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A case was 73-year-old man, who had history of laparoscopic high anterior resection surgery for rectal cancer, followed by adjuvant chemotherapy 2 years ago. Preoperative diagnosis was anterior mediastinal tumor, with multiple intrapulmonary nodules noted, though no increasing tendency. During adjuvant chemotherapy for colorectal cancer, the anterior mediastinal tumor showed some shrinkage, while that and 3 intrapulmonary nodules slowly increased in size after completion, thus rectal cancer pulmonary and mediastinal metastasis were suspected. Complete resection of the intrapulmonary nodules and anterior mediastinal tumor was considered feasible. Thoracoscopic observation revealed multiple small pleural seeding lesions and all speculated to be intrapulmonary metastases before surgery were also pleural lesions. Intraoperative rapid diagnostic findings of a biopsy section revealed possible colorectal cancer metastasis, though histological type was not revealed. Final histopathological diagnosis was pleural dissemination of thymic carcinoma. Lenvatinib was introduced 2 months later for thymic carcinoma with pleural dissemination. Two years after surgery, the anterior mediastinum primary tumor had slightly decreased and the pleural nodules also showed a shrinking tendency. In such cases of small tumor with increasing tendency and irregular margins, thymic carcinoma should be considered when planning treatment.

A man in his 70s was concurrently suspected of having a submucosal tumor(SMT)of the stomach and a liver tumor during a medical examination. Abdominal contrast-enhanced CT scan revealed S8 hepatocellular carcinoma(HCC)and an SMT of the stomach, which was strongly enhanced from the early to the later phase. Upper gastrointestinal endoscopy revealed a 20 mm SMT in the antrum of the stomach. Endoscopic ultrasonography showed a hyperechoic tumor in the fourth layer of the gastric wall. T2-weighted MRI showed a 25 mm SMT in the antrum of the stomach with a faint high signal intensity compared with that of the gastric wall. The patient was diagnosed with HCC and gastric glomus tumor, and a liver segmentectomy and a local gastrectomy were performed. Immunohistochemistry of the SMT revealed the expression of α-SMA but no expression of desmin, c-kit, CD34, or S-100. Therefore, a diagnosis of a Glomus tumor of the stomach was made. Gastric Glomus tumors are very rare; therefore, we have reviewed some citations and would like to discuss our case.

We report 2 cases of recurrent colon cancer with BRAF mutation. Case 1, a 75-year-old man, had rapid progress of multiple liver metastasis 5 months after curative resection, and died on 37 days after recurrence without induction of systemic therapy. Case 2, a 67-year-old man with diagnosis of peritoneal dissemination at 8 months after curative resection, received encorafenb and cetuximab (doublet-therapy) with certain effect, nevertheless advanced triplet-therapy with binimetinib was forced to pause due to severe skin disorders and he died on 123 days after recurrence. We considered that closed follow- up should be required after curatively resected colorectal cancers with BRAF mutation for early detection of recurrence, and prompt induction and evaluation of systemic treatment also should be required after unresectable recurrence including careful management with the attention to the features of doublet and triplet-therapy.

Hypertrophic pulmonary osteoarthropathy(HPO)is a tumor-associated syndrome that features the triad of clubbed fingers, periosteal bone growth in long bones, and arthritis, and is often associated with an adenocarcinoma or squamous cell carcinoma. This report presents details of a case of HPO associated with pleomorphic carcinoma, which was relieved by treatment. A 47-year-old woman was presented with a complaint of generalized arthralgia. A physical examination showed swollen joints in the body and clubbed fingers. Chest CT revealed a mass shadow in the left upper lobe and ultrasound- guided biopsy findings led to a diagnosis of non-small cell lung cancer. Furthermore, bone scintigraphy indicated symmetrical accumulation in bones and joints throughout the body. A right upper lobectomy was performed along with combined chest wall resection and mediastinal lymph node dissection with an open chest, and the presence of lung cancer complicated with HPO was indicated. Pathological examination results revealed a diagnosis of pleomorphic carcinoma(pT4N0M0, Stage ⅢA). Systemic arthralgia was resolved on the first postoperative day. One year after surgery, a solitary brain metastasis developed and was removed, with no recurrence at the time of writing. Joint symptoms related to HPO can be expected to improve with treatment of pulmonary lesions, thus aggressive procedures for diagnosis and treatment are desirable.

Introduction: In our hospital, we measure the body composition of patients undergoing gastrointestinal surgery. For patients who have a skeletal muscle mass(SMM)of less than 90% of the ideal, we provide them with guidance on having oral nutritional supplements(ONS)and self-exercise therapy. Therefore, we perform operations after taking measures on preserving/improving patient's preoperative conditions. This study was aimed to evaluate the effects on body weight, SMM, and fat mass(FM)in the patients scheduled for gastrectomy., Patients and Methods: From January 2017 to December 2020, we retrospectively analyzed 64 gastric cancer patients whose body composition changes were measured at the time of initial diagnosis and immediately before surgery. The body composition was measured by a nutritionist using the BIA method, while the self-exercise therapy was instructed by a rehabilitation therapist., Results: A total of 64 patients were divided into 2 groups: ONS group(36 patients)and Non-ONS group(28 patients). The median preoperative ONS administered to the ONS group was 15 packs. Body weight change showed a significant difference between the 2 groups(+0.73% and -0.91%[p<0.01]in the ONS group and Non-ONS group respectively). SMM change showed no significant difference between the 2 groups(+1.18% and +0.64%[p=0.19]in the ONS group and Non-ONS group respectively). Likewise, FM change showed no significant difference between the 2 groups(-1.08% and -3.50%[p=0.39]in the ONS group and Non-ONS group respectively)., Conclusion: This study suggested that SMM and FM could be preserved, and body weight could be increased by the support of preoperative ONS administration even in patients with gastric cancer close to having sarcopenia.

The case is a 50-year-old woman. Colonoscopy performed by a local doctor for the purpose of stool occult blood positive revealed a 15 mm tumor in the lower rectum, biopsy showed chromogranin positive, synaptophysin positive, and Ki-67 index<1% showed a neuroendocrine tumor(NET), G1 was diagnosed and introduced. Colonoscopy revealed a smooth- surfaced circular hemispherical tumor with a lower edge 30 mm from the anal margin and 20 mm from the dentate line, and EUS showed 10.7×5.2 mm in layers 2 to 3. It was visualized as a well-defined hypoechoic tumor. Contrast-enhanced CT examination showed a 12×5 mm mass showing a contrast-enhancing effect, and no lymphadenopathy or distant metastasis was observed. Contrast-enhanced MRI showed no evidence of pelvic lymphadenopathy. Based on the above, it was diagnosed that NET, G1, and infiltration to the submucosa exceeding 10 mm. Although endoscopic resection as a diagnostic treatment was also an option, we determined surgical resection policy, therefore we performed laparoscopic rectal intersphincteric resection and upper D2 dissection. Histopathological findings showed a tumor of 11×8 mm infiltrating the submucosa( 5,000μm)with metastasis to the pararectal lymph nodes, and the diagnosis was T1b, N1, Ki-67 index 3%, Ly1, V1a, NET G2, pStage ⅢB. Her postoperative course was uneventful, and 6 months later, we performed her artificial anal closure. One year after the operation, there are frequent bowel movements but no fecal incontinence and she is alive without recurrence. For rectal NET with a tumor diameter of 10 mm or more, radical surgery with dissection is recommended because of the high risk of lymph node metastasis. In this case lymph node metastasis was observed surgical resection according to the above reason, but endoscopic resection was possible except that the preoperative size exceeded 10 mm to 0.7 mm and the distance from the anus was short, therefore it took some thought to decide the policy.

An 80-year-old man visited our hospital because of abdominal distension and epigastralgia. He was diagnosed esophageal cancer(Mt, SCC, T3N0M0, Stage Ⅱ). Because he was elderly, he received chemoradiotherapy(CRT)with S-1. At 54 Gy/27 Fr, he was admitted to the hospital because of cough exacerbation, fever, and food intake loss. A chest and abdominal CT showed a pneumonia pattern. First, antibiotics were started for suspected bacterial pneumonia. Nevertheless, elevation of inflammatory reactions and continuous fever were observed. As interstitial pneumonia was suspected, we started to administer an injection of prednisolone 60 mg. His respiratory symptoms were improved. However, we observed that disseminated erythema of the trunk spread throughout the body and liver enzymes further increased. As blood examination revealed elevated CMV-IgG antibody and C7-HRP positive, we diagnosed cytomegalovirus(CMV)reactivation. Administration of ganciclovir improved liver damage and disseminated erythema. He discharged our hospital while the steroid dose was reduced and valganciclovir continued administrating. The therapeutic effect of esophageal cancer was partial response(PR). We are following his symptoms and CT scan while adjusting the steroid dose. This is a rare case of CMV reactivation due to immunosuppression caused by steroids therapy during CRT against esophageal cancer. We should be aware of CMV infection during CRT and steroid therapy.

We examined the perioperative situation according to estimation of physiologic ability and surgical stress(E-PASS)score of 35 colon cancer patients aged 85 years or older who underwent operation in our facility. The incidence of Grade 2 and Grade 3 complications according to Clavien-Dindo classifications increased with age. The preoperative risk score(PRS)also increased with age; however, the surgical stress score(SSS)did not. The comprehensive risk score(CRS)also increased with age. Because the PRS was already high in these elderly patients, since 2016, we implemented methods to lower the SSS to reduce patient risk, including decreasing the operative time and increasing the laparoscope rate. Compared to before these efforts, the SSS decreased, resulting in a reduced incidence of Grade 3 complications.

Case 1: A 74-year-old man underwent total gastrectomy for gastric cancer, but peritoneal dissemination(P1c)was con- firmed intraoperatively in July 2011. Postoperatively, S-1/docetaxel(DTX)combination chemotherapy was administered; after 32 courses of treatment, S-1 was continued as monotherapy. However, in November 2013, CT scan showed a portal vein tumor. We modified the chemotherapy regimen, but he died 3 years and 7 months after the operation. Case 2: A 77-year-old man underwent distal gastrectomy for gastric cancer with peritoneal dissemination(P1b)in September 2013. He was treated with S-1/DTX/trastuzumab(Tmab)combination chemotherapy. After 5 courses of treatment, S-1was continued as monotherapy until October 2015. He has since survived without recurrence. Case 3: A 75-year-old woman was diagnosed with gastric cancer with peritoneal dissemination(P1c)by laparotomy in September 2014. She was treated with S-1/DTX combination chemotherapy. After 23 courses of treatment, chemotherapy was discontinued according to the patient's wish. She died 2 years and 6 months after the surgery. We suggest S-1/DTX combination chemotherapy as an option for advanced gastric cancer with peritoneal dissemination.

Palliative surgery for advanced gastric cancer with serious symptoms such as hemorrhage or obstruction may be meaningful in the point of improving quality of life(QOL). However, the meaning of palliative gastrojejunostomy for unresectable gastric cancer with obstruction is controversial. We retrospectively evaluated the effectiveness of gastrojejunostomy for unresectable gastric cancer with obstruction using preoperative inflammatory biomarkers. Blood lymphocyte monocyte ratio(LMR), neu- trophill ymphocyte ratio(NLR)and C-reactive protein/albumin ratio(CAR)were analyzed as inflammatory biomarkers in this study. The percentage of improvement in food intake, discharge from the hospitaland performance of chemotherapy were significantly higher in the patients without any preoperative inflammatory reaction compared to those with any inflammation. Moreover, the survival of the patients without any inflammatory change was significantly longer compared to those with any inflammation. In conclusion, preoperative status of inflammation may be a useful marker to predict the effect and outcome of palliative gastrojejunostomy for unresectable gastric cancer with obstruction. Especially when there is any inflammation, the surgical indication should be carefully judged.

An 87-year-old woman was diagnosed with advanced gastric cancer and primary lung cancer in November 2012. She underwent distal gastrectomy for the gastric cancer in December 2012, and right upper wedge resection for the primary lung cancer in February 2013. After surgery, the patient received S-1 chemotherapy. However, she subsequently experienced adverse effects, and so S-1 chemotherapy was stopped. In February 2016, a computed tomographic scan of the chest showed a nodular shadow at S8 in the left lung. Because the nodular shadow gradually increased in size, we suspected that the diagnosis would be either primary lung cancer or metastatic lung cancer arising from gastric cancer. In July 2016, we performed left lower wedge resection. Histopathological examination of the resected specimen resulted in a diagnosis of metastatic lung cancer arising from gastric cancer. After pulmonary resection, the patient had no recurrent tumor. It is thought that surgery is an effective treatment for solitary pulmonary metastasis arising from gastric cancer.

A 88-year-old female suffered of ileus due to advanced transverse colon cancer. Pneumonia was observed and nutrient condition was bad. Operation was found to be difficult because of the bad condition with complication on this present time. Self-expandable metallic stent(SEMS)was inserted to extend obstruction. But SEMS dropped out next day and SEMS, thicker than previous one, was reinserted. Main tumor was huge protruding tumor and the reason of ileus was invagination of the cancer. The fixation of SEMS was not so good, but the generalcondition was improved while a week after reinsertion of SEMS. Laparoscopic colon partial resection was performed safely. Bridge to surgery with SEMS for the case of invagination of protruding colon cancer was thought to be useful.

A 69-year-old man was diagnosed with advanced gastric cancer accompanied by multiple liver metastases in April 2009. Because of worsening anemia due to bleeding from the primary tumor, we performed a distal gastrectomy. After gastrecto- my, he underwent S-1/CDDP combination chemotherapy. After 5 courses of chemotherapy, the size of the liver metastases was reduced. S-1/irinotecan combination chemotherapy was administered as second-line chemotherapy, but he developed grade 3 diarrhea, and the S-1/irinotecan combination chemotherapy was immediately stopped.Weekly paclitaxel chemother- apy was administered as third-line chemotherapy, and S-1/docetaxel combination chemotherapy was administered as fourth-line chemotherapy. After 11 courses of S-1/docetaxel combination chemotherapy, the liver metastases could not be detected by CT and PET-CT in October 2012, and it was concluded that a complete response(CR)had been obtained. He receive maintenance therapy with S-1 chemotherapy for 10 months. Now, he is alive without chemotherapy and has maintained a CR for 4 years 8 months after achieving a CR.

Pancreatic neuroendocrine tumor(P-NET)often involve liver metastases. We report a 52-year-old woman who underwent distal pancreatectomy for a pancreatic body tumor with a diameter of 8 cm. The pathological findings were P-NETG2 . After 1 year 6 months, a liver metastasis was detected. We performed partial hepatectomy. The pathological findings showed a Ki-67 index of 23%. After surgery, CPT-11 plus CDDP therapy and AMR therapy were administered., Conclusion: Multimodal therapies should be considered for P-NETliver metastases based on the Ki-67 index.

We report 3 cases of gastric cancer with rare presentations of oncologic emergency. Case 1 involved cardiac tamponade caused by mediastinitis-induced pericarditis. Metastatic lymph nodes became enlarged after total gastrectomy and invaded the esophagojejunal anastomotic region. Then, a fistula to the mediastinum occurred, resulting in mediastinitis. The drainage was efficacious, but the patient died of cancer 1 month after admission. Case 2 involved cardiac tamponade caused by invasion of metastatic peritoneal tumor into the pericardium. The drainage was successful, but the patient died of cancer 2 weeks after drainage. Case 3 involved perforation of the stomach during the third course of chemotherapy. A total gastrectomy was urgently performed. Thereafter, chemotherapy was continued. However, the patient died of cancer 6 months later. These oncologic emergencies should be considered, although they are rare.

A 77-year-old man was found to have advanced gastric cancer and underwent total gastrectomy (pT4aN2H0P0M0, Stage ⅢB). Two years after gastrectomy, we found an elevated tumor marker level, and a liver metastasis appeared in segment 5 (20 mm in diameter). He was treated with S-1/CDDP combination chemotherapy. After 2 courses of chemotherapy, the tumor marker level kept rising and a CT scan detected a progressive tumor. S-1/irinotecan combination chemotherapy was administered as second-line chemotherapy. After 6 courses of chemotherapy, the size of the liver metastasis was reduced and the tumor marker level normalized. Because lymph node metastasis or peritoneal recurrence was observed, a partial resection of the liver (S5) was performed. After the operation, he was treated with S-1 chemotherapy again for 1 year and has had no recurrence.

Based on the results of the trastuzumab for gastric cancer (ToGA) trial, the regimen of Xeloda/5-FU+CDDP+trastuzu- mab (XPT/FPT) has become the standard of care for treatment of HER2-positive unresectable or recurrent gastric cancers. In our hospital, the percentage of HER2-positive gastric cancer patients is 16.7%; we present a case of recurrence 26 months after gastric cancer surgery. A 67-year-old man presented with locoregional lymph node recurrence, with swelling in a paraaortic lymph node. ¹⁸F-fluorodeoxy glucose positron emission tomography (FDG-PET) examination revealed abnormal accumulation in these lymph nodes. He was treated with a regimen of XPT chemotherapy because of the HER2-positive status of his gastric cancer. After 8 courses, the lymph nodes had shrunk and FDG-PET examination revealed no abnormal accumulation. Imaging revealed the presence of interstitial pneumonia, and the adverse events of venous thromboembolism, and grade 3 hand-foot syndrome were detected; as a result, chemotherapy was suspended. The XPT regimen may be an effective treatment for HER2-positive unresectable or recurrent gastric cancers. HER2 status should be the key determinant in the strategy for the treatment of unresectable and recurrent gastric cancers in the future.

We present a case of gastric cancer with portal vein tumor thrombosis. A 77-year-old man visited our hospital because of epigastric pain. Esophagogastroduodenoscopy and computed tomography (CT) revealed advanced gastric cancer. Total gastrectomy was performed. During surgery, peritoneal dissemination was found. Histopathological diagnosis was Stage IV gastric cancer (por2, T4aN3M1) with massive vascular invasion. He was treated with a chemotherapy regimen of S-1 plus docetaxel for approximately 2 years after which the regimen was changed to S-1 monotherapy. Six months later, CT revealed portal vein tumor thrombosis (PVTT) without progression of peritoneal dissemination. The metastatic route of PVTT was believed to be hematogenous because neither liver nor lymph node metastasis was detected. The regimen was shifted to CPT- 11 plus cisplatin therapy since the effects of the treatment was evaluated as progressive. The patient was alive with stable disease after 5 courses of chemotherapy. PVTT should be taken into consideration as a possible type of recurrence when the tumor is associated with massive vascular invasion, although gastric cancer with PVTT is rare.

We describe the case of a patient with sigmoid colon cancer liver metastasis accompanied by multiple liver abscesses. The 59-year-old female patient presented with a fever at a body temperature of 39.0°C. On abdominal computed tomography (CT), multiple liver abscesses were detected, and percutaneous transhepatic abscess drainage (PTAD) was performed. The day after the PTAD, the patient's fever subsided and her inflammatory response abated. A lower gastrointestinal examination, performed to identify the origin of her symptoms, revealed a type 1 tumor in the sigmoid colon. A biopsy indicated a moderately differentiated adenocarcinoma. Prior to surgery, a second abdominal CT scan was performed, and a single liver metastasis was detected. Laparoscopic sigmoidectomy and partial liver resection were simultaneously performed. The histopathological diagnosis of the colon cancer was tub2, pN1, pH1, P0, ly1, v1, stage IV. To date, the patient remains free from hepatic abscess and colon cancer recurrence. Gastrointestinal examinations should be performed as early as possible to identify the cause of hepatic abscesses. Moreover, therapeutic decisions should only be made after imaging and examinations have been performed, which will be sufficient to identify the presence of liver metastases.

We report a case of advanced lung cancer with recurrence of liver and tracheal metastases that were responsive to multimodality therapy. The patient was a 77-year-old man who suffered from advanced lung cancer with chronic obstructive pulmonary disease (COPD) and alcohol-induced liver cirrhosis. The primary lung cancer was surgically resected. Eight months after resection of the primary lung cancer, a solitary liver tumor appeared and hepatic resection was performed. Histological findings showed that both the primary lung tumor and the solitary liver tumor were squamous cell carcinoma (SCC). Subsequently, he developed a recurrence in his trachea 8 months after hepatic resection. Radiotherapy, endobronchial argon plasma coagulation (APC), and systemic chemotherapy were administered. The tracheal tumor remained stable without any liver metastasis for 25 months.

In June 2010, a 67-year-old man presented with advanced gastric cancer. He underwent 2 courses of combination chemo- therapy with S-1/CDDP. After chemotherapy, total gastrectomy was performed (pT4aN3aM0, Stage IIIC). Although he underwent S-1 chemotherapy, colon tumors recurred 22 months after the operation. Colonoscopy revealed the presence of type 2 advanced cancer in the ascending colon, and type IIa early cancer in the transverse colon, which were diagnosed as either primary colon cancers or recurrent gastric cancers upon pathological examination. In October 2012, resection of the right side of the colon was performed in order to prevent malignant bowel obstruction. Pathological examination of the resected specimen identified recurrent gastric cancers. After the surgery, he is currently undergoing S-1 chemotherapy and has no sign of recurrent tumors.

Malignant gastric outlet obstruction( GOO) compromises the ability to eat and drink. Surgical gastrojejunostomy has long been the standard palliative procedure for patients with GOO. However, it might not be applicable for patients with a poor general condition. In Japan, duodenal stenting for malignant GOO has been covered by health insurance since April 2010. In our hospital, 5 patients with malignant GOO underwent duodenal stenting using a WallFlexTM stent( Boston Scientific Corporation). Subsequently, we evaluated the safety and efficacy of duodenal stenting for malignant GOO. Most of the patients in this study were elderly, had systemic inflammation, and were malnourished. We achieved 100% technical and clinical success rates. Four patients were discharged from the hospital. No major complications such as perforation were noted. The median survival time after stenting was 86 days. In conclusion, endoscopic duodenal stenting for malignant GOO is safe and effective, and it could be an option for palliative therapy.

A 64-year-old man was diagnosed as having advanced gastric cancer with peritoneal and para-aortic lymph node metastases. He received 2 courses of chemotherapy with S-1 and cisplatin( CDDP) and 5 courses of combination chemotherapy with capecitabine, CDDP, and trastuzumab. The peritoneal and para-aortic lymph node metastases disappeared after chemotherapy, and subsequently, total gastrectomy was performed (pT2N3aM0, stage IIIA). Although the patient received combination chemotherapy with capecitabine and trastuzumab, para-aortic lymph node recurrence was noted 6 months after the operation. Radiation therapy at a total dose of 50 Gy targeted at the para-aortic lymph node metastasis along with S-1 and trastuzumab chemotherapy was administered. No serious adverse effects were observed during chemoradiotherapy. Following chemoradiation therapy, tumor recurrence was not observed. Therefore, chemoradiotherapy is considered an effective treatment for lymph node metastasis from gastric cancer.

We report a case of hemobilia developing after RFA for hepatocellular carcinoma. A 75-year-old woman with hepatitis C was diagnosed as hepatocellular carcinoma (d=15 mm) located in subsegment 7. Laboratory data on admission are AFP 37.3 ng/mL, PIVKA-II 20 mAU/mL, GOT/GPT 84/52 IU/L, T-Bil 1.1 mg/dL, Alb 3.8 g/dL, Plt 8.9x104/microL, and PT 11.8 seconds (INR 1.28) "Child classification A". Under general anesthesia, percutaneous RFA (Cool-tip radionics 10 minutes) was performed. Tumor appeared to be well treated, but on day 5 after the procedure, the patient had sudden upper abdominal pain, followed by the elevation of total bilirubin conc. (3.3 mg/dL) and decrease of Hb. Abdominal ultrasonography showed a debris-like shadow in the gall bladder. Hemobilia was confirmed because endoscopic examination revealed blood contaminated bile from the papilla Vater. Since spontaneous thrombolysis is known to occur in the bile, the patient was only followed by MRI. Symptoms were subsided in a week without any treatment. Obstructive jaundice due to hemobilia is a rare complication of RFA, and may be followed without any treatment.

We report a case in which advanced lung cancer with mediastinal lymph node metastasis and recurrence of brain metastasis was completely responsive to combination chemotherapy and gamma knife radiosurgery. The patient was a 61-year-old woman, who suffered from advanced lung cancer (SCC) with bilateral mediastinal lymph node metastasis and contralateral lung nodule. She was treated with CBDCA combined with PTX. Bilateral lung nodules were surgically resected. Seven months after resection, solitary brain metastasis appeared, and gamma knife radiosurgery was performed. Histological efficacy of both primary lung tumor (SCC) and metastatic brain tumor was evaluated as Ef 3 (pCR). She has had no recurrence for 3 years after radiosurgery.

The prognosis of pancreatic cancer is most dismal in all gastrointestinal cancers, because the patients with pancreatic cancer are vulnerable for recurrence such as local relapse and liver metastasis even after a complete surgical resection. We herein report a case of pancreatic cancer, which underwent resection of local relapse and multiresections of liver metastases, resulting in a relatively longer survival. A 71-year-old woman was referred to our hospital for a local recurrence in the tail of the pancreas in October 2006, 17 months after the first distal pancreatectomy. A second distal pancreatectomy was curatively performed on this patient. After the second surgery, sequent solitary liver metastases appeared, and we then performed partial hepatectomies repeatedly in August 2007, December 2007 and December 2008. The histopathological findings of each specimen from the resected liver showed tubular adenocarcinoma, same as the original pancreatic tumor obtained from the first surgery. Although chemotherapy was not permitted due to gemcitabine-induced interstitial pneumonitis, the patient is still alive over 4 years after the first operation under palliative care. This study discusses a controversial issue about the resection of the liver metastases from pancreatic cancer, along with the necessity for careful selection of the patients before attempting the operation.

We report a case of advanced unresectable pancreatic cancer (cT4N1M0/stage IVa). The patient was a 68-year-old man. Chemo-radiation therapy (CRT) with GEM (1,000 mg/body) was administered once a week on days 1, 8 and 15 for 3 weeks. The radiotherapy dose was 45 Gy (1.5 Gy x 2/day, 15 days). After CRT, the patient was treated with a GEM+ UFT-E combination chemotherapy. When that was done, CT scan revealed metastases of umbilicus (Sister Mary Joseph's nodule) and the liver. Microwave Coagulation Therapy for the liver metastasis and tumorectomy for metastasis of umbilicus were performed. But he died after 4 months from the therapies.

We report a case of advanced unresectable pancreatic cancer with multiple liver metastases (cT4N x M1, stage IVb). The patient is a 68-year-old man. Serum DUPAN-2 was 15,800 U/mL. Abdominal CT scan revealed the body and tail of pancreatic cancer and multiple liver metastases. Chemo-radiation therapy (CRT) with GEM 1000 mg/body was given once a week on days 1, 8 and 15 for 3 weeks. The radiotherapy dose was 45 Gy (1.5 Gy x 2/day, 15 days). Hematological side effect such as anemia (grade 3) and thrombopenia (grade 2) appeared, but could be well controlled. Abdominal CT scan revealed no change in size, but serum DUPAN-2 decreased up to 4590 U/mL. After CRT, the patient was treated thereafter by the combination chemotherapy with GEM and S-1. After 7 months, CT scan revealed no change in tumor size.

We report a case of advanced hepatocellular carcinoma (HCC). A 73-year-old man with positive HBV and HCV underwent a partial hepatectomy (S6 and S5) twice and transcatheter arterial (chemo) embolization (TAE) four times, thereafter. During these treatments, HCC became intractable and the patient complained of general fatigue. The liver function was Child's classification A, and serum AFP was 6,737 ng/ml. Abdominal CT scan revealed recurrent lesions in the right hepatic lobe and left adrenal gland. The catheter for hepatic arterial infusion chemotherapy was inserted from the left femoral artery. Arterial chemotherapy with 5-fluorouracil (5-FU 750 mg) and cisplatin (CDDP 10 mg) was performed every two weeks. During 6 courses of this regimen, a significant side effect did not appear. Abdominal CT revealed no change in size, but serum AFP decreased up to 794 ng/ml and the general fatigue subsided. After 2 months, serum AFP began to increase and became 1454 ng/ml. The regimen of arterial chemotherapy was changed to epirubicin (EPI 40 mg every two weeks) and UFT-E (300 mg/day for four weeks), followed by a week off. An appetite loss (grade 2) appeared, but it could be well controlled. Serum AFP decreased again, up to 54 ng/ml. A good QOL was kept for about one year after the initiation of hepatic arterial infusion chemotherapy.

A male in his eighties underwent abdominoperineal resection under the diagnosis of adenocarcinoma associated with anal fistula (P0, H0, n (-), A1, stage II, ly0, v0). Ten years after the surgery, a painful lymph node swelling was noticed in the left inguinal region. Biopsy specimen showed adenocarcinoma consisting of severe dysplastic cells. Radiotherapy was performed in the pelvic region at a total dose of 50 Gy (2 Gy/day). After the radiotherapy, left inguinal and pelvic lymph nodes markedly shrank and became painless. After one month, the chemotherapy with UFT (UFT 300 mg/day) was started. One year thereafter, para-aortic lymph nodes were found to be enlarged, but a good quality of life was obtained without elevation of tumor markers.

We present a case of a 70-year-old man with an anamnesis of intra-cerebral bleeding that resulted in right half of the body paralysis and right diaphragm paralysis, The present clinical history indicated hepatocellular carcinoma (HCC) caused by hepatitis C and liver cirrhosis during a regular hospital visit, and the patient had a total of 4 TAEs enforced from three years before. A 4 x 3.5 cm neoplasm at the left adrenal was detected by CT inspection this time. The diagnosis was a metastatic adrenal gland tumor from HCC. Since HCC is controlled by TAE, the metastatic lesions were not found in other organs and were isolated, of 10 cm or less in size. Hence, laparoscopic adrenalectomy was performed in March, 2006. He started having a meal from the 2nd day after the operation. He left the hospital on the 9th day. Pathologial diagnosis was a metastatic adrenal gland tumor from moderately differentiated hepatocellular carcinoma. When observing the adaptation standard strictly to the high-risk case, it was thought that the metastatic tumor extraction under laparoscopic surgery could become a low stress cure in consideration of QOL being useful as a local treatment for cancer.

We report a patient with a case of advanced rectal cancer with unresectable liver metastasis, who received the combination of systemic chemotherapy of 5-FU/l-LV and external radiation therapy. He was alive for 21 months. He had been able to maintain a good quality of life without any complaints of the primary rectal tumor.

In colorectal cancer, hepatic and pulmonary metastases are the most common and most important prognostic factors. Surgical resection is the first choice of treatment for hepatic and pulmonary metastases if completely resectable. However, only a few patients survived long term after metastatectomy. We present the two cases, in which surgical resection for pulmonary and/or hepatic metastases from colorectal cancer resulted in long-term survival for more than ten years without recurrence.

A 44 year-old woman presented with epigastralgia in March 2004 was diagnosed as having type II gastric cancer by gastrofiberscope, and histological diagnosis of biopsy specimens was group V (tub2, por1). Since multiple liver metastases were observed in subsegments 2, 3, and 5 by abdominal ultrasonography, systemic chemotherapy was first conducted for tumor down sizing. The patient was treated by three cycles of the one month regimen (CDDP 70 mg/m2, day 8, for 24hrs, and TS-1 80 mg/m2, day 1-14; 2 week cessation of the drugs). CT scan taken on May 16, 2005 revealed that the tumor diameters in subsegments 2, 3, and 5 were 1 cm, 3 cm, and 1.5 cm, respectively. On September 14, liver tumors were markedly shrunk. Tumor in subsegment 2 became undetectable, and the diameters in those in subsegments 3 and 5 were 1.5 cm, and 0.5 cm, respectively. On September 28, a distal gastrectomy associated with S3 partial hepatectomy and microwave coagulation therapy for S5 tumor was performed without any macroscopic residual lesions. The prognosis of liver metastasis of gastric cancer is generally poor, and there is no comprehensive therapy. The marked clinical response in this patient suggests that this combination therapy with CDDP and TS-1 might be a promising preoperative chemothepapy for unresectable gastric cancer.

A 56-year-old man is presented with diarrhea, which he had experienced since February 2004. He was diagnosed as having advanced pancreatic cancer by enhanced abdominal CT scan in May 2004. He was diagnosed with unresectable pancreatic cancer, and treated with a combination of radiation (3 Gy/day) and injections of gemcitabine (GEM) 1,200 mg/week (800 mg/m2, BSA 1.6). Abdominal CT scan revealed a minor response (tumor diameter 5.7 x 4.8 --> 5.2 x 4.4). Accordingly, the improvement of performance status and reduction in serum levels of arcinoembryonic/carbohydrate antigen 19-9 (CA19-9) were observed. In July 2004, chemotherapy and radiotherapy were switched to GEM+UFT (UFT 360 mg/day, a total of 4,320 mg, GEM 1,200 mg according to the body mass, a total of 2,400 mg). The patient's performance state was stable for 6 months but serum levels of CA19-9 increased from March 2005, and he complained of diarrhea and back-pain. Therefore, the combination chemotherapy with GEM and cisplatin (CDDP) was started in April 2005, but there was no clinical effect. GEM and TS-1 are currently being administered. Pancreatic cancer is one of the worst prognoses of any malignant disease. Although the prognosis of unresectable pancreatic cancer is very poor, we presented a case where performance status and survival benefits were obtained by undergoing chemoradiation with GEM and combination chemotherapy with UFT and GEM.

In colorectal cancer, liver metastasis is the most common and most important prognostic factor. Although surgical resection is the first choice of treatment for liver metastasis of colorectal cancer, there are many cases we cannot choose the surgical treatment. The chemotherapy is very important in such cases. We examined 18 cases of unresectable liver metastases from colorectal cancer which were adapted a hepatic arterial infusion of 5-FU (HAI) with a weekly high-dose infusion method (WHF) as the first-line treatment, and then systemic chemotherapy of CPT-11 in combination with 5-FU as the second-line treatment. The response rate of this treatment is 72% (13/18) and the 1-, 2-, 3-year survival rates were 100% (16/16), 83% (10/12), and 50% (5/10), respectively. The combination chemotherapy of HAI with systemic chemotherapy using CPT-11 seemed to be an effective treatment method.

To evaluate the clinical effectiveness of metallic stent in the palliation of malignant bile duct obstruction in aged patients, 30 patients over 65 years of age with malignant biliary obstruction were investigated retrospectively. Overall survival duration after the stent placement was 13-1,275 (mean: 278, median: 169) days. The period of tube-free on the outpatient basis after stent insertion was 0-1,162 (mean: 192, median: 121) days. The estimated cost savings by eliminating hospitalization was greater than the stent cost. Four patients survived over 18 months despite their advanced clinical stages. It seems difficult to develop guidelines for the indication of stent placement in the treatment of malignant bile duct obstruction for aged patients.

The patient, a 40-year-old woman, underwent total gastrectomy and excision of the pancreatic tail, spleen and gallbladder for gastric cancer in September 2000. The lesion was judged to be P1, SE, H0, N2 and Stage IV and the patient was managed on a regular schedule as an outpatient. In September 2004, she passed blood-stained feces and rectal palpation detected a hard nodule at the anterior rectal wall. A fiber optic examination of the sigmoid colon detected an ulcerous lesion with a hemorrhage at the anterior rectal wall. A biopsy revealed the lesion to be Group V poorly differentiated adenocarcinoma. Starting in October 2004, 100 mg/day of TS-1 was administered for 3 weeks; intravenous drip infusion of 100 mg/body of CDDP was conducted in the second week for a period of 24 hours. After 3 courses of this regimen, a fiber optic examination of the colon conducted in February 2005 no longer detected the rectal tumor, leaving only a cicatrix. Upon a CT examination, the para-aortic lymph nodes that had been enlarged were notably reduced in size and an improvement was eminent in the hypertrophic rectal wall. The patient no longer experienced constipation or melena. Her clinical course is being observed while an oral administration of 100 mg/day of TS-1 continues.

We analyzed methods and clinicopathological factors for multiple (> or = 5) bilobar liver metastases (H3) from colorectal cancer and evaluated the indication of surgical and microwave coagulation therapy (MCT) for them. Twenty-four patients with H3 underwent surgical therapy and were divided into two groups. Group a: 9 patients with a prognosis of more than 700 days. Group b: the remaining 15 patients. There was no significant difference in prognosis between those receiving MCT and resection + MCT as a surgical therapy. The number and maximum diameter of tumors tended to be smaller in Group a. The number of tumors was less than or equal to 9 and the maximum size of the tumors was 38 mm. Moreover, the tumor could be controlled by MCT alone if the tumor size was less than 30 mm. MCT is a useful therapy for these cases and the indication for surgical therapy may depend on the number and maximum size of tumors.

We assessed 23 patients who underwent surgical therapy of hepatectomy or microwave coagulation therapy (MCT) for bilobular multiple hepatic metastatic foci following curative resection of the primary lesion of colorectal cancer. Hepatectomy was the first surgical therapy for 10 patients, and 6 of them received combined intra-arterial chemotherapy. All 13 patients in the MCT group received intra-arterial chemotherapy, and 8 of them underwent combined hepatectomy. The two-year survival rate of the hepatectomy group, classified according to the first surgical therapy, was 40% against 52% in the MCT group. In comparison with the H2 (2-5 foci) patients in the hepatectomy group, there were 7 H2 patients in the MCT group, and the two-year survival rate of these 7 patients was 50%. No significant difference was observed between hepatectomy and the MCT as the first surgical therapy. The survival rates of the 5 patients who received treatment for recurrence after the first surgery and of the 18 patients without any recurrence treatment were 80% and 40%, respectively. No significant difference existed between the two groups, but a p value of 0.06 was noted. MCT was considered to be useful local therapy for cancer as the first therapy and as a therapy following recurrence.

Transcatheter arterial chemo-embolization (TACE) using degradable starch microspheres (DSM) was performed for multiple recurrence after hepatectomy in a patient with cholangiocarcinoma. The patient was a 68-year-man. He received treatment for hepatitis type C starting in 1996 at a nearby hospital. In November 1997, an increased AFP level was noted and a CT scan of the abdomen revealed an abnormal shadow in the liver. On May 21, 1998, imaging results led to the diagnosis of cholangiocarcinoma or a mixed type of hepatocellular carcinoma with cholangioma. Hepatic S7 sub-sequential resection was performed. The lesion was found to be a tumor-forming type, measuring 2.2 x 2.0 cm in diameter, diagnosed histopathologically as cholangiocarcinoma, tw (-), but Stage III since a nodule suggesting intrahepatic metastasis was noted in the cut surface of the resected liver. CT scan after a month revealed multiple metastatic lesions in the liver. TACE was performed by administering 450 mg of DSM, 10 mg of MMC and 30 mg of FARM, given in three divided doses on October 30, 1998, and February 9, 1999, according to Seldinger's method. A CT scan on January 31, 2000 revealed nearly complete remission of the hepatic SOL. Accordingly, TACE was considered to be useful therapy in combination with DSM, MMC and FARM for intrahepatic recurrence of cholangiocarcinoma.

We report a 75-year-old man with invading bladder cancer and enlarged lymph nodes, which decreased following 5'-DFUR treatment. A postoperative abdominal CT showed lymph node swelling around the great vessels. The patient refused aggressive chemotherapy, so he was given a 5-FU derivative, 5'-DFUR, 800 mg/day orally. The enlarged lymph node had decreased in size by the 22nd day after the treatment, and the patient has maintained a near CR.

A 47-year-old male patient with chronic hepatitis had a high AFP level during the follow-up period. Abdominal CT revealed at S5, which led to a diagnosis of hepatocellular carcinoma. In August 1992, partial resection of S5 was performed, and ethanol was injected into the tumor at S2. In July 1993, recurrent tumors were observed at S5 and S3. PEIT was performed for each lesion. In December 1994, multiple recurrence was observed and 4 mg SMANCS was injected through the proper hepatic artery. In July 1995, another 4 mg of SMANCS was injected into the tumors. In June 1996, only a 20 mm lesion at S5 remained while the other lesions disappeared. Under general anesthesia, the patient underwent percutaneous microwave tumor coagulation. In December 1997, the AFP level was normal, and imaging revealed disappearance of the recurrent tumor. Selection of local therapy for hepatocellular carcinoma achieved long survival in our case considering the QOL and frequent therapy administration.