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The gastrointestinal stromal tumor(GIST)guidelines state that the use of neoadjuvant chemotherapy(NAC)for curable GIST is not apparent. However, NAC is performed for massive rectal GIST at our hospital to reduce surgical invasion and improve surgical results. The cases were a 39-year-old man, a 48-year-old man, and a 78-year-old man. The site was Rb in all cases, and the maximum diameters at the rectal GIST diagnosis were respectively 70 mm, 75 mm, and 60 mm, which were massive tumors. Imatinib mesylate(imatinib)was started as NAC. The duration of NAC was respectively 6, 11, and 12 months. The maximum tumor diameter on preoperative CT was smaller than before NAC, and the average reduction rate was 23%. Two cases underwent laparoscopic abdominal perineal resection, and 1 underwent laparoscopic ultra-low anterior resection and ileostomy. No perioperative complications of Clavien-Dindo classification Grade Ⅱ or higher were unsettled. All patients were in the high risk group and received imatinib as postoperative adjuvant chemotherapy. Currently, respectively 2 years and 3 months, 1 year and 2 months, and 1 year after surgery, all are alive without recurrence. NAC with imatinib has contributed to minimally invasive and radical surgery for giant rectal GIST.

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

Robot-assisted laparoscopic surgery(RALS)for rectal cancer has been covered by National Health Insurance in Japan since April 2018. We launched RALS in our hospital in October 2019 and now report the short-term results(up to January 2020). Altogether, 15 consecutive patients(12 men, 3 women: median age 70 years)with rectal cancer underwent RALS during that period. For the first 2 cases, we performed RALS under the instruction of an experienced proctor from another institution. Among the 15 patients, 6 underwent high anterior resection and 9 low anterior resection. Median operating time was 358 min, median intraoperative blood loss was 0 mL, and there were no apparent intraoperative complications. Median postoperative length of hospital stay was 13 days, and only 1 patient developed a high-grade complication(Clavien-Dindo Grade Ⅲb)postoperatively. Hence, RALS for rectal cancer was launched successfully in our institution.

Two cases of neuroendocrine carcinoma, complicated with ulcerative colitis, were examined. Case 1:The patient developed ulcerative colitis at the age of 38, surgery was performed after a diagnosis of rectal cancer at the age of 53, and the patient was diagnosed with neuroendocrine carcinoma by pathological examination after resection. Post-surgery, metastatic nodules were detected in the liver and lungs. The patient is undergoing chemotherapy at this time. Case 2:The patient developed ulcerative colitis at the age of 59;at 72, a sigmoid colon tumor, in addition to multiple liver tumors, was detected. The patient was diagnosed with neuroendocrine carcinoma following biopsy. Chemotherapy was initiated;however, the patient died of cancer 12 months later.

The patients had Hartmann's operation for rectal cancer when she was 61 years old. After that, she underwent the operation for small bowel cancer when she was 68 years old. After 5 months, the only metastatic lesion was detected near the Scolon stoma. For the first therapy, She received chemotherapy(mFOLFOX6 plus bevacizumab)and had a reducing effect. She was introduced to our hospital for the purpose of resection of the recurrent lesion. CT scan detected a nodule near the Scolon stoma with FDG uptake for PET-CT scan. The lesion was resected with S-colon stoma. The abdominal wall defect was so large, we performed abdominal wall plasty with a femoral fascia patch. Seven months after surgery, there is no recurrence. Small bowel tumor is a rare case. This disease frequency about 0.1-0.3% and the treatment strategy is not well established. We reported that complete resection of the recurrence small intestinal carcinoma with abdominal wall repair using femoral fascia after the chemotherapy.

The patient was a 47-year-old man, whose chief complaint was melena. He visited a nearby hospital, and further evaluation showed rectal cancer invading the prostate, with multiple lung and liver metastases. The clinical diagnosis was cT4b(prostate), cN1, cM1b(H2, PUL2), cStage IV . We performed colostomy in the transverse colon prior to chemotherapy. He was administered 1 course of mFOLFOX6 plus bevacizumab and 7 courses of FOLFOXIRI plus bevacizumab. The primary tumor showed PR. The liver metastases were localized and shrunken, while the lung metastases disappeared. Approximately 6 months after the start of chemotherapy, a laparoscopic total pelvic exenteration and ileal conduit were performed following the diagnosis of ycT4b(prostate), ycN1, ycM1a(H2), ycStage IV . About 3 months later, a partial resection of the left liver lobes(S1 and S5/S8)was performed laparoscopically. He has been cancer-free for 8 months.

Regorafenib is an oral multikinase inhibitor; the CORRECTtrial evaluated its efficacy in patients with metastatic colorectal cancer following disease progression with standard therapies. However, regorafenib has toxicities that develop quickly. Few studies have reported the safe dose and usage of regorafenib to avoid these adverse events in Japanese patients. We examined the side effects and safe administration technique of regorafenib in this study. We administered regorafenib to 15 patients with metastatic colorectal cancer following disease progression with standard therapies. Between August 2013 and January 2014, 5 patients received 160 mg oral regorafenib once daily on days 1-21 of a 28 day course(group A). Between February 2014 and July 2015, 10 patients received initiating therapy with 120 mg regorafenib, with the intention of increasing the dose(group B). We retrospectively assessed side effects, number of dose courses, and total dose of regorafenib in both groups. The median dosing course was 5 coureses in group B, which was more than the 1 course in group A. The median total dose was 10,800 mg in group B, which is about 4 times as much as the 2,400 mg in group A. In group B, 7 out of 10 patients (70%)were successful in the dose escalation of regorafenib from 120 to 160 mg daily over 3-5 courses. The disease control rate was 40% in both groups. The rate of adverse events of Grade 3 or higher was 60% in group A, compared to 40% in group B within 2 courses. The overall survival time was 308 days in group B, which was significantly longer than the 168 days in group A. Initiating therapy with 120 mg regorafenib with the intention of increasing the dose improves safety and allows an increase in dosing courses, as well as in the total dose of regorafenib and overall survival time.

Small bowel carcinoma has poor prognosis. The basis of treatment is surgical resection. There are no established guidelines for chemotherapy. We report a case in which we performed surgical resection of recurrent jejunal carcinoma. A 62-year-old woman underwent laparoscopic partial resection of the small intestine for primary jejunal carcinoma. The final diagnosis was T3N0M0, fStage II A. After 16 months of follow-up, she developed abdominal pain and vomiting. We diagnosed recurrence of jejunal carcinoma in the ileum and right ovary. Single-port laparoscopic small intestinal resection and right ovariectomy were performed. The patient underwent curative resection for recurrent lesions. The type of tumor in the ileum and right ovary was consistent with primary jejunal carcinoma by histopathological examination, and was diagnosed as recurrence of jejunal carcinoma. She is now on adjuvant chemotherapy with XELOX.

We report a case of rectal metastasis of gastric cancer associated with dermatomyositis showing paraneoplastic syndrome. The patient was a 70-year-old man who had undergone curative total gastrectomy for Stage III Agastric cancer in March 2005. He was diagnosed with dermatomyositis and treated with prednisolone after gastrectomy. In April 2006, erythema of his face relapsed, and his serum CPK level was abnormally elevated. He experienced muscle weakness and dysphagia, and was treated with increased doses of prednisolone and gamma-globulin. At this time, endoscopic examination and computed tomography(CT)revealed a rectal tumor with hepatic metastasis. We performed Hartmann's operation in July 2006. The rectal tumor was predominantly submucosal, was 7 cm in diameter, involved #251 lymph node, and had positive peritoneal lavage cytology. The histopathological findings of the rectal tumor were comparable with those of gastric cancer, and we therefore diagnosed metastatic adenocarcinoma of gastric cancer. After surgery, we could control the patient's dermatomyositis with prednisolone at a reduced dose. However, chemotherapy with S-1 was ineffective and the patient died 8 months postoperatively.

A79 -year-old woman underwent right hemicolectomy and D3 dissection for ascending colon cancer. Pathologically, the tumor was diagnosed as moderately differentiated adenocarcinoma, pSS, ly1, v1, pPM0, pDM0, pRM0, pN1(3/19), M0, pStage III a. Adjuvant chemotherapy using UFT/UZEL was administered. One and a half years after surgery, PET-CT showed para-aortic lymph node swelling with high FDG uptake. Chemotherapy administration(capecitabine plus bevacizumab)was started and the lymph node swelling reduced. However, 1 year after chemotherapy, the node was swollen again. Para-aortic lymphadenectomy was performed. Pathological examination of the resected specimen showed metastatic adenocarcinoma. No adjuvant chemotherapy was administered. Three years after the last surgery, the patient is alive without any sign of recurrence. In this case, surgical treatment for para-aortic lymph node metastasis of colon cancer resulted in excellent QOL maintenance. We recommend para-aortic lymphadenectomy if the metastasis is localized.

Patients with amyotrophic lateral sclerosis (ALS) often suffer from salivation problems such as drooling and dry mouth. We examined resting salivation rate cross-sectionally in 66 advanced ALS patients with tracheostomy invasive ventilation using a cotton roll method, and investigated clinical factors associated with salivation rate. Resting salivation rate in the patients was well preserved (median value 0.6 g/min), and was significantly more increased in patients with impairment of jaw movement (P = 0.007) or mouth opening (P = 0.003) than in patients with less impairment, and in patients with the mouth being constantly open ≥ 10 mm in rostrocaudal length than in patients with < 10 mm. These data indicate that salivation rate was increased with progression of dysfunction of voluntary jaw movement. Appropriate oral care is required in advanced ALS patients to maintain their oral hygiene and to avoid penetration of saliva into the airway.

It is sometimes difficult to differentiate between metastatic and primary liver tumors, when the liver tumor occurs simultaneously with a gastric cancer. We encountered a case of resected gastric cancer, which occurred concomitantly with intrahepatic cholangiocarcinoma after S-1 plus cisplatin chemotherapy, in a patient who was previously diagnosed with metastatic liver tumor before treatment. An 80-year-old man was admitted to our hospital because of epigastralgia. Endoscopic study of the upper gastrointestinal tract showed a type 3 tumor at the upper body of the stomach. A plain CT scan showed an irregular, low-density area, which was enhanced by contrast medium in the lateral segment of the liver. We performed an ultrasound- guided needle biopsy, because it was impossible to make a definitive diagnosis by dynamic CT, contrast-enhanced ultrasonography, and MRI. Immunohistochemical analysis for cytokeratin 7/20 resulted in 7 (+)/20 (-) for both the gastric cancer and the liver tumor. Therefore, we diagnosed the patient with gastric cancer, which occurred concomitantly with the metastatic liver tumor, and administered chemotherapy with S-1 plus cisplatin. After 3 courses of the regimen, a reduction in the size of mass was observed in the stomach and the liver. We subsequently performed left hepatectomy and total gastrectomy with lymph node dissection. Microscopic examination revealed the gastric cancer, which occurred simultaneously with the intrahepatic cholangiocarcinoma. The postoperative course was uneventful, and the patient remains well without recurrences.

The prognosis of esophageal cancer patients who undergo non-curative resection is very poor. Here, we retrospectively analyzed the factors associated with non-curative resection. Thirty-five patients with cT3 or T4 thoracic esophageal cancer treated with neoadjuvant chemotherapy or chemoradiotherapy followed by esophageal resection were included in this study. Among the 35 patients, 27 underwent curative resection (R0 group), while 8 underwent non-curative resection (R1R2 group). A comparison of the clinicopathological factors between groups revealed no significant differences in presurgical factors. The pathological T factor was significantly deeper in the R1R2 group than in the R0 group (p=0.0086). Histopathological response tended to be higher in the R0 group (p=0.055). An accurate preoperative diagnosis of T factor is important.

We report the cases of 2 patients with advanced rectal cancer who achieved pathological complete response to treatment with preoperative therapy. Case 1 was a 72-year-old man diagnosed with cT3N1M0 advanced rectal cancer. Neoadjuvant chemoradiotherapy with S-1 (120 mg/day) and radiation (50 Gy/25 Fr) was administered. Eight weeks after the last chemoradiation therapy, we performed laparoscopic Hartmann's operation. Case 2 was a 59-year-old man diagnosed with cT4aN0M0 advanced rectal cancer. He was treated with XELOX plus bevacizumab as neoadjuvant chemotherapy. Four weeks after 4 courses of treatment, he underwent laparoscopic Mile's operation. Neoadjuvant therapy was performed without any complications, and a pathological complete response was achieved in both patients. These cases demonstrated that neoadjuvant therapy can be a promising option for locally advanced rectal cancer.

The diagnosis of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas includes radiographic (CT, MRI) and endoscopic evaluation (ERCP, EUS). The treatment strategy is outlined in the 2012 International Consensus Guidelines (ICG). Herein, we report a case initially not indicated for surgery. Four months after the initial diagnosis, the cystic lesion transformed into a solid mass-like lesion visible on CT. FDG-PET showed abnormal FDG uptake at the same location. Surgical resection was performed immediately, and the tumor was diagnosed as IPMN with inflammation. FDG-PET showed a false-positive diagnosis for the malignancy in this case of IPMN.

Purpose: Here, we investigated the efficacy of chemotherapy with trastuzumab for patients with advanced or recurrent gastric cancer., Materials and Methods: We investigated the progression free survival (PFS) and overall survival (OS) of advanced gastric cancer patients who received first-line chemotherapy with trastuzumab in our hospital., Result: After first-line chemotherapy, the median PFS and median OS of patients who received trastuzumab combined with capecitabine/cisplatin chemotherapy was not significantly longer than those of patients who received trastuzumab combined with S-1/cisplatin chemotherapy (PFS, 138 [95%CI: 118-187] vs 169 [95%CI: 83-251] days, p=0.9684; OS, 393 [95%CI: 240-469] vs 466 [95%CI: 256-482] days, p=0.4703). After second-line chemotherapy, the median PFS of patients who received trastuzumab plus irinotecan chemotherapy was not significantly longer than that of patients who received trastuzumab plus paclitaxel chemotherapy (PFS, 63 [95%CI: 52-266] vs 58 [95%CI: 26-184] days, p=0.5447).

We report the case of a 70-year-old man with unresectable advanced gastric cancer because of invasion to the pancreas and multiple liver metastases. He could have continued with fourth-line chemotherapy by controlling intermittent bleeding from the cancer by means of 2 rounds of radiotherapy and trans-arterial embolization. The serum hemoglobin level declined to 4.5 g/dL during second-line chemotherapy. As the venous bleeding from the cancer was difficult to control by endoscopic hemostasis, radiotherapy with 40 Gy/20 fractions was applied to the cancer. We were able to restart chemotherapy after the hemostasis, but 6 months later, the serum hemoglobin level declined to 6.1 g/dL. Additional radiotherapy of 20 Gy/10 fractions was delivered to the tumor, and successful hemostasis was achieved; the serum hemoglobin level reached 7.5 g/dL. However, a contrast-enhanced CT, which was performed 3 weeks later, demonstrated extravasation from the cancer into the gastric cavity. We conducted trans-arterial embolization, and the patient no longer required transfusion. We planned to restart chemotherapy soon, but after 1 month, he died of pneumonia.

Approximately 20% of patients develop some complications after gastrectomy. These complications should be treated appropriately to achieve a positive outcome. The records of 6 patients with postoperative intra-abdominal abscesses treated with interventional radiology (IVR) were analyzed. The cause of abscess was anastomotic leakage in 4 patients and contaminated surgery after gastric perforation in 2 patients. Intra-abdominal abscesses were detected on postoperative day 12 (median), and an IVR-guided drainage tube was inserted with a median interval of 1 day. The drainage tube was kept in place for 26 days (median), and patients were discharged 6.5 days (median) after drainage tube removal. No patients were converted to open surgery. Early IVR-guided drainage was essential and effective for intra-abdominal abscess treatment after gastrectomy.

Skin metastases from esophageal cancer are comparatively rare but have poor prognosis. Here, we report a case of esophageal cancer metastases to the skin. A 70-year-old man was admitted to our hospital for nodules with ulceration in the nose, and biopsy revealed a metastatic carcinoma. FDG-PET indicated FDG accumulation in the skin, liver, and esophagus, while an endoscopic study of the upper gastrointestinal tract showed a type 3 tumor at the upper mid-thoracic esophagus. We diagnosed the patient with metastatic esophageal cancer and administered chemotherapy. Radiation therapy (40 Gy/20 Fr) was simultaneously administered for the tumor in the nose because the patient's quality of life (QOL) decreased daily owing to pain and bleeding caused by metastatic skin cancer. The radiation therapy reduced the size of the tumor in the nose, but the tumor had remained along with the presence of a scar 3 to 6 months after the start of radiation therapy. Radiation effectively promoted the QOL of our patient with skin metastases.

Purpose: The efficacy of chemotherapy for advanced or recurrent gastric cancer in patients who were aged over 75 years was investigated., Materials and Methods: Progression free survival (PFS) and overall survival (OS) of advanced gastric cancer patients who received first-line chemotherapy with TS-1 plus cisplatin or TS-1 in our hospital from 2009 to 2013 were determined. The patients were divided into two groups: H and L. H group patients were aged over 75 years, and L group patients were aged less than 75 years., Results: Median PFS and median OS of patients in the H and L groups who received TS-1 plus cisplatin chemotherapy were not significantly different. PFS was 77[range, 13-211] days and 139[range, 53-211]days for the H and L groups, respectively(p=0.141), while OS was 523[range, 22-1,030] days and 402 [range, 322-623] days, respectively (p=0.620). Similarly, median PFS and median OS of patients who received TS-1 chemotherapy were not significantly different between the H and L groups. PFS was 103[range, 51-156]days and 152.5[range, 85-278]days for the H and L groups, respectively (p=0.230), while OS was 414 [range, 224-714]days and 605[range, 452-1,077] days, respectively ( p=0.1337)., Conclusion: PFS and OS were not significantly different in younger patients with advanced gastric cancer who received TS-1 plus cisplatin or TS-1 chemotherapy compared to that in similarly treated elderly patients with advanced gastric cancer.

A regimen of capecitabine plus oxaliplatin(XELOX)has become one of the standard postoperative adjuvant chemotherapies for colon cancer. However, few tolerability studies have been conducted in Japan. In this study, we retrospectively examined treatment continuation and the adverse events that occurred during 8 courses of postoperative adjuvant chemotherapy with XELOX in 21 patients with colorectal cancer who had undergone curative resection. The completion rate for 8 courses of treatment with XELOX was 71.4%, while the median relative dose intensities of capecitabine and oxaliplatin were 85.0% and 75.0%, respectively. Although the incidence of subsequent Grade 3 or higher hand-foot syndrome was 14.3%, the rate of peripheral neuropathy was 0%. Our hospital had a high rate of XELOX treatment continuation, suggesting that XELOX adjuvant chemotherapy would be well tolerated in clinical practice as well.

We report a case of human epidermal growth factor receptor(HER)2-positive advanced gastric cancer successfully treated with a combination of capecitabine, cisplatin(CDDP), and trastuzumab as first-line chemotherapy. A 66-year-old woman diagnosed as having advanced gastric cancer underwent chemotherapy after abdominal computed tomography (CT)revealed multiple metastases to the liver, lung, lymph nodes, and peritoneum. Histopathological examination indicated a type 3, tub1, cT3(SS), N3, H1, P1, M1(LYM, PUL), cStage IV gastric tumor. Because overexpression of HER2 protein was observed in primary tumor immunostaining, combination therapy of capecitabine+CDDP+trastuzumab was administered as first-line chemotherapy. After 4 courses, CT scans revealed decreased primary tumor size, liver lesion, lymph nodes, and elimination of the lung lesion, thereby suggesting a partial response(PR). The grade 3 adverse events were neutropenia, anemia, and anorexia. After discontinuation of CDDP because of elevation of serum creatinine levels, combination therapy with capecitabine and trastuzumab was continued.

Purpose: Public knowledge-based application for paclitaxe(l PAC) has been approved for advanced or recurrent esophageal cancer. We investigated the feasibility of weekly PAC chemotherapy as a second-line or subsequent regimen for metastatic or recurrent esophageal cancer., Materials and Methods: Patients received PAC( 100 mg/m2 intravenously) on days 1, 8, 15, 22, 29, and 36 of each 8-week period. We analyzed the toxicity and efficacy in 6 patients treated with the weekly PAC chemotherapy., Results: Grade 3-4 toxicities were neutropenia, leukopenia, and anemia. Two patients had stable disease and 2 had progressive disease., Conclusion: By managing the side effects, weekly PAC therapy is considered a feasible regimen that can be administered on an outpatient basis.

We report the case of a patient with paclitaxel (PTX) -resistant recurrent gastric cancer who was effectively treated with S-1 plus docetaxel( DOC). A 62-year-old woman underwent total gastrectomy for Stage IV advanced gastric cancer (type 4, por 2>sig, pT4a (SE), pN3a, pP1, CY1) in 2009. Although S-1 was administered as first-line chemotherapy, recurrent peritoneal metastasis was diagnosed 22 months after surgery. S-1 plus irinotecan (CPT-11) was administered as second-line chemotherapy, and this was followed by weekly PTX (80 mg/m2) as third-line chemotherapy. However, computed tomography (CT) showed increased ascites and peritoneal wall thickening in the pelvis. As the tumor proved resistant to PTX, making the treatment ineffective, S-1( 80 mg/m2, day 1-14, q3w) plus DOC( 40 mg/m2, day 1, q3w) was initiated. Two months later, the ascites and peritoneal wall thickening in the pelvis disappeared. Twelve months after initiation of S-1 plus DOC chemotherapy, no sign of recurrence has been noted.

We report a case of advanced gastric cancer successfully treated with preoperative S-1/Lentinan (LTN)chemotherapy followed by curative gastrectomy. The patient was a 75-year-old man with right hypochondralgia. Endoscopic examination revealed a huge type 2 gastric cancer in the middle body of the stomach. Abdominal computed tomography (CT) revealed multiple perigastric lymph node metastases and bulky para-aortic lymph node metastases. The clinical diagnosis was cT 4N3M1( LYM) with cStage IV. We thought a complete resection would be difficult, so he was treated with S-1( 80 mg/m2 day 1-28/q6w) and LTN (2 mg weekly) in May 2010. After 3 courses, the primary lesion was markedly reduced, and gastric endoscopic biopsy showed no malignant lesion. After 4 courses, abdominal CT showed no lymph node swelling at the perigastric and para-aortic areas. After 5 courses, distal gastrectomy with D2 lymphadenectomy was performed. The histological diagnosis was ypT2( MP) N0M0, Stage IB. Histological features of the primary tumor and lymph nodes were judged to be Grade 2 and Grade 3, respectively. After surgery, S-1/LTN treatment was continued for 1 year. During this period, there were no serious adverse events. The patient has been in good health without recurrence for 28 months after surgery.

Purpose: We investigated the background factors, histopathological results, and prognosis of patients with gastrointestinal neuroendocrine tumors., Materials and Methods: The medical records of 42 patients with gastrointestinal neuroendocrine tumors who were diagnosed and treated at our hospital from 2002 to 2012 were collected and retrospectively reviewed., Result: The ratio of male to female patients was 29:13; the mean age was 66.1 years. The tumors were located in the esophagus( 2 patients), stomach( 13 patients), duodenum( 9 patients), colon( 1 patient), and rectum( 18 patients). Regarding the depth of the tumor, invasion of the submucosa( SM) was observed in 26 patients; invasion of the muscularis propria( MP), in 1 patient; invasion of the subserosa( SS), in 3 patients; penetration of the serosa( SE)( AD), in 1 patient, invasion of the adjacent structures( SI)( AI), in 3 patients; and the extent of tumor invasion was unknown in 1 patient. Patients who experienced relapse had a poor prognosis, and all the patients died.

We retrospectively examined the transversus abdominis plane (TAP) block performed in 8 infants (range, 1-115 days) from July 2010 to March 2011. Ultrasound images clearly visualized the fascial plane between the transversus abdominis and the internal oblique muscle and it was possible to confirm proper administration of local anesthetics into the plane in all patients. Complications resulting from opioid overdose were noted in two cases. One infant required reintubation. Another infant developed delayed emergence from anesthesia. We should tailor the dose of systemic opioid, considering the fact that the simultaneous administration of nerve block and systemic opioids may cause sedation and respiratory depression in young infants.

Background: Ultrasound guided nerve block has become popular in pediatric practice. We applied this technique to infants undergoing pyloromyotomy., Methods: We retrospectively reviewed the hospital records of infants who underwent pyloromyotomy with the aid of the ultrasound guided nerve block from July 2010 to March 2011., Results: Rectus sheath block was performed in 4 infants. In one infant ilioinguinal/hypogastric nerve block was also placed for simultaneous repair of inguinal hernia. There were no complications attributable to the ultrasound guided nerve block., Conclusions: We performed ultrasound guided nerve block safely in infants undergoing pyloromyotomy.

Background: Rapid and transient uterine relaxation is sometimes required for fetal distress or difficult delivery due to uterine hyperactivity during cesarean section. For its rapid onset and short duration, intravenous nitroglycerin (NTG) is commonly used for this purpose. But its suitable dose is unclear., Methods: We evaluated the effect of NTG 200 microg on uterine relaxation in 14 parturients who required rapid uterine relaxation during cesarean delivery from October 2010 to March 2011. We assessed the softness of the uterus, maternal hemodynamic changes after NTG administration, blood loss, uterine contraction after delivery, and Apgar scores., Results: Obstetricians graded the uterus as "moderately soft" in 9, and "very soft" in 5 patients, respectively. Uterine contraction after delivery was good with intravenous oxytocin or dinoprost. Blood loss was acceptable. Six patients exhibited moderate but transient hypotension, and in two of which blood pressure was immediately restored with phenylephrine 100 microg. Four patients complained of nausea and 1 patient complained of headache, but all of which were transient. Median Apgar scores at 1 and 5 minutes were 8.0 and 8.5, respectively., Conclusions: This study indicated that an intravenous administration of NTG 200 microg was effective for rapid uterine relaxation during cesarean delivery.

Objective: Based on the results of the X-ACT study, capecitabine has become one of the standard postoperative adjuvant chemotherapies for colon cancer. However, few studies of tolerability have been conducted in Japan., Method: In this study, we retrospectively examined treatment continuation, and the adverse events that occurred during eight courses of postoperative adjuvant chemotherapy with capecitabine, in 34 patients with colon cancer who had undergone curative resection., Result: The completion rate for eight courses of treatment with capecitabine was 79. 4%(27 of 34 subjects), the median relative dose intensity was 94. 4%(13% to 106%), and the proportion of subjects with relative dose intensity B 60% was 82. 4%(28 of 34 subjects). The following Grade 3 or higher adverse events were reported: hand-foot syndrome, in 11. 8%(4 of 34 subjects); mucositis oral, in 2. 9%(1 of 34 subjects); diarrhea, in 2. 9%(1 of 34 subjects); and glans penis ulcer, in 2. 9%(1 of 34 subjects)., Conclusion: In our hospital, a high rate of capecitabine treatment continuation comparable to that reported in the X-ACT study was obtained, suggesting that capecitabine adjuvant chemotherapy would be well tolerated in clinical practice as well.

Pathogenic bacteria of Mycoplasma pneumonia, Mycoplasma pneumoniae, do not respond to β-lactam antimicrobial agents. Therefore, it is clinically important to promptly identify infection with this type of bacteria. However, conventional examination methods such as culture and antibody tests are not useful for the rapid diagnosis of this bacterial type. In this study, we examined a Loopamp Mycoplasma P-detecting Reagent Kit developed based on the LAMP (Loop-mediated isothermal amplification) method, which may overcome the limitations of the conventional methods. The consistency rate for the conventional polymerase chain reaction (PCR) method was 98.3%. That for a rapid antibody test, immunocard Mycoplasma antibody, was 54.0%, suggesting the limitation of the rapid antibody test. We compared a pretreatment method using a Loopamp PURE DNA Extraction Kit, as a simple DNA extraction method, with that using a QIAamp DNA Mini Kit. The consistency rate was 91.4%, suggesting the usefulness of the simple DNA extraction method. The use of this kit may facilitate a more rapid diagnosis. The Loopamp Mycoplasma P-detecting Reagent Kit is useful for the accurate and rapid diagnosis of Mycoplasma pneumoniae infection.

There is no standard therapy for advanced gastric cancer patients who had already failed treatment with major anti-cancer drugs including fluoropyrimidine, cisplatin, taxans, and irinotecan. We report the results of treatment with capecitabine and cisplatin(XP)after the failure of all other conventional therapies. A total of five advanced gastric cancer patients were treated. The median age was 59 years(range, 46-76); there were 3male and 2 female patients; performance status was 0/1/2: 2/2/ 1 patients, respectively. The median duration from start of first-line chemotherapy to XP was 653 days(range, 372-1,107). Three patients were treated after fourth-line therapy and two patients after fifth-line therapy. All of the patients had received S-1, cisplatin, irinotecan, paclitaxel, and docetaxel previously. Patients received 80mg/m2 of cisplatin intravenously on day 1, and 1,000mg/m2 of capecitabine orally twice a day from day 1 to day 14 followed by a 7-day rest period. Treatment courses were between 2 to 5. Median time to progression was 107 days. Median overall survival was 245 days. One PR and one SD were reported. All reported adverse events were manageable. XP is considered one of the effective regimens for advanced gastric cancer after all conventional therapies have failed.

Purpose: There is no standard second line regimen for metastatic or recurrent esophageal cancer. We investigated the feasibility of combination chemotherapy with Docetaxel (DOC) and Nedaplatin (CDGP) as a second-line regimen for metastatic or recurrent esophageal cancer., Materials and Methods: Patients received DOC (60 mg/m2 intravenously) on day 1 and subsequently CDGP(70 mg/m2 intravenously) on day 1 of each 4-week period thereafter. We analyzed the toxicity and efficacy in 9 patients treated with combination chemotherapy with DOC and CDGP., Result: The observed Grade 3-4 toxicities were neutropenia and anemia. Three patients had stable disease and 6 patients had progressive disease. The median progression free survival and overall survival were 4.3 and 8.1 months, respectively., Conclusion: Combination chemotherapy with DOC and CDGP is considered a feasible second line regimen for metastatic or recurrent esophageal cancer.

Surveillance is very important for preventing the nosocomial spread of methicillin-resistant Staphylococcus aureus (MRSA), and the pulsed-field gel electrophoresis (PFGE) method has long been used to identify the infection source and route as a molecular and epidemiological genotyping method. However, the use of the method in routine clinical laboratory measurements is difficult due to its complicated procedures. Since a molecular and epidemiological genotyping kit based on the POT (Phage Open-reading Frames Typing) method has been developed, we examined 192 MRSA isolates newly detected from inpatients in our hospital in 2010 in order to investigate the usefulness of POT for surveying outbreaks of MRSA. Among the 192 isolates 118 were suspected of nosocomial spread by the previous method, which defined a MRSA detection at more than 48 hours after admission as a nosocomial spread. The POT method was introduced at our laboratory in 2010, and we were able to recognize 38 patients as having strongly suspected nosocomial MRSA infection with the POT method taking into consideration the infection situation, such as places (wards and transfer) and time (date of admission and date of collected samples). Our Infection Control Division was confidently able to demonstrate the current condition of the nosocomial spread by providing the results to the clinical staff, who were also able to practice infection control confidently. We concluded that the POT method was very useful and convenient for investigating MRSA isolates and evaluating collected data because no particular analysis other than the digitizing electrophoretic pattern method was necessary.

KL-6 is a high-molecular-weight mucinous glycoprotein discovered as a pulmonary adenocaricinoma related antigen. Its levels are used as a biomarker of lung injury in interstitial pneumonia. We here report a case of multiple myeloma with Bence-Jones lambda type whose serum KL-6 level was revealed high at a concentration of 19,400 U/ml. Next, we analyzed the blood test profiles and the concentrations of KL-6 in 20 patients with multiple myeloma. CD19/CD56 double negative fraction on myeloma cells with high expression of CD38 was found in all 5 patients with multiple myeloma having elevated KL-6 level. Patients with interstitial pneumonia show high level of KL-6. We, therefore, need to differentiate the interstitial pneumonia and the above-mentioned multiple myeloma when serum KL-6 level is high.

Microscopic examination is usually used for analysis of urinary sediment. The problem of it is difference of the examination results among hospital's clinical laboratories. Photo-survey, training conference using photographs and seminars are held for each examiner to obtain accurate results. However, diagnosis of urinary sediment with photographs is difficult because detailed 3-dimensional cell morphology of urinary sediment cannot be analyzed only with photographs. It is also difficult to have opportunity for all examiners to get enough times of real microscopic training. To evaluate the availability of multi-focal virtual software, diagnosis of urinary sediment under 17 hospital's laboratories was compared between multifocal virtual software survey and conventional photo-survey. Questionnaires were also filled out by the examiners. The rate of correct answers to virtual software survey was 73.9% that was almost same as the result of the survey by Saitama Sightron Society. The rate of correct answers by virtual software survey was higher than photo survey. As a result of questionnaires, the participants take certain advantages of virtual software in spite of several problems. In conclusion, multifocal virtual software enables an accurate diagnosis of urinary sediment in 3-dimension, which leads to reduce the discrepancies of examination results among laboratories.

The presence in serum of the Hepatitis B surface antigen (HBsAg), the outer envelope of the hepatitis B virus (HBV), indicates viral infection, used in laboratory tests to confirm this. We report a case of discrepancy among HBsAg test results detected between measurements in a subject with HB infection. Gene analysis demonstrated several S region gene mutations, not detected previously. We tested 12 measurements e.g., EIA, CLIA, CLEIA, F-EIA, MAT, and IC for whether they could detect our subject's HBsAg and found that it was not recognized by a method using only a single monoclonal antibody to detect HBsAg in two detection processes, in contrast to the 11 other measurements, which used two different antibodies. This case shows that amino acid substitution may cause a false negative result for HBsAg. Gene mutations known to occur in HBV, should thus trigger an awareness of the need to keep in mind that false negative results can happen in case such as ours.

We evaluated the efficacy of chemotherapy using S-1 after gastrojejunostomy for unresectable gastric cancer with pyloric stenosis. We performed gastrojejunostomy to relieve obstruction in 40 patients from 1993 to 2007. After gastrojejunostomy, 15 patients were treated with S-1(S-1 group), 12 patients were treated with another anticancer drug(non S-1 group)and the other 13 patients received no chemotherapy. After informed consent was obtained, S-1(80 mg/m(2)day)and another anticancer drug was administered. The mean period of administered was 16(range 2-56)weeks in the S-1 group. In the non S-1 group, 5-FU was used in 1 patient, 5'-DFUR in 2, UFT in 3, FP chemotherapy in 3, CPT- 11/CDDP chemotherapy in 1, and 5-FU/PTX chemotherapy was conducted in 2 patients. The one-year survival rate was 63% and the median survival time was 394 days in the S-1 group, against 33% and 169 days, respectively, in the non S-1 group. Appetite loss of grade 3 was observed in one(7%)patient with nonhematological toxicity, but no patient suffered grade 3 hematological toxicity. We observed the course of all patients on an outpatient basis. In conclusion, S- 1 administration after gastrojejunostomy appears to be an effective treatment modality for far advanced gastric cancer patients with pyloric stenosis in view of toxicities, antitumor effects and QOL of the patients.

FOLFOX/FOLFIRI chemotherapy is usually applied through central venous catheters because of possible occurrence of phlebitis during application of these regimen via peripheral vein. However, the exact frequency and degree of the problems at peripheral venous access site during FOLFOX/FOLFIRI chemotherapy via peripheral vein in the clinical setting has not been reported previously. We investigated the frequency of infusion failure and phlebitis in 43 patients with advanced or recurrent colorectal cancer who received FOLFOX4, mFOLFOX6 or FOLFIRI chemotherapy in our institution. After informed consent, FOLFOX/FOLFIRI chemotherapy was applied via peripheral vein in 29 cases; all courses (13.1+/-8.1 (Mean+/-SD)courses, 5-FU: 3,510+/-743 mg/body/course) were completed via peripheral vein in the 20 cases (70%). In the other 9 cases, the access site was converted to the central vein because of the problems of access site following completion of 5.9+/-2.0 courses via peripheral vein. Fifty eight times of phlebitis were recognized during total of 301 courses; severe phlebitis requiring medical treatment was not recognized in any case. Seventy seven times of the change of venous access site were required during total of 301 courses. These data would be essential for the exact informed consent for choosing the access site for FOLFOX/FOLFIRI chemotherapy.

We report a patient with unresectable gastric cancer who was effectively treated with S-1 after gastrojejunostomy. A 64-year-old man was referred to our hospital for anorexia and epigastric palpable mass. Upper gastrointestinal endoscopy revealed an ulcerous tumor in the antrum of the stomach, and gastric roentgenography showed pyloric stenosis. CT showed simultaneous multiple liver metastases. We performed gastrojejunostomy to allow oral intake. He was treated with daily oral administration of 120-80 mg S-1 for two weeks followed by one week rest as one course. The treatment was repeated for 19 courses until remission was observed. Weekly paclitaxel therapy (80 mg/m(2)/week) was then chosen as second-line chemotherapy. Administration was continued for three weeks with one-week rest. The treatment course was repeated for 6 courses. Bi-weekly administration of CPT-11 (80 mg) and CDDP (30 mg) was chosen as third-line chemotherapy. He died of progressive disease 2 years and 2 months after surgery. During chemotherapy, he maintained a performance status of 0 to 1, and maintained quality of life. This case suggested that the gastrojejunostomy was a useful method for treating unresectable gastric cancer, allowing the possibility of oral intake, and the use of S-1.

We report a case of a 68-year-old man with a posterior mediastinal tumor. He remembered having difficulty in food passage through his esophagus in childhood. The preoperative thoracic computed tomography (CT) revealed a 5 x 3 cm mass with strong enhancement in the posterior mediastinum. A right thoracotomy was performed to resect this indeterminate mass. Complete resection was achieved. The pathologic diagnosis was paraganglioma. Postoperatively, he experienced more comfortable food passage through his esophagus than ever before. There has been no sign of recurrence 3 years after the operation. The tumor was clinically diagnosed as benign paraganglioma because of its long silent course.