant tumor shrinkage to date. Although a recurrence more than 5 years after curative resection of colorectal cancer is extremely rare, the possibility of late recurrence must be considered in patients with well-differentiated tumors who received adjuvant chemotherapy and had negative vascular invasion.

A 60s woman was diagnosed to transverse colon cancer and she underwent laparoscopic right hemicolectomy. Localized peritoneal dissemination surrounding tumor was detected during surgery. She was administrated to chemotherapy due to a hepatic metastasis in S2/3 postoperatively. Subsequently, PET-CT revealed a left ovarian metastasis in addition to a liver metastasis during chemotherapy. Laparoscopic hepatic left lateral segmentectomy and bilateral adnexectomy was performed at 1 year and 9 months after the first surgery and histopathological examination showed a metastasis of transverse colon cancer. The growth of liver and lung metastases and peritoneal disseminations was detected at 6 months later after the second surgery and the patient is currently receiving palliative treatment. Previous literatures described that ovarian metastasis of colon cancer showed bilateral metastasis and resistance to chemotherapy frequently and ruptured in some cases. We should consider to resect bilateral ovary even if unilateral metastasis alone was detected by imaging examination.

The case is a female, 50s. She presented to our hospital because of her intestinal obstruction. A CT scan at her visit showed wall thickening of her ascending colon. Colonoscopy revealed type 2 advanced cancer in the ascending colon. The pathological examination was a diagnosis of adenocarcinoma. Laparoscopic right hemicolectomy was performed for cT3N1M0, cStage Ⅲb ascending colon cancer. The pathological result was pT3N1M0, Stage Ⅲb. Contrast-enhanced CT was performed 10 months after the operation. As a result, she was found to have recurrent multiple liver metastases. A laparoscopic partial hepatectomy was performed at the site of recurrence. The pathological result was adenocarcinoma. It was a diagnosis of metastasis recurrence from colorectal cancer. A CT scan 16 months after primary surgery revealed enlarged cardiodiaphragmatic lymph nodes. A PET-CT scan revealed an accumulation of SUVmax 3.0 in the same area. She was diagnosed with lymph node recurrence of colorectal cancer and underwent resection. Histopathological result was adenocarcinoma. It was diagnosed as metastasis from ascending colon cancer.

A 58-year-old man with chronic renal disease underwent ileo-cecal resection with lymph node dissection for cancer of the ascending colon at his previous physician. The pathological diagnosis was pT3N0M0, pStage Ⅱa. One year and 7 months after surgery, he was diagnosed with local and lymph node recurrence and referred to our department. Contrast- enhanced CT revealed that an irregular nodal shadow 25 mm in size adjacent to the superior mesenteric artery and the transvers part of duodenum, which was suspicious for lymph node recurrence. We regarded this patient as marginally resectable and neoadjuvant treatment was considered, but because the patient was on dialysis, we decided to operate without pre-operative treatment. Surgical findings showed invasion of a recurrent lymph node into a primary branch of the superior mesenteric artery and vein. We temporarily blocked these vessels and cut off these vessels after checking that blood flow in the intestine was maintained by intravenous injection of ICG. The lymph node was also invading the uncinate process of the pancreas and the transvers part of duodenum, we performed partial resection of those organs. Pathology revealed no tumor exposure on the dissected surface and R0 resection was achieved. The patient received 5 courses of postoperative folinate/ uracil/tegafur therapy and is alive 1 year postoperatively without recurrence.

The patient was a 90-year-old man. He was referred to our department with a diagnosis of ascending colon cancer after lower gastrointestinal endoscopy for a positive stool occult blood test. Lower gastrointestinal endoscopy revealed a type 1 tumor 30 mm in the ascending colon and a type 3 tumor 50 mm in the cecum. Biopsy revealed Group 5(tub1)for the ascending colon lesion, but Group 2 for the cecum lesion. The patient was clinically diagnosed as having overlapping ascending colon cancer and cecum cancer, and a right hemicolectomy of the colon was performed. Histopathological examination revealed ascending colon cancer and primary malignant lymphoma of the cecum.

We report the rare case of an 89-year-old female with axillary lymph node recurrence after curative surgery for transverse colon cancer who had undergone right hemicolectomy with D3 lymphadenectomy with an uneventful postoperative course. Pathological examination confirmed the tumor's status as tub2>sig, T4aN3M0, and pStage Ⅲc, and signet-ring cell carcinoma was remarkably found in the metastatic lymph node. Genetic testing revealed wild-type RAS, a BRAF mutation, and a high MSI. After 9 months of follow-up without adjuvant chemotherapy, CEA increased sharply to 41.3 ng/mL by 9 months postoperatively, and CT showed nodules in the right axilla, adrenal gland, and retroperitoneum. PET-CT showed abnormal fluorodeoxyglucose uptake in the same regions. A core needle biopsy of the axillary lymph node revealed signet-ring cell carcinoma, which was diagnosed as a recurrence of transverse colon cancer. Although we suggested chemotherapy due to the unresectable recurrence of colorectal cancer, she preferred to receive supportive care instead. Three months after the recurrence was diagnosed, CEA increased to 248.4 ng/mL, and CT showed enlargement of the axillary lesion and a new lesion in the hilum of the lung.

There is a liver damage in a serious side effect of regorafenib. Case 1 was a 54-year-old woman, and she had an operation of rectal cancer and metastasized to multiple organs afterwards and started regorafenib as third-line. Erythema exudativum multiform developed on the 8th day after a start and regorafenib was canceled once and reduced on the 21st day when a skin symptom was relieved and restarted. However, because a significant rise of AST, ALT, T -Bil was recognized afterwards, regorafenib was canceled on the 27th day and enforced steroid pulse therapy and was relieved afterwards. Case 2 was a 61-year-old woman, and she had an operation of ascending colon cancer, ovarian metastasis and peritoneum dissemination. Regorafenib was started by frequent occurrence lung metastasis, cancerous pleurisy afterwards as fifth-line. Dissemination erythema developed on the 16th day and a liver damage developed on the 22nd day. Because a rise of AST, ALT went and was prolonged, liver biopsy was enforced in a cause close inspection purpose on the 45th day. A medicamentosus liver damage was diagnosed. The liver enzyme decreased afterwards. It may be easy to make the liver damage by regorafenib serious, and attention is necessary.

A 64-year-old woman underwent right hemicolectomy for transverse colon cancer. Histopathological findings revealed T, type 2, 24×22 mm, tub2, pT2N1a(1/23)M0, and pStage Ⅲa. Postoperative adjuvant chemotherapy was not administered at the patient's request. One year after surgery, carcinoembryonic antigen(CEA)level was elevated, and Gd-EOB-DTPA- enhanced MRI revealed a nodule in segment 2 and 4/8 of the liver. Based on the diagnosis of hepatic metastasis, laparoscopic partial hepatectomy was performed. Three years after hepatectomy, CEA level was found to be elevated again, and chest CT showed a solitary pulmonary nodule in segment 7 of the right lung. With a diagnosis as pulmonary metastasis, FOLFIRI plus bevacizumab was performed. After 41 courses of FOLFIRI plus bevacizumab, the pulmonary nodule decreased in size, and no new lesions appeared. The chemotherapy was terminated at the patient's request. Six months later, the pulmonary nodule increased in size, and thoracoscopic partial pulmonary resection was performed. Hepatic and pulmonary resection specimens were histopathologically consistent as metastasis of colorectal cancer. The patient has been alive without recurrence for about 4 years after final surgery(pulmonary resection)without postoperative adjuvant chemotherapy. We report a case of long-term survival with metachronous hepatic and pulmonary metastases from transverse colon cancer by multidisciplinary treatment.

A 77-year-old female patient presented with a medical history of 4 cancerous lesions, each with a surgical history. She was referred to our hospital due to anemia. Upon examination, she was diagnosed with transverse colon cancer. Duodenal invasion was suspected, which made performing R0 surgery difficult; therefore, the NAC approach was chosen. Three courses of CAPOX were administered, resulting in tumor obstruction, leading to the formation of an ileum stoma. MSI testing revealed MSI-H, and pembrolizumab treatment was initiated. CT scans showed tumor shrinkage, and PET scans indicated no accumulation, resulting in a cCR. Colon resection including the lesion suspected of stenosis was performed with a strong desire for stoma closure and the determination of potential curative resection. Additionally, a partial resection of the duodenum was performed. Pathological examination did not reveal any evident tumor cells, leading to the determination for a pCR. The patient has been under postoperative surveillance for 1 year without any recurrence.

A 52-year-old male patient with Stage Ⅲc ascending colon cancer underwent laparoscopic right hemicolectomy with D3 lymph node dissection. Adjuvant chemotherapy was administered for 6 months, and no recurrence was observed during the follow-up period. Left lung metastasis was detected and surgically removed 7 years after the initial surgery. He underwent open partial small bowel resection with lymph node dissection when mesenteric lymph node metastasis was identified 2 years later. Although chemotherapy was conducted on the identification of mediastinal lymph node metastasis 2 years later, the mediastinal lymph nodes increased. Although attempted, lymph node dissection was impossible because of the strong adhesion to the trachea. Subsequently, chemotherapy and radiation therapy were administered. However, an infiltration of the mediastinal lymph nodes into the trachea was observed. The patient underwent bronchoscopic laser tumor ablation. The patient died 4 months after the resumption of chemotherapy(18 years after the initial surgery). Mediastinal lymph node recurrence after curative resection for colon cancer is a rare clinical condition. Nevertheless, long-term survival could be achieved by multimodal treatments in such patients.

A 78-year-old male was diagnosed with a primary gastric B-cell malignant lymphoma and metastatic lung tumor 10 years ago. He underwent chemotherapy at another hospital, achieved complete remission, and was actively undergoing follow- up. He presented to our hospital with a 1-month history of a bulge in his right lower abdomen. CT revealed thickening of the ascending colon and dilatation of the oral intestine. He was diagnosed with ascending colon cancer and underwent right hemicolectomy. The subsequent pathological examination revealed a collision tumor involving diffuse, large B-cell lymphoma and well-differentiated adenocarcinoma. He was discharged from our hospital and received chemotherapy at another institution. Unfortunately, the patient died of interstitial pneumonia 31 months postoperatively. This report describes the resection of a collision tumor involving ascending colon cancer and malignant lymphoma. Surgical treatment combined with postoperative chemotherapy improved this patient's long-term survival.

The patient is a 72-year-old man. He was diagnosed as a duplication of left upper lobe lung adenocarcinoma cStage ⅣB and transverse colon cancer cStage Ⅳc. Because he had symptoms of atelectasis and esophageal stricture due to the progression of lung cancer, we decided to precede immunochemotherapy(CBDCA plus PEM plus pembrolizumab)for lung cancer. After the start of treatment, both lung and colorectal cancer were shrinking, but after the 3 courses of treatment, he developed intestinal obstruction due to transverse colon cancer. Because generalized peritonitis due to perforation of the colon by endoscopic stenting for the obstruction and then emergency surgery was performed. The resected transverse colon lesion was diagnosed as pathologically complete response. Lung cancer was also diagnosed as clinically complete response. Since his ADL decreased postoperatively, he is under observation without reintroduction of immunochemotherapy. Fourteen months have passed since the last administration, and no progression has been observed in either lung nor colon cancers. Pembrolizumab is considered to be successful in the patient with dMMR colorectal cancer lacking MLH1 and PMS2.

We report a case of colon metastasis from gastric cancer treated by laparoscopic-assisted segmental colectomy. An 81-year-old man was undergone distal gastrectomy, D2 dissection and Billroth Ⅰ reconstruction for gastric cancer 3 years previously, with a final diagnosis of gastric cancer L, Post, Type 2, sig/por2, pT4a(SE), pN3b(30/56), H0, P0, M0, pStage ⅢC. Three years after gastrectomy, CT scan showed an elevated lesion in the transverse colon, which was suspected to be metastatic colorectal cancer on closer examination. As no metastatic lesions were found other than the tumor of transverse colon, we performed laparoscopic-assisted segmental colon resection. A small incision was placed in the umbilical region, and the transverse colon was extracted from the umbilical region after dissection of the adhesions by single-incision laparoscopic surgery. The transverse colon containing the mass lesion was partially resected extracorporeally and reconstructed with a functional end-to-end anastomosis. The postoperative pathological findings revealed tumor cells predominantly below the submucosal layer and partly showing the signet ring cell carcinoma, and the transvers colon tumor was diagnosed as a metastasis from gastric cancer. The postoperative course was uneventful and the patient was discharged 8 days after surgery, and is alive for 10 months after the segmental colon resection followed by chemotherapy.

The patient was a 77-year-old woman. She visited her family doctor with a complaint of bloody stools, and was pointed out a Type 3 colon cancer in the cecum with a colonoscopy. In addition, an enlarged lymph node(#203)was found on the right side of the superior mesenteric vein(SMV). Laparoscopic surgery was initiated, and when the patient was moved to vascular processing, a firm adhesion of the lymph node(#203)was observed on the right side of the SMV. A small laparotomy was added, and a partial combined resection of the SMV was performed en bloc to complete the ileal resection. Histopathological findings showed T4b(transverse colon)N3M0, pStage Ⅲc, and metastatic lymph node(#203)showed evidence of invasion to the SMV. Adjuvant chemotherapy was administered, but lung metastases appeared 4 months and liver metastasis appeared 29 months after surgery. The patient was transferred to a different hospital for best supportive care(BSC)at 34 months after surgery.

An 84-year-old man visited our department for further examination of anemia and elevation of tumor marker levels. Colonoscopy revealed a huge circumferential type 3 tumor in the ascending colon. Significant hypoalbuminemia was observed at 1.1 g/dL, and prolonged hypoalbuminemia was considered to be caused by protein-losing gastroenteropathy due to the large tumor. In this case, we performed right hemicolectomy, and performed single-stage anastomosis. The resected specimen showed a huge type 3 lesion with a diameter of 140×120 mm in the ascending colon, which directory invaded to the cecum and ileum. After the operation, there were no particular complications, and albumin levels gradually improved. Although hypoalbuminemia is one of the risks of anastomotic leakage, there are many reports with one-stage anastomosis and with a good course, including our case. Therefore, it was considered necessary to examine each case regarding the surgical procedure.

An 84-year-old woman presented with anorexia. CT showed ascending colon and multiple liver tumors, and a colonoscopy showed severe stenosis due to a tumor in the ascending colon. We diagnosed obstructive colon cancer with multiple liver metastases. It was difficult to approach this case with a colonic stent, and we suggested a colostomy, but the patient strongly objected and requested to undergo resection; thus, a laparoscopic right hemicolectomy was performed. Intraoperatively, there was no normal liver tissue, and liver metastases were diffuse. Histopathologically, neuroendocrine carcinoma and differentiated tubular adenocarcinoma were found; MANEC was diagnosed. Oral intake was started on the third postoperative day, but liver failure progressed gradually. Despite the best supportive care and medication, the patient died of liver failure 16 days after surgery. We report our experience of a MANEC case with a poor prognosis along with a literature review.

A 60s male, who had laparoscopic ileocecal resection for ascending colon cancer 2 years ago, had enhanced computed tomography(CT)for follow-up and a 12-mm nodule in Douglas' pouch adjacent to right seminal vesicle and rectum was found. 18F-fluorodeoxyglucose(FDG)-positron emission tomography CT revealed abnormal accumulation of 18F-FDG only to the lesion(standardized uptake value max 2.60)and the diagnosis of peritoneal recurrence of ascending colon cancer was made. We planned and safely performed laparoscopic concomitant right seminal vesiculectomy in low anterior resection. The pathological diagnosis was peritoneal dissemination of colon cancer and the margin was pathologically negative. The postoperative course was smooth except for temporary dysuria and he was discharged on postoperative day 17. As of writing 1 year after surgery, the patient continues to do well with no sign of recurrence. Laparoscopic concomitant seminal vesiculectomy in low anterior resection can be a good option for the curative resection of peritoneal recurrence.

The patient was a 61-year-old man who visited the emergency department of our hospital for the exacerbation of left lower abdominal pain. CT scan revealed a tumor in the descending colon and fluid accumulation and extensive foamy gas in the retroperitoneal space, suggesting that the tumor in the descending colon penetrated the parietal peritoneum and formed an abscess. After percutaneous drainage for the retroperitoneal abscess, a transverse colostomy was performed. After the improvement of the general conditions, the patient underwent an endoscopic biopsy and was diagnosed with well-differentiated adenocarcinoma. After 4 courses of FOLFOX plus panitumumab(PANI), with the drainage and wound care continued, he was discharged and underwent 2 additional courses of chemotherapy. PET-CT revealed marked shrinkage of the descending colon tumor without distant metastasis. Therefore, left colectomy and transverse colostomy closure were performed as curative surgeries. After discharge, the patient underwent 6 courses of chemotherapy and has been followed up without recurrence for 13 months after the curative surgeries.

A 72-year-old man was referred to our department with suspected intestinal obstruction. CT showed irregular descending colon wall thickening. Lower endoscopy showed severe descending colon stenosis. Biopsy results were group 1. FDG accumulation of significant SUV was found in the lymph nodes on the left supraclavicular region, left axilla, right mediastinum, posterior part of the right diaphragmatic leg, around the abdominal aorta, and in the liver. The accumulation in the descending colon was not definitely neoplastic. Consequently of left axillary lymph node biopsy, axillary lymph node metastasis of colorectal cancer was suspected, and laparoscopic left semicolon resection was performed. Among the simultaneous distant colorectal cancer metastases, Virchow's and left axillary lymph node metastases are extremely rare(0.1%). We report a case of descending colon cancer with simultaneous Virchow's and left axillary lymph node metastases, with some literature discussion.

A 49-year-old female was underwent laparoscopic right hemicolectomy for ascending colon cancer and liver metastasis. Then, she was underwent laparoscopic hepatectomy. She received BEV plus mFOLFOX6 therapy as postoperative adjuvant chemotherapy, but she had liver recurrence. She received FOLFOXIRI therapy. Although tumor tended to progressive, it was localized, so laparoscopic hepatectomy was performed again. She received AFL plus FOLFIRI therapy. Fourteen months after hepatic resection, disseminated nodules and lung metastases were found. However, both of peritoneal dissemination, and lung metastasis were localized, so it was judged that peritoneal dissemination and lung metastasis could be resectable. Then, peritoneal dissemination resection and sigmoid colectomy were performed, and then lung resection was performed to perform R0 resection. R0 resection and multimodal therapy for simultaneous and heterotopic metastases of colorectal cancer can contribute to provide a long-term prognosis.

Background and Purpose: The right colic artery(RCA)and gastrocolic trunk(GCT)traverse around the pancreas and duodenum and branch divergently, thus, complicating right-sided colon cancer surgery. The usefulness of pancreatic/duodenum 3DCT imaging(pancreas/duodenum CT: PDCT)for laparoscopic right-sided colon cancer surgery was investigated., Patient and Method: The patient was a woman, in her 80's with 2 sites of ascending colon cancer:(1)A-C, cT4b(retroperitoneum) N2aM0, Stage Ⅲc;(2)A, cT3N1bM0, Stage Ⅲb. A radical surgery was planned. Contrast-enhanced CT colonography( CTC)was performed preoperatively, and 3 3DCT images(CTC, arteriovenous 3DCT, and PDCT)were created using Workstation: Ziostation 2®(Ziosoft). These 3DCT images were combined and used for preoperative simulation and intraoperative navigation., Result: Composite images of CTC and arterial 3DCT identified the dominance of ileocolic artery(ICA)and RCA. In addition, a composite venous 3DCT image confirmed the branching and course of ileocolic vein(ICV)and right colic vein(RCV). Composite images of PDCT and arteriovenous 3DCT showed that the RCA branched from the superior mesenteric artery at the level of the third part of duodenum and ran ventral to the pancreatic head, while the RCV branched from the GCT in front of the pancreatic head, with the right gastroepiploic vein(RGEV). A laparoscopic combined ileal and retroperitoneal resection and D3 lymph node dissection with ICA/V and RCA/V root dissection were planned. Surgical simulation facilitated the identification of ICA/V and RCA/V and surgical procedure. The operative time was 310 minutes, and blood loss was 90 mL. Histopathological examination confirmed the diagnosis of(1)pT3(SS)N1bM0, Stage Ⅲb and(2)pT3 (SS)N1aM0, Stage Ⅲb. The patient was discharged 10 days post-surgery, without any complications. Currently, there is no apparent recurrence at 1-year follow-up., Conclusion: PDCT clarified the location of the RCA and GCT in relation to the pancreas and duodenum and complemented the laparoscopic right-sided colon cancer surgery.

We report a rare case of postoperative ascending colon cancer metastasis to the right external iliac lymph nodes. A 57- year-old woman underwent a laparoscopic right colectomy and D3 lymph node dissection. Pathological findings indicated a Stage Ⅲb, pT4aN1bM0 cancer. Because side effects were observed on adjuvant chemotherapy with FOLFOX, she was switched to S-1 administration every other week. Sixteen months postoperatively, right inguinal pain and elevated CEA values were noted. CT revealed two swollen right external iliac nodes with high FDG uptake on PET-CT. With the diagnosis of lymph node metastasis, an open celiotomy was performed to remove the lymph nodes. Pathological findings confirmed lymph node recurrence of ascending colon cancer. Postoperatively, her CEA values were normal and no recurrence was noted. This rare occurrence highlights the importance of examining adjacent lymph nodes for possible tumor recurrence. We report this case with the necessary literature review.

A 71-year-old woman who have been taking Sanshishi for 50 years until the age of 70 for dermatitis underwent colonoscopy( CS)to reveal the reason of abdominal pain. CS showed ascending colon tumor(AT)with major axis 3 cm and suspicious of the mesenteric phlebosclerosis. Although endoscopic submucosal dissection(ESD)was performed for AT, colon perforation due to colonic wall fibrosis was occurred and ESD was suspended. Therefore, surgical resection was planned. Intraoperative observations by laparoscopy showed that the color of colon serosa from the cecum to the splenic flexure was grayish white and colonic wall thickening with lead tubular change was observed. From the descending colon to the sigmoid colon, wall thickening was mild, and Haustra was confirmed. Although the tumor location was in the ascending colon, laparoscopic subtotal colectomy and functional end-to-end anastomosis of ileum and sigmoid colon was performed for safe intestinal anastomosis. For treat of colon cancer complicated mesenteric phlebosclerosis(MP), endoscopic resection is considered difficult due to fibrosis and extended resection of the colon may be required to reduce the risk of anastomotic leakage. Herein, we report our case and details of past reported literatures.

An 84-year-old woman presented with a 9mm sized solitary liver metastasis in liver S8 18 months after the surgery for sigmoid colon cancer. The patient was treated with stereotactic body radiation therapy(SBRT)for local control, because the patient chose not to undergo surgery or chemotherapeutic treatment for metastatic liver cancer. SBRT is a minimally invasive treatment with a very short treatment period. Therefore, it may be considered as an alternative treatment for patients who are not suitable for surgery.

A 50-year-old man underwent low anterior resection for rectal cancer. The final diagnosis was rectal cancer of pT3N0M0, fStage Ⅱ. CT performed for examination of obstructive jaundice at 17 months after surgery revealed metastatic lesions of the pancreatic head and right lung. By core needle biopsies, the lesions were pathologically diagnosed as metachronous metastases of rectal cancer. Chemotherapy was carried out but was discontinued at 5 courses due to severe side effects. The pancreatic metastasis disappeared after 11 months. As the lung metastasis remained, a right upper lobectomy was performed 1 month later. The patient remains alive without recurrence 6 months after the partial lung resection.

The patient was a 79-year-old man. He had ascending colon carcinoma and multiple hepatic metastases, and right hemicolectomy( D2)was performed in June 2012(SE, N1, P0, M1[H3], Stage Ⅳ). After surgery, 8 courses of mFOLFOX6 plus panitumumab biweekly, then, 5-FU/l-LV biweekly and panitumumab every 4 weeks were administered because he had wild- type KRAS. Before chemotherapy, his serum CEA level was 122 ng/mL, but the value decreased rapidly to a normal level after 7months. The hepatic metastases also decreased, and the lesion was only slightly observed on CT after 7months. Five years after the surgery, images and his CEA level are both normal, and the effectiveness is maintained. Even for right colon cancer, anti-EGFR antibodies might be effective if RAS is wild-type.

We report a case of good quality of life(QOL)and favorable response to transarterial chemoembolization(TACE)against synchronous multiple liver metastases. An 85-year-old man was admitted to our hospital because of melena. Colonoscopy showed multiple type 2 tumors in the sigmoid colon and upper rectum. CT and EOB-MRI examinations revealed that there were multiple liver metastases. Because of his age and surgical stress, he underwent a laparoscopic Hartmann's procedure. After the resection of the primary tumor, he received tegafur/uracil for his liver metastases. However, he discontinued receiving the drugs 2 weeks later because of the development of adverse events. Instead of systemic chemotherapy, he chose to undergo TACE. He underwent TACE with irinotecan and HepaSphereTM(BioSphere Medical)8 times for his multiple liver metastases. Consequently, all multiple liver metastases disappeared. Therefore, TACE may be useful for patients who are not suitable for systemic chemotherapy.

A 65-year-old woman with cecum cancer underwent laparoscopic right colectomy.After 3 years, she was diagnosed with a local recurrence with small bowel invasion and underwent tumor resection.One year later, she had a re-recurrent lesion involving her right iliac bone.After one year of chemotherapy, a PET-CT showed no other abdominal lesions suggestive of malignancy.She underwent resection of the re-recurrent tumor involving the right iliac bone and R0 resection was achieved. She was able to ambulate postoperatively and returned home.In selected cases, extended surgery including bone resection can be an option for the local recurrence of advanced colon cancer.

A 72-year-old man with ascending colon cancer was admitted to our hospital. Right hemicolectomy and lymph node dissection(D3)were performed. The pathological diagnosis was signet-ring cell carcinoma, T4a(SE), N2b, M1a(LYM), Stage Ⅳ, R0, Cur B. Capecitabine was administered after surgery. Subcutaneous bleeding, thrombocytopenia, and a rapid increase in tumor marker levels occurred 9 months after surgery. He had already developed disseminated intravascular coagulation and was admitted to our hospital immediately. CT scan revealed metastasis in the thoracic vertebrae. Bone scintigraphy demonstrated multiple abnormal areas of uptake in the costal bones and the thoracic and lumber vertebrae. We made a final diagnosis of disseminated carcinomatosis of the bone marrow by histopathological examination. Unfortunately, before starting chemotherapy, his general condition deteriorated, and he died 14 days after hospitalization. We present here a case of colon cancer with disseminated carcinomatosis of the bone marrow.

A67 -year-old man was diagnosed with ascending colon cancer and multiple liver metastases and underwent laparoscopic right hemicolectomy(D3 lymphadenectomy). Pathological examination indicated tubular adenocarcinoma(tub1, pT4apN2H2M1[HEP], pStage Ⅳ). After chemotherapy, he underwent hepatectomy. One year and 9 months after the first operation, obstructive jaundice appeared. Abdominal computed tomography revealed a tumor 2 cm in size in the head of the pancreas. After several detailed examinations, he was diagnosed with pancreatic metastasis of ascending colon cancer. After partial resection of the left lung metastasis, pancreaticoduodenectomy(SSPPD-Ⅱ A-1, D1 lymphadenectomy)and low anterior resection(LAR)for early rectal cancer were performed. The tumor was positive for CDX2(+), resulting in a diagnosis of pancreatic metastasis. There has been no indication of recurrence 8 months after the pancreatic surgery. Resectable pancreatic metastasis from colon cancer is rare, and there are no clear indications for resection. Some cases of long-term survival have been reported; however, further studies are needed in order to establish a consensus.

We present a case of long-term survival in a patient with advanced ascending colon cancer and multiple liver metastases after receiving multimodality therapy, which included hepatic atrial infusion(HAI)and 4 hepatectomies. At diagnosis, the 65- year-old woman underwent right hemicolectomy for advanced ascending colon cancer with multiple liver metastases (T3N1M1[H2], Stage Ⅳ). The 11 liver metastatic lesions were treated by weekly HAI of 5-fluorouracil(5-FU). The lesions reduced in size(response rate 28.9%)immediately following treatment, and no new lesions were detected, but 10 months after treatment the size of the S2 tumor had increased. Systemic chemotherapy with irinotecan and S-1 was administered. Continued development of the S2 tumor in the liver prompted a radical lateral segment hepatectomy. Four months later, a computed tomography(CT)scan revealed a S6 tumor of the liver, for which a posterior segment hepatectomy was performed. A CT scan showing a S1 tumor in the liver 9 months later resulted in chemotherapeutic treatment with CapeOX, followed by mFOLFOX6. Despite treatment, the S1 tumor developed further, prompting a S1 partial hepatectomy. A further partial S8 hepatectomy was performed 7 years after surgery for the primary lesion following a CT scan that revealed a S8 tumor in the liver. There has been no recurrence of tumors in the 5 years and 5 months since this last hepatectomy.

The safety and feasibility of chemotherapy for elderly patients is unclear. We report a super-elderly patient with liver metastases from colorectal cancer successfully treated with capecitabine plus bevacizumab chemotherapy. An 87-year-old woman underwent a colectomy for transverse colon. At 4 months postoperatively, she underwent hepatectomy for liver metastases. At 9 months after the first surgery, a new liver metastases(S4)was found. At this time, she rejected another hepatectomy. Therefore, we selected capecitabine plus bevacizumab chemotherapy, considering her age. After 18 courses of administration, the liver metastasis did not progress, and no new metastatic lesions were found on CT examination. Although as adverse events Grade 2 hand-foot syndrome developed, no other adverse event occurred. The patient's PS score was maintained at 0. We suggest capecitabine plus bevacizumab chemotherapy is an effective regimen for super-elderly patients with colorectal cancer.

A 94-year-old woman, who had been treated for multiple colon cancers 4 years ago, complained of umbilicus induration and had been followed up in a previous hospital with a diagnosis of periumbilical inflammation. Four years and 3 months postoperatively, the umbilical induration was enlarged, and umbilical metastasis of adenocarcinoma was diagnosed on biopsy. Umbilical resection was performed, and multiple peritoneal metastases were revealed. Umbilical metastases may worsen the patient's quality of life; thus, local resection was recommended positively.

We report a case of ascending colon cancer with hepatic metastases that was treated by CapeOX plus bevacizumab with remarkable efficacy. A 40-year-old female patient presented with a medical history of surgery for resection of right breast cancer4 years ago, left-sided transverse colon 2 years ago, and right ovarian cancer 6 months ago. Follow-up computed tomography(CT)found wall thickening from the ascending colon to cecum. She was diagnosed with an ascending colon cancer by colonoscopy, and underwent right hemicolectomy. One month after the surgery, her serum marker carcinoembryonic antigen(CEA)and carbohydrate antigen 19-9(CA19-9)levels were high. She was diagnosed with unresectable multiple hepatic metastases by CT 2 months after the surgery. Her tumor was epidermal growth factor receptor(EGFR)- positive and wild-type for RAS; she received 4 courses of CapeOX plus bevacizumab. Thereafter, liver metastases were remarkably decreased in size, and she could undergo central bisegmentectomy. Pathology examination revealed no tumor and that the center of the tumor was changed to necrotic tissue and the surrounding area was changed to fibrous tissue and lymphocyte infiltration. The patient is disease-free since the last operation.

A 57-year-old female patient received ileocecal colon resection because of colon cancer. Pathological findings showed pSSN2M0(pStage III b). After surgery, CapeOX was administered as an adjuvant chemotherapy. On day 13 of CapeOX treatment, severe oral mucositis and Grade 4 myelosuppression appeared, and the CapeOX treatment was immediately stopped. However, these adverse effects continued for 19 days, and she gradually recovered. The severe myelosuppression was caused bydeficiencyof DPD, which is a keyenzy me that metabolizes 5-FU. While DPD deficiencyis veryrare, we need to consider that 5-FU causes severe adverse events in patients with DPD deficiency.

A 47-year-old woman presented with a hard umbilical nodule that appeared red and was painful. A biopsy of the umbilical nodule revealed adenocarcinoma. As a result of general examinations, the patient was diagnosed with umbilical, hepatic, and ovarian metastases from transverse colon cancer. She was treated with S-1 and oxaliplatin(SOX)plus bevacizumab chemotherapy. After 4 courses of chemotherapy, CT revealed that the primary lesion and umbilical and hepatic metastases had reduced in size. We considered this to be a partial response and thus administered 4 additional courses of SOX plus bevacizumab chemotherapy. Finally, she remained well for 22 months and achieved relatively good prognosis. An umbilical metastasis from an internal malignancy is known as a Sister Mary Joseph's nodule, and it has very poor prognosis. Most studies show that the survival period from the time of diagnosis is within 1 year. However, our case suggests that novel anti-cancer drugs or molecular-targeted agents may improve survival.

We report a case of recurrent colon cancer that achieved partial response with chemotherapy of combined 5-fluorouracil (5-FU), irinotecan, Leucovorin(FOLFIRI), and aflibercept. A 65-year-old man was diagnosed with colon cancer with lymph node metastasis. He underwent surgery, but after 1 year, he had a recurrence of peritoneal dissemination, nodal enlargement, and liver metastases. He received chemotherapy(mFOLFOX plus bevacizumab), but suffered progressive disease. Thereafter, FOLFIRI plus aflibercept was administered, and CT revealed a decrease in peritoneal dissemination after 2 cycles of chemotherapy. After 23 cycles, a PET-CT showed no evidence of the disease. We also examined 9 recent cases treated with aflibercept in terms of Grade 3 and 4 adverse effects, leukopenia, neutropenia, thrombocytopenia, hypertension, and sweating. Placentalderived growth factor(PIGF)has been reported to stimulate macrophages and induce production of IL-6, and thus it promotes inflammation and growth of extant cancer. Among the responses to chemotherapy based on the RECIST criteria, a partial response was significantly higher in patients with a low neutrophil-to-lymphocyte ratio(NLR)(p≤0.05)compared to those with high NLR. As regards the relationship between NLR and OS in patients treated with FOLFIRI plus aflibercept, OS was significantly worse in patients with high NLR than those with low NLR(p≤0.05). NLR may be a useful marker in conjunction with aflibercept treatment.

We report a case of effective treatment comprising mFOLFOX6 plus bevacizumab for neuroendocrine carcinoma of the ascending colon. A 60-year-old woman was admitted for diarrhea and abdominal pain. Colonoscopy showed a Type 2 tumor in the ascending colon. She was diagnosed with neuroendocrine cell carcinoma based on biopsy and immunostaining. CT and MRI showed liver metastasis and lymph node #12a metastasis. Right hemi-colectomy, lymphadenectomy, and partial hepatectomy were performed(T4a, N2, M1b, Stage IV). Neuroendocrine cell carcinoma(small-cell type)was finally diagnosed based on a histological examination because the nuclear fission image was 30(/10HPF)and the Ki-67 index was 42%. Three months after the surgery, multiple lymph node metastases were found using CT and MRI. mFOLFOX6 plus bevacizumab was initiated. After 4 courses of the chemotherapy, the metastases responded completely. A total of 10 courses of chemotherapy were administered. About 2 years and 6 months after the surgery, no recurrence is allowed.

A 72-year-old man with advanced dementia presented with a right lower abdominal painful mass, and on detailed examination and investigation, was diagnosed to have moderately differentiated circumferential tubular adenocarcinoma infiltrating the abdominal wall in the middle of the ascendingcolon. It was extremely painful, and there was also a risk of ileus if left untreated. Therefore, laparoscopic right hemicolectomy was performed. One year after surgery, examination revealed local recurrence. After consultation with family members, we started with chemotherapy, usingcapecitabine and bevacizumab. It is our policy to administer chemotherapy under adequate surveillance. Thus, outpatient chemotherapy was safely administered in a dementia patient with shrinkage of local recurrent lesions.

A 77-year-old man was diagnosed with ascending colon cancer with synchronous liver metastasis. Per our policy we first only performed a right hemicolectomy (pSSN2H2M0, stage IV). We then planned S-1 and oxaliplatin (SOX) plus bevacizumab (Bmab) chemotherapy as a neoadjuvant for the resection of liver metastasis. After 4 courses, enhanced CT and EOB-MRI findings showed the liver tumor had significantly decreased in size with no side effects, and we performed a partial liver resection for the S7 lesion. Postoperatively, histopathological analysis revealed only a fibrotic lesion and no cancerous cells in the resected specimen, indicating that chemotherapy had downgraded the tumor to Grade 3. Adjuvant chemotherapy was not continued owing to the patient's refusal, but no recurrence was noted 18 months after the second operation. SOX plus Bmab chemotherapy is, therefore, effective in terms of its anti-tumor effects, tolerance, and accessibility. We believe SOX plus Bmab chemotherapy can be considered as an effective option for cases with synchronous liver metastasis of colon cancer as neoadjuvant chemotherapy for interval liver resection.

Patients with metastatic colon cancer can be treated with alternating courses of FOLFOX6 and FOLFIRI in order to reduce their adverse events. We report 2 patients with para-aortic lymph node metastasis treated with 4 courses each of FOLFOX6 and FOLFIRI in combination with bevacizumab, which led to a complete response. Case 1: The patient was a 53-year-old woman with transvers colon cancer tub2 pSS, ly3, v2, n4, H0, P0. Case 2: The patient was a 60-year-old woman with upper rectal cancer tub1 pSS, ly3, v3, n4, H0, P0. The administration of tegafur/uracil plus oral Leucovorin was continued for 6 months. Furthermore, only the administration of oral doxifluridine was continued for 4 years. Complete response has been maintained for over 5 years since resection. Four courses each of FOLFOX6 and FOLFIRI in combination with bevacizumab will not only provide a remission rate of 100% but will also be effective radical therapy for patients with para-aortic lymph node metastasis.

We report a 50-year-old man with local recurrence of descending colon cancer with ileus obstruction and brain metastasis, 2 years 6 months after initial resection due to perforation of descending colon cancer(Hartmann procedure, D2 lymph node resection, Stage II, tub2). He complained of left upper abdominal pain and abdominal fullness. He also complained of paresis of the right upper extremity and of experiencing convulsions 1 month before admission. He was diagnosed with local recurrence of descending colon cancer, based on findings of contrast radiography and the presence of colonic fiber. We subsequently performed transanal decompression as a bridge to surgery and performed partial resection of the local recurrence in the anastomosis at the descending colon and ileum involved with the cancer 2 weeks after decompression. In addition, multiple lung and liver metastases, and solitary brain metastasis(2.5 cm in size located in the left side of the parietal region) were detected by cerebral plain computed tomography. However, he refused both chemotherapy after surgery, as well as further surgery and/or radiation therapy for the brain metastasis. He desired to return to his home as soon as possible. In order to improve his quality of life(QOL), in-home treatment involving the best supportive care(BSC)conservative therapiesincluding, anticonvulsant and anti-intracranial hypertension drugs-were administered to prevent brain metastasis symptoms, such as paresis of the right upper extremities and convulsions. He was discharged from our hospital 14 days after surgery. Regrettably, he died due to bronchial asthma 75 days after palliative surgery in his home.

A woman in her 50s was admitted to our hospital with fever and lower abdominal swelling. Abdominal CT/MRI examinations revealed irregular thickening of the transverse colon wall, which was attached to a subcutaneous abscess. An abdominal wall mass, a patent urachus, and a tumor in the 5th segment of the liver were also noted. Colonoscopy revealed type 2 advanced transverse colon cancer. The solitary, sessile tumor was observed at the apex of the bladder under cystoscopy, suggesting the formation of the urachal carcinoma. Transcutaneous liver biopsy obtained from the liver tumor indicated adenocarcinoma, which was morphologically different from the existing transverse colon cancer. Right hemicolectomy with resection of the umbilicus, abdominal wall, urachus, and part of the bladder wall was performed. Diagnosis of the transverse colon cancer invading the abdominal wall and bladder was confirmed by histopathological examination. Hepatectomy was performed in the next surgery, and the tumor was histopathologically diagnosed as an intrahepatic cholangiocarcinoma. Both the transverse colon cancer and the intrahepatic cholangiocarcinoma were radically resected. Radical surgical diagnostic resection may be valuable in cases of multicentric cancers of unknown primary origin, if radical resection of each individual tumor is required.

Systemic chemotherapy based on 5-fluorouracil(5-FU)is a standard treatment for unresectable or recurrent colon cancers. Here, we report a case of hyperammonemia induced by chemotherapy using 5-FU for metastatic colon cancer. An 84-yearold male patient with past histories of liver cirrhosis related to hepatitis C virus and renal dysfunction underwent an operation for the rectosigmoid colon cancer 8 years ago. Three years after that operation, a local recurrence of the colon cancer was diagnosed, and chemotherapy using sLV5FU2 was initiated. The recurrence lesion reduced markedly by this chemotherapy, which was ceased 2 years ago. Two years after the cessation the recurrent tumor had been enlarged, and the chemotherapy using the same drugs at the same dose was performed. On the treatment day 3, he was emergently transported to our hospital due to the disturbance of consciousness. Since laboratory tests showed the high concentration of plasma ammonia and the progressed renal dysfunction with no other definite cause of obnubilation, he was diagnosed as the hyperammonemia induced by 5-FU. He was treated by administrating the branched-chain amino acids solutions combined with fluid therapy, which quickly recovered him from the encephalopathy. He is followed up without any chemotherapy because of his high age. When a patient treated with the chemotherapy using 5-FU is sent with the disturbance of consciousness, we should take hyperammonemia into consideration, especially when he or she has the hepatic or renal dysfunction.

There is a clear consensus regarding the combined resection of organs with cancer invasion, patients with colon cancer. However, there are very few reports to our knowledge regarding the use of pancreato-duodenectomy(PD)for colon cancer patients with cancer invasion in the duodenum. We here report a colon cancer patient in whom we performed PD and right hemicolectomy, who showed favorable results with no recurrence. The patient was a 69-year-old woman. Her chief complaint was hypogastric pain. Her previous doctor performed colonoscopy and a colonoscopic biopsy, and detected a type 2 lesion, throughout the entire circumference of the transverse colon near the liver, and she was diagnosed with adenocarcinoma. From further imaging analyses, she was diagnosed as having transverse colon cancer with invasion into the superior mesenteric vein(SMV), duodenum, and pancreatic head, and No. 223 lymph node metastasis. The patient's cancer was concluded to be unresectable, and she underwent chemotherapy, namely mFOLFOX6 with cetuxiumab(Cmab). One course of mFOLFOX with Cmab, the patient decided to consult our hospital for a second opinion. We concluded that her cancer was resectable, so we performed PD, right hemicolectomy, and resection and reconstruction of a part of the SMV. The operation time was 5 hours 17 minutes, and total blood loss was 190 mL. The histopathological diagnosis was tub2, T4b(duodenum and, tissue surrounding the SMV), int, INF b, ly1, v2, PN1b, EX(+)/ND(PN+, v+), PM0(25 cm), DM0(14.3 cm), N1(1/ 20), H0, P0, M0, pStage III a. She was discharged 15 days after surgery with no complications, and thereafter received ajduvant chemotherapy(capecitabine with oxaliplatin)as an outpatient. After 3 courses, capecitabine with oxaliplatin was changed to capecitabine because she developed a nervous system disorder, and she was further treated for approximately about 6 months. She is doing well at the time of writing, with no recurrences for 2 years. We suggest that PD should be performed on colon cancer patients in which the colon cancer has invaded other organs and has been evaluated as being unresectable.

A woman in her 70s was confirmed as presenting with multiple liver and lung metastases from transverse colon cancer. After undergoing resection of the primary lesion, partial response(PR)was achieved after undergoing the first regimen (sLV5FU2 and bevacizumab[Bmab]); therefore, partial hepatectomy was performed. Adjuvant chemotherapy was administered for 7 months, but liver metastasis recurrence, multiple lung metastases, and brain metastasis were confirmed. As the brain metastasis was a single lesion and was accompanied by symptoms, resection of the lesion was performed. Treatment with regorafenib was initiated, but Grade 3 severe erythema multiforme was detected, and the treatment had to be discontinued. Therefore, combined TFTD and Bmab therapy was initiated as the third regimen. Liver and lung metastases were maintained as stable disease(SD), and the treatment was continued for approximately 1 year together with stereotaxic radiation therapy for the newbrain metastatic lesion. The utility of combined TFTD and Bmab therapy has been reported in a phase II trial, and it has also been indicated that Bmab is effective for reducing brain edema. As this treatment was effective in this case, we will report on it together with a discussion of the literature.

The patient was a 70-year-old man. He was diagnosed with advanced transverse colon cancer. A computed tomography (CT)revealed liver metastasis and tumor thrombosis of portal vein. We started combination chemotherapy with capecita- bine/oxaliplatin(CapeOX). Perforation of the tumor was observed 5 days after CapeOX therapy was started. Treatment with abscess drainage and ileostmy, infection was controlled and general condition was improved. After 9 courses of CapeOX, we changed chemotherapy regimen to irinotecan/tegafur-gimeracil-oteracilpotassium (IRIS)due to strong side effects. In CT and FDG-PET examination after 8 courses of IRIS, the tumor of transverse colon, liver metastasis, and the tumor thrombosis of portalvein became unclear. A year and 6 months have passed since chemotherapy was started, recurrence was not observed. For the patients with unresectable colorectal cancer, it is necessary to consider multidisciplinary treatments including chemotherapy while considering the general condition of them.

We experienced 3 impressive colorectal cancer patients who developed peritoneal recurrences and underwent surgery several times and survived for more than 5 years. Case No. 1 was of a 44-year-old woman who underwent right hemicolectomy for her stage II A ascending colon cancer. She developed left ovarian metastasis, which was resected 3 years later. Five years later, she developed a pelvic peritoneal recurrence, which was resected successfully. Thirteen years later, she is doing well. Case No. 2 was of a 61-year-old man who underwent transverse colectomy for his stage II B colon cancer. He developed ileus 2 years 9 months later due to peritoneal recurrence, which was removed successfully. He underwent another resection for peritoneal metastasis 2 years 6 months later. He was administered 15 courses of FOLFOX6. He has remained cancer-free since 2009. Case No. 3 was of a 62-year-old man who underwent sigmoidectomy for his stage II A colon cancer. One year 8 months later, he underwent resection for a painful abdominal wall metastasis. Eight months later, he developed another abdominal wall recurrence, which was resected successfully. He underwent thoracoscopic resection 4 times for lung metastases and was given 16 courses of FOLFOX6. In 2009, he developed pelvic peritoneal nodules, which were resected. He later needed lymphadenectomy twice. He has remained cancer-free for the last 5 years and 6 months. Curative resection must be performed for a patient with peritoneal recurrence of colorectal cancer when surgery is indicated.