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Malignant spinal cord compression(MSCC)is defined as a compression of the spinal cord or cauda equina with neuropathy caused by tumor spreading to the vertebral body. The common symptoms of MSCC are back pain, neck pain, muscle weakness, sensory reduction, bladder and rectal disturbance. The risk of MSCC is relatively high in patients with lung cancer, breast cancer, and prostate cancer. MSCC is one of the oncologic emergencies that requires prompt diagnosis and treatment to preserve and improve neurological function. Evaluation by magnetic resonance imaging(MRI)and computed tomography( CT)are useful for the diagnosis. The prognosis of these patients is often poor at the time of diagnosis of MSCC, thus it is important for deciding the treatment strategy to consider the prognosis and background of the patient in addition to the objective findings including the degree of MSCC and spinal instability. Treatment options consist of medical, surgical, and radiation therapy. We need a multidisciplinary approach because the pathology of MSCC involves multiple departments, such as medical oncology, orthopedics, and radiology. Supportive care including rehabilitation and preventing skeletal related events are also important. The cancer board, in which each physician and multidisciplinary health care professionals regularly have a discussion and review the cases, is required.

A 64-year-old man was admitted to our hospital because of epigastralgia. Gastrointestinal endoscopyrevealed a submucosal tumor with ulceration in the upper bodyof the stomach. The tumor was histologicallydiagnosed as a neuroendocrine carcinoma. CT showed that the tumor had directlyinfiltrated the pancreas and splenic vessels. The patient underwent onlyan exploratorylaparotomybecause the tumor seemed to involve the celiac artery. Chemotherapywas conducted using CPT-11/ CDDP. After 15 courses of chemotherapy, a significant tumor reduction was obtained. We performed total gastrectomy with D2 lymphadenectomy, distal pancreatectomy and splenectomy. Histopathological examination of surgical specimens showed that onlyfew carcinoma cells remained in the stomach and pancreas. Neoadjuvant chemotherapycan be a useful treatment for unresectable locallyadvanced neuroendocrine carcinoma of the stomach.

An 82-year-old man with upper abdominal pain was referred to our hospital because of an elevated serum CEA level and dilatation of the intrahepatic bile ducts on ultrasonography.Computed tomography revealed a hypovascular mass measuring 5.0 cm in size in the lateral section, dilatation of the peripheral intrahepatic bile ducts, and swollen lymph nodes around the lesser curvature of the stomach, the common hepatic artery, and the paraaorta.He was diagnosed with unresectable intrahepatic cholangiocarcinoma, and he received chemotherapy with biweekly gemcitabine plus cisplatin.After 33 courses of the chemotherapy, computed tomography revealed that the tumor size decreased over 63%, and all swollen lymph nodes had almost resolved.He underwent a left hemihepatectomy 1 year 6 months after the start of the chemotherapy.He remains alive and well with no evidence of recurrence, 11 months after resection.

A 77-year-old woman with rectal cancer and synchronous liver metastasis underwent a Hartmann operation with D3 lymph node dissection in June 2014. mFOLFOX6 plus bevacizumab(bev)was then administered to treat the liver metastasis.In February 2015, multiple liver metastases were detected and the regimen was changed to FOLFIRI plus bev.After 3 courses, peritonitis due to intestinal perforation around the descending colostomy occurred, and an emergency operation(partial resection of the descending colon and transverse colostomy)was performed.FOLFIRI was then administered from 2 months after the operation.After 3 courses of this regimen, a CT scan showed progression of the hepatic metastases.The regimen was therefore changed to mFOLFOX6.Five months later, another CT scan showed an intestinal perforation of the transverse colostomy at the abdominal wall, and an emergency cecostomy was performed.At this stage, chemotherapy was ceased.This case highlights the risk of intestinal perforation during chemotherapy, regardless of the use of bev.

A 59-year-old woman had recurrences in the spleen and lung 10 years after radical excision of cecal cancer. After 27 months of treatment with 5-fluorouracil/Leucovorin, oxaliplatin, irinotecan, bevacizumab, and anti-EGFR antibodies, multiple bone metastases and a left adrenal metastasis developed, and the patient's performance status (PS) deteriorated to grade 3. Regorafenib was administered at 80 mg/day. The pain and appetite improved within 2 courses, and her PS improved from grade 3 to 2. Regorafenib was increased to 120 mg/day for the 2nd course, and the patient was treated for 5 months without severe adverse effects. Regorafenib is considered to be a salvage-line treatment only for patients in relatively good condition, because full-dose regorafenib treatment often leads to severe adverse effects. Dose escalation of regorafenib from the low initial dose of 80 mg/day may be a safe and effective way of providing an opportunity of this chemotherapy to patients with impaired PS.

The palliative care team of Tokai University Hospital began its activities in 2004. After several changes in its organization, the activities of the palliative care team have become well known, and this department has become very active. Palliative care at our hospital has now broadened its scope and now includes both inpatients and outpatients. Initially, the patients primarily consisted of terminal-stage cancer patients, but in recent years patients who are being treated for cancer have also been included in the palliative care department. In terms of our collaboration with the region, the health care providers responsible for palliative care are making continued efforts to establish good relationships through regular scheduled palliative care training workshops and study sessions. Regional collaborations with oncologists is the ultimate/primary goal. As an educational institution we conduct clinical practical training and clinical training in core hospitals and private practices with medical students and junior resident physicians. However, few of these training institutions are home-care-supporting clinics or home-care-supporting hospitals. It remains unclear whether medical students and resident physicians are involved in home care. Knowledge of palliative care has gradually increased among the health care providers at our hospital. However, the dissemination of knowledge about home care among medical students, resident physicians, and oncologists is found to be lacking; hence, we have made this our goal. Another goal of ours would be to train existing physicians to equip them with knowledge and experience necessary for dealing with home care.

Systemic treatment for metastatic or advanced colorectal cancer(mCRC)has remarkably progressed during recent years. All previously untreated mCRC patients at our institution between November, 2007 and June, 2010 were retrospectively evaluated. Of 72 patients, 39 were treated with chemotherapy alone, and 33 were treated with chemotherapy plus bevacizumab(BV). The median progression-free survival(mPFS)was 329 days in the group given chemotherapy plus BV, compared with 209 days in the group given chemotherapy alone(p=0. 0189). In sub-group analysis of those treated with chemotherapy plus BV, mPFS between 70 y/o

We experienced 3 patients(Cases 1, 3, and 4)with pelvic tumor-related rectal tenesmus showing favorable responses to antiarrhythmic drugs. Based on this experience, we administered antiarrhythmic drugs preferentially to 2 others with tumor derived rectal tenesmus(Cases 2 and 5), and again obtained favorable responses. These 5 patients(1 man, 4 women)were 28-89(mean 58)years of age. The primary lesion was cervical cancer in 3 patients, ovarian cancer in 1, and bladder cancer in 1. In the 3 with cervical cancer, the tumor had directly infiltrated the rectum and vulva. The patient with ovarian cancer had a residual tumor in the Douglas pouch postoperatively. The patient with bladder cancer had undergone total cystectomy and urinary diversion using an ileal conduit at another institution. All 5 patients complained of a frequent desire to defecate without feces(rectal tenesmus). Their rectal tenesmus was attributed to pelvic neurological dysfunction around the rectum. Drug therapy was initiated with oral mexiletine hydrochloride(Mexitil)150 mg in 3 divided doses in 4 patients and with continuous infusion of intravenous lidocaine 2%(Xylocaine)500mg/day in the other(Case 2). None had adverse reactions; all 5 experienced palliation of symptoms and improved quality of life.

A fifty-six year-old woman visited our institute, suffering from lower abdominal pain. A tumor was palpable in the pelvic cavity, having the diameter of 9.7 cm, as measured by transvaginal ultrasonography (US). Computed tomography and magnetic resonance imaging (MRI) revealed a high contrast-enhancement and the central necrosis of the tumor. Surgical resection was performed, and the tumor was found to have originated in the duodenum. Immunohistochemistry confirmed positive KIT, and the mitotic index was 4 per 50 high power field, so that the final diagnosis was a gastrointestinal stromal tumor of intermediate risk. After two years of observation, multiple liver metastases were found. Hepatectomy was performed as a volume reduction surgery, leaving three small lesions in the remnant liver. Imatinib administration was initiated at 400 mg a day two weeks after the surgery, but was interrupted two weeks later because of severe anorexia and a body weight gain of 7 kg due to the increased ascites and edema. Imatinib was resumed at 200 mg/day after a one-month interval. She has been enjoying relapse-free survival for 8 years since the recurrence was diagnosed. Although neither reduction surgery nor dose reduction of imatinib below 300 mg/day is recommended, there may be a possibility that a smaller tumor might be controlled by a lower dose of imatinib.

A 62-year-old female presented with an erosion of the left nipple. At the preoperative examination, it was diagnosed as a Pagetoid carcinoma with an invasive carcinoma. After primary systemic therapy(weekly paclitaxel/trastuzumab), we performed an operation. The only remaining Paget cell was confirmed in the resected specimen, and no other malignant cells were confirmed. There is no report that the preoperative chemotherapy for the Pagetoid carcinoma with an invasive carcinoma. The patient has had no evidence of recurrence 1. 5 years after the operation.

Background: Many cancer patients suffer from rapidly-progressing dyspnea that is difficult to relieve., Methods: The subjects were 26 patients who had dyspnea that was difficult to relieve. The Numeric Rating Scale was used to evaluate their dyspnea. For all patients, the cause of the dyspnea was investigated by CT and x-rays., Results: The principal causes of the dyspnea were pleural effusion that increased daily, complications from pneumonia, massive ascites, multiple metastatic lung tumors and atelectasis, recurrent laryngeal nerve paralysis and narrowing secondary airway compression. Dyspnea was caused by a variety of conditions that overlapped over time, intensifying patients' discomfort. Among 14 patients for whom we recommended treatment with sedation, only 8 of them consented. Among the patients who were treated with sedation, the median interval between the exacerbation of dyspnea and death was 16 days; among non-sedated patients it was 18 days., Conclusions: Palliative care physicians who specialize in the respiratory system can, to some extent, predict the occurrence of rapidly progressive dyspnea in cancer patients. It is important to explain the methods of relieving dyspnea to the patient, the patient's family, and the oncologist early, so that decisions on how to manage dyspnea can be made in advance.

Treatment of primary malignant melanoma of the esophagus remains challenging. We treated a 53-year-old man with pT4N2M0, Stage IVa malignant melanoma of the esophagus with esophagectomy followed by adjuvant chemotherapy. Six months later, computed tomography revealed a 12 cm disseminated tumor of the mesenterium, multiple peritoneal dissemination, and a large amount of ascites. We administered chemotherapy consisting of dacarbazine combined with cisplatin and nimustine, and radiotherapy(50 Gy)was applied to the disseminated mesenteric tumor. At another clinic, the patient was administered synchronous cellular immunotherapy consisting of dendritic cells pulsed with autologous tumor lysates and lymphokine-activated killer cells. The mesenteric tumor was extremely responsive to this trimodal treatment. Because recurrence occurred later within the left orbita muscle, we added 50 Gy of radiation to prevent blindness. The patient responded to this treatment and survived another 6 months with high quality of life. It is difficult to treat advanced malignant melanoma of the esophagus, and patient prognosis is extremely poor. In this patient, the recurrent tumors responded well to trimodal therapy consisting of chemotherapy, radiotherapy and cellular immunotherapy.

We experienced a patient with an ileal artificial anus who suffered from abdominal pain caused by peritoneal dissemination of ovarian cancer, for which slow-release oxycodone was ineffective, but fentanyl patch proved effective. The patient was a 28-year-old female who developed abdominal pain caused by peritoneal dissemination on postoperative day 60 after radical hysterectomy and colostomy. For pain relief, administration of 10-mg slow-release oxycodone and 180-mg loxoprofen sodium was begun. When the dose was increased to 25 mg on postoperative day 240, the slow-release oxycodone in its original form was confirmed in feces from the artificial anus.When the same drug was changed to a fentanyl patch(12. 5 mg/hr), the pain was relieved. A palliative care doctor needs much knowledge regarding the changes in the patient's body with the progress and treatment of cancer, in addition to the drug mechanism.

The palliative care team's roles are to provide a symptom relief to cancer patients, help them accept their medical conditions, and offer advice regarding the selection of appropriate medical treatments to suit their needs. Seeking the comfort of their homes, patients prefer a home care of superior medical care provided at hospitals. In 2008, 25 of the end-stage cancer patients at hospitals were expressed their desires to have a home medical care, and 10 of them were allowed to do so. We considered the following contributing factors that a patient should have for a smooth transition from hospital care to home medical care: (1) life expectancy of more than 2 months, (2) no progressive breathing difficulties experienced daily, (3) good awareness of medical condition among patients and families, (4) living with someone who has a good understanding of the condition, (5) availability of an appropriate hospital in case of a sudden change in medical requirements, and (6) good collaboration between emergency care hospitals, home physicians, and visiting nurses. To treat the end-stage cancer patients at home, there is a need for information sharing and a joint training of physicians specialized in cancer therapy, palliative care teams, home physicians, and visiting nurses. This would ensure a sustainable "face-to-face collaboration" in community health care.

A 60-year-old woman with Stage II, ER-positive, PgR-positive, HER2 (2+) cancer in the right breast underwent right mastectomy with right axillary dissection after chemotherapy with EC followed by docetaxel (DOC) alone. Exemestane was used for postoperative adjuvant treatment. She underwent a right chest wall tumor resection for local recurrence. Hormone therapy was continued with toremifene in place of exemestane. In December 2007, two years after the second surgery, CEA was elevated and PET showed a local recurrence in the right chest wall and metastases to the right axillary nodes and liver. The tumor was ER-positive, PgR-negative and HER2 (3+) at recurrence, and vinorelbine/trastuzumab combination was initiated as first-line chemotherapy for the recurrent lesion and liver metastasis. All lesions in the right chest wall, right axillary nodes and liver disappeared from PET and CT images after five courses of the regimen, resulting in clinical CR. Vinorelbine combined with trastuzumab appears to be a useful therapy for HER2-positive recurrent breast cancer.

We performed breast reconstruction surgery with mastectomy after neoadjuvant chemotherapy(NAC)for a patient with NAC indication desiring breast conservation. The case was a 34-year-old single woman. In March, 2007, she was aware of a lump in her left breast and visited our hospital. The diagnosis was solid-tubular carcinoma 3 cm in diameter from close examination. We performed preoperative chemotherapy with EC(epirubicin 90 mg/m(2), cyclophosphamide 600 mg/m(2))x4, followed by 3w-paclitaxel 175 mg/m(2)x4, and then performed mastectomy with axillary dissection and breast reconstruction surgery using the flap of latissimus dorsi at the same time. Pathologically, pCR was provided. We thought that there are many advantages to both treatment of breast cancer and the cosmetic characteristics. The patient was very satisfied. But further cumulative examinations are awaited because there is not much evidence at present.

Purpose: Oxaliplatin in combination with infusional 5-fluorouracil/Leucovorin (FOLFOX) has emerged as the treatment of choice for advanced-stage colorectal cancer. Sensory neurotoxicity is its dose-limiting toxicity. We decided to use Gosha-jinki-gan for prevention of oxaliplatin-related neurotoxicity following the report of Fushiki et al., Methods: The subjects were 14 patients with metastatic colorectal cancer. Oxaliplatin (85 mg/m(2)) was given intravenously as a FOLFOX4 regimen. All 14 patients received Gosha-jinki-gan every day after first oxaliplatin infusion., Result: 7 patients had grade 3 toxicity(neutropenia 6, thrombocytopenia 1). Sensory neuropathy occurred in 10 patients (71.4%). There was no neurotoxicity with functional impairment in this study., Conclusions: Gosha-jinki-gan seems to prevent acute oxaliplatin-induced neurotoxicity.

Exemestane was administered orally to postmenopausal women with advanced/recurrent breast cancer at a dose of 10 mg/day or 25 mg/day once daily for more than 8 weeks in order to evaluate the drug's anti-tumor effects and safety in a dose-finding study. The response rate (CR + PR) in the 10 mg and 25 mg group was 25.0% (8/32) and 31.4% (11/35), respectively, demonstrating no significant differences between the two groups, yet a higher efficacy rate was observed in 25 mg group. The efficacy rate in hormone-treatment-resistant patients within the 10 mg and 25 mg groups was 14.3% (3/21) and 26.1% (6/23), respectively, demonstrating more than a 20% response rate in 25 mg group. Incidences of the adverse events of which relevance to the drug could not be excluded were 30.6% (11/36) in the 10 mg group. 13.9% (5/36) in the 25 mg group and 22.2% (16/72) in the total group. The major adverse events were, hot flashes, numbness of the limbs, nausea, headache etc. Abnormal findings in clinical laboratory tests were as follows: ALP increase; GOT increase; GPT increase; gamma-GTP increase; total cholesterol increase; urinary sediment present. Abnormal findings in endocrine function were as follows: aldosterone decrease; testosterone.cortisol.DHEA-S decrease. But discontinuation due to abnormal laboratory findings was not found. No abnormal findings in physical tests were observed. A significant decrease in plasma estrogen concentration at week 4 was observed in both the 10 mg and 25 mg groups compared with baseline. These low levels were maintained throughout the study period. On the basis of these results, the efficacy of exemestane 25 mg/day was verified to be slightly higher than 10 mg/day. In addition the safety profile had no major adverse events to notice. In these patients with advanced/recurrent breast cancer, 25 mg/day was recommended as the most appropriate dose to be used clinically.

Mismatches in the treatment of gastric cancer to date in Japan are as follows: 1. Difference in the definitive pathological diagnosis even among well-known, experienced pathologists. The case of a patient who was successfully treated by the authors is reported in this paper. 2. The insufficient number of medical oncologists for gastric cancer. 3. The administration of adjuvant chemotherapy after surgery without obvious evidence that it is needed. 4. Inadequate preventive measures, i.e. refrainment from smoking and eradication of Helicobacter pylori. 5. The application of standard surgery, which is designed basically to treat advanced gastric cancer with serosal and nodal involvement, in cases of early gastric cancer. These mismatches have been corrected recently by the adoption of modified surgery and an endoscopic approach to the early gastric cancer. These modifications could be attained through our pioneering effort to find a balance between the two contradictory approaches of radical treatment and preservation of organic function, which are often irreconcilable in cancer treatment in general, after the accumulation of sufficient data on early gastric cancer in a Japanese nationwide study.

This interim report, for findings as of May, 1998, covers data on 435 gastrectomized patients with semi-advanced stomach cancer collected from 144 institutions between November, 1993 and March, 1996. The active arm of the study involved CDDP i.p. administration of 70 mg/m2 at the time of resective surgery, followed by UFT oral administration for one year at 3-4 capsules daily. A randomized control involved no adjuvant therapy after CDDP i.p. administered as in the active arm. The results obtained indicated no significant difference between the groups in terms of 3 year survival or disease free survival rates. Reports appearing elsewhere have suggested that 3-4 capsules/day of UFT may be insufficient to reach the threshold of the effective tissue level, and that 6 capsules may be necessary to obtain the expected results. (JFMTC: Japanese Foundation of Multidisciplinary Treatment for Cancer).

T-type reservoir sheets (anti-adhesion sheets developed to prevent adhesions + reservoir) were intraperitoneally implanted in 16 patients with unresectable gastric cancer and postoperatively used to suction off ascitic fluid, to prevent cancerous adhesions of the intestines, and to intraperitoneally infuse anticancer drugs with a view to improving QOL and prolonging survival time. The results showed that whereas all of the patients had been class V according to intraoperative cytodiagnosis, postoperatively they were all class I-II and their ascites had either completely or temporarily resolved. Performance status (PS) improved in 14 patients (87.5%), and 14 patients (87.5%) were discharged. According to the Cancer Body Cavity Efficacy Rating Criteria (Japan Society for Cancer Therapy), CR was achieved in 10 cases, PR in 3 cases, NR in 3 cases, and the mean home care rate was 45.4%. Mean survival time to date, February 1997, is 7.8 months, two patients are alive, and the longest survival time has been 22 months. This method facilitates suctioning of ascitic fluid. It prevents irregular adhesions of the intestine, and protects against the development of ileus. It enables repeated intraperitoneal administration of high concentrations of anticancer drugs, uniformly, extensively, safely and easily. It facilitates intraperitoneal cytodiagnosis, ascitic fluid sampling, and monitoring of the efficacy of anticancer agents. The special features of this method are the high percentage of patients residing at home and the ability to administer intraperitoneal infusions of anticancer agents continually and repeatedly on an outpatient basis.

Radiation therapy is an effective modality for curative treatment with organ preservation, palliative treatment for pain control and combined/prophylactic treatment for local-regional control after surgery in head and neck cancer. For early lesions, 70-90% of local control may be expected in radiation therapy. However, some hurdles must be cleared with regard to advanced lesions. We reviewed the prospective randomized controlled trials (phase III trial) concerning adjuvant chemotherapy and multiple fractions per day of radiotherapy for advanced head and neck cancer. Adjuvant chemotherapy may be used in three ways in the treatment, i.e., induction therapy, concomitantly with radiotherapy and maintenance therapy. We reviewed the former two treatments because no "pure" phase III trial could be found in maintenance therapy after radiotherapy. As for multiple fractions per day of radiation therapy, the following definition is used. Hyperfractionation: Total dose is increased; dose per fraction is reduced; fractian number is increased,; overall time is relatively unchanged. Accelerated fractionation: Overall time is reduced; number of fraction total dose, and dose per fraction are either unchanged or somewhat reduced, depending on the extent of overall time reduction. Adjuvant chemotherapy combined with radiotherapy and multiple fractions per day of radiotherapy have been attempted to increase local-regional control and survival in a few randomized studies. However, these survival results were disappointing despite good local control. We need a more effective chemotherapy regime, fractionation schedule and also to clarify the indications for these treatments by analyzing the prognostic factors.

An early phase II clinical study with the proteolysis inhibitor FUT-187 was carried out on patients with reflux esophagitis. FUT-187 was administered orally at the dose of 300 mg/day or 400 mg/day four times daily, after meals and at bedtime, for 4 consecutive weeks. The total number of patients admitted to this study was 40, of whom 9 were assigned to 300 mg/day group and 31 to 400 mg/day group. The rate of effectiveness on postgastrectomy reflux esophagitis was 88% (7/8) in 300 mg/day group and 85%(22/26) in 400 mg/day group when "improved" or better final general improvement ratings were taken into consideration, and 75% (6/8) in 300 mg/day group and 69% (9/13) in 400 mg/day group when "improved" or better endoscopic general improvement ratings were used. The overall safety rating "no problem as to the drug safety" was 89% (8/9) in 300 mg/day group and 71% (22/31) in 400 mg/day group. The main side effect was diarrhea, which was experienced in 6 patients in 400 mg/day group. However, it was resolved by discontinuation of the drug treatment. Other symptoms of gastrointestinal upsets, such as nausea and anorexia, were also induced. Based on these results, it may be concluded that FUT-187 can be a drug with clinical utility that benefits postgastrectomy reflux esophagitis at the dose level of 300 mg/day or less.

In the first study by the "Kinki Head and Neck Tumor Study Group," we performed a comparative study to investigate intergroup difference between a control group consisting of patients given radical treatment only, and a HCFU group consisting of patients receiving long-term administration of HCFU after radical treatment. We earlier reported that subsequent observations by stratification revealed a favorable tendency in the cumulative disease-free rate in Stage II and Stage III patients in the HCFU group. In the second study, the same methods of treatment as in the first study were compared in a prospective control study. No differences were found between the two groups in Stage II patients. In Stage III patients, however, the disease-free rate tended to increase significantly in the HCFU group as in the first study.

Intraperitoneal infusion of anticancer drugs via a catheter fitted with a subcutaneously implanted reservoir, when repeated frequently, usually becomes increasingly more difficult to perform owing to the catheter's becoming more and more clogged. Moreover, intraperitoneally administered anticancer drugs give rise to severe intestinal adhesions, which in turn interfere with rapid, even and widespread diffusion of the infused drugs in the peritoneal cavity. With the aim of overcoming the difficulties and inconveniences with conventionally used apparatuses for the intraperitoneal administration of drugs, we tentatively manufactured a new apparatus for intraperitoneal drug infusion. A special protective sheet, devised by Tanaka, for the prevention of postoperative intestinal adhesion following abdominal surgery, is connected with a reservoir to be implanted in the subcutis. The apparatus is inserted into the peritoneal cavity of gastric patients with peritoneal dissemination to allow it to remain in place therein. Treatment with anticancer drugs administered intraperitoneally with the use of this device proved apparently more successful than without it, resulting in improvement of QOL, disappearance of ascites, shrinkage in the size of tumor mass and depressed serum levels of a tumor marker, CA 19-9. The sheet was thus found to have the advantages of permitting safe repeated administration of anticancer drugs, even and extensive drug delivery to the peritoneal cavity, sampling of intraperitoneal cancer cells and ascitic fluid without inconvenience, and easy-to-perform continual infusion of anticancer drugs at the outpatient service.

In order to evaluate the efficacy of HCFU as an adjuvant chemotherapy agent for squamous cell carcinoma of the head and neck areas, a randomized comparative study was performed with cooperative facilities. 191 patients who had undergone radical therapy were randomly assigned to the following two groups: Group A was the control group, which underwent radical therapy only, and Group B was a group which received long-term HCFU administration (300-600 mg/day x 12 weeks or more). In the comparison of non-recurrence rate in both groups, Group B had better results among patients who were at the advanced clinical stages such as N1 through N3, Stage II (p = 0.0583) and Stage III (p = 0.0970). The adverse reactions to HCFU included pollakiuria, feverishness, and digestive symptoms, but these were mild and the recovery was possible.

The standard operation for gastric cancer is carried out for advanced gastric cancer with serosal invasion accompanying patent disseminative metastasis to the peritoneum of the omental bursa and lymph node metastases. It consists of subtotal or total gastrectomy, omentobursectomy and extended lymph node dissection. An early stage cancer, which in Japan accounts for almost a half of the resectable cases of gastric cancer, shows no serosal invasion, and lymph node metastases are rare if the cancer remains intramucosal. Such cases represent about a half the cases of the early stage cancer. The diagnosis of the early stage cancer, especially if it remains intramucosal, is made by means of preoperative radiological and endoscopic examinations and intraoperative examination. Since 1977 we have been performing a modified operation as well for cases of the early stage cancer. The surgical procedure is as follows: reduction in the size of gastric resection by 2/3, pylorus-preserving gastrectomy and proximal gastric resection; preservation of the distal portion of the greater omentum and transverse incision of the upper abdomen instead of upper midline incision to prevent ileus due to intestinal adhesion to abdominal wound around umbilicus; sparing bursectomy; narrowing the area of lymph node dissection; sparing thoracotomy for cancer in the esophagogastric junction; sparing splenopancreatectomy; preservation of the hepatic branch of the vagal nerve and postoperative temporary oral administration of cholagogue to prevent postgastrectomy cholelithiasis. In addition, the primary lesion is isolated from the blood circulation by means of ligation of the drainage veins to diminish metastasis through the blood vessels (hepatic metastasis, etc.), which is the main cause recurrence after surgery for the early stage cancer. The results of this new surgery are satisfactory; the five-year postoperative survival rate is 100.0% and it reduced the time needed for surgery, anesthesia and blood transfusion.

To improve the targeting effect in cancer chemotherapy, liposomes containing Adriamycin (Lip-ADM) and monoclonal antibody-conjugated Lip-ADM (Lip-ADM = Ab) were prepared and examined experimentally and clinically. The liposomes used as biodegradable drug carriers, were prepared from a lipid mixture of egg yolk phosphatidylcholine, cholesterol and dipalmitoyl phosphatidic acid and Adriamycin (ADM) solution was added to prepare multilamellar vesicles (MLV). Small unilamellar vesicles (SUV) were prepared from MLV by sonication and monoclonal antibodies were conjugated to SUV by the SPDP method. Experimentally, antigen-specific acceleration of in vitro and in vivo anti-tumor effects was observed. As a high tissue distribution of Lip-ADM in the liver was observed and as sinusoidal capillaries, which are found in the liver, were expected to allow penetration of liposomes through the relatively large gaps in the endothelium into the underlying organ parenchymal cells, clinical application of Lip-ADM was started for patients with hepatic metastasis of gastrointestinal cancer by selective hepatic arterial infusion. Ten patients were treated by Lip-ADM which was administered at 8-30 mg/body cumulatively. No serious adverse reaction was observed except slight fever and leukocytopenia. The preliminary evaluation of anti-tumor effects on hepatic metastasis was LPR, 1MR, 6NC and 1PD. Repeat administrations of Lip-ADM or Lip-ADM = Ab using a retained infusion catheter and silicone reservoir were started in order to improve the more accelerated clinical effects.

Between July 1977 and October 1983, 40 patients with nasopharyngeal carcinoma were treated by radiation therapy. From the investigation of this series, prophylactic treatment for distant metastases was recommended for good prognosis. Between November 1983 and May 1985, 10 patients with nasopharyngeal carcinoma were treated using a combination of cis-diamminedichloroplatinum (CDDP) and radiation therapy. Treatment results showed complete response in all 10 patients. One patient failed in the out field of boost therapy after whole-neck irradiation. This patient has shown no distant metastases. The remaining 9 patients have been controlled well. Major side effects were renal toxicity, and nausea and vomiting, which were mostly transient. However, severe mucositis of the oral cavity was observed in 4 patients (40%) of the CDDP-radiation group in contrast with 3 patients (8%) of the radiation-therapy-only group (p less than 0.01).

A clinical evaluation of re-operation after primary gastric resection for stomach carcinoma as "Second Look Operation" was performed with reference to a surgical treatment for gastric remnant cancer. Ninety-one cases among gastrectomized patients with gastric cancer from 1973 to 1987 underwent re-operation. Gastric remnant cancer in 25 cases (27%), was the second indication for the operation next to ileus. It consisted of 17 cases of recurrent cancer and 8 cases of metachronous cancer. The mean interval between the primary and secondary laparotomy in the former (32 months) was significantly shorter than in the latter (117 months). Resectability of gastric remnant cancer was 100% (8/8) in metachronous cancer and 27% (9/33) in recurrent cancer. A long-term follow-up system for over 10 years with modern physical and laboratory examinations for gastrectomized patients has been a substitute for "Second Look Operation" for find cancer in the gastric remnant.

To obtain a sufficient operative field at the operation for cardiac cancer, especially with esophageal infiltration, thoracotomy or sternotomy has been added to laparotomy. These procedures are not easy and cause great stress in patients. Through our new technique, left sided thoracotomy and sternotomy can be eliminated in favor of transabdominal phrenotomy, which is able to be performed much easier to obtain a good operative field. In order to perform the phrenotomy, the diaphragm has to be stretched using our modified hook suspender, by which the costal arch is lifted strongly upward and cranially. With these procedures, about a 5cm long esophagus is able to be resected with lymph node dissection in the lower mediastinum without difficulty. No marked influence of the hook suspender as well as the phrenotomy has been recognized on respiratory and circulatory systems. The anastomosis between the esophagus and jejunum or residual stomach seems to be very difficult, because the site of the anastomosis is located quite deep in the mediastinum. This problem, however, can be completely resolved by means of a surgical stapling autosuture instrument.

Neo-adjuvant chemotherapy, followed by definitive surgery and/or radiotherapy was utilized in nine patients with carcinoma of the hypopharynx and cervical esophagus starting in December, 1983. They were treated with combination chemotherapies which included CDDP, PEP (BLM), and MTX. The patients' ages ranged from 52 to 70 years with an average of 57. The histologic types were all squamous cell carcinoma and performance status was 1 in all cases. There were 7 stage III and 2 stage IV. Of 9 patients, 3 showed complete response and 6 showed partial response of the primary tumor with an overall response rate of 100%. Of 8 patients, 3 showed complete response and 2 showed partial response of the metastatic node with an overall response rate of 62.5%. Toxic effects included alopecia in 9 patients, nausea/vomiting in 7, eczema in 4, RBC below 350 X 10(4)/mm3 in 5, WBC below 3000/mm3 in 1, peak serum creatinine above 2 mg/dl in 1. All patients except one with renal toxicity were able to start definitive treatment soon after chemotherapy, the primary and regional lesions being subsequently well controlled in all 9 patients. Neo-adjuvant chemotherapy appears to be very effective for the reduction of tumor bulk. This multidisciplinary therapy should be expected to increase survival rate.

The prognosis of the laryngeal carcinoma is better than that of other head and neck carcinomas. The five-year survival rate ranges between 70 and 80%. The proportion of cases of early glottic carcinoma has increased at our clinic. In 1986, about 70% of all laryngeal carcinomas were glottic carcinoma, and about half of these were early-stage cases. The principle of management is, primarily, life-saving and then functional preservation. For this purpose, it is mandatory to make an exact diagnosis and to treat the condition appropriately. Generally, the modality of treatment is mainly radiation and surgery; radiation or partial laryngectomy for early-stage cancer, total laryngectomy for advanced-stage cancer. However, selection of therapy should not only be based on stage, but also on various other factors, e.g., type of growth, medical facilities available and the patient's situation (age, etc.). Recently, laser therapy has been tried for early carcinoma. Patients with advanced carcinoma still have a poor prognosis, and so planned combined therapy including chemotherapy and immunotherapy should be considered. Vocal rehabilitation following total laryngectomy is also very important. There are three main methods of rehabilitation, i.e., esophageal speech, artificial larynx (pneumatic larynx or electro-larynx) and surgery (reconstructive laryngectomy, tracheoesophageal shunt).