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This patient visited our hospital for the purpose of detailed examination of prostate cancer in his seventies. Abdominal contrast-enhanced computed tomography(CT)revealed a low-density mass of 2 cm in the pancreatic head. He was diagnosed with pancreatic cancer. Pancreaticoduodenectomy was performed after 2 courses of gemcitabine and S-1 therapy were performed as neoadjuvant chemotherapy. An intraoperative clamp test of the gastroduodenal artery showed that the pulsation of the common hepatic artery and the proper hepatic artery was weak but sufficient, so the gastroduodenal artery was cut and the operation was completed as planned. A blood test on the 1st day after the operation showed elevated levels of AST 537 U/L, ALT 616 U/L, and 7 hours later blood sampling showed further increases in AST 1,455 U/L, ALT 1,314 U/L. After a detailed review of the preoperative CT, celiac artery stenosis due to compression of the arcuate ligament was suspected, and urgent median arcuate ligament release was performed on the same day. Dissection of the arcuate ligament significantly improved the pulsation of the common hepatic artery and proper hepatic artery. Postoperatively, hepatic enzymes improved and ISGPS showed Grade B pancreatic juice leakage, but the patient was discharged from the hospital on the 49th postoperative day without any other complications. He took S-1 as adjuvant chemotherapy, and no signs of recurrence have been observed 9 months after the operation.

A 98-year-old woman presented with hematochezia and a circumferential type 2 tumor in the rectum Rb identified on fiberoscopy. We a performed laparoscopic Hartmann's operation and D2 lymphadenectomy for advanced rectal cancer. A sigmoid colostomy was created via the intraperitoneal route. On the postoperative day 12, the patient experienced abdominal pain. Computed tomography showed that the small intestine formed a closed loop in the pelvic space. The patient was diagnosed with a strangulated bowel obstruction of the small intestine for which an emergency exploratory laparotomy was performed. The small intestine, which had passed through a defect between the lifted sigmoid colon and the left abdominal wall, was strangulated by the lifted sigmoid colon. We performed partial resection of the small intestine. The patient died on postoperative day 32 of acute deterioration of aortic valve stenosis. There have been few reports of strangulated bowel obstruction resulting from internal hernia associated with colostomy. These findings demonstrate that it is important to select the appropriate route for colostomy creation in each case.

A 54-year-old woman visited to a doctor nearby medical clinic complaining of loss of appetite. She was diagnosed with right hydronephrosis on abdominal ultrasonography, and referred to our hospital for further examination. Contrast abdominal computed tomography(CT)revealed that a 6.2 cm tumor with a contrast-enhancing effect inside in the retroperitoneum near the lower pole of the right kidney. She was diagnosed with hydronephrosis due to infiltration of the right kidney of a retroperitoneal tumor. The tumor was suspected of invading the duodenum and inferior vena cava, but no obvious lymph node or distant metastasis was observed. Abdominal MRI revealed a tumor showed hyperintensity on T2-weighted and diffusion-weighted images. We performed pancreaticoduodenectomy with inferior vena cava resection and right nephrectomy. The pathological diagnosis was leiomyosarcoma originating from retroperitoneum and pT2, pN0, pM0, pStage ⅢA. The postoperative course was good, and she was discharged 10 days after the operation. Thoracoabdominal CT showed a tumor 4 cm at the hepatic hilum three months after surgery, and EOB-MRI showed many tumors other than the same site, so multiple liver metastases were diagnosed as recurrence. Doxorubicin has been started and is still being treated.

In aging society, the number of colorectal cancer patients who take antithrombotic drugs is increasing. However, there are not established guidelines for perioperative management for antithrombotic drugs in laparoscopic surgery. Here, we investigated the clinical outcomes of antithrombotic drugs withdrawal and perioperative heparinization in laparoscopic surgery for colorectal cancer patients taking antithrombotic drugs. From January 2015 to December 2017 in our center, patients who took antithrombotic drugs and underwent laparoscopic surgery for colorectal cancer were reviewed retrospectively. The association between postoperative complications and heparinizations was analyzed. Among 79 patients taking antithrombotic drugs, heparinization was performed in 40 patients(50.6%). The total length of hospital stay in heparinization group was 21 days and significantly longer than 13 days in the non-heparinization group. There were no significant differences in the operation time, intraoperative blood loss, and postoperative complications between the 2 groups. The antithrombotic drugs withdrawal and perioperative heparinization were suggested to be safe and feasible in laparoscopic surgery for patients with colorectal cancer.

A 79-year-old man visited the hospital because of constipation. Colonoscopy showed a transverse colon carcinoma. Dynamic CT showed a renal neoplastic lesion and 2 lesions in the liver with early staining and late wash out, and the liver lesions showed ring enhancement on EOB-MRI. The preoperative diagnosis was either transverse colon cancer, renal cell carcinoma, hepatocellular carcinoma, or metastatic liver cancer. The patient underwent partial transverse colon resection, partial right nephrectomy, and partial hepatic resection. Additional to the 2 liver lesions in S6, an intraoperative ultrasound showed 1 tumor in S5; therefore, 3 partial hepatectomies were performed. Histopathological findings revealed that the tumors in S5 and S6 were liver metastases of transverse colon cancer and renal cell carcinoma, respectively. The final diagnosis was transverse colon cancer, pT4a, pN0, pM1, pStage Ⅳa and papillary renal cell carcinoma, pT1a, pN0, pM1, pStage Ⅳ. For 9 months postoperatively, there was no apparent recurrence.

A 69-year-old female underwent a mesh repair for an abdominal incisional hernia 4 years previously in our hospital. She visited local hospital for abdominal pain and fever. Abdominal CT showed a localizes abscess formation above the mesh, then she was taken to our hospital. We suspected mesh infection and performed emergent mesh removal. After the operation, we examined for her anemia. Her colonoscopy and CT findings pointed to transverse colon cancer. We performed right hemicolectomy, and final diagnosis was transverse colon cancer pT4aN0M0, pStage Ⅱb. She underwent adjuvant chemotherapy, and 9 months after surgery, no recurrence was found.

A patient was 70-year-old female. Because unknown fever following operation of left knee in December 20XX-1, abdominal simple CT was performed, diagnosed as cholecystitis and liver abscesses. However, her unknown fever did not improve with antibiotics therapy. Abdominal enhanced CT and MRI revealed to gallbladder cancer with liver invasion and metastases. These lesions were relatively localized in liver S4a/S5 and gallbladder, hepatoduodenal mesentery. Because unknown fever was exhausting, cholecystectomy, S4a+S5 hepatectomy with extrahepatic bile duct resection and lymph node dissemination were performed in January 20XX+1. In these pathological findings, there were moderate to poorly differentiated adenocarcinoma with squamous cell differentiation in almost area of gallbladder, diagnosed as adeno-squamous carcinoma with liver invasion and metastasis(pT3a[SI][H-inf], int, INF-β, ly1, v3, pn1, pN1, pM1, pStage ⅣB). One months after operation, abdominal CT revealed multiple liver metastatic recurrences. She died 7 months after operation. Although gallbladder adeno-squamous carcinoma has a poor prognosis, these many cases had a tendency to local infiltration accompanied with tumor fever. If curative resection might be obtained and the symptoms might be improved, aggressive resection should be performed.

Objective: To evaluate the efficacy and safety of CAPOX plus bevacizumab as second-line chemotherapy for metastatic colorectal cancer., Methods: In this multicenter phase Ⅱ study, the planned number of patients was 48, but owing to poor case accumulation, registration was discontinued for 20 patients. The primary endpoint was the response rate(RR). Secondary endpoints were progression-free survival(PFS), overall survival(OS), disease control rate(DCR), and safety., Results: First-line treatment was combined with irinotecan in 14 cases and bevacizumab in 12 cases. The median number of second- line treatment courses was 7, and the median treatment period was 203 days. The reason for discontinuation of treatment was disease progression in 13 cases, adverse events in 4 cases, and other reasons in 3 cases. The best response was PR in 5 cases, SD in 8 cases, and NE in 4 cases. The RR was 25%, and the DCR was 65%. The median PFS was 7.2 months, and the median OS was 18.6 months. Grade≥3 adverse events were neutropenia in 3 cases and diarrhea and peripheral neuropathy in 2 cases each. There were no treatment-related deaths., Conclusion: CAPOX plus bevacizumab was a safe and effective second-line treatment option for metastatic colorectal cancer.

A 60's woman was admitted to our hospital because of palpitations that occurred with exertion. Coronary angiography computed tomography(CT)of suspected angina detected a tumor in the pancreatic head region. Abdominal CT showed a poorly enhanced 40×32 mm solid tumor in the hepatoduodenal ligament that contained a fatty component and calcification. During surgery, the tumor was located in the hepatoduodenal ligament, adhered to the pancreatic head, common hepatic artery, gastroduodenal artery, portal vein and common bile duct. However, the tumor was resected by preserving them. The tumor contained stratified squamous epithelium, a sebaceous gland, nerve, a pancreatic gland, and an adrenal gland. The histological diagnosis was a mature cystic teratoma. The patient showed no recurrence in 2 years and 10 months post-surgery. Mature teratomas in the hepatoduodenal ligament are extremely rare. Some reports showed that combined resection was performed when the tumor was in contact with the common bile duct, portal vein, and arteries. However, in our case, the tumor was removed relatively safely without combined resection.

A 78-year-old woman had undergone subtotal stomach-preserving pancreatoduodenectomy for acinar cell carcinoma (ACC)of the pancreatic head approximately 2 years before presentation, and the pathological diagnosis had been pT2pN0pM0, fStageⅠB(JPS 7th). Adjuvant chemotherapy was discontinued after 3 months because of side effects. Contrast- enhanced CT and PET-CT 2 years postoperatively revealed a tumor measuring 2 cm with a high concentration of FDG in the minor curvature of the stomach. During laparotomy, a 3 cm large lymph node was palpated in the minor curvature of the stomach, and a small lymph node was found adjacently. We diagnosed the patient with multiple lymph node recurrences and performed gastric lymph node dissection of the minor curvature. The pathological diagnosis was a single 2 cm large ACC lymph node metastasis. The patient did not consent to postoperative adjuvant chemotherapy and showed no recurrence for 1 year and 7 months postoperatively. Pancreatic ACC is a rare pancreatic tumor, and its clinicopathologic features are still largely unknown. In recent years, there have been reports of active resection or long-term survival with anti-cancer drug treatment even in recurrent cases, such as the present case. However, the indication and method of anti-cancer treatment are unclear and might need the accumulation of many more cases.

The patient was a 79-year-old woman. In January 20XX, upper gastrointestinal endoscopy revealed a duodenal tumor with bleeding and ulceration. This tumor was diagnosed as a duodenal neuroendocrine tumor(NET)based on biopsy findings. In March 20XX, the patient underwent pancreatoduodenectomy with lymph node dissemination. Based on these pathological findings, the tumor was diagnosed as a duodenal NET(G2)with a lymph node metastasis(T2, N1, M0, Stage Ⅲ). Twenty months after the operation, abdominal CT revealed multiple liver metastases(S4, S7, and S8). After this recurrence, she underwent the subcutaneous somatostatin analogue injection therapy every 28 days, and transarterial chemoembolization( TACE)when these recurrent tumors showed remarkable regrowth, once a year, accounting for her age. She has maintained good disease control for 5 years.

There are few reports of using oxaliplatin(L-OHP)for esophageal squamous cell carcinoma.We report a case of long-term disease control after administration of L-OHP for esophagogastric junction squamous cell carcinoma(EG).A woman in her 40s was diagnosed with EG(cT3, cN2, cM0, cStage Ⅲ).She received thoracoscopic, laparoscopic-assisted, subtotal esophagectomy with 3-field dissection after 3 courses of preoperative chemotherapy with DCF(docetaxel hydrate, cisplatin, 5- fluorouracil).Reconstruction was achieved using a retrosternally shifted gastric tube and transesophageal gastro-tubing. Pathological examination showed EG(ypT3, ypN2, ypM0, ypStage Ⅲ)(chemotherapy evaluation: Grade 1a).After 12 months, para-aortic lymph node recurrence(#112aoP, #16a2lat)was observed on a follow-up CT examination.First, we administered 5 courses of chemotherapy with SOX(S-1 100mg/m2 day 1-14 and L-OHP 100 mg/m2 day 1).Recurrent lymph nodes shrunk slightly, and there were no new lesions.Subsequently, there was no other adverse event except for Grade 1 chemotherapy-induced neuropathy.Second, we administered 3 courses of chemotherapy with FOLFOX(5-FU 400mg/m2, L-OHP 85mg/m2, Leucovorin 200 mg/m2 day 1, 5-FU 1,600mg/m2/46 hr)in combination with radiotherapy(total 60 Gy/ 30 Fr).Recurrent lymph nodes shrunk slightly, and there were no new lesions.Subsequently, there was no other adverse event except for Grade 1 chemotherapy-induced neuropathy.No new recurrence was observed 19 months after the first recur- rence.The patient continues to receive weekly nab-PTX(85mg/m2).A regimen that includes L-OHP is useful in the treatment of advanced or recurrent esophageal squamous cell carcinoma.

A man in his 50s was admitted to our hospital due to hematemesis.Esophagogastroduodenoscopy revealed an 8 cm type 2 gastric tumor.The tumor was histologically diagnosed as a neuroendocrine carcinoma.CT showed that the tumor had directly infiltrated the liver but there was no distant metastasis.We performed open distal gastrectomy, D2 lymph node dissection, partial hepatectomy, and cholecystectomy.Four months after the surgery, metastases of the right adrenal gland and dorsal part of the inferior vena cava were found.Although a significant tumor reduction was obtained by 12 courses of chemotherapy with CDDP plus CPT-11, this effective treatment was discontinued for the patient's convenience.Fifteen months after the surgery, metastasis of the right adrenal gland and dorsal part of inferior vena cava demonstrated re-growth without any further metastasis.After 4 courses of the same regimen, a partial response was obtained for the recurrences.As a salvage surgery, we performed open right adrenal gland and the lymph nodes of dorsal of IVC resection.The patient is alive without recurrence 1 year after the salvage surgery.

A woman in her 40s was hospitalizedfor jaundice. Six years before, she hadbeen diagnosedwith synchronous esophageal andgastric cancers andhadund ergone subtotal esophagectomy andtotal gastrectomy, accompaniedby reconstruction with the pedicled jejunum. Multimodal imaging revealed a tumor at the pancreatic head, probably pancreatic cancer, which induced severe stenosis of the intrapancreatic bile duct. Scraping cytology findings of the lesion via the percutaneous transhepatic cholangial drainage(PTCD)route strengthenedthe suspicion. In the image, although no obvious invasion of the major vessels or apparent distant metastases were detected, an abnormal shadow was found continuously lining the main tumor andpara -aortic region, which was a contraindication for curative resection. Therefore, we performed neoadjuvant chemotherapy with gemcitabine plus S-1. After 3 courses, the lesion size reduced notably, and pancreatoduodenectomy was performed. The pathological diagnosis was pancreatic cancer(ph, ypT3, ypN1a, ypM0, ypStage ⅡB). Except for pancreatic fistulas(Clavien-Dindo Ⅲa), the postoperative clinical course was uneventful, andshe was dischargedon postoperative day 27. To date, the patient is alive without recurrence and is undergoing adjuvant chemotherapy with S-1.

A 78-year-old man who underwent esophagectomy for middle thoracic esophageal squamous cell carcinoma(pT1bN0M0, pStage Ⅰ)was diagnosed with lymph node recurrence 12 months after the initial surgery. He received chemoradiotherapy(5- fluorouracil plus cisplatin); however, the treatment was terminated at the middle of the treatment course because of progressive disease. He received chemotherapy(docetaxel plus 5-fluorouracil plus cisplatin)as a second-line treatment, which was also canceled due to serious adverse events. Partial response was achieved after the second therapy; therefore, surgical excision was performed. Thirteen months after the second surgery, he was diagnosed with second local recurrence with invasion to the trachea. Another course of chemotherapy(docetaxel[2-weekly]plus 5-fluorouracil plus cisplatin)was administered, which also achieved a partial response. Thus, surgical excision with partial tracheal resection and mediastinal tracheostomy was performed. He has been alive without recurrence for 6 months after the final operation. In case of postoperative solitary lymph node recurrence of esophageal cancer, long-term survival can be expected with multidisciplinary treatment.

Case 1: A man in his 70s was referred to our hospital for further examination of a liver tumor(S3, 3 cm)detected by ultrasonography. Multimodal image examination showed a cystic lesion with solid papillary components located in the S4 accompanied by dilatation of the surrounding intrahepatic bile duct. Although biliary cytology did not indicate confirmed malignancy, the lesion was thought to be an intraductal papillary neoplasm of bile duct(IPNB)with malignant potential, and a left lobectomy was performed. Histopathological examination revealed a papillary tumor in the intrahepatic bile duct which consisted of atypical epithelial cells of pancreatobiliary type, and the lesion was diagnosed as an IPNB with high-grade intraepithelial neoplasia. Case 2: A woman in her 70s was referred to our hospital because of a liver tumor(S4, 8 cm)detected by ultrasonography. Multimodal image examination showed a cystic lesion localized to the liver(S3, 8 cm), and endoscopic retrograde cholangiopancreatography(ERCP)showed continuity of the cyst and the intrahepatic bile duct. The biliary cytology was positive, and the lesion was thought to be a malignant IPNB. After preoperative drainage of the cystic lesion, a left lobectomy was conducted. Histopathological examination showed that the papillary tumor localized to the bile duct and atypical epithelium cells of pancreatobiliary type were infiltrating into the surrounding matrix. We diagnosed this tumor as an IPNB with an associated invasive carcinoma.

Case: A man in his 60s reported upper abdominal pain; close examination revealed a tumor in the body-tail of the pancreas that was suspected to be infiltrating the stomach. Multiple liver lesions(S3, S4)were also detected. Histological examination by EUS-FNA showed poorly-differentiated carcinoma; thus, this case was diagnosed with unresectable pancreatic cancer with liver metastases(cT3, cN1[No. 7], cM1[P0, H1], cStage Ⅳ: JPS 7th). After 2 kinds of systemic chemotherapy(9 courses of GEM plus nab-PTX and 9 courses of modified FOLFIRINOX), obvious distant metastases or local progression did not appear and conversion surgery was scheduled. Although a metastatic lesion was identified at S5 of the liver just before the surgery, it was assumed that an R0 resection could be achieved; therefore, the operation(distal pancreatectomy with combined proximal gastrectomy, left adrenalectomy, lymph node dissection, partial hepatectomy of S5, and cholecystectomy)was performed. Histopathological examination showed squamous metaplasia of the epithelial tissue combined with glandular formation. This case was, thus, diagnosed as adenosquamous carcinoma of pancreas. This patient was discharged 90 days after the operation. The patient is still alive 2 years and 2 months since the first diagnosis.

Case 1 is a 68-year-old woman with locally recurrent rectal cancer(LRRC)developed 5 years after resection of primary rectal cancer. The tumor seized right lateral side in pelvic. We performed tumor excision after preoperative chemoradiation comprised external beam radiation with oral S-1(tegafur/gimeracil/oteracil). He has been relapse-free for 3 years 3months after surgery. Case 2 is a 74-year-old man with LRRC developed 2 years after resection of primary rectal cancer. The tumor was located dorsal to anastomosis site in pelvic. We performed abdominoperineal resection for LRRC after preoperative chemoradiation with oral S-1. He has been relapse-free for 2 years. It was suggested that preoperative radiotherapy combined with oral FU for local recurrence after rectal cancer may contribute to distant and local control.

Akathisia is a condition wherein sitting calmly and quietly is impossible, with a representative complaint of restless legs. It is generally assumed to be caused by anti-dopamine activity. In severe cases, it has been known to result in suicide attempt. We reported a case of drug-induced akathisia with difficulty in oral intake, in which fentanyl citrate sublingual tablets were found to be effective in relieving symptoms. The patient was a female aged 50's who had a gastric cancer with peritoneal dissemination causing pain and vomiting. Palliative care was requested for management of symptoms. Metoclopramide and haloperidol were administered for vomiting. However, because of the complaints of restless legs, the case was diagnosed as drug-induced akathisia. Fentanyl citrate sublingual tablets were then administered for pain management, resulting in temporary improvement of akathisia symptoms.

Superselective intra-arterial chemoradiation therapy for oral cancer induces the complication of mucositis. Although the associated pain is controlled using opioids, major questions from patients in clinical practice are as follows:(1)the mean number of days from the completion of superselective intra-arterial chemoradiation therapy to the discontinuation of opioid administration, and(2)patient factors enabling the discontinuation of opioids. The purpose of this study was to clarify these points. A retrospective follow-up study was conducted from April 2016 to March 2017 on patients who underwent superselective intra-arterial chemoradiation therapy at our department of oral surgery. The patients were divided into 2 groups:one who discontinued opioids, and the other who did not. Clinical backgrounds and data were compared between the 2 groups. The mean number of days from the completion of superselective intra-arterial chemoradiation therapy to the discontinuation of opioid administration was 51±34.4 days. The absence of diabetes and deliria during treatment were determined as factors contributing to the discontinuation of opioids.

Superselective intra-arterial chemoradiation therapy for locally advanced oral cancer induces complications such as mucositis, which impedes oral intake. Thus, at our hospital, a gastrostomy is performed in almost all patients during the treatment period to ensure the presence of an alternative administration route for nutrition and drugs. The purpose of this study was to calculate the mean number of days from completion of superselective intra-arterial chemoradiation therapy to the decannulation of gastrostomy, and extract patient factors for the decannulation. A retrospective follow-up study was conducted from April 2016 to March 2017 on patients who underwent superselective intra-arterial chemoradiation therapy at our department of oral surgery. The patients were divided into 2 groups:one who was decannulated and the other who did not. Clinical backgrounds and data were compared between the 2 groups. In the group with the decannulation, the mean period from treatment completion to the decannulation was 132±51.6 days. Heavy alcohol consumption, absence of haphalgesia before treatment, and possible securement of the opening with the breadth of 3 fingers, were determined as factors contributing to the decannulation of gastrostomy tube.

We investigated the usefulness of suvorexant for complicated delirium in patients with cancer who experience sleep disturbance during hospitalization. Nine patients with malignant tumors complicated with symptoms of delirium and insomnia were included in this study; their palliative care was managed by the palliative care team of our hospital for a period of one year from April 2016 to March 2017. A retrospective follow-up study was then conducted. The Japanese version of DRS-R98 was used to evaluate the severity of the patient's delirium. The total severity score of DRS-R98 significantly decreased after the administration of suvorexant when compared to the score before its administration(6.66±1.73 vs 10±3.20, p=0.0031). In addition, suvorexant did not exhibit any harmful effects. Our results indicate that suvorexant was useful in alleviating delirium symptoms in cancer patients who experience sleep disturbance.

A 67-year-oldman underwent lower anterior resection for rectal cancer andresection of liver metastatic tumor 5 years later. Seven years and 2 months after the initial surgery, a soft tissue mass was detected in the left diaphragm. Further retrospective review of CT scan images showedthat the diaphragmatic tumor was present just before the hepatectomy. Partial resection of the left diaphragm was performed, and no relapse has occurred since then for 2 years. Most cases of diaphragmatic metastasis are considered to arise from dissemination, but we considered this case as more likely to be hematogenous. When surgery is chosen to treat metastatic tumors of colorectal cancer, checking for other metastasis via preoperative imaging andperforming curative resection is important.

A 56-year-old woman was referred to our hospital because of epigastric discomfort and jaundice. Contrast-enhanced computed tomography and gastrointestinal endoscopy revealed an ampullary tumor. A biopsy specimen showed adenocarcinoma of the ampulla of Vater. The carbohydrate antigen (CA19-9) level was elevated, but insulin and glucagon levels were in the normal range. Based on a diagnosis of adenocarcinoma of the ampulla of Vater, we performed subtotal stomach-preserving pancreatoduodenectomy with regional lymph node dissection. Postoperative histopathological examinations indicated both neuroendocrine carcinoma (40%) and adenocarcinoma (60%) components in the ampulla of Vater and regional lymph node metastasis. According to the 2010 WHO Classification of Tumours of the Digestive System, the diagnosis of mixed adenoneuroendocrine carcinoma (MANEC) of the ampulla of Vater was confirmed. The patient was treated for 6 months with oral administration of TS-1 as adjuvant chemotherapy. Currently, the patient is alive without recurrence 8 months after surgery. MANEC of the ampulla of Vater is rare. It is a highly malignant tumor, and the standardization of its treatment, including surgery, chemotherapy, and radiotherapy requires further study.

We report a case of a 71-year-old man with liver metastases from a rectal neuroendocrine tumor(NET). The patient's chief complaint was melena. He was diagnosed with rectal carcinoma with liver metastases during his initial visit. Therefore, we started UFT/LV as first-line chemotherapy. After 2 courses, the patient's disease had progressed, so the treatment was changed to S-1 as second-line chemotherapy. The patient showed a partial response. In February 2010, we performed an anterior resection, and in April 2010 we performed a posterior segment and S2/8 partial hepatectomy. Histopathological examination showed rectal NET with liver metastases. In December 2011, multiple liver metastases were found, and multimodal treatment including TACE, RFA and somatostatin analogues was selected to treat the recurrent tumor. The patient survived for 10 years after his first visit and for 3 years and 6 months after the recurrence. Multidisciplinary therapy was effective for treating rectal NET with liver metastases.

An 83-year-old man underwent extended cholecystectomy for gallbladder cancer. On postoperative day 13, he developed fever and computed tomography (CT) revealed fluid collection at the cut surface of the liver. Ultrasound-guided fluid drainage was conducted, and he was diagnosed with biliary leakage. Radiological examination using a contrast agent revealed that the anterior branch of the bile duct (B5) was completely interrupted. Simple drainage and ethanol injections into the bile duct proved ineffective. Thus, we performed transcatheter arterial embolization (TAE) in the anterior segmental artery (A5) to stop the production of bile in the injured part of anterior segment. The treatment was effective, and he was discharged 15 days after TAE. TAE might be a useful method for treating intractable interrupted-type bile leakage.

Objective: To examine the effect of S-1 adjuvant chemotherapy on muscle volume after curative gastrectomy in gastric cancer patients., Patients: Forty-eight gastric cancer patients (31 men and 17 women) who underwent curative gastrectomy (distal gastrectomy: n=37, and total gastrectomy: n=11) between April 2010 and July 2011 were enrolled in this study. Sixteen patients underwent S-1 adjuvant chemotherapy (S-1 group) for 1 year after the operation, and 32 patients did not (NT group)., Methods: The psoas muscle areas were measured at the fourth lumbar vertebrae on CT images obtained before the operation, and at 6, 12, and 24 months after the operation. Muscle areas was statistically examined by comparing the preoperative and postoperative ratios., Results: The muscle areas 12 months after the operation decreased to 0.86 ± 0.11 in the S-1 group and to 0.96 ± 0.08 in the NT group (p<0.05), and the significant difference disappeared at 24 months (0.93 ± 0.10 vs. 0.93 ± 0.11, NS). In the patients who underwent distal gastrectomy, the muscle areas decreased to 0.90 ± 0.05 in the S-1 group and to 0.96 ± 0.09 in the NT group at 12 months (p<0.05). Meanwhile, in those who underwent total gastrectomy, the muscle areas decreased to 0.80 ± 0.15 and 0.93 ± 0.03, respectively (NS)., Conclusions: S-1 adjuvant chemotherapy affected muscle volume loss after gastrectomy in the gastric cancer patients, but the patients recovered from the adverse effect by 12 months after chemotherapy.

The patient was a 73-year-old male with advanced gastric cancer in the lesser curvature of the antrum.Abdominal computed tomography revealed multiple liver metastases(S5, S8).He was diagnosed with clinical Stage IV gastric cancer (cT3N0M1H1).He received 3 courses of combined neoadjuvant chemotherapy with capecitabine, cisplatin, and trastuzumab because immunostaining indicated the tumor was human epidermal growth factor receptor 2(HER2)-positive.The therapeutic response, as assessed by imaging studies, was partial for the primary lesions and stable for liver metastases.Distal gastrectomy, D2 lymph node dissection, and S5 extended subsegmentectomy of the liver were performed.Histopathological findings indicated that both the primary tumor and liver metastases were neuroendocrine carcinoma.The patient declined post-operative adjuvant chemotherapy and he is alive 6 months after the surgery with no evidence of recurrence.Surgery with neoadjuvant chemotherapy appears to be a promising option for advanced gastric cancer with liver metastases.

The patient was a 74-year-old woman with advanced gastric cancer in the greater curvature of the antrum and lesser curvature of the angle.Abdominal computed tomography revealed bulky lymph node metastases of No. 3, 8a, and 11p.She was diagnosed with clinical Stage IIIA gastric cancer (cT3N2M0) and underwent surgery.Laparotomy findings revealed invasion of bulky lymph nodes to the common hepatic artery and pancreas.Since radical resection was not feasible, exploratory laparotomy was performed.After the surgery, she received 1 course of S-1 monotherapy and 3 courses of S-1/cisplatin (CDDP) therapy.The therapeutic response, as assessed by imaging studies, was partial for the primary lesions and complete for the enlarged lymph nodes.Distal gastrectomy and D2 lymph node dissection were performed.Histopathological findings showed no evidence of lymph node involvement, allowing the patient to undergo radical surgery.The patient received postoperative adjuvant chemotherapy with S-1.She is alive 11 months after the surgery, with no evidence of recurrence.Induction chemotherapy appears to be a promising option for advanced gastric cancer with significant lymph node involvement.

A 74-year-old man with chronic hepatitis C was diagnosed with liver tumors. Contrast-enhanced computed tomography (CT) and ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI) revealed hepatocellular carcinomas(HCC) in segments 8 (S8)and 5/8 (S5/8), and detected a lymph node (LN) swelling of 75 mm diameter in the posterior aspect of the pancreatic head. Fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET) was positive for the swollen LN (SUVmax 12.3), but negative for the intrahepatic HCCs. The alpha-fetoprotein (AFP) and protein induced by vitamin K absence or antagonist-II (PIVKA-II) values were elevated, and soluble interleukin- 2 receptor levels were also increased (1,440 U/mL). Based on a diagnosis of HCCs with either LN metastasis, or with malignant lymphoma, partial hepatectomy (S8 and S5/8), lymphadenectomy (#13LN), and cholecystectomy were performed. Histopathological examination indicated well differentiated HCC in S5/8, and moderately to poorly differentiated HCC in S8, while poorly differentiated HCC was detected in the LN. Therefore, the final diagnosis was HCCs with metastasis to #13LN originating from the HCC in S8. At present, the patient is alive without further extrahepatic recurrence. The extent of FDG accumulation is related to the degree of differentiation of the HCC; furthermore, there are discrepancies between the FDG uptake in intrahepatic and extrahepatic lesions.

We report a case of a patient in whom a giant mucinous cystadenocarcinoma was treated with distal pancreatectomy. A 37-year-old woman was admitted to the hospital complaining of intermittent epigastric pain. The laboratory data revealed a marked increase in serum levels of carcinoembryonic antigen( CEA 22 ng/mL), cancer antigen( CA) 19-9( 258,129 U/ mL), and CA125 (53 U/mL). A computed tomography (CT) scan revealed a cystic tumor, 15 cm in diameter, in the body of the pancreas. The tumor presented as a multilocular cyst with enhanced nodules. On positron emission tomography (PET)-CT,[ 18F] fluorodeoxyglucose uptake by the nodules of the cyst was noted. Under the diagnosis of malignant mucinous cystic neoplasm, we performed distal pancreatectomy, splenectomy, partial gastrectomy, and left adrenalectomy because the tumor was suspected to be invading the stomach and left adrenal gland. The tumor was histologically diagnosed as invasive mucinous cystadenocarcinoma with ovarian-like stroma. The patient survived for 14 months after surgery without tumor recurrence. Invasive mucinous cystadenocarcinoma of the pancreas has high rates of lymph node metastasis and early recurrence after surgery. We believe that we would have had to perform complete tumor resection equivalent to that of invasive ductal carcinoma of the pancreas if the mucinous cystic neoplasm was found to be malignant preoperatively.

We report a case of long-term survival of a patient who underwent hepatic resection for metastatic gastric cancer. The patient was a 75-year-old man who underwent distal gastrectomy for gastric cancer in 2004. On pathological examination, the tumor was diagnosed as T4a (SE) N0M0, stage IIB. A metastatic lesion was detected in segment 6 of the liver at 2 years after gastrectomy. With regard to radiological findings, a single metastatic lesion and no lymph node metastasis or peritoneal recurrence was observed. The hepatic lesion was curatively resected. Another metachronous liver metastasis was identified in segment 7 of the liver at 3 years after gastrectomy. We resected the remnant liver metastasis, after which the patient has not exhibited any evidence of tumor recurrence for more than 5 years. This case suggests that patients could survive for a long period after undergoing resection of hepatic metastasis because no lymph node metastasis was observed during the operation of the primary gastric cancer, only a single hepatic metastasis without any metastasis to other organs was observed, and the metastatic lesion of the liver could be curatively resected.

Duodenal stenting for malignant disease related to gastric outlet obstruction(GOO) has been covered by health insurance in Japan since April 2010. We inserted WallFlexTM duodenal stents(WDS) in 4 patients with GOO caused by unresectable gastric cancer. WDS insertion was successful in all 4 cases. Duodenal perforation occurred in 1 case. One case each of stent obstruction and stent migration occurred. All patients could eat a soft-food diet for 3-6 months (median, 5.3 months). Survival time ranged between 5 and 14 months (median, 6 months). Three patients underwent S-1 combination chemotherapy. Duodenal stenting is expected to be effective for advanced gastric cancer related to GOO.

We encountered 2 cases of endocrine cell carcinoma of the stomach. One patient had a type 3 tumor in the cardia, and the other patient had a submucosal tumor in the posterior wall of the gastric angle, both of which were detected by upper gastrointestinal endoscopy. The first patient underwent total gastrectomy(D1+No.7, 19) with cholecystectomy. Microscopic histological examination fortuitously revealed a tumor thrombus in the vessel of the gallbladder. Eight months after the operation, a paraaortic lymph node recurrence was detected, and the patient died 28 months after the operation. The second patient underwent distal gastrectomy, cholecystectomy, S5 subsegmental hepatectomy, and S8 radiofrequency ablation(RFA). Despite undergoing adjuvant chemotherapy[irinotecan(CPT-11)/cisplatin(CDDP)], multiple liver recurrences were detected 6 months after the operation. Consequently, systemic chemotherapy (S-1/CDDP) was performed.

As the treatment for inoperable advanced gastric cancer, S-1/CDDP combination therapy (SP chemotherapy) has become a standard treatment. In our hospital, a second course of chemotherapy was performed on an outpatient basis in order to improve a traditional QOL. In this case, it showed remarkable effects in 15 months after starting chemotherapy. Then gastrectomy was performed. Histological findings of the resected specimens confirmed pCR in all tumors. We report on progress of this case and explain about the ingenuity of SP chemotherapy.

The patient was an 84-year-old man, who was diagnosed with cT3N2 (101L, 109L) M0, stage III esophageal cancer. The tumor, immunohistochemically, was stained positive for CD56 and NSE yielding a definitive diagnosis of endocrine cell carcinoma of the esophagus. We selected chemo-radiation therapy (5-FU/CDDP and 2 Gy/day total 60 Gy) for this patient. As adjuvant chemotherapy, 7 courses of chemotherapy with 5-FU/CDDP, was performed. At 8 months from the chemo-radiation therapy, the disease was diagnosed as cCR. But two years later, lung metastasis appeared, so we started chemotherapy with docetaxel/CDDP/5-FU. After 2 courses, lung metastasis was almost disappeared. He has been survived for four years and five months after chemo-radiation. This case suggests that chemo( FP) -radiation therapy and adjuvant chemotherapy could be an effective treatment for endocrine cell carcinoma of the esophagus.

A 40s male was performed proximal gastrectomy with D1+alpha dissection and interposition reconstruction for type 1 esophago-gastric junctional cancer in January 2002. Pathological findings were as follows: pap, se, ly0, v0, n1 (#3, 1/9) stage IIIA, curability B. Adjuvant chemotherapy by 5'-DFUR (800 mg/day) was done for 1 year. Bilateral pulmonary metastasis was detected in left S6 (3.8 cm) and right S10 (3 cm) in February 2006. After S-1 (120 mg/day) was administered for 4 courses, right pulmonary metastasis had become scar, and the other was remained and growing. S-1 (100 mg/ day 1-21)+CPT-11 (120 mg div day 1, 15) was done for 6 courses. However, the tumor was growing. As no other lesions but left pulmonary metastasis in S10, radical thoracoscopic left lower lobectomy with ND1 lymph node dissection was performed. Pathological finding was pulmonary metastasis from gastric cancer with no lymph node metastasis. There were no recurrences observed in May 2009 since gastrectomy was done 7 years ago, and 3 years since pulmonary metastasis was detected.

We report herein a long-term survival case of liver metastasis after distal gastrectomy for gastric cancer. A 72-year-old woman, whom we performed distal gastrectomy with D2 lymph node dissection for type 2 gastric cancer at age 66, was diagnosed as pT2N1M0, stage II. No adjuvant therapy was performed. Liver metastasis was found 1 year and 7 months after surgery. PTX plus CPT-11 was performed. Six courses of therapy were done, and found cCR in the liver metastasis. A total of 23 courses of therapy were done. A recurrence of liver metastasis was found, transcatheter arterial chemoembolization (TACE), radiofrequency ablation( RFA)and operation were performed. She received S-1 plus CDDP, and cCR has been maintained for 6 years and 11 months after gastrectomy (5 years and 4 months after liver metastasis) suggesting that the interdisciplinary therapy was effective.

A patient is a 62-year-old man who was presented by epigastralgia. He was pointed out super advanced gastric cancer with paraaortic lymph node metastasis and pancreatic invasion by gastrointestinal endoscopy (GIS) and computed tomography (CT). We diagnosed as cT4N3M0, and started with chemotherapy as follows. S-1 (120 mg/day) was orally administered for 3 weeks followed by 2-week rest as one course, and CDDP (90 mg/body)was administered by intravenous drip on day 8. Partial response was indicated after 6 courses of this procedure. We changed the procedure to S-1 single treatment for 2 weeks followed by 2-week rest. After 12-course of this procedure, he was attacked by brain infarction, the procedure was interrupted for about 8 months. After rehabilitation, an S-1 single treatment was restarted. The main tumor and metastatic lymph node appeared no change before the interruption of S-1 single treatment. So, we considered that complete response was continued. S-1+CDDP and S-1 single regimen appears to be effective for super advanced gastric cancer.

The first case is a man in his 30s with gastric cancer, of which clinical finding was T3N0M0P0M0 (Stage II), underwent a distal gastrectomy with D2 lymphadenectomy. CY1 was detected during the operation and the final findings was T3N2M0H0P0CY1 (Stage IV). After the operation, we administered 120 mg/day of S-1 for 38 months and the patient remains alive for 6 years and 2 months. The second case is a man in his 20s with gastric cancer, of which clinical finding was T3N0M0P0M0 (Stage IIIa), underwent a distal gastrectomy with D2 lymphadenectomy. CY1 was detected during the operation and the final findings was T3N2M0H0P0CY1 (Stage IV). After the operation, we administered 120 mg/day of S-1 for 13 months and the patient remains alive for 6 years and 2 months. A combination gastrectomy with D2 lymphadenectomy and postoperative chemotherapy was considered to be a radical treatment for CY1, Stage IV gastric cancer.

The patient was a 75-year-old woman, who was diagnosed with type 3 gastric cancer. Total gastrectomy with D2-#10 lymph node dissection and partial hepatic resection was performed. Histological findings showed it to be stage IV (pT2N1M0P0CY0H1) and AFP producing gastric cancer. After the operation, liver metastasis was found, and RFA, partial hepatic resections, hepatic intra-arterial infusion chemotherapy (5-FU, CDDP), intravenous chemotherapy (docetaxel, paclitaxel, CPT-11) were applied. Although liver metastasis was disappeared, paraaortic lymph node recurrence appeared, and chemotherapy was not effective. Radiation therapy (2 Gy/day, total 50 Gy) for paraaortic lymph node metastasis was performed. The metastatic node underwent complete remission following a radiation therapy. Three years and six months passed since the first operation, and the patient has shown no signs of relapse. Therefore, our case suggests radiation therapy could be an effective treatment modality for the lymph node metastasis in AFP producing gastric cancer.

A 63-year-old man was found to have advanced gastric cancer and staging laparoscopy revealed positivity of peritoneal washing cytology. Since curative surgery was deemed not possible, we started chemotherapy using S-1 (80 mg/m2) orally administered for 2 weeks and paclitaxel (50 mg/m2) administered intravenously on days 1 and 8. After 3 courses of chemotherapy, the primary lesion and regional metastatic lymph node were diminished by CT. We confirmed a peritoneal washing cytology negative by laparoscopic examination. We performed a total gastrectomy and dissection of regional lymph node (D2). Pathologically, cancer cells disappeared both in the main tumor and lymph nodes, and histological efficacy was evaluated as grade 3. Adjuvant chemotherapy was done with same regimen, and he has had no recurrence as of 15 months after surgery.

A 69-year-old man was diagnosed with squamous cell carcinoma of the lung, and underwent right upper lobectomy in October 2000. Histological findings were as follows: 2.5 cm in diameter, moderately differentiated squamous cell carcinoma of the lung, ly0, v0, n0, pT1N0M0, stage IA. No adjuvant therapies were performed. Multiple lung metastases were detected on CT scan in June 2001, and four cycles of chemotherapy with cisplatin+vindesine (day 1: cisplatin 100 mg/body, days 1, 8 and 15: vindesine 3 mg/body) were performed. The metastases were completely disappeared on CT scan in December 2001. No relapse has been seen for six years and two months.

We performed chemotherapy with combination of S-1 and CDDP for two patients with progressive gastric cancer accompanied by disseminated carcinomatosis of bone marrow due to bone metastasis with DIC, which was successfully controlled, and they had about one-year prognosis. We think it is worth trying the chemotherapy for the patients with such a severe condition like DIC.

A 70-year-old man was presented with esophageal and gastric cancer pointed by his personal doctor in November 2002. Both of the esophageal and gastric cancer were diagnosed as multiples with cStage II and cStage IA, respectively. In consideration of the patient's quality of life (QOL), chemo-radiotherapy (CRT) for esophageal cancer was preceded, and then total gastrectomy was done. Although esophageal cancer was responded as being complete response (CR), 14 courses of FP therapy were added as supportive chemotherapy. Ten months following CRT, pericardial effusion was noticed, so that pericardiocentesis was performed. Also diuretic has been administered up to the present. Nineteen months following CRT, pleural effusion was noticed and thoracentesis was performed several times into both of the pleural cavities, and that was depending on the degree with OK-432 infusion. Consequently, the patient has been controlled well. As a treatment for esophageal and gastric double cancer, we chose CRT rather than esophagectomy because of the excessive invasiveness. Despite of CR, we have had a difficulty with pleural and pericardial effusions due to the late toxicity of radiotherapy. We need to pay attention to the late toxicity in the case of long-term survival following CRT.

The patient is an 86-year-old man who was presented with right submandibular mass and tarry stool. He was diagnosed having right buccal carcinoma with right cervical lymph node metastasis, gastric cancer with double lesions, and suspected right superior lung cancer by endoscopy and computed tomography. We started with an operation for the right buccal carcinoma. After the operation, superficial-esophageal carcinoma was found. Due to his old age and a lack of physical strength in the operation, we performed an endoscopic mucosal resection for esophageal cancer and argon plasma coagulation for gastric cancer. Symptomatic therapy was only performed for lung cancer. He died from lung cancer 18 months later. However, he had a good quality of life during the progress without recurrence, and the gastric cancer was also controllable without symptoms. It was difficult to decide the treatment for duplicated multiple organ cancers caused by numerous factors such as in our case. We assume that patient's quality of life is the most appropriate factor to be considered in selecting the treatment for elderly patients.

A 50-year-old woman with a past history of breast cancer was referred to our department of radiology for detailed examination after abnormal shadows on chest x-ray were detected following a routine medical examination. After lung biopsy via thoracotomy, segmental resection of the lung was performed and mediastinal lymph nodes were dissected. A histopathological diagnosis of breast cancer with lung metastasis and mediastinal lymph-node metastases was made. Later, the patient complained of pain in the left lower extremity. A diagnosis of a left tibial metastasis was made according to bone scintigraphy and MRI. Radiation therapy at 50 Gy was then initiated. Chemotherapy and hormone therapy combined with bisphosphonate therapy (Bisphonal, once in 2 weeks), was also begun. During the treatment, the patient had multiple organ metastases including multiple brain metastases, and metastases to submental lymph nodes and the left adrenal gland. However, her bone metastasis was limited to the left tibial bone and no other bone lesions were detected by bone scintigraphy and MRI. She did not experience adverse effects from the bisphosphonate therapy. We consider that the inhibition of extension and further metastases of the tibial bone metastasis noted in this patient reflected the efficacy of bisphosphonate therapy, and that bisphosphonate therapy might become an essential treatment in patients with bone metastasis of breast cancer.

Combination chemotherapy with THP, CDDP and 5-FU for squamous cell carcinoma of the head and neck was conducted in 13 institutions in Hyogo Prefecture as a multi-institutional cooperative study. In the initial study (Nov. 1990-Nov. 1993), THP was administered intravenously at 20 mg/m2 on day 1, CDDP at 80 mg/m2 on day 2, and 5-FU at 1,000 mg/body/day in a continuous drip infusion for 120 hours from day 2 to day 6. In the second study (May, 1996-Mar. 1998), THP was administered at 20 mg/m2 on day 1, 5-FU at 10 mg/kg/day from day 1 to day 5, and CDDP at 70 mg/m2 on day 6 in the same way as the initial study. Forty-nine patients (Stage I in 3, Stage II in 12 including 2 recurrent cases, Stage III in 6, Stage IV in 28 including 3 recurrent cases; 1 course chemotherapy in 13 and 2 or more courses in 36) were subjected as complete cases in the initial study, and 36 patients (Stage I in 5 including one recurrent case, Stage II in 11 including 1 recurrent case, Stage III in 9 including 2 recurrent cases, Stage IV in 11 including one recurrent case; 1 course in 18 and 2 or more courses in 18) in the second. The overall response rate was 65.3% (CR in 3 cases) in the initial study and 63.9% (CR in 5 cases) in the second. Primary cases showed a response rate of 65.9% (29/44) in the initial study and 71.0% (22/31) in the second, whereas recurrent cases showed a 60.0% (3/5) response rate in the initial study and a 20.0% (1/5) rate in the second. Treatment-naive patients showed a response rate of 72.7% (24/33) in the initial study and 71.0% (22/31) in the second, whereas previously treated patients showed a 50.0% (8/16) response rate in the initial study and a 20.0% (1/5) rate in the second. Adverse reactions of more than Grade 3 in the initial study were leukopenia in 18.4%, thrombocytopenia in 8.2%, decrease of hemoglobin in 6.1%, loss of hair in 6.1%, anorexia in 36.7%, nausea and vomiting in 26.5%, and diarrhea in 4.1%, whereas those of Grade 3 in the second study were decrease of hemoglobin in 2.8%, anorexia in 22.2% and nausea and vomiting in 8.3%. From these results, it is suggested that the regimen in the second study was more useful than that in the initial study.