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There are no established treatment protocol for isolated lateral lymph node recurrence in patients with T1 lower rectal cancer, because such case is very rare. In our institution, this is the only recorded case of lateral node recurrence post-resection. It has been documented in several studies that salvage surgery for colorectal cancer improves prognosis. However, there were only 3 reported cases found for lateral lymph node metastasis from colorectal cancer that underwent excision. In this study, we report a rare case of lateral lymph node recurrence after trans-anal resection for T1 lower rectal cancer wherein we performed laparoscopic right lateral pelvic lymph node dissection. The procedure was done safely without any complications. No recurrence noted on follow-up. Hence, we can perform resection of isolated lateral lymph node recurrence in selected patients to achieve good prognosis.

A 66-year-old man presented with recurrences in the peritoneum 3 years after heavy particle beam therapy with hepatocellular carcinoma(HCC)and underwent laparoscopic surgery.Five months after surgery, a new peritoneal dissemination found in the vicinity of the colon hepatic flexure area by CT examination, and laparoscopic resection was planned again.Indocyanine green(ICG)0.5 mg/kg was administered on the day before surgery.ICG imaging by the PINPOINT®system revealed 2 small ICG accumulation sites in the diaphragm, as well as the main lesion, and each lesion was excised laparoscopically.All lesions were diagnosed as peritoneal dissemination of HCC, and the postoperative course was uneventful.Although new dissemination nodules were appeared 6 months after surgery, he underwent laparoscopic surgery again and survives.In PINPOINT fluorescence mode, high-definition white-light image and fluorescence image was combined, and it was easy to determine the cut line but also to visualize the small lesion difficult to identify in the visible light mode.It was suggested that the PINPOINT®system might be useful in cases of HCC peritoneal dissemination.

A 61-year-old man untreated with hepatitis C virus presented to our hospital.He was diagnosed advanced hepatocellular carcinoma(HCC)with portal vein tumor thrombosis(PVTT).The hazy tumor was located in the left lobe, and the tumor thrombus extended into the left portal vein.The patient received stereotactic body radiotherapy(SBRT, 48 Gy/4 Fr)for PVTT. The extended left lobectomy with thrombectomy was performed 12 days after SBRT.Resected specimen was diagnosed histopathologically as a poorly differentiated HCC, vp1, and no viable tumor cells in the tumor thrombosis.The patient's postoperative course was uneventful, and hepatic arterial infusion chemotherapy was started 1 month after the operation.He remains free of recurrence 5 years after the hepatectomy.Multidisciplinary therapy including preoperative SBRT was feasible and might be a treatment option for HCC with PVTT.

We developed a reliable prediction model for colorectal cancer(CRC)patients after surgically curative resection. Using clinicopathological factors, prediction models were constructed for liver metastasis-free survival(LMFS). Between January 2004 and December 2010, 528 CRC patients were investigated. On univariate analysis of clinicopathological factors, the following factors associated with LMFS: pathological tumor invasion, lymph node metastasis, lymphatic invasion, venous invasion, and preoperative serum CEA. Using these factors, a prediction model was constructed using a Cox regression model with a concordance index of 0.824 for LMFS. These individualized prediction models could help clinicians in the treatment of postoperative CRC patients.

The patient was a 76-year-old woman who underwent laparoscopic-assisted low anterior resection for rectal cancer. According to the Japanese classification of colorectal carcinoma (8th Edition), the tumor was tub1, ly0, v0, and pStage Ⅰ (pT1bN0M0), Cur A. She received no adjuvant chemotherapy. A chest CT scan obtained 42 months after the surgery revealed 3 lung metastases in the left lung, with the biggest measuring 12 mm; the CA19-9 level was elevated to 72U/mL (normal≦38 U/mL). She declined surgery for the recurrence. She was treated with XELOX plus bevacizumab (Bev) therapy. Before XELOX plus Bev, the 3 lung metastases had enlarged, with the biggest now measuring 15 mm, and the CA19-9 level was elevated to 166 U/mL. After 4 cycles, the lung metastases decreased in size and the CA19-9 level decreased to 4 U/mL. We did not perform pulmonary resection or additional chemotherapy. No progression of the recurrent tumors was detected on CT after 2 years, and the CA19-9 level was within the normal range. XELOX plus Bev therapy may be effective for unresectable pulmonary metastasis from colorectal cancer.

We report 3 cases of advanced gastric cancer with peritoneal dissemination (PD) who underwent oophorectomy for ovarian metastases that occurred during chemotherapy. Case 1: The patient was a 43-year-old woman who had type 4 advanced gastric cancer with PD. After 24 courses of S-1 plus IV and IP paclitaxel (PTX) combination therapy, oophorectomy was performed for a rapidly growing left ovarian metastasis. Thirty-four months after the start of therapy, she has completed 44 courses of S-1 plus IV and IP PTX therapy and she is continuing the treatment. Case 2: The patient was a 77-year-old woman who underwent total gastrectomy with D2-#10 lymph node dissection and cholecystectomy for gastric cancer with PD. Right ovarian resection was performed for an ovarian metastasis 30 months after gastrectomy. She continues receiving chemotherapy 8 months after oophorectomy. Case 3: The patient was a 42-year-old woman who received S-1 plus CDDP combination therapy and 22 courses of S-1 plus IV and IP PTX for gastric cancer with PD, and oophorectomy for bilateral ovarian metastases was performed. After 10 courses of S-1 plus IV and IP PTX therapy, she died of cancer. We discuss the significance of oophorectomy during chemotherapy for advanced gastric cancer with PD.

Peritoneal dissemination (PD) is the most common type of metastasis in advanced gastric cancer. The standard treatment of gastric cancer patients with PD is combination therapy with S-1 and cisplatin (SP therapy). Here, we describe the results of SP therapy for gastric cancer with PD. Sixteen gastric cancer patients with PD were treated with SP therapy as first-line chemotherapy. Second-look staging laparoscopy was performed for 10 patients who showed a good response to SP therapy. Gastrectomy was performed for 5 patients with P0CY0 and 1 case with P0CY1. The median survival time of all 16 patients was 571 days (19 months). The patients, who had surgery, had a significantly better survival time than the others (25 months vs 12.7 months). In conclusion, SP therapy is effective for gastric cancer with PD, and surgery for cases showing a good response to chemotherapy might improve the prognosis of patients with PD.

Here, we report 2 patients with gastric cancer and peritoneal dissemination who were successfully treated with chemotherapy after undergoing treatment for an oncologic emergency caused by peritoneal dissemination. Case 1 involved obstruction of the sigmoid colon caused by peritoneal dissemination. After urgent colostomy, S-1/IP IV paclitaxel chemotherapy was introduced. The patient continued the therapy for 2 years and 2 months. Case 2 involved acute renal failure due to bilateral ureter obstruction and obstructive jaundice caused by peritoneal dissemination. This patient underwent emergency treatment consisting of Double-J ureteral stent insertion and endoscopic nasobiliary drainage. He was successfully started on chemotherapy with S-1/oxaliplatin/IP paclitaxel. He continued the therapy for 8 months without symptoms. Aggressive treatment might be effective for advanced gastric cancer showing oncologic emergency.

Background: Laparoscopy endoscopy cooperative surgery (LECS) for gastrointestinal stromal tumors (GIST) is an established technique for safe tumor resection, with lesser surgical margin than laparoscopic wedge resection (WR). We report the usefulness of LECS for GIST compared with WR., Method: Between 2008 and 2012, 8 patients with GIST underwent LECS and 11 patients underwent laparoscopic WR. Intraoperative blood loss, surgical margin, and operation time were compared between LECS and WR., Results: Patients undergoing LECS had significantly less surgical margin compared with those undergoing WR (mean 5.6mm versus 28.0 mm, p<.05). The difference in operation time between LECS and WR (214 min versus 112min)was also significant. Intraoperative blood loss was very little and not significantly different between both groups., Conclusion: LECS for GIST was a safe procedure with lesser surgical margins.

A 57-year-old man with jaundice was diagnosed as having advanced gallbladder cancer involving the extrahepatic bile duct.We initiated neoadjuvant chemoradiation therapy with 3-dimensional conformal irradiation (2 Gy × 25 Fr/5 weeks)and gemcitabine (1,000 mg/m²) on days 1, 8, and 15, every 28 days for 3 courses. After percutaneous transhepatic portal vein embolization (PTPE), we performed right hepatectomy with extrahepatic bile duct resection. A follow-up examination 5 years after the operation showed no evidence of recurrence. Therefore, neoadjuvant chemoradiation therapy has the potential to improve the prognosis of patients with advanced gallbladder cancer involving the extrahepatic bile duct.

Background/aims: Recently, laparoscopic distal gastrectomy has become one of the standard therapies for early gastric cancer. However, there are still some obstacles in performing laparoscopic total gastrectomy (LTG) as a standard therapy due to the difficulties in surgical techniques. We have performed LTG for patients with early gastric cancer in the upper portion of the stomach since 2010. In this study, we compared early clinical outcomes of LTG with those of open total gastrectomy (OTG) for patients with cT1N0 gastric cancer., Methodology: We reviewed 69 patients who had gastric cancer of cStage IA between January 2010 and December 2013. We performed a comparative study of short-term clinical outcomes, quantity of dissected lymph nodes, and in-hospital costs between patients undergoing LTG (n=34) and those undergoing OTG (n=35)., Results: The clinical characteristics of patients were well matched in the LTG and OTG groups. The median operating time was significantly longer for the LTG group (p<.0001). The estimated blood loss was significantly reduced in the LTG group (p< 0.0001). The postoperative morbidity rate was 14.7% in the LTG group and 14.2% in the OTG group with no significant difference. There were no differences in the total cost for hospital stay between the LTG and OTG groups., Conclusions: We were able to perform LTG safely and successfully for early gastric cancer in our institute. The total cost of the treatment was almost the same between LTG and OTG. We conclude that LTG is a potential alternative in the management of early gastric cancer.

A 73-year-old woman underwent a craniotomy for an atypical meningioma in 1993, and underwent re-excision for local recurrence 4 years later. In 2008, a chest X-ray film revealed 2 nodules in the right lung. A wedge resection of S2 and a middle lobectomy of the right lung were performed. Pathological findings indicated that the 2 tumors originated from the intracranial meningioma resected in 1993. In 2013, a computed tomography (CT) scan demonstrated hypervascular masses in the liver (S4), pancreatic body, and lower portion of the right kidney. She underwent partial hepatectomy, distal pancreatectomy, and partial nephrectomy, and the final diagnosis was hepatic, pancreatic, and renal metastases from meningioma. After 10 months, a transcatheter arterial embolization (TAE) was performed for hepatic recurrence (S5). She is presently doing well, 5 months after TAE, without any signs of recurrence.

A female patient in her 70s underwent an abdominoperineal resection and bilateral lymph node dissection for advanced lower rectal cancer. The patient did not receive neoadjuvant therapy. In the Japanese classification of colorectal carcinoma (8th Edition), the tumor was a moderately differentiated type 2 adenocarcinoma, and was 4.5 cm in size. Histologically, the tumor was considered to be Stage IIIb (T3N0M0). She received no adjuvant chemotherapy. After 39 months, pelvic computed tomography (CT ) revealed a 29 mm tumor in the right pelvic wall. The patient declined surgery for recurrence so radiotherapy was planned. First, chemotherapy with mFOLFOX6 was administered for 4 courses to reduce tumor size. Consequently, irradiation with carbon ions was given to the site of recurrence at a total dose of 74 GyE in 37 fractions. There were no severe complications. Carcinoembryonic antigen (CEA) level decreased to the lower limit of the normal range from a maximum of 4.9, and no progression of the recurrent tumor was detected on CT for approximately 4 years. Systemic chemotherapy followed by irradiation with carbon ions may be effective for recurrent rectal cancer.

To evaluate the risk factors associated with lymph node(LN)metastases described in the Japanese Society for Cancer of Colon and Rectum (JSCCR) guidelines, we retrospectively analyzed 40 patients with submucosal invasive colorectal cancer who underwent surgical resection after endoscopic resection at Osaka Medical Center for Cancer and Cardiovascular Diseases between 2006 and 2008. We examined clinicopathological factors such as sex, age, tumor diameter, morphology, histological grade, submucosal invasion, lymphatic invasion, venous invasion, and LN metastasis and 5-year disease-free survival(DFS) and overall survival (OS). All patients had tubular adenocarcinoma. Ten patients had LN metastasis. Histological grade, tub2, and a positive vertical margin were significant risk factors. Submucosal invasion was greater than 1,000 µm in patients with LN metastasis. There was no difference in clinicopathological factors between patients with colon cancer and those with rectal cancer, but LN metastasis occurred in 18.7% and 50.0% of colon cancer and rectal cancer patients, respectively. There were no recurrences or cancer-related deaths, although one patient died of other causes. In conclusion, patients who were treated according to the JSCCR guidelines had a favorable prognosis.

A 70s man with advanced hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) (Vp-HCC) in the main trunk (Vp4) was referred to our hospital. He was negative for hepatitis C virus (HCV) and hepatitis B virus (HBV), and his liver function was well preserved. The main tumor was in the right lobe and exceeded 10 cm in diameter. There were no intrahepatic metastases to the left lobe. The patient underwent stereotactic body radiation therapy (SBRT) (48 Gy/4 fractions) to the area of the PVTT. Six days after SBRT, the patient underwent right lobectomy for removal of PVTT. The postoperative course was uneventful, and low-dose 5-fluorouracil and cisplatin(FP)intra-arterial chemotherapy was administered for 3 months. Histopathological findings for the tumor indicated a poorly differentiated HCC, vp4, with moderate to severe tumor necrosis or degeneration in the area that received SBRT. Tumor markers (alpha-fetoprotein [AFP], proteins induced by vitamin K absence [PIVKA-II]) decreased within the normal range, and there was no apparent HCC recurrence 6 months after the hepatectomy. Multidisciplinary treatment combined with preoperative SBRT and radical resection for Vp-HCC was feasible and effective in this case.

Patients with colon cancer who present with stenosis are treated with emergency surgery. Colostomy or Hartmann's operation are commonly performed, but are associated with an increased risk of complications such as anastomotic leakage, which reduce the quality of life of the patient. In our patient, emergency surgery was avoided by metallic stent placement. Metallic stents can be an effective bridge to surgery in colon cancer patients with ileal symptoms.

A phase III clinical trial to evaluate the efficacy of combination chemotherapy with intraperitoneal administration of paclitaxel for gastric cancer with peritoneal metastasis has been ongoing in Japan. A male patient in his 50s who was diagnosed as having advanced gastric cancer with peritoneal metastasis was enrolled in this trial. The patient was assigned to receive a regimen of intravenous and intraperitoneal paclitaxel combined with S-1. Although an intraperitoneal access port had been implanted to provide access to the peritoneal cavity, tube obstruction occurred twice. Laparoscopic examination revealed that the tube in the abdominal cavity had been totally covered with the great omentum. Therefore, the intraperitoneal regimen was discontinued. Although intraperitoneal chemotherapy for the treatment of peritoneal dissemination in gastric cancer is promising, precaution should be taken to avoid tube obstruction, which is a complication of the intraperitoneal tube placement.

A 64-year-old man was diagnosed as having advanced gastric cancer with peritoneal and para-aortic lymph node metastases. He received 2 courses of chemotherapy with S-1 and cisplatin( CDDP) and 5 courses of combination chemotherapy with capecitabine, CDDP, and trastuzumab. The peritoneal and para-aortic lymph node metastases disappeared after chemotherapy, and subsequently, total gastrectomy was performed (pT2N3aM0, stage IIIA). Although the patient received combination chemotherapy with capecitabine and trastuzumab, para-aortic lymph node recurrence was noted 6 months after the operation. Radiation therapy at a total dose of 50 Gy targeted at the para-aortic lymph node metastasis along with S-1 and trastuzumab chemotherapy was administered. No serious adverse effects were observed during chemoradiotherapy. Following chemoradiation therapy, tumor recurrence was not observed. Therefore, chemoradiotherapy is considered an effective treatment for lymph node metastasis from gastric cancer.

We report a case in which advanced lung cancer with mediastinal lymph node metastasis and recurrence of brain metastasis was completely responsive to combination chemotherapy and gamma knife radiosurgery. The patient was a 61-year-old woman, who suffered from advanced lung cancer (SCC) with bilateral mediastinal lymph node metastasis and contralateral lung nodule. She was treated with CBDCA combined with PTX. Bilateral lung nodules were surgically resected. Seven months after resection, solitary brain metastasis appeared, and gamma knife radiosurgery was performed. Histological efficacy of both primary lung tumor (SCC) and metastatic brain tumor was evaluated as Ef 3 (pCR). She has had no recurrence for 3 years after radiosurgery.

We report a case of hemobilia developing after RFA for hepatocellular carcinoma. A 75-year-old woman with hepatitis C was diagnosed as hepatocellular carcinoma (d=15 mm) located in subsegment 7. Laboratory data on admission are AFP 37.3 ng/mL, PIVKA-II 20 mAU/mL, GOT/GPT 84/52 IU/L, T-Bil 1.1 mg/dL, Alb 3.8 g/dL, Plt 8.9x104/microL, and PT 11.8 seconds (INR 1.28) "Child classification A". Under general anesthesia, percutaneous RFA (Cool-tip radionics 10 minutes) was performed. Tumor appeared to be well treated, but on day 5 after the procedure, the patient had sudden upper abdominal pain, followed by the elevation of total bilirubin conc. (3.3 mg/dL) and decrease of Hb. Abdominal ultrasonography showed a debris-like shadow in the gall bladder. Hemobilia was confirmed because endoscopic examination revealed blood contaminated bile from the papilla Vater. Since spontaneous thrombolysis is known to occur in the bile, the patient was only followed by MRI. Symptoms were subsided in a week without any treatment. Obstructive jaundice due to hemobilia is a rare complication of RFA, and may be followed without any treatment.

The prognosis of pancreatic cancer is most dismal in all gastrointestinal cancers, because the patients with pancreatic cancer are vulnerable for recurrence such as local relapse and liver metastasis even after a complete surgical resection. We herein report a case of pancreatic cancer, which underwent resection of local relapse and multiresections of liver metastases, resulting in a relatively longer survival. A 71-year-old woman was referred to our hospital for a local recurrence in the tail of the pancreas in October 2006, 17 months after the first distal pancreatectomy. A second distal pancreatectomy was curatively performed on this patient. After the second surgery, sequent solitary liver metastases appeared, and we then performed partial hepatectomies repeatedly in August 2007, December 2007 and December 2008. The histopathological findings of each specimen from the resected liver showed tubular adenocarcinoma, same as the original pancreatic tumor obtained from the first surgery. Although chemotherapy was not permitted due to gemcitabine-induced interstitial pneumonitis, the patient is still alive over 4 years after the first operation under palliative care. This study discusses a controversial issue about the resection of the liver metastases from pancreatic cancer, along with the necessity for careful selection of the patients before attempting the operation.

The case was a 70-year-old man with type-2 gastric cancer in the lesser curvature accompanied by multiple liver metastases. He received combination chemotherapy of S-1 and CDDP. S-1 was administered at 100 mg/body/day for 21 days followed by withdrawal for 14 days, and CDDP was prescribed at 80 mg/body/day div on day 8. After 3 courses of treatment, the multiple liver metastases disappeared. The primary gastric lesion had changed to a scar and endoscopic biopsy revealed no cancer cell. After the 4th course, we changed the therapy to S-1 alone and after that to UFT alone. Now, 3 years and 3 months after inducing CR, the patient continues to receive UFT with no regrowth of the tumor.

We report a case of advanced unresectable pancreatic cancer (cT4N1M0/stage IVa). The patient was a 68-year-old man. Chemo-radiation therapy (CRT) with GEM (1,000 mg/body) was administered once a week on days 1, 8 and 15 for 3 weeks. The radiotherapy dose was 45 Gy (1.5 Gy x 2/day, 15 days). After CRT, the patient was treated with a GEM+ UFT-E combination chemotherapy. When that was done, CT scan revealed metastases of umbilicus (Sister Mary Joseph's nodule) and the liver. Microwave Coagulation Therapy for the liver metastasis and tumorectomy for metastasis of umbilicus were performed. But he died after 4 months from the therapies.

A 74-year-old male with advanced gastric cancer(cT3N1M0H0P0CY0, cStage III A)was treated with paclitaxel/ CDDP as neoadjuvant chemotherapy. Paclitaxel (80 mg/m(2)) and CDDP (25 mg/m(2)) were administered on days 1, 8 and 15 as one cycle. After the second course, a significant tumor reduction was obtained. Total gastrectomy, splenectomy, and D2 type nodal dissection were performed. The histological diagnosis revealed complete disappearance of cancer cells in the stomach and all of the lymph nodes, a so-called pathologically complete response. The patient has now been in good health without any recurrence for 9 months after surgery. This case suggests that neoadjuvant chemotherapy with paclitaxel/CDDP is a potential regimen for advanced gastric cancer.

We report a case of advanced unresectable pancreatic cancer with multiple liver metastases (cT4N x M1, stage IVb). The patient is a 68-year-old man. Serum DUPAN-2 was 15,800 U/mL. Abdominal CT scan revealed the body and tail of pancreatic cancer and multiple liver metastases. Chemo-radiation therapy (CRT) with GEM 1000 mg/body was given once a week on days 1, 8 and 15 for 3 weeks. The radiotherapy dose was 45 Gy (1.5 Gy x 2/day, 15 days). Hematological side effect such as anemia (grade 3) and thrombopenia (grade 2) appeared, but could be well controlled. Abdominal CT scan revealed no change in size, but serum DUPAN-2 decreased up to 4590 U/mL. After CRT, the patient was treated thereafter by the combination chemotherapy with GEM and S-1. After 7 months, CT scan revealed no change in tumor size.

A male in his eighties underwent abdominoperineal resection under the diagnosis of adenocarcinoma associated with anal fistula (P0, H0, n (-), A1, stage II, ly0, v0). Ten years after the surgery, a painful lymph node swelling was noticed in the left inguinal region. Biopsy specimen showed adenocarcinoma consisting of severe dysplastic cells. Radiotherapy was performed in the pelvic region at a total dose of 50 Gy (2 Gy/day). After the radiotherapy, left inguinal and pelvic lymph nodes markedly shrank and became painless. After one month, the chemotherapy with UFT (UFT 300 mg/day) was started. One year thereafter, para-aortic lymph nodes were found to be enlarged, but a good quality of life was obtained without elevation of tumor markers.

We report a patient with a case of advanced rectal cancer with unresectable liver metastasis, who received the combination of systemic chemotherapy of 5-FU/l-LV and external radiation therapy. He was alive for 21 months. He had been able to maintain a good quality of life without any complaints of the primary rectal tumor.

We present a case of a 70-year-old man with an anamnesis of intra-cerebral bleeding that resulted in right half of the body paralysis and right diaphragm paralysis, The present clinical history indicated hepatocellular carcinoma (HCC) caused by hepatitis C and liver cirrhosis during a regular hospital visit, and the patient had a total of 4 TAEs enforced from three years before. A 4 x 3.5 cm neoplasm at the left adrenal was detected by CT inspection this time. The diagnosis was a metastatic adrenal gland tumor from HCC. Since HCC is controlled by TAE, the metastatic lesions were not found in other organs and were isolated, of 10 cm or less in size. Hence, laparoscopic adrenalectomy was performed in March, 2006. He started having a meal from the 2nd day after the operation. He left the hospital on the 9th day. Pathologial diagnosis was a metastatic adrenal gland tumor from moderately differentiated hepatocellular carcinoma. When observing the adaptation standard strictly to the high-risk case, it was thought that the metastatic tumor extraction under laparoscopic surgery could become a low stress cure in consideration of QOL being useful as a local treatment for cancer.

We report a case of advanced hepatocellular carcinoma (HCC). A 73-year-old man with positive HBV and HCV underwent a partial hepatectomy (S6 and S5) twice and transcatheter arterial (chemo) embolization (TAE) four times, thereafter. During these treatments, HCC became intractable and the patient complained of general fatigue. The liver function was Child's classification A, and serum AFP was 6,737 ng/ml. Abdominal CT scan revealed recurrent lesions in the right hepatic lobe and left adrenal gland. The catheter for hepatic arterial infusion chemotherapy was inserted from the left femoral artery. Arterial chemotherapy with 5-fluorouracil (5-FU 750 mg) and cisplatin (CDDP 10 mg) was performed every two weeks. During 6 courses of this regimen, a significant side effect did not appear. Abdominal CT revealed no change in size, but serum AFP decreased up to 794 ng/ml and the general fatigue subsided. After 2 months, serum AFP began to increase and became 1454 ng/ml. The regimen of arterial chemotherapy was changed to epirubicin (EPI 40 mg every two weeks) and UFT-E (300 mg/day for four weeks), followed by a week off. An appetite loss (grade 2) appeared, but it could be well controlled. Serum AFP decreased again, up to 54 ng/ml. A good QOL was kept for about one year after the initiation of hepatic arterial infusion chemotherapy.

In colorectal cancer, hepatic and pulmonary metastases are the most common and most important prognostic factors. Surgical resection is the first choice of treatment for hepatic and pulmonary metastases if completely resectable. However, only a few patients survived long term after metastatectomy. We present the two cases, in which surgical resection for pulmonary and/or hepatic metastases from colorectal cancer resulted in long-term survival for more than ten years without recurrence.

The patient, a 40-year-old woman, underwent total gastrectomy and excision of the pancreatic tail, spleen and gallbladder for gastric cancer in September 2000. The lesion was judged to be P1, SE, H0, N2 and Stage IV and the patient was managed on a regular schedule as an outpatient. In September 2004, she passed blood-stained feces and rectal palpation detected a hard nodule at the anterior rectal wall. A fiber optic examination of the sigmoid colon detected an ulcerous lesion with a hemorrhage at the anterior rectal wall. A biopsy revealed the lesion to be Group V poorly differentiated adenocarcinoma. Starting in October 2004, 100 mg/day of TS-1 was administered for 3 weeks; intravenous drip infusion of 100 mg/body of CDDP was conducted in the second week for a period of 24 hours. After 3 courses of this regimen, a fiber optic examination of the colon conducted in February 2005 no longer detected the rectal tumor, leaving only a cicatrix. Upon a CT examination, the para-aortic lymph nodes that had been enlarged were notably reduced in size and an improvement was eminent in the hypertrophic rectal wall. The patient no longer experienced constipation or melena. Her clinical course is being observed while an oral administration of 100 mg/day of TS-1 continues.

In colorectal cancer, liver metastasis is the most common and most important prognostic factor. Although surgical resection is the first choice of treatment for liver metastasis of colorectal cancer, there are many cases we cannot choose the surgical treatment. The chemotherapy is very important in such cases. We examined 18 cases of unresectable liver metastases from colorectal cancer which were adapted a hepatic arterial infusion of 5-FU (HAI) with a weekly high-dose infusion method (WHF) as the first-line treatment, and then systemic chemotherapy of CPT-11 in combination with 5-FU as the second-line treatment. The response rate of this treatment is 72% (13/18) and the 1-, 2-, 3-year survival rates were 100% (16/16), 83% (10/12), and 50% (5/10), respectively. The combination chemotherapy of HAI with systemic chemotherapy using CPT-11 seemed to be an effective treatment method.

A 44 year-old woman presented with epigastralgia in March 2004 was diagnosed as having type II gastric cancer by gastrofiberscope, and histological diagnosis of biopsy specimens was group V (tub2, por1). Since multiple liver metastases were observed in subsegments 2, 3, and 5 by abdominal ultrasonography, systemic chemotherapy was first conducted for tumor down sizing. The patient was treated by three cycles of the one month regimen (CDDP 70 mg/m2, day 8, for 24hrs, and TS-1 80 mg/m2, day 1-14; 2 week cessation of the drugs). CT scan taken on May 16, 2005 revealed that the tumor diameters in subsegments 2, 3, and 5 were 1 cm, 3 cm, and 1.5 cm, respectively. On September 14, liver tumors were markedly shrunk. Tumor in subsegment 2 became undetectable, and the diameters in those in subsegments 3 and 5 were 1.5 cm, and 0.5 cm, respectively. On September 28, a distal gastrectomy associated with S3 partial hepatectomy and microwave coagulation therapy for S5 tumor was performed without any macroscopic residual lesions. The prognosis of liver metastasis of gastric cancer is generally poor, and there is no comprehensive therapy. The marked clinical response in this patient suggests that this combination therapy with CDDP and TS-1 might be a promising preoperative chemothepapy for unresectable gastric cancer.

To evaluate the clinical effectiveness of metallic stent in the palliation of malignant bile duct obstruction in aged patients, 30 patients over 65 years of age with malignant biliary obstruction were investigated retrospectively. Overall survival duration after the stent placement was 13-1,275 (mean: 278, median: 169) days. The period of tube-free on the outpatient basis after stent insertion was 0-1,162 (mean: 192, median: 121) days. The estimated cost savings by eliminating hospitalization was greater than the stent cost. Four patients survived over 18 months despite their advanced clinical stages. It seems difficult to develop guidelines for the indication of stent placement in the treatment of malignant bile duct obstruction for aged patients.

A 56-year-old male was admitted to our hospital for hepatoma with portal vein thrombus and multiple intrahepatic metastases. He underwent an extended left lobectomy and a partial resection of the liver in May 2002. After two weeks from the surgery, he received intra arterial 5-FU infusion chemotherapy combined with subcutaneous interferon-alpha injection to treat the lesions in the residual liver. Four months after the surgery, hepatic vein tumor thrombus appeared in the remnant liver and it extended to the inferior caval vein. And another 4 months later, multiple pulmonary metastases were detected with computed tomography and they grew rapidly in the view of their sizes and numbers. Because the combined therapy of 5-FU/interferon-alpha was not effective to distant metastases, we started a new regimen of oral administration of TS-1 and a subcutaneous interferon-alpha injection. After 1 treatment cool, hepatic vein thrombus was markedly reduced the size and vascularity in the CT. Multiple pulmonary metastases also decreased in their sizes and numbers. No adverse effect was seen during this treatment. It was suggested that a combination therapy of TS-1 and interferon-alpha may be one of the most effective treatment modalities against advanced HCC with distant metastasis.

A 56-year-old man is presented with diarrhea, which he had experienced since February 2004. He was diagnosed as having advanced pancreatic cancer by enhanced abdominal CT scan in May 2004. He was diagnosed with unresectable pancreatic cancer, and treated with a combination of radiation (3 Gy/day) and injections of gemcitabine (GEM) 1,200 mg/week (800 mg/m2, BSA 1.6). Abdominal CT scan revealed a minor response (tumor diameter 5.7 x 4.8 --> 5.2 x 4.4). Accordingly, the improvement of performance status and reduction in serum levels of arcinoembryonic/carbohydrate antigen 19-9 (CA19-9) were observed. In July 2004, chemotherapy and radiotherapy were switched to GEM+UFT (UFT 360 mg/day, a total of 4,320 mg, GEM 1,200 mg according to the body mass, a total of 2,400 mg). The patient's performance state was stable for 6 months but serum levels of CA19-9 increased from March 2005, and he complained of diarrhea and back-pain. Therefore, the combination chemotherapy with GEM and cisplatin (CDDP) was started in April 2005, but there was no clinical effect. GEM and TS-1 are currently being administered. Pancreatic cancer is one of the worst prognoses of any malignant disease. Although the prognosis of unresectable pancreatic cancer is very poor, we presented a case where performance status and survival benefits were obtained by undergoing chemoradiation with GEM and combination chemotherapy with UFT and GEM.

The patients of unresectable cholangiocellular carcinoma (CCC) have extremely poor prognosis. Case 1 was a 72-year-old male who had CCC in the left lobe of liver with intrahepatic metastasis. From June 2003, he received hepatic arterial infusion chemotherapy (FAP: 5-fluorouracil 250 mg/day continuous infusion, day 1-5, adriamycin 10 mg/day, day 1, and CDDP 10 mg/day, day 1). After 5 courses, abdominal CT revealed that the main tumor had regressed. Case 2 was a 66-year-old male who had CCC with portal vein tumor thrombus of anterior branch (Vp2). He received FAP arterial infusion chemotherapy that was a same regimen as with the case 1 patient. After 5 courses were administered, Abdominal CT revealed that the size of the main tumor at S8 had not changed, and that portal vein tumor thrombus had disappeared. In both cases, there was no complication related to the chemotherapy. They are alive for more than 1 year after chemotherapy had started. FAP hepatic arterial infusion chemotherapy might be promising as an effective therapy for non-resectable CCC without extra hepatic metastasis.

The prognosis of unresectable advanced gallbladder cancer is extremely poor. We presented a 61-year-old female with unresectable advanced gallbladder cancer who received FAP therapy, Gemcitabine + UFT therapy, and an intra-arterial FAP therapy that followed. She is still alive 18 months after the first diagnosis. It may be possible to improve the prognosis by maintaining QOL using the combination of chemotherapies such as FAP, Gemcitabine, and UFT.

To investigate the effect of biochemical modulation on antitumor activity shown by the combination of 5-Fluorouracil (5-FU) and interferon-alpha (IFN-alpha), experimental therapy was performed on human hepatocellular carcinoma cell (HuH7, PLC/PLF/5) xenografts inoculated into nude mice, using 5-FU and IFN-alpha, either alone or in combination. These agents showed antitumor activity in different degrees. Although IFN-alpha, given as 100,000 units/mouse/3 times/week subcutaneously x 6, and 5-FU, given as 0.5 mg/mouse/3 times/week intraperitoneally, showed addititive antitumor effect against HuH7 and PLC/PLF/5, the activities of thymidylate synthase (TS), dihydropyrimidine dehydrogenase (DPD), thymidine phosphorylase (TP), orotate phosphoribosyltransferase (OPRT), uridine phosphorylase (UP) and uridine kinase (UK) were not significantly influenced in the tumors treated with the 5-FU/IFN-alpha combination, compared with those treated with 5-FU or IFN-alpha alone. This suggested that antitumor activity of 5-FU and IFN-alpha in combination was not significantly involved in 5-FU metabolism in two human hepatocellular carcinoma cell lines examined.

A 52-year-old male was admitted to our hospital with huge hepatoma of the right lobe. He underwent a right lobectomy of the liver in July 1999. After five months from the surgery, multiple recurrences in the liver and lung were revealed with Computed tomography (CT). TAE was performed for intrahepatic recurrence and a combination therapy, consisting of UFT and interferon-alpha, was started for pulmonary metastasis. Then 5-FU/CDDP/interferon-alpha therapy was given in 2001 and TS-1/interferon-beta therapy was given thereafter in 2002. Consequently, the patient survived for 31 months with no disturbance in quality of life. No intrahepatic recurrence was also detected during the survival period. It was suggested that a good prognosis may be expected, even in the HCC case with distant metastasis after hepatic resection, if the primary cite was curatively treated.

A phase I study of gemcitabine (GEM) and UFT combination chemotherapy was performed for unresectable pancreatic cancer. The regimen included UFT orally from day 1 through day 6 and from day 8 through 13, GEM intravenously on day 7 and 14, and 1 week rest as 1 course. Administration of more than 2 courses was attempted for each patient, with the same dosage levels at all 3 scheduled steps. Nine patients were enrolled in the study. Leukopenia and neutropenia of grade 3 occurred in 2 of 6 patients at level 2, and maximum tolerated dose (MTD) was considered to be 800 mg/m2 for GEM and 250 mg/m2 for UFT. Clinical effects of the patients included: 2 PR, 4 NC, and 3 PD, for a response rate of 22% (2/9 patients). Reduced CA19-9 level of less than half of that at starting time was observed in 4 of 9 (44%) patients. The recommended dose for the phase II study is GEM 800 mg/m2 and UFT 250 mg/m2 with consideration of application to outpatients and continuing courses.

For the difficulty of the giving sufficient dose because of the poor liver function and low sensitivity for the anti-cancer agents, the chemotherapy may not play a central role for the hepatocellular carcinoma (HCC) patients with liver cirrhosis. However, the chemotherapy must be the one of important possibility as a multimodal treatment for the advanced HCC, for which hepatic resection, TAE and other general therapy would not be effective. The intraarterial perfusion chemotherapy is common as a chemotherapy for HCC and it is not difficult to maintain; the effective rate is not sufficient. Recently, the combination therapy with subcutaneous IFN-alpha and intraarterial 5-FU showed a outstanding effective rate for intractable HCC with Vp3. For the further advance of the HCC treatment and prognosis, this therapy might be the promising treatment modality and expected of the development.

A 55-year-old female was admitted to our hospital for a third recurrence of hepatoma. She was treated with transcatheter arterial embolization (TAE) in April and November 1996. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed multiple tumors of S4/S8 and S7 in the liver. After the third TAE using SMANCS, Lipiodol and Spongel, abdominal CT revealed insufficient Lipiodol retention and the in efficacy of this treatment. A right lobectomy of the liver was performed for the TAE resistant multiple recurrence of HCC. After the surgery, the patient survived for over 5 years with no recurrence. It appears that this surgery may be a useful modality for TAE resistant multiple recurrence hepatoma in cases of good liver function and lesions limited to the hemi lobe.

The prognosis of advanced hepatocellular carcinoma (HCC) is extremely poor. Patient 1 was a 43-year-old male with major portal tumor thrombi. He received combination therapy consisting of continuous arterial infusion (MTX 30 mg/m2, day 1, CDDP/5-FU 6 mg/m2: 250 mg/m2, day 1-14) and subcutaneous injection of IFN-alpha (500 x 10(4) U, 3 times a week, 4 weeks). Patient 2 was a 66-year-old male with major hepatic venous tumor thrombi. He received combination therapy consisting of continuous arterial infusion (5-FU 6 mg/m2: 250 mg/m2, day 1-14) and subcutaneous injection of IFN-alpha (500 x 10(4) U, 3 times a week, 4 weeks). Decrease in tumor was observed in both patients markers and marked regression of tumor was observed in both patients. They are still in complete response. This combination therapy is an effective strategy for advanced HCC.

The patient is a 75-year-old male. Abdominal ultrasound tomography in June 2002 revealed hepatocellular carcinoma with intrahepatic metastasis (IM3) and tumor thrombi (Vp4, Vv3) at S4 in the major portal and hepatic vein. From July 2002, he received hepatic arterial infusion therapy (FAP: 5-fluorouracil, CDDP and adriamycin) for these lesions. In December 2002, these lesions had disappeared completely after 6 sessions of arterial infusion therapy. The patient is still alive with no recurrence after 2 years since the beginning of this treatment. Recently, we treated 9 patients with combined arterial infusion chemotherapy (FAP), and the response rate (CR and PR) was 44% and no major side effect was observed. In conclusion, some patients may obtain longer survival through this treatment, even in cases of advanced HCC with tumor thrombus in the major trunks of portal vein and/or hepatic vein.

We report a patient in whom systemic chemotherapy using gemcitabine was effective against liver metastases of pancreatic cancer. A 72-year-old woman underwent pancreatoduodenectomy with lymphadenectomy and partial resection of the portal vein following a diagnosis of pancreatic cancer, and her postoperative course was uneventful. The diagnosis was stage III anaplastic ductal carcinoma (t2n1P0H0M0). One year and 3 months after the operation, however, her serum level of carbohydrate antigen 19-9 (CA19-9) was found to be elevated, and CT examination revealed a mass in the liver that was diagnosed as liver that was metastases. Systemic chemotherapy was performed with a regimen of gemcitabine 600 mg/m2/week for 3 weeks, followed by a week rest, for the first three courses. On and after fourth course, gemcitabine 1,000 mg/m2/week was administered. The serum CA19-9 level was down from 882 U/ml to normal after 5 courses of chemotherapy and CT examination revealed that liver metastases had completely vanished. Although no evidence of deterioration was observed, the patient died of infectious pneumonia 10 months after recurrence. The prognosis of liver metastases of pancreatic cancer is quite unfavorable. However, if remission is achieved with gemcitabine, the patient has the possibility to obtain a better outcome.

A 61-year-old male who underwent radical resection for gastric cancer was diagnosed with multiple hepatic metastasis 2 years and 2 months after the surgery. He first underwent percutaneous microwave hepatic coagulation therapy with segmental hepatic blood flow occlusion and obtained complete coagulation of the main tumor. Consecutively, he received hepatic arterial infusion chemotherapy (FAP: 5-FU, cisplatin, adriamycin) against residual multiple hepatic tumors. These hepatic recurrent lesions disappeared completely after 3 sessions of arterial infusion chemotherapy. At present, this patient is alive with no recurrent lesions, 1 year and 6 months from the beginning of treatment for hepatic metastasis. Recently, we tried hepatic arterial infusion chemotherapy (FAP) in four cases in which the recurrence from gastric cancer was not only in the liver but elsewhere. The response rate (CR and PR) was 75% and no major side effects were observed. In conclusion, some cases can obtain longer survival if the multimoderate therapy including hepatic arterial infusion chemotherapy (FAP) and microwave coagulation therapy are effective.

The patient was 63-year-old male. Abdominal CT revealed a tumor at S2/S3, which led to a diagnosis of hepatocellular carcinoma, in April 1998. On April 15, 1998 transcathetereal arterial embolization was performed and on May 11, 1998 percutaneous ethanol injection therapy was given, but a viable lesion remained. On July 2, 1998, partial resection of S2/S3 was performed. There was an intrahepapic metastatic lesion at Glisson's site of the main tumor, which was suspected of implantation. In December 2000, the patient had a high AFP level, and a recurrent tumor was observed at S3 on abdominal CT. In June 2001, S3 subsegmentectomy was performed, because the recurrent tumor existed in the Glisson S3 area.

We report a patient with hepatocellular carcinoma (HCC) with portal vein thrombosis in the 1st branch who was treated by transcatheter arterial embolization (TAE) and survived more than 3 years. A 58-year old male was diagnosed as having unresectable massive type HCC in the area of S8 with portal vein thrombosis from the P8 branch to the right portal branch. He was treated by TAE via the anterior branch of right hepatic artery. One week later, localized hepatic infarction in the anterior segment was recognized. Five months later, the portal vein thrombosis had disappeared and become necrotic. After 3 years and 4 months, he died of a relapse of a gastric varix, but with no portal thrombosis and a well controlled intra-hepatic recurrence that was treated by repeated TAE. This case suggests that TAE might be effective for cases of HCC with portal vein thrombosis in the 1st branch, if the liver function and portal flow are suitable.