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A 27-year-old man was referred to our hospital for a detailed examination of abdominal distention, bloody stool, anorectal pain, and weight loss. A colonoscopy revealed a circumferential type 2 tumor at 9 cm from the anal verge which was diagnosed as an adenocarcinoma based on biopsy. Contrast-enhanced CT of the abdomen showed an elevated perineal lipid concentration in the rectum(Ra)which was suspicious for clinical T4a stage, and simultaneous S7/8 liver metastasis. We strongly suspected familial adenomatous polyposis(FAP)because his mother had a past history of total proctocolectomy for FAP. We decided to first create a loop stoma at the transverse colon for the obstructive rectal cancer, and then administer neoadjuvant chemotherapy(mFOLFOX6 plus panitumumab). We performed total proctocolectomy with permanent stoma and S8 ventral resection for the liver metastasis after 5 courses of mFOLFOX6 plus panitumumab. As for clinicopathological findings, round 50 polyps were identified in the colon and rectum, and rectal cancer invaded into the muscularis propria. Finally, the patient was diagnosed as a clinically attenuated FAP with ypT2 rectal cancer.

Biosimilar(BS)drugs have recently been introduced owing to concerns with healthcare economics. In this report, we present a case in which a patient discontinued bevacizumab treatment following an allergic reaction to a BS formulation of bevacizumab but was able to safely continue treatment by switching to an original bevacizumab formulation in the late-line setting. The patient was a 66-year-old man diagnosed with unresectable colorectal cancer with synchronous multiple liver metastases. After primary tumor resection, chemotherapy including the original bevacizumab formulation was initiated. Allergic reactions to the BS formulation of bevacizumab occurred during the second-line treatment; however, in the late-line setting, switching back to the original bevacizumab formulation enabled the safe continuation of therapy. Overall, our case study suggests that switching of biologic agents may contribute to the ongoing management of chemotherapy.

We experienced a case of resection of a metastatic umbilical tumor(Sister Mary Joseph's nodule: SMJN)derived from a pancreatic tail carcinoma. The patient was a 70-year-old woman. She visited her previous doctor with a chief complaint of lower abdominal pain and came to our hospital due to suspicion of pancreatic tail cancer. She was found to have metastases to multiple organs which was unresectable by surgery. After chemotherapy up to the second-line of treatment, she was diagnosed to have progressive disease. The decision was made to provide the best supportive care for the patient. Thereafter, the patient developed SMJN. She had hemorrhage from the tumor accompanied by body movement, and her activity of daily living became impaired. She had difficulty controlling the bleeding despite repeated hemostatic treatment at the outpatient clinic and at her home. However, she required frequent blood transfusions for her severe anemia. Therefore, we performed a resection of the SMJN to control bleeding and to relieve her symptoms. She had a good postoperative course and was discharged on the fifth postoperative day. Due to deterioration of her general condition, she expired on the 59th day after surgery. However, the patient was able to live at home without bleeding or pain by the umbilical tumor. The local resection was considered to be useful as a palliative surgical treatment for SMJN.

Case: An 83-year-old female. At 82 years of age, the patient sought evaluation with a complaint of rectal bleeding. A 35-mm rectal gastrointestinal stromal tumor(GIST)was treated by laparoscopic ultra-low rectal resection and transanal anastomosis following trans-anal rectal dissection by perineal manipulation. Approximately 1 year later, a 20-mm metastatic lymph node within the right lateral lymph node group at the pelvic cavity was detected. The patient was diagnosed with a recurrence of rectal GIST. The patient had no symptoms and did not wish to undergo surgery. After 7 weeks of treatment with an imatinib dose reduction(200 mg), the dosage was increased and the patient was admitted to the hospital with edema of the face and lower limbs, and pleural and pericardial effusions(grade 2). After discharge from the hospital, the medication was terminated early at the patient's request. One year later, the lymph nodes had decreased in size to 7.5 mm, indicating a partial response. The treatment-free period continued, and after 5 years at 89 years of age the lymph nodes had not enlarged, thus the patient was thought to be clinically cured. We report a rare case of long-term tumor suppression using short-term low-dose imatinib therapy.

The case is a 59‒year‒old woman. A detailed examination of fecal occult blood revealed a diagnosis of cStage Ⅳ sigmoid colon cancer cT3N1M1b(liver H2, hilar liver and celiac artery lymph nodes). After excision of the primary lesion, decided to give chemotherapy. The gene test was RAS gene mutation negative and EGFR positive, and mFOLFOX6 plus panitumumab (pani)was started as the first‒line treatment. Imaging tests at the end of 13 courses showed that the maximum diameter of liver metastases was reduced from 54 mm to 16 mm, and CEA was normalized from 93.9 ng/mL. However, metastasis was found in the hilar lymph nodes, it was judged that hepatectomy is not indicated, radiofrequency ablation therapy was performed. But FOLFIRI plus pani was restarted because metastatic liver tumor relapsed on CT 5 months later. After 6 courses, she felt tired, so I consulted her and changed to TAS‒102 plus bevacizumab. Sudden headache and vomiting appear during 3 courses, head CT revealed subarachnoid hemorrhage. No brain metastases or organic lesions such as cerebral aneurysms and stenotic lesions, the relationship with bevacizumab was strongly suspected.

The patient was a 77-year-old woman who visited our hospital with a chief complaint of blood in the stool. The patient had a colonoscopy 2 years earlier, which led to suspicions of total colitis-type ulcerative colitis(UC). However, the histological findings did not lead to a definitive diagnosis. Upon the withdrawal of urine in an outpatient visit, fecaluria was noted. Based on various examinations, we diagnosed this patient with Rs, cT4b(bladder), cN0, cM0 adenocarcinoma. We then performed Hartmann operation with partial cystectomy. The pathological findings indicated colorectal cancer with ulcerative colitis (CAC)(low grade and high grade dysplasia and carcinoma). Postoperative examinations of the oral side of the colon revealed a flat squamous elevated lesion in the ascending colon, which was diagnosed as adenocarcinoma. Therefore, we waited for the improvement of performance status and performed additional total colectomy with resection of the anus and ileostomy. We experienced a case of progressive CAC due to the difficulty of histological diagnosis via biopsy and a lack of appropriate surveillance post clinical suspicions. In cases of colitis-type UC, appropriate surveillance by endoscopists and pathologists is important.

An 84-year-old woman presented with a 9mm sized solitary liver metastasis in liver S8 18 months after the surgery for sigmoid colon cancer. The patient was treated with stereotactic body radiation therapy(SBRT)for local control, because the patient chose not to undergo surgery or chemotherapeutic treatment for metastatic liver cancer. SBRT is a minimally invasive treatment with a very short treatment period. Therefore, it may be considered as an alternative treatment for patients who are not suitable for surgery.

A 60-year-old woman was administered mFOLFOX6 therapy as postoperative adjuvant chemotherapy for fStage III a ascending colon cancer. The patient developed a disorder of consciousness(Japan Coma Scale[JCS]III-200)immediately after the completion of the therapy. Blood ammonia levels were high at 319 mg/dL, and a diagnosis of disturbance of consciousness due to hyperammonemia was made. The patient's state of consciousness improved on the following day as blood ammonia levels decreased due to treatment with branched chain amino acid(BCAA)formulation and oxygen. Two months later, mFOLFOX6 therapy was again administered with strengthening measures for side effects to nausea and vomiting and reducing 5-FU, but the patient again developed a disorder of consciousness(JCS III-200). The 5-FU administration rate was considered as a potential cause of hyperammonemia. Hyperammonemia induced by 5-FU is relatively rare, with a reported incidence of 5-9%; however, caution is required with high dosage regimens of 5-FU that are currently recommended for colorectal cancer therapy because hyperammonemia is an important side effect.

When a medical provider(medical personnel)becomes a medical receiver(patient), does the consciousness about chemotherapy change ? If yes, what is the main reason ? In this study, we conducted a questionnaire on the consciousness of doctors and pharmacologists engaged in chemotherapy for gastric and/or colorectal cancer. The number of questionnaires collected was 83 and 92 for gastric and colorectal cancer, respectively. In adjuvant chemotherapy, 5%and 4%do not want to receive any chemotherapy for gastric and colorectal cancer if they are patients. The main reasons are binding hours, side effects, and no wish for life extension. About 11%and 9%change their consciousness regarding chemotherapy according to whether they are care providers or receivers. The main reasons are medical perspective and their sense of duty. In chemotherapy for advanced cancer, 6% and 5% of gastric and colorectal cancer patients, do not want to receive any chemotherapy. The main reasons are low expectations for being cured, binding hours, and no wish for life extension. Further, 21%and 14%wish to have limited chemotherapy. As regards consciousness on chemotherapy, 26% and 18% reported changes according to whether they are providers or receivers. The main reasons are medical perspective and their sense of duty. As for the purpose of chemotherapy for advanced gastric and colorectal cancer, 96% and 43% answered prolonging life and relief, respectively. The proportion of persons who answered complete cure is statistically higher in colorectal(32%)than in gastric cancer(18%). The most common answer for an adverse event they want to avoid if they are patients is peripheral neuropathy. These results clearly demonstrate that a considerable proportion of medical personnel hold a negative attitude against or are reluctant to receiving chemotherapy, especially for advanced gastric and colorectal cancer. It is of great importance to make use of these results in clinical practice.

We report a case of aortoesophageal fistula rupture during the course of chemotherapy following colon cancer resection. The patient was a 77-year-old woman. Following recurrence of cancer of the sigmoid colon, the patient received a course of XELOX plus bevacizumab(Bmab)to treat peritoneal dissemination and lung metastases. She was brought by ambulance to our hospital's emergency department 55 days after the last dose of Bmab, with a chief complaint of hematemesis. Hematolo- gy results showed severe anemia with a hemoglobin level of 4.0 g/dL. Descending thoracic aortic dissection was noted on chest CT with contrast, and the patient was diagnosed with an aortoesophageal fistula rupture. She underwent emergent endovascular chest stent grafting to control the bleeding. Although the ruptured esophagus was a potential source of infection, the patient and family members chose palliative treatment. Therefore, conservative treatment was administered without removing the esophagus. The patient's postoperative course was good; instead of resuming oral intake, the patient was discharged on home IVH 59 days after surgery. Outpatient follow-up continued, but multiple metastases led to gradual worsening of the patient's general condition. She died 168 days after being admitted for surgery.

A 74-year-old woman was diagnosed with advanced rectal cancer and stenosis. To resolve the rectal stenosis, we successfully placed an expandable metallic stent across the stenosis. After stent placement, food intake improved, and a good quality of life was maintained. Subsequently, the patient received systemic chemotherapy with modified FOLFOX6 (mFOLFOX6). The tumor responded remarkably to chemotherapy, and the patient did not experience any complications. After 2 courses of mFOLFOX6, the patient underwent high anterior resection. The postoperative course was satisfactory, and she has now been disease-free for 6 months after surgery.

Unlabelled: We report 5 cases of colorectal liver metastases (CRLM) with hepatic arterial infusion (HAI) oxaliplatin after systemic infusion chemotherapy failure. Patients with unresectable CRLM and history of systemic chemotherapy failure were treated with HAI oxaliplatin (L-OHP 100 mg/body, 2 hours) combined with intravenous (iv) levofolinate calcium (175 mg/body, 2 hours) and iv bolus 5-FU (500 mg/body) every 2 weeks., Result: An average age was 58 years. All patients had previously received FOLFOX. Lung metastases had already existence before HAI oxaliplatin in 4 patients. A median of 10 treatments were administered (range 5-14). Serum level of CEA was decreased in 4 cases. In 2 patients, lung metastasis developed while a PR was obtained in the liver metastasis. Progress disease (PD) was confirmed in other 3 patients. No major toxicity was presented. The median time to progression free survival was 3.0 months and the median overall survival was 7.1 months., Conclusion: HAI oxaliplatin might be beneficial as a salvage therapy for CRLM without extrahepatic metastasis, which demonstrated an acceptable tolerability and maintenance of QOL.

We experienced a case in which the hepatic artery catheter system could be used long term. Even after 5 years and five months, there was no damage to the hepatic artery, and we could still use this system. For insertion of the catheter, a fine catheter with the tip tapered at 2.7 F was selected. This catheter was inserted into the hepatic artery peripheral branch in the liver, after a side hole was created 11 cm from the tip, and the side hole was adjusted to stay in the common hepatic artery. We speculated that the reason for little injury to the hepatic artery was use of a fine catheter despite possible damage to the hepatic artery wall like saw cutting in this case. We classified the patterns according to which a catheter damaged the inner wall of the hepatic artery into 5: "straight punch type", "hook punch type", "whiplash type", "elbow blow type", "and saw type".

Metastasis to the regional lymph nodes is an important prognostic factor in colorectal cancer, and nodal evaluation is essential for accurate staging. In colorectal cancer, the aim of evaluating sentinel lymph nodes (SLNs) is the selection of patients for adjuvant therapy and the detection of aberrant lymphatic drainage patterns, leading to modification of the initial therapeutic plan. In a review of the literature, tracer, technique, tumor-related factors (location and size of tumor, T stage, status of lymph node metastasis), neoadjuvant chemoradiation therapy, and body mass index were important factors in the accurate diagnosis of SLNs in colorectal cancer. In recent multicenter SLN trials, ultrastaging has been possible in 10-38% of NO colon cancer patients. Most recently, the trial conducted by Bilchik et al., which investigated the prognostic significance of micrometastases in SLNs in colon cancer patients, found that all NO colon cancer patients with recurrence had positive SLN findings after reverse transcriptase-polymerase chain reaction (RT-PCR)-ultrastaging, whereas none of those with negative SLN findings in immunohistologic staining had recurrence, and there was only a significant correlation between recurrence and molecular markers in RT-PCR. However, further prospective multicenter trials are warranted to evaluate the ultimate clinical relevance of SLN diagnosis in colorectal cancer including anal cancer.

We report 27 cases of liver metastases treated with transarterial chemoembolization (TACE) with CPT-11, DSM, and mitomycin C (CPT-DSM therapy). In the 27 patients with liver metastases from colorectal cancer, CPT-DSM therapy was performed 47 times. All of these patients were a contra indication of hepatectomy. We compared a tumor marker before and after the treatment, and measured a serum level of SN-38, which is an active substance of CPT-11 and resolved from CPT-11. Although the level of CPT-11 was wearing off after CPT-DSM therapy, the peak of SN-38 level delayed 1 hour after the infusion. The CEA and CA19-9 levels were decreased to 54.2% and to 45.1% of the level before the treatment, respectively. Nine of the partial response and stable disease patients underwent surgery. The response rate was 59%. A 3-year survival rate was 20%. These results suggest that CPT-DSM therapy is one of the most effective anticancer agents. This TACE can be a feasible therapy for colorectal liver metastases as the first-line therapy.

In the surgical treatment of advanced rectal cancer, wide lymphadenectomy has been replaced by autonomic nerve preservation because of serious problems such as postoperative urinary and sexual dysfunction. This may offer a considerable clue to as whether metastasis of lateral lymph node can be diagnosed by a new technique in order to provide more benefits to many patients with advanced rectal cancer. Moreover the sentinel lymph node (SLN) concept has lately attracted attention as a new technique. We studied SLN in 40 patients with advanced lower rectal cancer using 99mTc-Sn colloid as a tracer. SLN was successfully identified in 35 (87.5%) of 40 patients, and the mean number of SLNs identified per patient was 5.6 lymph nodes (range 1-14). In this study overall accuracy was 86%, and it was suggested that lateral lymphadenectomy was excluded in 91%, thanks to application of the SLN technique. Although the role this technique plays in the individualization of the therapy for rectal cancer will be large in the near future, many problems remain to be solved in the exact identification of SLN.

We measured TS and DPD activities in 40 patients with colorectal cancer who had undergone surgical reduction in our department between May 1997 and April 1998, including 26 patients with preoperative UFT (450 mg/body/day) chemotherapy for 2 weeks, and evaluated the clinical significance of TS and DPD activities as predictive factors of UFT sensitivity. TS activity was collated with histological type from a clinical pathological examination (p = 0.0103). Also, the tendency for TS activity to become high with the stage was observed. According to the evaluation of pathological response, histological effectiveness greater than grade 2 was noted in 7.7%. The apoptosis index (AI) in tumors with preoperative UFT chemotherapy was higher than those without such treatment, which showed a higher correlation with DPD activity of tumor tissue than TS activity (p = 0.0465). Recurrence was seen in 7 cases (lung metastasis: 2, liver metastasis: 4, and local recurrence: 1) in the preoperative chemotherapy group. TS activity was high in all patients with recurrence. TS showed significantly high activity in patients with recurrence compared with the non-recurrence (p = 0.0034) patients. Therefore, these results suggested that activity of both TS and DPD was a key factor for anti-tumor effectiveness of UFT. In particular, TS activity was an important predictive factor for effectiveness of UFT in recurrences.

We report a case in which low-dose CPT-11 chemotherapy was effective for metastatic liver tumor of sigmoid colon cancer. A 49-year-old male with metastatic liver tumor, who had undergone sigmoidectomy with D2 lymphadenectomy, was treated by low-dose CPT-11 chemotherapy (CPT-11 30 mg/m2 x 3 days, every 2 weeks). After 7 courses of this chemotherapy, CT and ultrasound examinations showed a reduction of tumor size in the liver. This chemotherapy also showed no high grade toxicities. Therefore, low-dose CPT-11 chemotherapy seems to be effective for metastatic colorectal cancer, and safe in view of toxicities.