Search

A 78-year-old man who was diagnosed as having hepatocellular carcinoma(segment 4/8)underwent laparoscopic hepatectomy. About 5 hours after the start of the operation, SpO2 and systolic blood pressure suddenly dropped to 87% and 40 mmHg. EtCO2 level decreased to 8 mmHg and PaCO2 was 48.5 mmHg. Based on the discrepancy between the PaCO2 and EtCO2, the patient was diagnosed as having pneumoperitoneum-induced carbon dioxide embolism. The surgical procedure was immediately interrupted and the patient was hyperventilated with pure oxygen. After surgical interruption, general status was recovered to the normal condition. We carefully restarted the operation and completed it laparoscopically. The patient was discharged from the hospital on the 15th day without any postoperative complications. Carbon dioxide embolization is a serious life-threatening complication that requires careful monitoring.

A woman in her 80s, had undergone radical surgery for an endometrial carcinoma 9 years earlier, and her 5-year postoperative follow-up had been completed without recurrence. She consulted an orthopedic surgeon with a chief complaint of a mass in the left inguinal region, and was referred to surgery after MRI scan revealed lymph node metastases in the left inguinal and external iliac region and a sigmoid colon tumor. Due to postoperative adhesion of the uterine cancer, the colonoscope could not be inserted to the tumor, and no tissue diagnosis was made. CT and PET scans revealed a sigmoid colon tumor plus periungual lymph node metastasis, and it was determined that radical surgery was possible, and the patient underwent resection. Surgery was performed by laparoscopic resection of the sigmoid colon and lymphadenectomy, with R0 resection. The sigmoid colon tumor and lymph nodes were of the same histology as the 9-year-old endometrial carcinoma, leading to the diagnosis of colon and lymph node recurrence 9 years after endometrial carcinoma surgery.

A woman in her 90s underwent laparoscopic hernia repair for a recurrent left inguinal hernia with abdominal wall defect 2 years ago. She came to our department with a complaint of a mass in the hernia wound, which was suspected to be a skin cancer, and the pathology diagnosis was adenocarcinoma. A colonoscopy was performed and she was diagnosed with sigmoid rectal cancer with only skin metastasis and the operation was performed. Laparoscopic anterior resection of the rectum, excision of the skin tumor, mesh removal, and rectus abdominis skin grafting were performed, and these were radical surgery. Simultaneous cutaneous metastasis of rectal cancer is extremely rare, being part of the 2.0% of other sites, and is reported with some literature review.

A 64-year-old woman underwent right hemicolectomy for transverse colon cancer. Histopathological findings revealed T, type 2, 24×22 mm, tub2, pT2N1a(1/23)M0, and pStage Ⅲa. Postoperative adjuvant chemotherapy was not administered at the patient's request. One year after surgery, carcinoembryonic antigen(CEA)level was elevated, and Gd-EOB-DTPA- enhanced MRI revealed a nodule in segment 2 and 4/8 of the liver. Based on the diagnosis of hepatic metastasis, laparoscopic partial hepatectomy was performed. Three years after hepatectomy, CEA level was found to be elevated again, and chest CT showed a solitary pulmonary nodule in segment 7 of the right lung. With a diagnosis as pulmonary metastasis, FOLFIRI plus bevacizumab was performed. After 41 courses of FOLFIRI plus bevacizumab, the pulmonary nodule decreased in size, and no new lesions appeared. The chemotherapy was terminated at the patient's request. Six months later, the pulmonary nodule increased in size, and thoracoscopic partial pulmonary resection was performed. Hepatic and pulmonary resection specimens were histopathologically consistent as metastasis of colorectal cancer. The patient has been alive without recurrence for about 4 years after final surgery(pulmonary resection)without postoperative adjuvant chemotherapy. We report a case of long-term survival with metachronous hepatic and pulmonary metastases from transverse colon cancer by multidisciplinary treatment.

The patient was 40s male, who underwent laparoscopic low anterior resection for his upper rectal cancer with final pathology results of tub2, pT3(SS), no lymph metastasis and fStage Ⅱ. He was followed up without adjuvant chemotherapy. Half a year after surgery, tumor marker was elevated and CT scan revealed multiple liver metastases. He was treated with oxaliplatin, irinotecan, Leucovorin and 5-fluorouracil(FOLFOXIRI)plus bevacizumab because of RAS mutant type. In the third courses, he has pain in the lower extremities and was diagnosed with acute lower extremity arterial occlusion. Subsequently, chemotherapy was resumed with the exception of bevacizumab, in combination with DOAC, which resulted in tumor shrinkage and allowed resection of the liver metastases.

Our patient was a man in his 70s who underwent proximal gastrectomy with double tract reconstruction in 2013. He was diagnosed with cStage Ⅳ unresectable remnant gastric cancer with paraaortic lymph node metastases in 2021. He was treated with 5 courses of S-1 plus oxaliplatin therapy. Computed tomography revealed that the lymph node metastases had decreased in size after treatment. We performed conversion surgery and achieved R0 resection. Furthermore, the elevated jejunum was preserved and total gastrectomy was possible without re-anastomosis. Postoperative adjuvant chemotherapy with S-1 was started and he remains alive without recurrence at 6 months postoperative.

Case 1 is a 56-year-old man. During postoperative adjuvant chemotherapy for pancreatic cancer, weakness in the right upper and lower limbs appeared, and a head CT scan was performed, but no abnormal findings were noted. Diffusion- weighted MRI scan of the head showed multiple cerebral infarcts, and a diagnosis of Trousseau syndrome was made. Case 2 is an 86-year-old man. During chemotherapy for postoperative recurrence of distal bile duct carcinoma, he developed weakness in the right upper and lower limbs, and a head MRI scan was performed. Diffusion-weighted MRI showed scattered high-signal areas, and a diagnosis of Trousseau syndrome was made. Trousseau syndrome is a condition in which stroke is caused by hypercoagulability associated with malignant tumor. The initial symptoms of cerebral infarction in patients with cancer are similar to those of chemotherapy-induced adverse events and brain metastases, and therefore, a head MRI scan is recommended even if there is no obvious abnormality on head CT scan.

The patient was a 74 year-old woman. She came to the hospital with the chief complaint of vomiting, difficulty walking, and disorientation. The MRI study showed increased FLAIR and DWI signals in the bilateral medial thalamus. Abdominal enhanced CT scan showed a 2.4 cm tumor in the jejunum. And ileus due to small intestinal tumor was observed. She diagnosed Wernicke's encephalopathy associated with gastrointestinal transit disorder. Vitamin B1 300 mg/day for 3 days was started, and eye movements and disorientation improved on the day following the start of administration. On the 10th day after admission, partial resection of the small intestine was performed for a small intestinal tumor. She was diagnosed as small intestinal cancer. She was transferred to the hospital on the 20th postoperative day.

Background: Diffuse midline glioma, H3K27M mutant is a glioma located in the thalamus, brainstem, or spine with the H3K27M mutation, which is a new entity in the 2016 revised WHO classification. The treatment of thalamic glioma(TG)and brainstem glioma(BSG), which includes diffuse midline gliomas, the H3K27M mutant is challenging, and there are no standard therapeutic strategies. It is important to determine the characteristics of these brain tumors. Here, we retrospectively reviewed 31 consecutive patients with TG and BSG who were treated at our institute between January 1994 and May 2018, including methionine-positron emission tomography(MET-PET)data., Results: Fourteen patients had TG, while 17 patients had BSG. Six patients were children, and 25 were adults. Nine patients with TGs and seven with BSG were enhanced by gadolinium. Twenty-seven patients were treated with radiotherapy, and 20 patients were treated with chemotherapy. All 21 tumors that underwent surgery showed wild-type IDH. The H3K27M mutation was present in four TG and two BSG. There was no statistically significant association between methionine uptake and gadolinium contrast enhancement and tumor grade. The median overall survival period(OS)of all cases was 16.9 months, whereas those of TG and BSG were 22.8 and 10.0 months, respectively., Conclusion: Because TG and BSG still have poor prognoses, it is necessary to elucidate the pathology of the disease and establish its standard therapy.

A 60-year-old female visited our hospital due to anorexia and jaundice in March 2016. She underwent pancreatoduodenectomy( PD)and was diagnosed with distal bile duct cancer. The histopathological diagnosis was distal bile duct cancer, tub2, pT3aN1M0, pStage ⅡB. Postoperatively, she received S-1 therapy as adjuvant chemotherapy. One year after surgery, abdomi- nal enhanced CT and EOB-MRI revealed a liver metastasis(S3; 20mm). After 4courses of gemcitabine(GEM)/cisplatin(CDDP) combination therapy, there was no new lesion; thus, we performed partial hepatectomy(S3)in July 2017. The histopathology findings revealed well differentiated adenocarcinoma that was similar to the primary lesion, and the tumor was confirmed as a recurrence of bile duct cancer. She remains alive without second recurrence for 2 years since the tumor resection(about 3 years since PD). Surgical intervention might be beneficial in selected patients with recurrent bile duct cancer.

Background: Palliative care delivered to cancer patients late in the course of disease are inadequate to improve advance care planning and quality of life; thus, early palliative care is recommended. We retrospectively analyzed early palliative care delivered to patients with gastric cancer., Method: Forty-nine gastric cancer patients who underwent surgery and had received interdisciplinary care from the first visit(early palliative care)were assessed for physical and psychosocial symptoms., Results: All patients were followed up continuously by a nurse certified in palliative care support to provide quality patient-centered care from the beginning(advance care planning). Four patients had experienced relapse, and 3 older patients had decided not to receive chemotherapy following their advance care planning. However, all 4 patients were admitted to a palliative care unit without barriers., Conclusion: Early palliative care might lead patients to have advance care planning, and a better quality of life.

We report a case of multiple lung metastasis of intrahepatic cholangiocarcinoma treated with chemotherapy, in which laparoscopic splenectomy was effective for thrombocytopenia. A 74-year-old woman was diagnosed with multiple lung metastasis of intrahepatic cholangiocarcinoma 6 years after partial liver resection(S3). She was undergoing treatment for post-transfusion hepatitis C infection since the age of 46 years and developed thrombocytopenia due to splenomegaly. The previous hospital determined that there was no indication for chemotherapy due to thrombocytopenia. Elective laparoscopic splenectomy resulted in an increase in the platelet count and facilitated the initiation of gemcitabine(GEM)and cisplatin (CDDP)combination chemotherapy. The patient has maintained a good treatment course without interruption due to thrombocytopenia during chemotherapy. In advanced cancer patients with thrombocytopenia complication due to splenomegaly, laparoscopic splenectomy may offer an effective auxiliary means for the safe implementation of chemotherapy.

A 60s woman with upper rectal cancer underwent low anterior resection; the patient was diagnosed with pSSN1, Stage Ⅲa cancer. She received adjuvant therapy with UFT. Three years after the primary resection, metastasis to the right ovary and local recurrence were diagnosed. She was treated with CAPOX plus bevacizumab(Bev), capecitabine, FOLFIRI, and irinotecan plus S-1. Because only the ovarian metastasis increased rapidly, we were able to perform surgery and R0 resection. Two years after resection, local recurrence became apparent, and chemotherapy was reinitiated. After treating the patient with chemotherapy and chemo-radiation therapy for 2 years, R0 resection was performed. Twelve years after primary tumor resection and 9 years after primary resection, we observed recurrence-free survival.

Here, we report a case of superficial-type gastric cancer with metastatic ovarian cancer(Krukenberg tumor)diagnosed by exploratory laparotomy. Chemotherapy was initiated at an early stage in this patient. A 43-year-old woman with superficialtype gastric cancer(0-Ⅱb plusⅡa), an ovarian tumor, and a solitary sclerotic bone lesion underwent exploratory laparotomy and bilateral salpingo-oophorectomy. Pathological findings showed that the resected ovarian tumor specimen contained the same type of signet ring cell carcinoma as the biopsy gastric cancer specimen; hence, the patient was diagnosed with superficial- type gastric cancer with metastatic ovarian cancer. She was treated with first-line chemotherapy(capecitabine plus oxaliplatin)15 days after exploratory laparotomy, followed by second-line chemotherapy(ramucirumab plus paclitaxel), thirdline chemotherapy(nivolumab), and fourth-line chemotherapy(irinotecan). Twenty-two months after the start of first-line chemotherapy, she finally died due to bone metastasis.

Aim: Alcohol consumption is high in the colder regions of Russia, and it is related to poor sleep quality, mental and physical health problems. Little known on the actual situation, and no appropriate amount of drinking has been shown as a health guidance. The purpose of this study is to examine the relationship between alcohol consumption (in pure alcohol) and sleep among older people living in the Russian Siberian region, and the factors related to alcohol consumption., Methods: A self-reported questionnaire survey was administered to 422 elderly over the age of 60 living in Novosibirsk, the central city of Siberia. Question items were basic attributes, health status, drinking habits, Short Form-8 Health Survey, Geriatric Depression Scale, and Pittsburgh Sleep Quality Index. For drinking elderly, daily amount of alcohol converted in pure alcohol was calculated, and logistic regression analysis among the two groups was compared based on the median value (32 g)., Results: The valid responses from the survey was 416 (98.9%). Of these, 293 with drinking habits were subjected to logistic regression analysis using pure alcohol (≥32 g/day) as the dependent variable. Significant relationships were found with gender (OR=0.586; 95%CI: 0.345-0.995), years of education (OR=1.538; 95%CI: 1.239-1.910), insomnia (OR=2.442; 95%CI: 1.185-5.032), alcohol intake, due to better sleep (OR=4.120; 95%CI: 1.044-16.258), effects of drinking, arousal during the night (OR=2.586; 95%CI: 1.317-5.077), effects of drinking, from family (OR=26.938; 95%CI: 3.368-215.431)., Conclusions: Among the elderly people in colder regions of Russia, high alcohol consumption reduces sleep quality, suggesting the need for appropriate standards for pure alcohol and health education.

We report a case of esophageal cancer with aortic thrombosis that occurred during chemotherapy and was successfully treated by aortic thrombectomy and video-assisted thoracoscopic esophagectomy. A 70-year-old man with esophageal cancer( Mt, Type 1c, cT2cN0cM0, cStage Ⅱ)was administered 5-FU plus cisplatin chemotherapy. On day 7 in the first course of the chemotherapy, he experienced abdominal pain. Abdominal CT revealed endo-aortic thrombotic deposits in the aortic arch about 3 cm in diameter. He immediately received heparin at a dose of 20,000 U/day administered intravenously, but the thrombus had not resolved by the next day. He underwent aortic thrombectomy, and warfarin was administered orally after the thrombectomy. He did not experience any difficulties or discomfort related to the thrombus after the thrombectomy. He then underwent video-assisted thoracoscopic esophagectomy and was discharged uneventfully on the 18th postoperative day. Currently, he is under follow-up with no recurrence.

We report a case of recurrent gastric cancer that was successfully treated by S-1 chemotherapy.An 81-year-old woman with advanced gastric cancer[L Less, Type 2, cT4a(SE), cN0H0P0M0, cStageⅡB]underwent distal gastrectomy.Abdominal CT performed 6 months after surgery revealed a low-density area in the liver.She was diagnosed with liver metastasis and started receiving S-1 chemotherapy.The liver metastasis achieved complete response, so S-1 chemotherapy was discontinued 12 months after recurrence.Abdominal CT performed 9 months after the discontinuation of S-1 chemotherapy revealed multiple low-density areas in the liver.She started receiving S-1 chemotherapy again, but S-1 chemotherapy was discontinued because of side effects after 2 courses.The patient died 24 months after receiving S-1 chemotherapy.

We report a case of liver metastasis of intrahepatic cholangiocarcinoma that achieved clinical complete response after gemcitabine(GEM)and cisplatin(CDDP)combination chemotherapy. The patient was a 69-year-old man who was diagnosed with intrahepatic cholangiocarcinoma with hilar invasion and intrahepatic metastasis(cT4N0M0, Stage ⅣA)and was initially treated with right trisegmentectomy with left portal vein resection, lymph node dissection, and reconstruction of the left portal vein and biliary tract after transhepatic portal vein embolization(PTPE). S-1 was administered continuously as postoperative adjuvant chemotherapy, and the patient showed no signs of recurrence. Three years after the surgery, a CT scan showed LDA 10mm in diameter in the middle area of the remnant liver. We suspected liver metastasis when both serum CA19-9 and DUPAN-2 levels were elevated with the increasing size of LDA; liver biopsy was then performed, and he was diagnosed with liver metastasis of intrahepatic cholangiocarcinoma. After 3 courses of combination chemotherapy containing GEM and CDDP, a CT scan revealed that the liver metastasis reduced in size, and PR was achieved based on the RECIST standard. After 12 courses, the liver metastasis disappeared, and the patient had achieved CR based on the RECIST standard. The patient has received S-1 following the combination chemotherapy and survived for 6 years since initial treatment without any other metastatic lesions.

Background: Malnutrition is a frequently observed phenomenon in patients with esophageal cancer after esophagectomy. Nutritional support and the enhanced recovery after surgery(ERAS)protocol may prevent malnutrition., Method: Nine patients who underwent esophagectomy for esophageal cancer received perioperative management according to the ERAS protocol and enteral nutrition support(ELENTAL®or ENEVO®). We retrospectively evaluated the efficacy and safety of our perioperative management., Results: The median day of first oral intake(water)was the second postoperative day. The median day of first oral intake(food)was the seventh postoperative day. The patients could consume more than one and a half bottle of enteral nutrition for a year after surgery. The prognostic nutritional index(PNI)was higher than 40, and the neutrophil-to-lymphocyte ratio(NLR)was lower than 3 for a year after surgery., Conclusions: Perioperative management according to the ERAS protocol and enteral nutrition support(ELENTAL®or ENEVO®)might be feasible and prevent malnutrition in patients after esophagectomy.

We report a case of advanced esophageal cancer that was successfully treated using chemotherapy, operation, and chemoradiotherapy. A 66-year-old man with advanced esophageal cancer(Mt, O-Is, T4[N0.7-stomach], N2, M0, Stage III)was administered chemotherapy(docetaxel[DOC], cisplatin[CDDP], and 5-fluorouracil[5-FU]: DCF). As the esophageal tumor achieved complete clinical response after 2 courses of chemotherapy, lymph node dissection and proximal gastrectomy were performed for the residual tumor. Abdominal CT 3 months after surgery revealed lymph node swelling. He was diagnosed with lymph node metastasis and was administered chemoradiotherapy. After chemoradiotherapy, liver metastasis was revealed, and he underwent immune checkpoint inhibitor immunotherapy. Despite the administration of immune checkpoint inhibitors, the liver metastasis developed, so he was treated with S-1 chemotherapy. S-1 chemotherapy resulted in a favorable response, and almost all metastatic lesions decreased. The patient is alive 12 months after S-1 chemotherapy without any signs of tumor regrowth.

Refractory ascites associated with cancerous peritonitis causes abdominal tension and reduced oral intake. Frequent ascites drainage can cause rapid worsening ofa patient's general condition. Cell-free and concentrated ascites reinfusion therapy (CART)for refractory ascites was first covered in 1981, and the general conditions ofpatients and their symptoms could be improved after undergoing CART. Herein, we report a case of effective palliative care with CART for refractory ascites associated with cancerous peritonitis. A 66-year-old man was admitted to our hospital because ofabdominal distension. Computed tomography revealed the presence ofascites and gastric wall thickness; upper gastrointestinal endoscopy revealed an ulcerated lesion with raised margins on the body ofthe stomach. Biopsy ofthis lesion confirmed the diagnosis ofadenocarcinoma, and he was diagnosed with gastric cancer(M, Type 3, cT4a[SE], cN0, cH0, cP1, cM1, cStage IV). He underwent palliative care for ascites, followed by FLTAX regimen chemotherapy(5-fluorouracil[5-FU]and Leucovorin[LV]combined with weekly paclitaxel[PTX]). He received CART for 8 courses without complications, and his symptoms improved after receiving CART. He survived for about 18 months, and could ingest a normal diet for a long time. CART may be favorable in palliative care for massive ascites associated with cancerous peritonitis.

A 50-year-old woman with abdominal fullness, lower abdominal pain, elevated serum CA125, and ascites, underwent neoadjuvant chemotherapy with 6 courses of PTX/CBDCA followed by total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and intrapelvic peritoneal stripping based on a diagnosis of serous surface papillary carcinoma(SSPC) of the peritoneum. Complete response(CR)was shown after adjuvant chemotherapy with 3 courses of the same regimen. After 6 months, serum CA125 level re-increased and abdominal CT showed small low density areas in the patient's spleen and the perisplenic fat tissue. After the additional chemotherapy with 3 courses of PTX/CBDCA were performed based on a diagnosis of metastatic lesion from SSPC, anaphylactic shock occurred as the severe adverse event. The patient was given 9 more courses of the chemotherapy changed the regimen to PTX/CDDP. The splenic metastatic lesion had grown rapidly in the followed CT and then, laparoscopic splenectomy with peritoneal resection was performed based on a diagnosis of splenic metastasis from SSPC. The pathological examinations showed the tumor to be a splenic metastasis and peritoneal dissemination from SSPC. No recurrent lesion has been detected in the 9 months since removal of the splenic metastasis without adjuvant chemotherapy and the patient has survived for 4 years and 6 months since initial treatment.

A 74-year-old femalewas admitted to our hospital dueto thebulky abdominal tumor pointed out by ultrasonography of medical screening. Abdominal CT revealed the tumor, in a diameter 20 cm, replaced the total pancreas and compressed the surrounding organs and portal vein. We diagnosed as a pancreatic serous cystic neoplasm with a possibility of malignancy. The operative findings showed the tumor tightly adhered to stomach, duodenum, liver, transverse colon mesenterium, retroperitoneum and the surrounding main vessels. Total pancreatectomy, cholecystectomy, splenectomy and distal gastrectomy were performed. As a histopathological finding, thetumor surfacewas smooth and theinsidewas sponge-likeappe arancemixe d with microcystic and solid components. No malignant finding was observed. The patient was discharged without major complications on postoperative day 42, and remains alive with no recurrence for 9 months after surgery.

The patient was a 50-year-old man who complained of bloody stool and proctal discomfort. After hospitalization, he was diagnosed bearing advanced lower rectal cancer with lateral lymph nodes and bilateral pulmonary metastases(cT3N3M1a, Stage IV ). He was treated with irinotecan, Leucovorin and 5-fluorouracil(FOLFIRI)plus cetuximab because of RAS wild type. After 11 courses of the chemotherapy, all pulmonary metastases were disappeared(CR). Six months after the initialtreatment, laparoscopic abdominoperineal resection with lateral lymph node resection was performed with curative intent. After the operation, additional1 2 courses of the same chemotherapy were carried out. One year after operation, there is no sign of recurrence. Though used to be considered non-curative, advanced rectal cancer with distant metastases could be potentially cured by multidisciplinary treatments.

Background: Chemotherapy-related adverse events can deteriorate the quality of life, as well as chemotherapy tolerance, for patients with gastric cancer. Nutritional support may prevent chemotherapy-related adverse events., Methods: Five patients who received chemotherapy for advanced gastric cancer were prescribed enteral nutrition(Elental®or ENEVO®). We retrospectively evaluated the efficacy and safety of chemotherapy while receiving enteral nutrition., Results: All patients consumed more than one bottle of enteral nutrition during chemotherapy. Median progression-free survival(PFS)and overall survival(OS)were 166 days(100-349)and 328 days(115-431), respectively. Major Grade 3 or 4 adverse events included neutropenia(0%), anemia(40%), and diarrhea(20%). The prognostic nutritional index(PNI)was higher than 40, and the neutrophil lymphocyte ratio(NLR)was lower than 3 over the course of chemotherapy., Conclusions: Nutritional support for gastric cancer patients receiving chemotherapy is feasible. There was a low incidence of chemotherapy-related hematological toxicity, with a relatively longer PFS in patients receiving enteral nutrition.

Objectives　Recently, social isolation has been reported to be a critical problem among Japanese elderly persons. However, few studies have compared social interaction in the past and the present or investigated its predictive factors. This study aimed to clarify the transitional changes in social interaction over 20 years and explore the factors related to social interaction focusing on the use of community resources.Methods　The participants were community-dwelling elderly persons aged 65 years and over. A survey was conducted 8 times from 1994 to 2014 in the suburban area of Tobishima, Japan. The Index of Social Interaction Scale was used and each subscale and the total score were calculated. Subsequently, the 2014 scores were compared with the 1994 scores using the Wilcoxon rank sum test. Logistic regression analysis was conducted to clarify the factors related to social interaction, focusing on the association between the use of community resources (local elderly management center, health care center, health promotion facility, library) in 2011 and social interaction 3 years later. Age, gender, disease, and mobility were also entered into the model as control variables.Results　Comparing social interaction in 1994 and 2014, total scores were found to have significantly increased in all age groups. Independence scores significantly increased in the overall group and in females aged 75-84. Curiosity scores also increased in both males and females. These results show that social interaction has increased over 2 decades. In addition, the use of local elderly management and health care centers, and health promotion facilities was associated with total social interaction scores 3 years later.Conclusion　The current study clarified changes in social interaction, both comprehensively and for each of its aspects, among community-dwelling elderly adults. Increasing social isolation has been reported in recent years; however, the current study showed that social interaction, including social curiosity and independence, has increased over 20 years. The effect of preventive intervention in local elderly management centers, health care centers, and health promotion facilities may be one of the causes for this increase.

The patient was an 81-year-old woman who underwent laparoscopic anterior resection for her descending colon cancer with final pathology results of tub2, pT3(SS), int, INFb, ly0, v1, EX(-), no lymph metastasis, and fStage II . She was followed up without adjuvant chemotherapy. Six months after the surgery, a CT scan revealed a tumor shadow 8mm in diameter near the clip fixed around the inferior mesenteric vein(IMV). After another 3 months, the tumor size increased to 11mm and it was diagnosed as a recurrence. Chemotherapy with capecitabine and bevacizumab was carried out for 6 months. Since her treatment response was judged as PR and no other recurrence was found, a local resection was planned. In order to identify the exact location of the recurrent lesion, a small laparotomy was performed at first to identify the tumor via palpation. A laparoscopic surgery was then performed to remove the recurrent lesion. Based on a pathological examination, the tumor was diagnosed as a lymph node recurrence and the histological response was judged as Grade 1b. A laparoscopic approach is technically feasible even for resection of recurrent lesions.

Purpose: Advanced gastric cancer patients with malignant ascites cannot tolerate S-1 plus cisplatin-containing therapy. The good toxicity profile of the FLTAX regimen(5-fluorouracil[5-FU]and Leucovorin[l-LV]combined with weekly paclitaxel) might make it a viable alternative treatment for these patients. We retrospectively evaluated the efficacy and safety of FLTAX in advanced gastric cancer patients., Materials and Methods: Patients with advanced gastric cancer with malignant ascites were treated with 60mg/m2 paclitaxel, followed by 500 mg/m2 5-FU and 250 mg/m2 l-LV on days 1, 8, and 15. Treatment courses were repeated every 28 days. Patients were treated in our hospital from 2014 to 2016., Results: Three advanced gastric cancer patients with malignant ascites received the FLTAX regimen. The median age was 66 years(range 58-66). The median number of treatment courses was 2(range 1-20). The median progression-free survival and overall survival were 55(95%CI 24-.)and 272(95%CI 108-.)days, respectively. Observed Grade 3-4 adverse events were as follows: hyponatremia(1), anorexia(1), upper gastrointestinal hemorrhage(1), and thromboembolic event(1). No treatment-related death occurred., Conclusion: FLTAX demonstrated an acceptable toxicity profile, and may be a good option for gastric cancer patients with malignant ascites.

A 69-year-old man was diagnosed with a large type 3, cT4bN2M0, cStage III c advanced gastric cancer located at the lesser curvature of the upper stomach. Neoadjuvant chemotherapy with S-1 plus CDDP was administered, and partial response was obtained after 2 courses. Subsequently, spleen preserving total gastrectomy with partial hepatectomy was performed. The final pathological diagnosis was UM, Less, yType 3, por1, ypT4b(SI liver), was ly2, v1, ypN2, M0, pStage III c, R0. Adjuvant chemotherapy with S-1 was administered; however, 5 months after the surgery, splenic-hilum lymph node recurrence was detected. Chemotherapy with CPT-11 plus CDDP was administered and a salvage operation was planned when the response to treatment was nonCR or nonPD. After 6 courses of chemotherapy, the treatment response was PR. Nine months after the first operation, spleno-pancreatic tail resection combined with partial hepatectomy was performed. The patient is currently disease-free without chemotherapy.

The patient was a 78-year-old man who was hospitalized with a 1-month history of tenesmus and body weight loss. Blood tests revealed a mild increase in tumor markers(CEA 9.7 ng/mL)and an elevation of the inflammatory response. Colonoscopic examination disclosed a full circular lateral spreading tumor(LST)extending from the second Houston valve to the rectosigmoidal region with a more than 10 cm length. Since invasion to the SM layer was suspected, endoscopic resection was judged inapplicable and laparoscopic low anterior resection with D2 lymph node dissection was performed, along with covering ileostomy. The final pathology diagnosis was villous adenoma with carcinoma in adenoma, showing multiple villous structures categorized as high dysplasia. Postoperatively, he was free from tenesmus and his body weight increased. In addition, normalization of the tumor markers occurred.

A 70-year-old woman with locally advanced pancreatic body cancer invading the celiac axis underwent 4 courses of preoperative chemotherapy consisting of gemcitabine(GEM)plus nab-paclitaxel(nab-PTX)on days 1, 8, and 15 every 4 weeks, followed by radiation therapy(CRT; 50.4Gy delivered in 28 daily fractions). The tumor size was greatly diminished and levels of all tumor markers were decreased. R0resection by distal pancreatectomy with en bloc celiac axis resection(DP-CAR)was performed. The histopathologic findings showed that the effect of CRT was grade 2b(Evans' classification), and the surgical margins were histologically clear. After the surgery, S-1 was administered continuously. The patient shows no signs of recurrence 1 year after surgery.

Background: Pylorus-preserving gastrectomy(PPG)has long been used for the treatment of early gastric cancer, and its survival benefits, postoperative symptoms, and functional outcomes have already been reported in several studies. This study aimed to evaluate the short-term outcomes after LAPPG in our hospital., Methods: Ten patients with early gastric cancer underwent LAPPG from 2013 to 2015 in our hospital. Their short-term outcomes after LAPPG were retrospectively analyzed., Results: No intraoperative complications were observed, and no patient required conversion to open surgery or reoperation. At 1 year after the operation, the relative body weight(present/preoperative)of the patients was 94.8%, and the incidence of nausea, diarrhea, abdominal fullness, and vomiting was, each, 1 in 7., Conclusion: The short-term results show that LAPPG seems to be beneficial in terms of postoperative symptoms and functional outcomes.

Patients with esophageal cancer often have various comorbidities, and these sometimes limit treatment choices. We report a case of esophageal cancer surgically treated using laparoscopic transhiatal esophagectomy after chemoradiotherapy in an elderly man with interstitial lung disease. A 77-year-old man who had undergone upper gastrointestinal endoscopic examination was admitted to our hospital with a diagnosis of esophageal cancer and interstitial lung disease. We diagnosed T4 esophageal cancer, and administered chemoradiotherapy. The chemoradiotherapy reduced the size of the tumor, but an esophageal stricture remained. A non-transthoracic approach was thought to be an appropriate choice for a patient at high risk for postoperative respiratory complications. Laparoscopic transhiatal esophagectomy was performed safely and successfully. In the postoperative course, temporary tracheotomy was necessary, but the tracheotomy tube was ultimately removed, after which he was able to consume food.

A 45-year-old man was admitted to our hospital because of taste disorders in March 2014. He exhibited cervical muscle weakness and left eye ptosis, which responded to Tensilon test, and was diagnosed with myasthenia gravis (MG). He developed aspiration pneumonia and myasthenic crisis, which was treated with intravenous immunoglobulin and steroid pulse therapy. All symptoms disappeared. Oral administration of prednisolone and tacrolimus was started. Chest CT revealed thymoma and extended thymectomy was performed in May 2014. In December 2014, seven months after the thymectomy, hematological examination showed pancytopenia including severe neutropenia. We diagnosed his illness as aplastic anemia (AA). Cyclosporine therapy with transfusion was administerd and led to reticulocyte count recovery. Since May 2015, hemoglobin recovery reached a blood transfusion free period. To our knowledge, this is the first case report with the patient supposed of relationship among taste disorders, AA and thymoma-associated MG.

The concept of traumatic grief was once maintained by Prigerson in the late 1990s to be soon replaced by various concepts such as persistent grief or complicated grief, to cause a con- fusion of diagnostic criteria, the common element across those concepts being the psychological disturbance caused by the loss of a beloved one. Most contemporary psychotherapy for compli- cated grief put an emphasis upon the cognitive restructure of the meaning of the loss reflect- ing the prevailing understanding that the basis of the pathogenesis of the disorder is the loss of attachment and that the intrusion symptom is actually the yearning for the deceased. In those cases, however, where the loss of attachment is complicated by the comorbid symptoms of PTSD, caused by the death due to accident or murder, contradictory psychological processes are generated by the desire to forget the traumatic nature of the event but to maintain the vivid image of the deceased. The trauma-focused treatment is often necessary for those cases and the concept of traumatic grief, grief caused by trauma, would be clinically beneficial and should be further verified through clinical practice and research.

We report the case of a patient who underwent conversion surgery after long-term chemotherapy for advanced gastric carcinoma with synchronous distant metastasis. She was admitted to our hospital because of back pain and elevated serum ALP level. Gastrointestinal endoscopy showed multiple 0-Ⅱa like lesions at the gastric antrum, and a biopsy specimen showed poorly differentiated adenocarcinoma negative for HER2. Colonoscopy showed a submucosal tumor at the cecum, and pathological examination revealed metastatic gastric adenocarcinoma. CT revealed regional lymph node metastasis, bilateral ovarian tumors, and systemic bone absorption indicating metastasis. Systemic chemotherapy with cisplatin and S-1 was carried out, and complete resolution of gastric and colic lesions was obtained. Afterwards, a new gastric lesion appeared with re-growth of regional lymph nodes and bilateral ovarian tumors. Distal gastrectomy with D2 dissection and bilateral ovariectomy was performed 2 years 6 months after the initial therapy. Although systemic chemotherapy is the standard treatment for advanced gastric carcinoma with distant metastasis, surgical resection can be justified when drug-resistant lesions are localized and conversion surgery is feasible. Postoperative chemotherapy is mandatory to prolong survival.

A 62-year-old man was diagnosed with gastric cancer and underwent distal gastrectomy, and D1+b lymph node dissection. He was diagnosed postoperatively with T1b (sm2) N0M0, StageⅠA gastric adenocarcinoma and did not receive any adjuvant chemotherapy after surgery. One year and 6 months after gastrectomy, blood analysis indicated high levels of carcinoembryonic antigen (CEA 262.1 ng/mL) while abdominal computed tomography (CT) revealed multiple liver tumors (S7: 15 mm, S7/8: 20 mm). The patient was diagnosed with metachronous multiple liver metastases from gastric cancer. Chemotherapy, combined with molecular targeted therapy (S-1 plus cisplatin [CDDP] plus trastuzumab), was administered because of overexpression of the human epidermal growth factor receptor 2 (HER2) protein in the primary tumor as assessed by immunohistochemistry, the CEA levels decreased immediately after 2 cycles of the chemotherapy, and the liver metastases shrank markedly with no evidence of new lesions on abdominal CT. However, after treatment, Grade 3 neutropenia and diarrhea were observed. Chemotherapy was suspended and hepatic resection was performed. After hepatic resection, the liver tumors were histologically evaluated as Grade 2 metastatic gastric adenocarcinoma, and the HER2 expression of remnant carcinoma cells was established. The patient has been in good health and remained free of recurrences in the 2 years and 3 months after the liver resection. Surgery with preoperative chemotherapy (S-1 plus CDDP plus trastuzumab) can be an effective treatment for liver metastasis from HER2-positive gastric cancer.

An 84-year-old patient underwent anterior resection for rectal cancer (RS, T4a, N2, M0, Stage Ⅲb), without adjuvant chemotherapy. Liver metastasis 30 mm in diameter was found in the S7/8 segment 2 years and 6 months after surgery, and segmentectomy of the liver was performed. One year after hepatectomy, lung metastasis 9 mm in diameter was detected in the right S1 lobe. The tumor enlarged after a 2-month follow-up period. We decided to apply stereotactic radiotherapy (50 Gy/10 Fr) to control the lesion. The tumor shrunk and became a scar after treatment. The patient was in good health without any recurrences 7 months after stereotactic radiotherapy. Surgical resection is an optimal method to control lung metastasis from colon cancer when operable; however, there are cases with no indication for surgery due to co-morbidities. Stereotactic radiotherapy can be an effective treatment for lung metastasis from colon cancer when surgery is contraindicated.

A 77 year-old man with asymptomatic microscopic hematuria underwent a cystoscopic examination, which identified a broad-based papillary tumor at the cervix of the bladder. Adenocarcinoma was detected in the biopsy specimen. MRI and CT examination showed a huge papillary tumor of the bladder invading the inner lobe of the prostate. In addition, the wall of the lower rectum exhibited thickening with enlargement of the regional lymph nodes. Endoscopy disclosed a hemi-circular rectal tumor and pathological examination revealed adenocarcinoma, the profile of which was similar to the bladder tumor. The levels of CEA and CA19-9 were 5.3 ng/mL and 39 U/mL, respectively. A differential diagnosis considering bladder cancer, rectal cancer, or both was necessary before planning a treatment strategy. Since both tumors were judged to be resectable, total pelvic exenteration was carried out. Through detailed postoperative pathological examinations, it was concluded that this tumor was of bladder origin and it invaded the prostate along with metastasis to the rectum. Adenocarcinoma of the bladder is extremely rare and exhibits aggressive behavior.

A 61-year-old man was referred to our hospital because of epigastric pain. Upper gastrointestinal endoscopy revealed a type 2 tumor at the gastric antrum, which was diagnosed as gastric adenocarcinoma (tub1) by pathological examination and was HER2 positive 3+ by the IHC method. Abdominal computed tomography revealed multiple metastases to regional lymph nodes (LNs), including bulky nodes at No. 3, 6, and 11p stations. In particular, No. 6 LN was 43 mm in diameter and had invaded to the pancreas. The clinical stage was Ⅲc (T4aN3M0) and neoadjuvant chemotherapy was conducted using S-1/CDDP/trastuzumab. After 2 cycles of chemotherapy, a partial clinical response was obtained and distal gastrectomy with LN dissection (D2 plus No. 16 LN) was performed. The pathological specimens showed no residual cancer cells in the stomach and LNs (Grade 3: pCR). Adjuvant chemotherapy was not administered. The patient is alive 10 months after the surgery with no evidence of recurrence.

A 37-year-old male patient presented with psychiatric symptoms, dysarthria, limb dystonia, increased tendon reflexes, and a Kayser-Fleischer ring in his late teens. Laboratory examinations showed decreased concentrations of serum copper and ceruloplasmin, and increased urinary copper levels. Magnetic resonance imaging (MRI) showed high-signal-intensity lesions in the bilateral putamen, globus pallidus, thalamus, and brainstem on T2-weighted images (T2WI). Based on the MRI results and laboratory data, we diagnosed this patient with Wilson's disease (WD). He was treated with trientine hydrochloride and zinc acetate. Four months after the initiation of treatment, the patient'symptoms began to improve. On a follow-up MRI that was obtained 6 years after treatment, the high-signal-intensity lesions on the T2WI had disappeared completely. However, the low-signal-intensity lesions in the basal ganglia had spread to the caudate nuclei. Here, we discuss the characteristics of the MRI changes in WD following treatment. The Pathological basis for the low-signal-intensity lesions on T2WI in WD remains unclear. Our results suggest that this lesion may reflect the accumulation of materials other than copper.

A 50-year-old man presented to our hospital with the chief complaint of right hypochondriac pain and a palpable tumor. Advanced hepatocellular carcinoma (HCC) and chronic hepatitis B infection were diagnosed and treated by twice-repeated transcatheterarterial chemoembolization (TACE) followed by administration of entecavir. Two months after the last TACE, alpha-fetoprotein(AFP)and protein induced by vitamin K absence or antagonistII (PIVKA-II) levels had elevated, and multiple small early enhancing nodules were detected on computed tomography(CT)scan. Based on his age and liver function (Child-Pugh score A5), a full dose of sorafenib (800 mg/day) was administered. The sorafenib dose was decreased after one month to 400mg/day because of hand-foot syndrome. Following sorafenib administration, the lesions shrank markedly, and complete response (CR) according to modified Response Evaluation Criteria In Solid Tumors(mRECIST)was achieved within 4 months. Six months after sorafenib treatment was begun, recurrent HCC was detected in segment 6, near the previously treated lesion. The decreased size of the main tumor and normalization of AFP levels allowed curative surgical resection. The patient was discharged 5 days after surgery and is currently treated with a half dose of sorafenib. Thirteen months after surgery, a small early enhancing lesion is visible on postoperative CT scan, but AFP and PIVKA-II levels are still keeping in a normal range. This case demonstrates that if sorafenib treatment is effective, then subsequent surgical treatment can be reconsidered in patients with advanced HCC responding to this combined therapy.

A 58-year-old woman underwent sigmoidectomy and partial cystectomy for sigmoid colon cancer following colostomy. The final staging of the tumor was T3, N1, tub2, M0, fStage IIIa. She received 6 courses of CapeOX (oxaliplatin 130mg/m², capecitabine 200mg/m²) as adjuvant chemotherapy, which was discontinued because of severe general fatigue. At the same time, an increase in the levels of serum carcinoembryonic antigen (CEA) was detected and abdominal computed tomography (CT) revealed an expanded adrenal mass. Since whole-body ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET/CT) showed no evidence of multiple organ metastases except for the right adrenal tumor, a solitary adrenal metastasis from sigmoid colon cancer was strongly suspected. Hence, colostomy closure and laparoscopic adrenalectomy were concurrently performed. Histological examination revealed non-functional adrenal adenoma. Therefore, laparoscopic surgery was a reasonable choice even in this complex case.

We report on 2 patients with gastric carcinoma who underwent surgical resection for local recurrence after gastrectomy. Patient 1 was admitted to our hospital because of left-upper abdominal pain caused by local recurrence with abdominal wall invasion. He had undergone distal gastrectomy for gastric cancer 2 years and 4 months previously. Surgical resection of the tumor involving the stomach-jejunum anastomosis region with partial hepatectomy and colectomy was performed. The patient was subsequently discharged without symptoms. A re-recurrence requiring ileocolic bypass then occurred. In spite of chemotherapy and radiotherapy, he died 6 months after the re-recurrence. Patient 2 was admitted to our hospital because of ileus by transverse colon obstruction. He had undergone total gastrectomy for gastric cancer 6 years and 7 months previously and received chemotherapy for local recurrence 4 years after the first surgery. Resection of the local recurrence involving the right transverse colon and the gallbladder was performed at that time. He was discharged without symptoms. He exhibited re-recurrence in the right-upper abdomen 2 months after the second operation. Surgical resection for local recurrence is useful for the improvement of quality of life (QOL) in appropriate cases, but the re-recurrence risk is high because of low curability in these cases.

A 70-year-old male was referred to our hospital because of an abnormally high prostate specific antigen (PSA) level (4.4 ng/ml) associated with lower urinary tract symptoms. Needle biopsy of the prostate did not reveal any malignant tissue. Four months later, the patient presented again with hydronephrosis, which was diagnosed using ultrasonography. Furthermore, contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) revealed left hydronephrosis caused by a soft tissue mass around the left iliac artery compressing the left ureter. Serum IgG4 level was 918 mg/dl. On immunohistochemical reevaluation of the prostate biopsy specimens, the samples were positive for IgG4 immunostaining. The patient was finally diagnosed with IgG4-related prostatitis with retroperitoneal fibrosis. With steroid therapy, the hydronephrosis and urinary symptoms were ameliorated. Our experience with this case suggests that in a male patient with urinary symptoms, biopsy of the prostate may be useful for exact diagnosis when IgG4-related disease is suspected.

The therapeutic strategy for biliary obstruction in patients with unresectable pancreatic cancer is controversial. We compared complications and prognosis between 2 groups: the B group, 8 patients who were diagnosed as having inoperable pancreatic cancer at laparotomy and underwent bypass surgery, and the S group, 7 patients who underwent endoscopic stent placement for biliary obstruction due to clinically unresectable pancreatic cancer. Although 1 patient developed cholangitis and surgical site infection in the B group, there was no difference in the duration of hospital stay between the 2 groups. In terms of long-term complications, re-drainage was performed in 1 patient because of stent deviation and gastrointestinal bypass surgery was performed in 2 patients because of duodenum stenosis in the S group. There was no difference in postoperative survival between the 2 groups. Stent placement is less invasive and is recommended for the treatment of biliary obstruction in patients with clinically unresectable pancreatic cancer. However, bypass surgery is acceptable for the treatment of patients diagnosed as having inoperable pancreatic cancer at laparotomy.