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An 85-year-old woman who visited the hospital with sores on the perianal skin was diagnosed with squamous cell carcinoma of the anal canal(cT3N1aM0, cStage ⅢC). She received chemoradiotherapy(radiation total 54 Gy/30 Fr, mitomycin C/capecitabine). The tumor initially shrank, but regrowth of the primary lesion, extensive perianal skin infiltration, and the appearance of para aortic lymph node metastases was observed 6 months later. Laparoscopic abdominoperineal resection was performed to mitigate strong local symptoms. The perineal defect was repaired with bilateral gluteus maximus flap(V- Y flap). The operation prevented anal pain and improved ADL. The patient is currently undergoing chemotherapy 7 months after surgery. We report the case with a review of the literature in which ADL was improved by salvage surgery for tumor regrowth with severe local symptoms and distant metastases after chemoradiotherapy for squamous cell carcinoma of the anal canal.

A woman in her 30s visited our hospital complaining primarily of melena. Colonoscopy revealed the presence of a type 1 tumor in 2 cm from anal verge. Contrast-enhanced CT showed an unresectable massive liver metastasis in the left lobe of the liver and another metastasis in the right lobe. The patient received front-line chemotherapy with Leucovorin, fluorouracil, oxaliplatin, and irinotecan(FOLFOXIRI)plus bevacizumab(BEV). A year later, a marked reduction of liver metastases and primary lesions was confirmed by CT scan imaging. A multidisciplinary team recommended resection of the liver metastases followed by laparoscopic intersphincteric resection for primary lesions. However, after 1 year, a recurrence was diagnosed in the liver; hence, FOLFOXIRI plus BEV was reintroduced for volume reduction. The patient underwent a repeat hepatectomy since enough volume reduction was confirmed. One year later, she experienced a re-relapse of the metastasis in the liver. Currently, she is still undergoing chemotherapy following 7 years since the first visit. Long-term survival can be expected following surgical treatment during chemotherapy.

A 62-year-old woman was diagnosed with gastric cancer, Type 4, cT4b(LN, mesentery of transverse colon), N1 M1H0P1CY1, cStage ⅣB. S-1 and L-OHP(SOX)were administered for 4 courses and clinical response was SD. She interrupted the treatment because of practicing folk therapy. She had an emergency hospitalization due to pyloric stenosis, vomiting, and an umbilical tumor with pain. She was treated with 1 course of mFOLFOX6(5-FU, L-OHP, l-LV)followed by palliative surgery(laparoscopy assisted distal gastrectomy, Roux-en-Y reconstruction, resection of umbilical tumor, and bypass for transverse colon stenosis due to dissemination). The pathological diagnosis was L, Circ, Type 4, 126×89 mm, porsig, pT4b(SI, mesentery of transverse colon), pN3a(12/13), H0P1CY1, pStageⅣ, and metastatic umbilical tumor. Following surgery, oral administration of mFOLFOX6 is continued. Umbilical metastasis(Sister Mary Joseph's nodule)is associated with poor prognosis, however, appropriate management including symptom control by palliative surgery and continuation of chemotherapy may lead a better prognosis.

The incidence of perineal wound complications after extended pelvic surgeries for locally advanced or locally recurrent cancer is high. The management of these refractory complications is usually difficult. Extended pelvic surgeries are commonly associated with severe infectious complications owing to pre-operative chemoradiation therapy, the tissue damage during surgery, and the dead space after radical resections. Negative pressure wound therapy(NPWT)is widely used for the management ofseveral wounds. Recently, the utility ofNPWT has been reported on the management ofinf ectious wound complications post-surgery. Some authors reported the drainage effect of NPWT on pelvic abscess after surgery. However, so far, only a few reports have been published on the usefulness of NPWT in the management of perineal wound disruption or pelvic abscess. We performed NPWT on patients with perineal wound disruption or intractable lymphorrhoea. In these cases, NPWP was effective in early successful treatment. In summary, NPWT is an effective treatment option for perineal disruption and pelvic abscess after surgery for locally advanced or locally recurrent cancers.

A 52-year-old man underwent total gastrectomy for advanced gastric cancer. The postoperative diagnosis was por1mucpor2tub2, pT4a(SE)N3bM0H0P0CY0, pStage ⅢC. He underwent 6 courses of adjuvant chemotherapy with capecitabine plus oxaliplatin. Six months after the surgery, CT showed 2 recurrent lesions: a tumor behind the esophago-jejunal anastomosis and another in the mesentery around the jejuno-jejunal anastomosis. Endoscopy showed intrajejunal invasion. Second-line therapy with paclitaxel and ramucirumab were administered for 3 courses, resulting in rapid progression of the disease. Palliative radiotherapy(39.6 Gy/22 Fr)for both lesions was performed for local control. Sequential administration of nivolumab was started 9 days after terminating radiotherapy. After 6 courses, both tumors markedly reduced PR, and the oral intake of food improved. After 10 courses, there was hyper-progression of the tumor behind the esophago-jejunal anastomosis and shrinkage of the other tumor. Surgery (left upper abdominal exenteration and enucleation of the tumor in the mesentery)was performed to release the jejunal limb obstruction. The tumor behind the esophago-jejunal anastomosis was a poorly differentiated adenocarcinoma, and no viable cancer cells were seen in the tumor in the mesentery. Radiotherapy and immune checkpoint inhibitors may be effective for gastric cancers, although the mechanism of action should be elucidated.

We reported a case of a 30s woman who underwent Hartmann's surgery for sigmoid cancer. Her pathological stage was Stage Ⅳ(pT4b, N1b, M1b[liver and lung]). Postoperatively, 10 courses of systemic chemotherapy with FOLFOX plus cetuximab( Cmab)or bevacizumab(Bmab)were administered. After the chemotherapy, partial liver dissection and radiofrequency ablation(RFA)for multiple liver metastasis were performed. After 2 years of systemic chemotherapy with FOLFIRI plus ramucirumab(RAM), no liver or lung metastasis was observed; however, left supraclavicular lymph node and para-aortic lymph node metastases existed and gradually increased. For the purpose of local control, the para-aortic lymph node metastasis was treated with cervical dissection and carbon ion radiotherapy. Therefore, carbon ion radiotherapy was a useful treatment for local control.

The patient, a woman in her 70s, was diagnosed with occlusive ileus caused by sigmoid colon cancer.She underwent transanal stent placement to release the occlusion.Subsequent detailed testing revealed a 70×60mm mass on the dorsal side of the pancreas and PET-CT indicated an SUVmax 18.2 FDG uptake. EUS-FNA was performed twice.However, the mass was unable to be definitively diagnosed.The patient was then referred to our hospital.She underwent laparoscopic sigmoid colectomy and laparoscopic biopsy of the mass for sigmoid colon cancer.The patient progressed well postoperatively and was discharged home on postoperative day 9.The postoperative diagnosis was colon cancer(S, Type 2, 58×50 mm, tub2, pT4a [SE], pN1, Stage Ⅲa)and the biopsied mass was found to be a nodal marginal zone B-cell lymphoma according to histopathological testing.After undergoing chemotherapy at our hematology department, she has experienced no recurrence.

We report a case of recurrent pancreatic cancer in the remnant pancreas after pancreatoduodenectomy(PD)that was successfully treated by surgical resection. A woman in her 70s who was treated for multiple lung metastases of breast cancer was referred to our hospital because of obstructive jaundice. A low-density area in the pancreas head(19mm in diameter) and dilatation of the main pancreatic duct were observed on abdominal CT. She was diagnosed with pancreatic head cancer and underwent PD. Twenty months after PD, abdominal CT revealed a tumor in the pancreas tail, and she started receiving chemotherapy containing gemcitabine(GEM)for the diagnosis of recurrent pancreatic cancer in the remnant pancreas. Twelve months after the induction of chemotherapy, we performed surgical resection of the tumor(total pancreatectomy). The pathological diagnosis was moderately differentiated adenocarcinoma, which was similar to the primary lesion, and the tumor was confirmed as recurrence of pancreatic cancer. Although she died of multiple lung metastases of breast cancer 62 months after the total pancreatectomy, the recurrence of pancreatic cancer was not observed without adjuvant therapy during that time.

A man in his 70s was diagnosed with gastric cancer and underwent total gastrectomy with D2 lymphadenectomy. The final diagnosis was T3(SS)N2M0, Stage ⅢA. After surgery, S-1 was administered for 1 year. One year and 6 months after surgery, abdominal computed tomography showed a single liver tumor(S4: 30mm). Based on overexpression of the human epidermal growth factor receptor 2(HER2)protein in the primary tumor, we selected capecitabine plus cisplatin plus trastuzumab as the combination chemotherapy. After the second course, the therapeutic response was stable. S4 partial liver resection was performed. The liver tumor was histologically evaluated as Grade Ⅰb metastatic gastric adenocarcinoma. After surgery, capecitabine plus trastuzumab was administered for 1 year. One year after resection of liver metastasis, the patient is alive without any relapse.

An 82-year-old man receiving oral administration of warfarin for atrial fibrillation underwent distal gastrectomy for advanced gastric cancer. The postoperative diagnosis was pT3(SS)N2M1H1P0CY0, pStage Ⅳ,(HER2, score 3+)gastric cancer. He received chemotherapy for the treatment of multiple liver metastases, following which, he developed lymph node metastases. Grade 3 anemia was observed at 46 months after initiation of chemotherapy when he was treated with third-line irinotecan plus cisplatin. Abdominal CT showed that CR for liver metastases and SD for lymph node metastases were maintained. Esophagogastroduodenoscopy and colonoscopy showed no intraluminal bleeding. As the anemia progressed, blood transfusion was required repeatedly instead of withdrawal of chemotherapy and replacement therapy of iron and vitamin B12. Double- balloon endoscopy revealed hemorrhagic tumor at duodenal stump. We diagnosed tumor bleeding from metastatic lymph node around pancreatic head invading to duodenum. Palliative radiotherapy(40 Gy/20 Fr)for hemostasis was performed. Finally, hemostasis and tumor shrinkage were achieved.

Here, we report a long-term survival case treated with docetaxel and S-1 combination therapy(DS therapy)for peritoneal dissemination of gastric cancer. A 58-year-old man was diagnosed with gastric cancer in 2006. Distal gastrectomy, D2 dissec- tion, and RY reconstruction were performed. The pathological diagnosis was gastric cancer, por2, pT3(SS), pN3a(8/27), pStage ⅢB. S -1 monotherapy was administered as an adjuvant chemotherapy for 1 year from 3 months after surgery. Five years after surgery, peritoneal dissemination and bladder recurrence caused rectal stenosis and hydronephrosis. We performed ileostomy and left nephrostomy. DS therapy was started 5 years and 2 months after the initial surgery. A complete clinical remission was observed 2 years and 10 months after starting DS therapy(23 courses). Multiple lymph node metastasis and bone metastasis were confirmed at 5 years and 5 months(57 courses). Even though irinotecan monotherapy was performed for five courses, the bone and lymph node metastasis increased at 5 years and 9 months after starting DS therapy, and the patient died at 69 years of age. DS therapy may be a useful option for peritoneal metastasis of gastric cancer.

We reported the outcome of colorectal peritoneal dissemination resection. Eleven patients who underwent R0 resection for colorectal peritoneal dissemination from January 2009 to December 2017 were examined in our hospital. The median observation period was 23 months, the 3-year overall survival rate was 72.8%, and the 3-year relapse free survival rate was 22.7%. Thus, surgical resection might be useful for peritoneal dissemination.

A 69-year-old man was admitted for the growing anal tumor and referred to our hospital. The tumor was about 40mm in size, and by biopsy, he was diagnosed the adenocarcinoma. Based on this diagnosis, abdominoperinealresection and edge resection were performed. Histopathologicalfindings showed mucinous carcinoma originating from analgl and with pagetoid spread. Postoperative chemotherapy was not performed, but 1 year 6 months after the surgery, inguinall ymph node recurrence was found, and lymph node dissection was performed. One year after the operation, recurrence was not found.

Appendiceal mucinous adenocarcinoma accompanied by cysts ruptures by surgical operation and leakage of mucus into the peritoneal cavity results in deterioration of prognosis.We report a case where the appendix mucinous adenocarcinoma was safely excised by laparoscopically preceding vascular treatment, lymph node dissection and intestinal dissection.The case was a woman in her forty-age suffering from the right lower quadrant and fever; no improvement was observed even when antibiotics were administered.A cystic lesion with a maximum diameter of 75mm was found on the right side of the pelvis with CT, and numerous lymph adenopathy was observed along the iliac artery.Preoperative diagnosis was diagnosed as appendiceal mucinous adenocarcinoma suspected and laparoscopic resection of the cecum was performed with the above procedure without breaking the cyst.Pathological diagnosis was findings of appendicular mucinous adenocarcinoma.She was discharged on the 7th postoperative day after surgery, 6 months after surgery without relapse survival.In order to resect a cystic tumor by laparoscopic surgery, it is considered to be useful to take care to prevent the forceps from touching the tumor, and perform a procedure that precedes vascular dissection and intestinal dissection.

The aim of this study was to evaluate the rate of surgical site infection(SSI)after hepatectomy in elderly patients with hepatocellular carcinoma(HCC). From June 2010 through December 2016, 276 cases of hepatectomy for HCC were performed in our hospital, and 39 cases included patients aged80 years. The rate of SSI in the elderly group compared to the non-elderly group was 15.38%(6/39 cases)vs 7.73%(p=0.0855). The Child-Pugh classification(A/B/C)in the SSI group (n=6)vs in the non-SSI group(n=33)was 6/0/0 vs 32/1/0(p=0.5605), the liver damage classification(A/B/C)was 4/ 2/0 vs 25/8/0(p=0.6467), BMI was 23.3 kg/m / 2 vs 22.8 kg/m2(p=0.6544), PNI was 43.1 vs 46.2(p=0.3804), the operation time was 348.5 minutes vs 315.1 minutes(p=0.4478), blood loss was a small amount vs 401.5mL(p=0.0143), and the hospital stay after the operation was 27.5 days vs 10.0 days(p=0.0401), respectively. Hepatectomy for elderly patients was safe and feasible, and the only significant risk factor for SSI in elderly HCC patients was intraoperative blood loss.

We report a case of a woman who was suffering from post-radiochemotherapy perineum abscess concurrent with the recurrence of vaginal cancer for which total pelvic exenteration was performed. A 66-year-oldwoman presentedat our hospital with irregular genital bleeding in November 2014. A series of examinations showedthat she was suffering from vaginal cancer(cT2N0M0, cStage II ). A radiochemotherapy regimen(external irradiation 45 Gy/25 Fr, CDDP 40mg/m2, 5 course)was commencedin January 2015. In the meantime, MRI revealedsome therapeutic effect, but in October 2015, MRI indicated the enlargement of the primary tumor(PD). The chemotherapy regimen was alteredanda regimen of paclitaxel plus nedaplatin was commenced in November 2015 andw as continueduntil April 2016. MRI was performedin March 2016 to distinguish the therapeutic response between PR and CR. In May 2016, the patient complainedof an increasedfrequency of melena. Colonoscopy was performedto reveal Grade 3 radiation enteritis, andargon plasma coagulation was requiredto stop bleeding. In June 2016, MRI was performedandrevealedCR. In July 2016, however, the radiation enteritis led to rectovaginal fistula, for which we performed transverse colostomy. Thereafter, the necrotic tissue gradually expanded into the perineum area to involve the urethra. Recurrence of the cancer was suspected; therefore, we decided to perform total pelvic exenteration in December 2016. Pathological examination of the surgical specimen indicated the recurrence of the vaginal cancer. We report this rare case andd iscuss the usefulness of total pelvic exenteration for the recurrence of vaginal cancer.

A 60-year-oldman was diagnosedwith ascending colon cancer with multiple bilobar metastases. He then received7 courses of tegafur-gimeracil-oteracil andoxaliplatin (SOX)plus panitumumab as downstaging chemotherapy. This treatment significantly reducedthe size of the metastatic tumor, andwe subsequently triedto perform a curative resection. A twostage hepatectomy was plannedto avoidthe risk of hepatic failure from small future liver remnant. First, the anterior segmentectomy andthe left portal vein ligation were performed. Then, a curative resection consisting of a left lobectomy andextend - edright hemicolectomy were performed2 0 days after the first surgery. No recurrence was observed1 5 months after the operation. Two-stage hepatectomy as well as a combination of induction chemotherapy and portal vein ligation may have contributedto the improvedprognosis of the initially unresectable multiple bilobar liver metastases.

We report a case of peritoneal metastasis of bile duct cancer that was successfully treated by surgical resection. A 70s man underwent pancreatoduodenectomy(PD)for bile duct cancer, and abdominal CT revealed a tumor in the peritoneum along the right kidney at 55 months after PD. As FDG uptake was seen at the lesion on PET-CT, he was diagnosed as recurrence of bile duct cancer or primary malignant tumor in the retroperitoneum. Because the tumor was solitary on CT and PET-CT, we conducted surgical resection of the tumor. Pathological diagnosis was well differentiated adenocarcinoma that was similar to the primary lesion, and the tumor was confirmed as recurrence of bile duct cancer. He remains alive without 2nd recurrence for 60 months since tumor resection(117 months since PD).

The patient was a 59-year-old woman with progressive sigmoid colon cancer with multiple metastasis(T3N2M1b[P2, H3, PUL2]Stage IV ). As the RAS gene in the patient was wild-type, we administered cetuximab monotherapy every week. One month after chemotherapy initiation, the tumor marker levels declined and the tumor size reduced. Patient's general condition was improved and mFOLFOX6 therapy was then continued in addition to cetuximab. As a side effect, acne-like rash is only grade 1 to 2, and there are no other serious side effects. Cetuximab monotherapy may contribute to the treatment of poor PS patients.

A 76-year-old woman had undergone a laparoscopic low anterior resection for rectal cancer. After 12 months, CT showed 2 tumors measuring 25mm in diameter in the pelvis and hydronephrosis. The patient was treated with CapeOX plus bevacizumab( Bmab). After 3 courses of chemotherapy, the size of the tumors was remarkably reduced. After 6 courses, the chemotherapy was withdrawn because of cystitis. Anaphylactic shock occurred after the 7th course after resumption of treatment. After 42 days, the chemotherapy(Cape plus Bmab)was resumed. The patient is recurrence free 13 months after achieving a complete response(CR).

Here we report a case of a hemorrhagic gastric cancer patient with severe coronary artery disease, in whom the cancer was successfully resected with the support of intra-aortic balloon pumping(IABP). An 80-year-old man was referred to our hospital for further examination of his anemia and tumor around the pancreatic head. He was diagnosed with type 3 gastric cancer with multiple bulky lymph node metastases invadingto the pancreas(cT4b[LN-Panc], N3a, M1[LYM No.16a2int], cStage IV ). Tarry stools continued and blood transfusion was repeatedly required. To control tumor bleeding, we considered that gastrectomy should be performed prior to chemotherapy. Since he had a history of acute myocardial infarction, coronary angiography was performed, which showed severe coronary stenosis in 3 vessels. Preoperative percutaneous coronary intervention or coronary artery bypass grafting were inappropriate because of tumor bleeding. We performed palliative distal gastrectomy under the support of IABP. The postoperative course was uneventful and he could initiate subsequent chemotherapy smoothly. IABP may be a useful option for hemorrhagic gastric cancer patients with severe coronary stenosis.

A 30-year-old woman was admittedto the hospital because of fecal occult bloodpositivity . Endoscopic colonoscopy indicated pressure on the right side of the rectum from the wall. Abdominal contrast CT and pelvic MRI revealed a cystic lesion with a maximum diameter of 5 cm on the pre-coccyx andthe right side of rectum. There was no continuity between the tumor andthe uterus/ovary. We diagnoseda pararectal tumor andremovedit via a sacral approach. The cyst was diagnosed as an epidermoid cyst. She was discharged on the 5th postoperative day. We could resect the tumor completely, because we chose an appropriate approach, considering the position, developmental direction, and size of the tumor.

A 80s-year-old man with hemophilia B underwent operation for rectal cancer.Metastasis of the lymph nodes was revealed, so he was treated with adjuvant chemotherapy involving capecitabine and oxaliplatin(CapeOX).For safety, we measured tissue factor IX before every course of chemotherapy, and he completed 8 courses safely.

Lynch syndrome is an inherited syndrome with the development of the colorectal and various other cancers. Lynch syndrome is caused by mutations in the mismatch repair genes. A 33 year-old male underwent XELOX adjuvant chemotherapy for ascending colon cancer with Lynch syndrome. Although efficacy of 5-FU is not demonstrated in Lynch syndrome, MOSAIC trial had suggested a benefit from FOLFOX compared with 5-FU in patients who have colorectal cancer with Lynch syndrome. Oxaliplatin-based adjuvant chemotherapy can be a therapeutic option for colorectal cancer in lynch syndrome patients.

A 75-year-old man was admitted with abdominal pain and taken to our hospital. CT and MRI showed a tumor measuring 60mm in diameter in the pelvic cavity. Based on the imaging findings, we suspected a schwannoma and decided to perform surgery. As the tumor was found to be benign in intraoperative frozen section diagnosis, the tumor was enucleated. Histopathological findings showed no nuclear atypia, and the patient was diagnosed with a schwannoma. He complained of paresthesia in his right leg after surgery, and underwent walking training. Six months after surgery, no recurrence was found.

A 64-year-old man reporting dysphagia was examined. Upper gastrointestinal endoscopy showed a type 3 cancer at the esophagogastric junction. Enhanced CT scan showed several swollen mediastinal and abdominal lymph nodes. We diagnosed the patient with advanced adenocarcinoma of the esophagogastric junction with multiple lymph node metastases(Siewert type II , cT3N2M1[LYM], Stage IV ). After 5 courses of chemotherapy(S-1 plus cisplatin), a significant reduction was observed in the size of the tumor and lymph nodes. Therefore, we performed conversion surgery. The patient underwent esophagectomy and mediastinal lymph node dissection using a right thoracotomy approach. He has survived without recurrence in the 10 months since this radical surgery.

A 60-year-old woman was diagnosed with a rectal neuroendocrine tumor(NET)with SM invasion.We performed laparoscopic low anterior resection with D3 lymph node dissection.Pathological findings were rectal NET, G1, pSM(9,000 mm), ly0, v0, pN0, PM0, DM0, pR0, pStage I .Four years and 6 months later, contrast enhanced abdominal computed tomography (CECT)and contrast enhanced magnetic resonance imaging revealed multiple liver metastases.The tumors were unresectable because they were bilobar; therefore, we performed transcatheter arterial chemoembolizaion(TACE).One month later, CECT showed the lesions had shrunk.The metastases were well controlled via repeated TACE.For unresectable liver metastases from rectal NET, TACE can be an effective treatment.

A 42-year-old woman was admitted to our hospital because of a positive fecal occult blood test. Colonoscopy examination revealed an elevated lesion measuring 25mm in diameter at the terminal ileum. A histological diagnosis of neuroendocrine tumor(NET)was made based on biopsy specimens taken from the lesion. Since no apparent distant metastasis other than the ileocolic lymph nodes was noted, laparoscopy-assisted ileocecal resection with regional lymph node dissection was performed. In the resected material, NET(G2)limited to the subserosa layer was present. The NET tested positive for synaptophysin, chromogranin A, and CD56. Metastases in the paraileal lymph nodes was detected. NET metastasis to the ileum is frequent, even if the tumor is small in diameter; therefore, it is necessary to resect the tumor entirely and to dissect the regional lymph nodes.

An 80-year-old woman had undergone a right hemicolectomy for ascending colon cancer 9 months prior to the current presentation. CT and PET-CT showed a solitary tumor measuring 55mm in diameter at the uterus and rectum. Three 5mm ports and two 12mm two ports were placed. The sigmoid colon was mobilized using a medial approach as usual in laparoscopic surgery. The rectum and uterus were mobilized and were resected. We inserted the End-catchTM in from the vagina and removed the specimen. The patient had no abdominal pain and was discharged from the hospital 9 days after the operation.

A 59-year-old man underwent total gastrectomy(with D2 dissection)and cholecystectomy for gastric cancer and a submucosal tumor of the stomach. The specimen was immunohistochemically positive for c-kit, the Ki-67 label index was 10%, and the mitotic count was 20/HPF. Finally, the patient was diagnosed with high-risk gastrointestinal stromal cancer with normal type gastric cancer. After discharge from hospital, we started administration of TS-1 as adjuvant therapy for the gastric cancer. As multiple recurrences of the GIST in the abdomen developed, the patient underwent 3 radical local resections. Mutational analysis revealed a PDGFRA mutation in exon 18, which causes resistance to both imatinib and sunitinib. As he was refractory to imatinib, the patient received regorafenib. After a while, it caused liver failure, which required 7 rounds of plasmapheresis. The patient died from multiple organ failure resulting from multiple recurrences 4 years after the first surgery.

A 70-year-old-man, whose chief complaint was epigastric pain, was referred to our hospital and diagnosed with advanced gastric cancer with multiple liver metastases. Gastrointestinal endoscopy showed a tumor on the anterior wall of the gastric lower body. Histologically, biopsy specimens indicated adenocarcinoma, and immunohistochemistry showed positive expression of HER2(3+). Chest and abdominal computed tomography showed multiple liver metastases and lymph node metastases. We started chemotherapy with capecitabine, cisplatin, and trastuzumab. Abdominal CT showed the primary tumor and metastases to be reduced after 3 courses, but a ringed enhanced space occupying lesion in the liver had appeared, which was diagnosed as a liver abscess. After administering antibiotics and performing percutaneous transhepatic abscess drainage (PTAD), we continued XPT chemotherapy. The patient received 6 courses of XPT, 15 courses of capecitabine and trastuzumab, and 6 courses of trastuzumab alone, and has remained progression free in the 1 year and 5 months after diagnosis. We experienced a case of advanced gastric cancer with multiple liver metastases successfully treated with capecitabine, cisplatin, and trastuzumab.

A n 85-year-old woman presented with a mass in the left breast. A3 7mm lobulated mass including enhancement of a cyst of 37mm was detected by sonography. An axillary lymph node had increased to 16 mm. Atypical cells dyed by light green and orange G were identified by fine needle aspiration and cytology. She was diagnosed with left breast cancer(cT2N1M0, Stage II B), histologically suspected to be squamous cell carcinoma. She underwent a left-breast-conserving surgery and axillary lymph node dissection. On pathology, a cyst of 34×30mm was noted. The tumor grew from inside the cyst to the surround- ing tissue and it had a trend for keratinocytes. Lymph node metastases affected 1/11. By immunostaining, the tumor was found to be ER(+), PgR(-), HER2(-), CK5/6(+), p40(+), mammaglobin(-), and GCDFP15(-). There was no component of ductal carcinoma. She received radiotherapy to the left breast and tamoxifen as an adjuvant therapy. Squamous cell carcinoma of the breast is rare. We encountered a case of pure squamous cell carcinoma of the breast in an elderly woman. We report this case with a discussion of the relevant literature.

Laparoscopic surgery is less invasive and has better cosmetic results. Laparoscopic liver resection(LLR)was covered by health insurance in April 2010, and has increasingly been performed in many hospitals, and also in cases of elderly patients. We report the results of laparoscopic liver resection for hepatocellular carcinoma(HCC)in patients ≥80 years old. From June 2010 through March 2016, 237 cases of laparoscopic hepatectomy for HCC were performed in our hospital, and 35 of 237 cases were patients ≥80 years old(the elderly group). The operation time in the elderly vs the non-elderly group was 321 minutes vs 340.9 minutes(p=0.4676), the blood loss was 447.2mL vs 331.5mL(p=0.6691), and the hospital stay after the operation was 18 days vs 16 days(p=0.6347). The 3 year disease free survival rate for stage I was 66.7% vs 58.6%(p= 0.1849), for stage II was 35.6% vs 31.8%(p=0.7538), for stage III was 33.3% vs 49.5%(p=0.8683), and for stage IV was 100% vs 32.4%(p=0.3452). Laparoscopic hepatectomy for HCC can be performed safely, even for patients ≥80 years old. Further studies are necessary to confirm the benefits of laparoscopic liver resection for elderly patients compared with the non-elderly.

A 69-year-old man with anemia underwent colonoscopy. Colonoscopy showed a black tumor, 2 cm from the anal verge. The biopsy specimen revealed malignant melanoma, which was preoperatively diagnosed as T1(SM), N0, M0, Stage I . We performed laparoscopic abdominoperineal resection. The tissue type and diagnosis were malignant melanoma, pT1b(10 mm), pN0, pM0, ly0, v0, pDM0, pPM0, pRM0, pStage I b, according to the Colon Cancer Handling Terms, 8th edition). The patient did not receive adjuvant chemotherapy. However, he survived postoperatively for 9 months, with no sign of recurrence.

We report the case of a 70-year-oldwoman with local recurrence of occult breast cancer after conserving therapy. Breast cancer metastasis to an axillary lymph node was suspected when she was 62-years-old. Even with mammography, ultrasound sonography, positron emission tomography/computedtomography, andmagnetic resonance imaging, the primary disease lesion could not be identified. She underwent axillary dissection, and received 5 years of endocrine therapy. Eight years after surgery, a new ipsilateral breast tumor was detectedusing ultrasoundsonography andvacuum assistedbiopsy, confirmedas invasive carcinoma. This time the patient had no distant metastases; therefore, she was diagnosed with local recurrence, and mastectomy with immediate breast reconstruction was performed. Breast conserving surgery aims to reduce the psychological burden on the patient but must be closely followed-up in case of local recurrence. Any incidences of local recurrence can also be treatedusing breast reconstruction surgery.

Pancreatic adenocarcinoma is one of the leading causes of cancer deaths in Japan.Albumin -bound paclitaxel (nab-paclitaxel)plus gemcitabine hydrochloride(GEM)combination chemotherapy provided significant improvements in the overall and progression-free survival in a phase III trial in Europe and America and a phase II trial in Japan.As a result, this combination therapy was approved for use in Japan.We evaluated the efficacy of nab-paclitaxel plus GEM with metastatic or recurrent pancreatic cancer.Between December 2014 and March 2016, 11 patients received nab-paclitaxel plus GEM as follows: nab-paclitaxel(125mg/m2 of body-surface area)followed by GEM(1,000mg/m2)on days 1, 8, and 15 every 4 weeks.The treatment was continued until disease progression, unacceptable adverse events, discontinuation as decided by the investigators, or patient refusal.The mean age was 65.6 years(range, 48-75 years), and 8 out of 11 patients were men.Ten patients had an Eastern Cooperative Oncology Group(ECOG)performance status(PS)of 0.Ten patients had metastatic disease.Only 4 patients had no prior therapy.The mean duration of treatment was 10.2 weeks(range, 2-41 weeks).The relative dose intensities of nab-paclitaxel and GEM were 90.6%(66.7-100%)and 87.5%(62.9-100%), respectively.The major Grade 3 or 4 hematological toxicities were leucopenia(54.5%), neutropenia(36.4%), anemia (27.3%), and thrombocytopenia(18.2%).The major grade 2 or 3 non-hematological toxicities were fatigue(45.6%), skin rash(27.3%), peripheral sensory neuropathy(9.1%), anorexia(9.1%), and stomatitis(9.1%).There were no treatmentrelated deaths.Interstitial lung disease was not observed.The 6 month progression-free and overall survival rate were 25.7% and 66.7%, respectively. The disease control rate was 90.9%(complete response, n=0; partial response, n=1; stable disease, n=9; progressive disease, n=1).Nab-paclitaxel plus GEM is well tolerated and associated with efficacy and improved survival outcomes.Nab -paclitaxel plus GEM can be the standard treatment for patients with metastatic pancreatic adenocarcinoma.

Pancreatic ductal carcinoma is a highly aggressive cancer, and chemotherapy is the standard therapy for pancreatic adenocarcinoma. We report curative resection for a case of pancreatic cancer with liver metastasis after chemotherapy. A 67-yearold woman presented with vomiting and weight loss, and was admitted to our hospital for an evaluation of pancreatic lesions. Computed tomography revealed a hypoattenuating tumor in the head of the pancreas. We would usually perform pancreatoduodenectomy based on a diagnosis of cStage III . However, this case was inoperable because we found 4 liver metastases during surgery, which we resected. Sixteen days after surgery, we administered FOLFIRINOX chemotherapy. The grade 2 toxicities were nausea, anorexia, diarrhea, and fatigue, but serious adverse events did not occur. After 7 courses of chemotherapy, no new metastases were noted. Therefore, radical subtotal stomach-preserving pancreatoduodenectomy was performed. The patient has survived without any recurrence for more than 17 months after hepatectomy.

There are almost no reports about drug excretion management during colorectal cancer chemotherapy. Anticancer chemotherapeutic drugs excreted in urine and feces may exert toxic effects and promote teratogenesis, mutagenesis, and carcinogenesis. To assess the knowledge of patients about drug excretion, a questionnaire survey was performed among 45 patients receiving chemotherapy for colorectal cancer in our hospital; among them, 36 patients completed the survey. Most of the patients did not know about the excretion and toxic effects of anticancer drugs. The results indicate that patients should be instructed on the management ofexcretion during chemotherapy to minimize toxic exposure. We believe that unnecessary exposure of patients and their families to anticancer drugs should be minimized. This study highlights the importance of issuing guidelines regarding excretion management during cancer chemotherapy.

Pancreatic adenocarcinoma is one of the leading causes of cancer-related deaths in Japan. oxaliplatin: L-OHP, irinotecan: CPT-11, fluorouracil: 5-FU, and Leucovorin: l-LV (FOLFIRINOX) combination chemotherapy provided significant improvements in overall and progression-free survival in a phase Ⅲ trial in France and in a phase Ⅱ trial in Japan. As a result, this combination therapy was approved for use in Japan. We evaluated the efficacy of FOLFIRINOX in metastatic or recurrent pancreatic cancer. Between October 2014 and July 2015, 10 patients received mFOLFIRINOX as follows: 2-hour infusion of LOHP at 85 mg/m2, 2-hour infusion of l-LV at 200 mg/m2 and infusion of CPT-11 over 90 min at 150 mg/m2, followed by continuous infusion of 5-FU over 46 hours at 2,400mg/m2. Prior to the treatment, a 5-hydroxytryptamine receptor antagonist, aprepitant, and dexamethasone were given. The treatment was repeated every 2 weeks until disease progression, unacceptable toxicity, discontinuation as decided by the investigators, or patient refusal. The mean age of the patients was 65.0 years (range, 59-75 years), and 4 out of 10 patients were men. Only 2 patients had no prior therapy. Nine patients had an Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 0. Eight patients had metastasis and 2 had locally recurrent disease. The median number of treatment cycles was 5 (range, 1-14). The relative dose intensities of 5-FU, L-OHP and CPT-11 were 93.3% (range, 58.3-100%), 84.0% (range, 63.2-100%), and 76.0% (range, 44.4-83.3%), respectively. The major Grade 3 and 4 hematological toxicities were neutropenia (40%), leucopenia (30%), and thrombocytopenia(10%). The major Grade 2 and 3 non-hematological toxicities were diarrhea (30%), nausea (60%), and vomiting (10%). Serious adverse events occurred in 2 patients. Severe biliary tract infection causing sepsis was observed in 1 patient with a biliary stent. Overwhelming post-splenectomy infection was observed in 1 patient after distal pancreatectomy. No cases of interstitial lung disease were observed. The 6-month progression-free and overall survival rates were 59.3% and 61.7%, respectively. The overall response rate was 10%, and the disease control rate was 90%(complete response [CR], n=0; partial response [PR], n=1; stable disease [SD], n=8; progressive disease [PD], n=1). Although FOLFIRINOX is associated with increased treatment efficacy and survival outcomes, because of its severe toxicity it cannot be administered to all patients. FOLFIRINOX can be used as the standard treatment for patients with a good performance status.

The Guidelines for Colorectal Cancer Treatment list indication and curative resection criteria for the endoscopic resection of mucosal and submucosal invasive colorectal cancers. Here, we report the case of a woman who underwent endoscopic mucosal resection (EMR) but should have undergone curative resection because the submucosal invasion depth in this case was 1,200 mm; however, she did not undergo additional curative surgery. Although liver and lymph node metastases were observed 7 years later, we were able to resect all of these tumors after neoadjuvant chemotherapy. We strongly recommend additional curative surgery for patients who fulfill the criteria for curative resection after EMR because of the very high recurrence rates in such cases.

Systemic chemotherapy based on 5-fluorouracil (5-FU) is a standard treatment for unresectable or recurrent colorectal cancer. Although hyperammonemia is known as one of the adverse side effects of 5-FU, a disturbance of consciousness caused by hyperammonemia is not a usual finding. We encountered a case of 5-FU-related consciousness disturbance with respiratory depression. A woman in her sixties was diagnosed with metastatic cecum cancer, involving peritoneal dissemination and hydronephrosis due to retroperitoneal invasion. After resection of the primary lesion, systemic chemotherapy, including capecitabine, irinotecan, bevacizumab and cetuximab, was administered for the metastatic lesions. As a third-line of treatment, the mFOLFOX6 plus bevacizumab regimen was administered. On the second day of the first course, the patient complained of nausea and vomiting. On third day, her consciousness level was deteriorating. The level of ammonia in the blood was abnormally high. Therefore, we diagnosed consciousness disturbance caused by hyperammonemia resulting from high-dose 5-FU infusion. The symptom improved immediately after mechanical ventilation and intravenous infusion. Renal dysfunction is considered a risk factor for hyperammonemia caused by 5-FU, and it is necessary to pay particular attention in patients with renal dysfunction who receive chemotherapy with 5-FU.

The patient was an 86-year-old woman. She underwent right breast-conserving surgery and sentinel lymph node biopsy for breast cancer in August 2006. The pathological diagnosis was invasive ductal carcinoma, T1N0M0, Stage Ⅰ, ER (+), PgR (-), HER2 (-). She was treated with tamoxifen for 5 years as adjuvant therapy and showed no signs of recurrence. In November 2014, CA15-3 was elevated and an accumulation of FDG in the right paracolic sulcus was observed on PET-CT. Peritoneal metastasis of breast cancer was suspected, and an operation was performed for a definitive diagnosis. During the operation, the tumor was seen on the paracolic sulcus, and laparoscopic-assisted right hemicolectomy was performed. A poorly differentiated adenocarcinoma was diagnosed by pathological examination, and immunostaining results were as follows: CK7(+), CK20(-), mammaglobin (-), GCDFP-15 (-), ER (-), PgR (-), and HER2 (-). Because there was no original lesion other than the breast cancer, the tumor was diagnosed as a metastasis of breast cancer. The frequency of peritoneal metastasis of breast cancer is low. In this case, pathological diagnosis was necessary for a definitive diagnosis. A change of subtype was also confirmed, and the treatment strategy was decided appropriately. Surgical resection should be considered for peritoneal metastasis of breast cancer when the operation can be performed safely.

A 68-year-old man diagnosed with type 0-Ⅰgastric cancer by gastrointestinal endoscopy underwent urgent distal gastrectomy due to a perforation during endoscopic submucosal resection. Pathological examination revealed pT3N2M0, pStage ⅢA. TS-1 was administered as adjuvant chemotherapy. Laboratory examinations 10 months after surgery revealed leukocytosis (19,100/mL). Positron emission tomography-CT demonstrated metastases in the bone marrow and ascending colon as well as around the liver. Chemotherapy using nab-PTX had poor efficacy and the leukocytosis worsened. Serum granulocyte- colony stimulating facto (r G-CSF) was high at 1,640 pg/mL, and immunohistochemical staining was positive for G-CSF. Thus, the patient was diagnosed with G-CSF-producing gastric cancer. The tumor was also positive for HER2 antibody by immunohistochemical staining. Combination therapy using TS-1 plus CDDP plus trastuzumab resulted in a good response, and the leukocytosis and elevated serum G-CSF gradually improved. The patient is living 30 months postoperatively and remains on chemotherapy.

Pancreatic ductal carcinoma is a highly aggressive cancer, with one of the highest mortality rates among gastrointestinal cancers. Nab-paclitaxel plus gemcitabine (GEM) significantly improved overall survival, progression-free survival, and response rate in a phase Ⅲ trial in 151 community and academic centers in 11 countries. As a result, nab-paclitaxel plus GEM was approved for use in December 2014 in Japan. We report a case of a patient with pancreatic cancer who underwent this chemotherapy. A 47-year-old man was admitted to our hospital for evaluation of pancreatic lesions. Computed tomography revealed a hypoattenuating tumor in the body of the pancreas. After the patient underwent preoperative chemoradiotherapy under the diagnosis of cStage Ⅳa cancer, we planned to perform distal pancreatectomy. However, this case was inoperable because we found 3 liver metastases during surgery. On postoperative day 14, we treated the patient with nab-paclitaxel plus GEM. Grade 2 toxicities included neutropenia, diarrhea, and peripheral neuropathy, but serious adverse events did not occur. The progression-free survival was 5 months. He remained alive for 7 months after the chemotherapy. In patients with metastatic pancreatic adenocarcinoma, nab-paclitaxel plus GEM can be considered as the standard treatment.

The indications for duodenal stent placement for gastric outlet obstruction caused by gastric cancers remain controversial. We report the case of a patient with inoperable advanced gastric cancer with gastric outlet obstruction in whom oral intake could be prolonged for more than 2 years by duodenal stenting. A 60-year-old man diagnosed as having cStage Ⅳ gastric cancer with liver, peritoneum, and lymph node metastases underwent duodenal stent placement before first-line chemotherapy. After 8 months, the duodenal stent was found to be dislocated in the horizontal part of the duodenum due to tumor shrinkage. It was removed immediately by endoscopy. The patient was able to take a solid diet orally for the next 19 months, while receiving systemic chemotherapy.Duodenal stent placement proved useful in a patient who showed response to chemotherapy, despite the need for management of late complications. This approach is expected to be a first-line treatment option for gastric outlet obstruction caused by inoperable gastric cancer.

A 71-year-old man was admitted to our hospital for epigastric pain. Upper gastrointestinal endoscopy revealed a type 2- like ulcerative lesion in the posterior wall of the upper and middle part of the stomach. Endoscopic biopsies showed malignant T-cell lymphoma histologically. A chest CT scan revealed a nodule in the apex of right lung, suggestive of primary lung cancer. A total gastrectomy with D2 lymphadenectomy and distal pancreatectomy with splenectomy was performed. Seventy-three days after surgery, the patient developed a lung abscess in the middle lobe of the right lung. A wedge-shaped resection of the upper lobe and total resection of the middle lobe of the right lung was performed. Histological examination revealed a primary pulmonary mucosa-associated lymphoid tissue lymphoma in the upper lobe of right lung and an abscess caused by Pseudomonas aeruginosa in the middle lobe of the right lung. Twelve months after surgery the man died of suffocation because of aspiration due to esophageal stenosis caused by progression of metastasis of the paraesophageal lymph node.

A man in his 60's was admitted to our hospital because of right lower abdominal pain. We diagnosed acute appendicitis with an abscess, and he was treated with laparoscopic-assisted appendectomy. The histopathological diagnosis was a goblet cell carcinoid (GCC) of the appendix. Because of the possibility of lymph node metastasis, the patient underwent laparoscopic- assisted ileo-cecum resection with lymph node dissection (D2). Metastasis was detected in one of the dissected lymph nodes. This patient has been followed-up for a year after surgery and no recurrences have been detected.

Laparoscopic surgery is less invasive and provides better cosmetic outcomes than conventional surgery. Laparoscopic liver resection has been covered by insurance since April 2010 and is increasingly performed in many hospitals. However, laparoscopic hepatectomy is sometimes difficult to perform safely in the case of HCC recurrence because adhesions restrict vision and manipulation of forceps. We report the results of laparoscopic hepatectomy for cases of HCC recurrence. From June 2010 through December 2014, 180 laparoscopic hepatectomy procedures for HCC were performed in our hospital; 33 were in patients with HCC recurrence. Of the 33 patients, 26 underwent pure laparoscopic partial hepatectomy. The median operative time was 242 min, the median bleeding amount was less than 5 g, and the median hospital stay after surgery was 12.0 days. In the group that underwent laparoscopic hepatectomy after open liver resection (12 patients), the median operative time was 303.5 min, the median bleeding amount was less than 5 g, and the median hospital stay after surgery was 9.0 days. Among the 21 patients that underwent laparoscopic hepatectomy after laparoscopic liver resection, the median operative time was 248 min (p=0.382), the median bleeding amount was less than 5 g (p=0.112), and the median hospital stay after surgery was 11.0 days (p=0.236). We could perform laparoscopic hepatectomy for cases of HCC recurrence. This procedure can be suitable for HCC recurrence, which sometimes requires poly-surgery.

An 81-year-old woman was admitted for leg edema. She was found to have membranous glomerulonephritis with advanced gastric cancer after renal biopsy and endoscopic examination. Serum albumin was 1.4 g/dL and total protein was 4 g/dL on admission. After albumin was administered, distal gastrectomy was performed. Albumin administration continued post-operatively. The post-operative course was unremarkable and she was discharged on post-operative day 19. Six months after the operation, serum albumin gradually increased and uric protein volume decreased. Possible remission of membranous glomerulonephritis with gastric cancer can be expected after gastrectomy but careful perioperative management is required.

A 58-year-old woman presented to our hospital with a huge hepatic mass. A CT scan showed an enhanced mass lesion on the fundus of the gallbladder and an enhanced mass ring on the gallbladder bed. Since FDG-PET showed no evidence of metastasis, we performed cholecystectomy, hepatectomy of S4a/5, and regional lymph node dissection. The immunohistochemical study of the specimen was positive for CK7, CK20, chromogranin A, and synaptophysin. The Ki-67 labeling index was 50%, and the SSTR2 score was 2+. The patient was diagnosed with neuroendocrine carcinoma. Since she was in poor condition and on hemodialysis, we started administration of somatostatin analog at the time of recurrence, and soon her diarrhea improved but the tumor increased in size.