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Background: S-1, an oral fluoropyrimidine, is one of the standard chemotherapeutic agents for the treatment of metastatic gastric cancer(MGC). However, the most effective second-line regimen after failure of treatment with first-line agents such as S-1 is yet to be determined. The aim of this study was to investigate the various second-line chemotherapy regimens in MGC patients., Methods: We retrospectively studied patients with MGC who received second-line treatment after failure of the first-line S-1 or S-1/cisplatin treatment. The overall survival times with each second-line regimen were determined using the Kaplan-Meier method, and the effect on overall survival was analyzed using Cox regression analysis., Results: The median survival time for all patients was 14. 2 months(95% confidence interval(CI): 12. 88-15. 43 months)with a 1-year survival rate of 60. 4%. Kaplan-Meier analysis revealed that the second-line regimens containing irinotecan significantly improved the median survival time as compared to regimens without irinotecan(median survival time: 16. 5 and 13. 8 months, respectively). Cox regression analysis showed that irinotecan-containing regimens were associated with improved overall survival(hazard ratio: 0. 165; 95% CI: 0. 041-0. 665)., Conclusion: The use of irinotecan-containing regimens as second-line chemotherapy after failure of first-line S-1 therapy may be beneficial for MGC patients.

Background: In Japan, esophagectomy with three-field lymphadenectomy is the standard therapy for resectable esophageal cancer. However, its outcome is considered unsatisfactory because the 5-year survival rate is less than 50%. Chemoradiotherapy (CRT) is the standard therapy for unresectable esophageal cancer and could also be considered as an option for resectable esophageal cancer. We retrospectively determined the efficacy and safety of CRT for patients with esophageal cancer., Methods: The study population comprised patients with esophageal cancer who had been treated with CRT between April 2004 and October 2009 in our institute. Acute and late toxicity was assessed with NCI-CTC and RTOG/EORTC late radiation morbidity scoring scheme, respectively. Survival time was calculated using Kaplan-Meier methods., Results: We enrolled 29 consecutive patients and classified them on the basis of clinical staging: stage I, 4 patients; stage II/III, 11 patients; and stage IV, 14 patients. Complete response was achieved in 37.9% and 45.5% of the total study population and the stage II/III group, respectively. The median survival time in these groups was 12.1 months and 15 months, respectively. Grade 3/4 acute toxicities were observed in 62.1% of the patients. Grade 3/4 late toxicities were observed in 12% of the patients. The first failure after CRT was almost locoregional., Conclusion: CRT appears to be an effective therapy for esophageal cancer; however, its outcome is not satisfactory. Therefore, it is necessary to evaluate the role of salvage surgery after CRT and new chemotherapeutic agents.

A 77-year-old man with history of distal gastrectomy with Billroth II reconstruction for peptic ulcer disease performed 55 years ago was admitted to our hospital for diarrhea and abdominal pain. Abdominal computed tomography revealed a dilatation of the afferent loop and the duodenum, and a low density mass located in the body of the pancreas, which invaded the gastro-jejunal anastomosis site as well as the celiac axis and the superior mesenteric artery. Judging from these findings, we diagnosed this case as acute afferent loop obstruction due to an unresectable pancreatic cancer. Endoscopic decompression of the afferent loop was unsuccessful. After a while, the patient complained a severe abdominal pain, and an emergency surgery was performed under the diagnosis of rupture of the afferent loop. At laparotomy, a perforation of the jejunum located at a 15 cm anal side from Ligament of Treitz was found, and Braun's anastomosis was performed using the perforated site. The patient was treated with chemotherapy and survived for 15 months after the operation. Prompt decompression of afferent loop should be performed for preventing a rupture in case of acute obstruction of the afferent loop.

Primary malignant melanoma of esophagus (PMME) is a rare tumor; therefore, the prognostic factors, predictive factors, and difference in biological behaviors of cutaneous melanoma and primary esophageal squamous cell carcinoma remain uncertain. Although we did not adopt a standard therapeutic strategy, we performed surgical resection, chemotherapy, immunotherapy, and radiotherapy either alone or in combination; all procedures resulted in poor outcomes. A 67-year-old woman presented with a swallowing disorder. An esophagogastroduodenoscopy was performed, leading to diagnosis of PMME. According to the Japanese Classification of Esophageal Cancer, the pathological stage was T1b, ly0, v0, N0, M0, stage I . KIT immunostaining was focally positive. After subtotal esophagectomy, adjuvant chemotherapy was performed, but the malignant melanoma relapsed in the mediastinum and the patient died 10 months after diagnosis. We serially monitored the patient using several new modalities, including PET/CT, metabolites of melanin: 5-S-CD, and circulating tumor cells (CTCs) by reverse transcription-polymerase chain reaction to identify the melanoma-specific gene. To our knowledge, this is the first report of a case in which CTCs in PMME were detected.

In May 2007, a 48-year-old woman was admitted to our hospital for acute intestinal obstruction, and she was subsequently diagnosed with metastatic colorectal cancer in the sigmoid colon. Jejunum-ileum anastomosis and colostomy were performed as palliative surgery because the locally-advanced primary tumor had involved the ileum and other surrounding organs and formed huge mass. After placement of a central venous port, palliative chemotherapy mFOLFOX6 was commenced. In May 2008, mFOLFOX6 was replaced with FOLFIRI because of progression of both the metastasized and the primary tumors. On November 20, 2008, cetuximab was added to FOLFIRI because of the further disease progression. However, on December 24, 2008, the patient presented with sudden-onset dyspnea. Her blood gas analysis revealed severe hypoxemia and metabolic acidosis, and CT scan showed bilateral pulmonary artery embolism. After intensive treatment, the patient was able to walk under the room-air condition. However, on January 19, 2009, she died of pneumonitis. We believe that this is an interesting case with respect to the relationship between pulmonary embolism and malignancy and may hint at a causal relationship between pulmonary embolism and cetuximab, which is currently uncertain. We report this case herein along with a literature review.

A 55-year-old woman underwent total mastectomy and axillary lymphnode dissection in 2001. Widespread lymphnode metastasis was found histologically (26/33). Neither PgR nor ER was positive. She underwent an AC regimen and paclitaxel chemotherapy. As CEA began to rise in 2002, she was given paclitaxel and docetaxel chemotherapy sequentially. As CEA rose again in 2004, capecitabine was begun. Painful erythema of the palms and soles of the feet appeared at the end of the second cycle. After admission, severe bone marrow suppression and jaundice were found. The bilateral hands, palms and soles of the feet became bullous and erosive with desquamation. The erosive lesions began to heal with epithelization in the third week. After general conditions had improved, capecitabine was restarted at a reduced dose. This patient had continued taking capecitabine even though she noticed the occurrence of the adverse effect. Patients and doctors must share confidential information when performing chemotherapy at the outpatient clinic.

Since the advent of imatinib mesylate (IM), its clinical efficacy against gastrointestinal stromal tumor (GIST) has been widely acknowledged, and therapeutic strategies for this disease have undergone great changes. We recently experienced a case of giant GIST of the stomach that was successfully treated with IM neoadjuvant therapy prior to surgical resection, but liver metastasis recurred 1 year and 7 months after the operation. The patient was a 65-year-old male who presented at our department with the chief complaints of dizziness, malaise, and fever in April 2002. An abdominal CT revealed a mass with a maximum diameter of 17 cm, as well as a cystic septate mass, 12 cm in diameter, with a thick capsule in the left lobe of the liver. The patient was diagnosed with GIST of the stomach and liver metastasis. Since radical operation was considered difficult at that point, IM (400 mg/day) was started on May 9. The result of treatment was determined to be PR, and radical operation was considered feasible. On March 18, 2003, total gastrectomy and left hepatic lobectomy/S 6 partial lobectomy were performed in the surgery department of our hospital. The postoperative course was favorable and oral administration of IM was resumed soon after the operation. However, the drug was discontinued for financial reasons and a decreased white blood cell count (grade 3) 2 months after the operation. Recurrence in the liver and abdominal wall was found in October 2004, and oral administration of IM was resumed again. Currently, treatment with IM is ongoing. Case reports on the efficacy of IM neoadjuvant therapy are occasionally found in the literature, but there are few reports on its long-term prognosis. We report this case with a discussion of future therapeutic options.