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A 59-year-old woman who has HER2-negative advanced gastric cancer with peritoneal dissemination was treated with nivolumab plus SOX therapy as primary treatment, and hemorrhagic cystitis occurred on the 28th day after the 6 courses. On the 21st day after the 7 courses, right knee arthralgia appeared, and on the 26th day, she was admitted to the hospital due to a fever of 39℃ and anorexia. After admission, frequent diarrhea occurred and new symptoms of neck pain and left knee arthralgia appeared. Abdominal CT showed increased fatty tissue density around the sigmoid colon, and wall thickening and contrast enhancement of the mucosal surface of the bladder. Lower gastrointestinal endoscopy revealed the diffuse redness and erosions in some areas, and lymphocytic infiltration in the epithelium of the crypts was seen in biopsy from the erosions. The hemorrhagic cystitis was aseptic pyuria. Therefore, we suspected that the series of symptoms were immune-related adverse events(irAE)and started prednisolone 50 mg(1 mg/kg/day), which quickly relieved the diarrhea, cystitis and arthralgia. As a result, the patient was diagnosed as having irAE. We report a case of advanced gastric cancer who experienced multiple irAE with nivolumab plus SOX therapy, with some discussion of the literature.

The patient was an 83-year-old woman. CT scan showed a 20 mm mass in the surgical anatomy of the medial segment (S4)of the liver, but the patient refused to undergo surgery and continued periodic clinical follow-up. After 1 year and 3 months of initial examination, a CT scan showed an enlargement of 36 mm. Therefore, surgical treatment was adopted. Preoperative lower gastrointestinal endoscopy revealed a type 1 tumor of the sigmoid colon quarter circumference 30 mm from the anal verge, and the biopsy led to a diagnosis of adenocarcinoma equivalent to tub 1. The hepatic mass showed heterogeneous contrast effect centered on the arterial phase margins and prolonged contrast effect in the equilibrium phase. Since the liver tumor was a single S4 mass with a 36 mm diameter, laparoscopic sigmoidectomy and laparoscopic partial hepatic resection were performed subsequently. Pathology results showed that the sigmoid colon tumor and hepatic S4 mass were predominantly well-differentiated and moderately-differentiated adenocarcinomas, respectively. Immunohistochemical results were cytokeratin 7 antibody-positive and cytokeratin 20 antibody-negative, leading to a definitive diagnosis of intrahepatic cholangiocarcinoma. The patient's postoperative course was well and was discharged from the hospital on postoperative day 12. After 1 year postoperatively, the patient remains recurrence-free.

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

A 61‒year‒old woman observed that she had a lower limb edema approximately 1 month ago and began to feel a general malaise. The symptom was caused by multiple liver metastases, and the primary lesion was suspected to be an ovarian cancer. Peritoneal disseminations throughout the abdominal cavity were found in the exploratory laparotomy. No obvious primary lesion could be found in the searchable gastrointestinal tract. The patient was diagnosed with a gastrointestinal stromal tumor(GIST)based on the biopsy results of the peritoneal dissemination. Treatment with imatinib mesylate(imatinib) was initiated 13 days after surgery. The severe lower extremity edema disappeared within 2 months. Computed tomography (CT)scan showed a reduction of the multiple liver metastases and peritoneal dissemination, and the appearance and increase of calcifications in the tumor and cystic degeneration inside the liver metastasis. The abnormal accumulation observed by bone scintigraphy also disappeared. Imatinib has a long‒term effect on GIST of unknown primary origin with multiple liver metastases, peritoneal dissemination, and bone metastasis. Five years after the initiation of the treatment, the patient is still alive, and new lesions have not developed.

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

Case 1: The patient was a 74-year-old man with a performance status(PS)of 0. He was referred to our department for pyloric gastric cancer with multiple liver, lung, and lymph node metastases. We started chemotherapy after making the diagnosis of an unresectable gastric cancer. During chemotherapy, the hemoglobin level dropped due to bleeding from the tumor. We attempted endoscopic hemostasis, which was not successful; therefore, we attempted a palliative radiotherapy. The total dose was 30 Gy in 10 Fr and hemostasis was achieved on the 10th day from the start of the radiotherapy. There were no adverse events due to the radiation, and the chemotherapy could be restarted 5 days after the end of the radiotherapy. Case 2: The patient was a 78-year-old man with a PS of 2. He was referred to our department because of vomiting and anemia. As a result of a close inspection, we made the diagnosis of an unresectable gastric body cancer with para-aortic lymph node metastasis and peritoneal dissemination, for which chemotherapy was initiated. Anemia was observed at the first visit, and we started radiotherapy to stop the tumor bleeding. The total dose was 30 Gy in 10 Fr, and hemostasis was achieved on the 12th day. There were no adverse events during the radiotherapy, and chemotherapy could be continued. Palliative radiotherapy is an available method of hemostasis that is less invasive than surgery or transcatheter arterial embolization and can be expected to have a certain effect for gastric cancer bleeding, although it takes several days to obtain a therapeutic effect.

The patient was a woman in her 80s. Operative treatment was performed for papillary thyroid cancer(pT3N0M0)13 years ago. A follow-up CT scan 1 year ago revealed a skin, lung, and lymph node metastasis. At the same time, a tumor with a size of 24 mm was initially observed in the tail of the pancreas, which was considered to be pancreatic metastasis of thyroid papillary cancer and was followed up. Only the pancreatic lesions tended to gradually increase, although other lesions did not increase. Therefore, the patient was referred to our department. It was difficult to diagnose preoperatively. Thus, diagnostic and therapeutic laparoscopic distal pancreatectomy with splenectomy was performed. The pathological diagnosis was dedifferentiated liposarcoma. Postoperatively, a Grade B pancreatic fistula was observed, but the patient recovered conservatively and was discharged on postoperative day 55. Primary liposarcoma of the pancreas is extremely rare, and few cases have been reported. Primary liposarcoma of the pancreas is very difficult to diagnose preoperatively by only diagnostic imaging.

A 60-year-old man underwent thoracoscopic subtotal esophagectomy and posterior mediastinal gastric tube reconstruction after neoadjuvant chemotherapy. One year and 8 months postoperatively, recurrence was observed in the abdominal lymph nodes around the celiac artery and abdominal aorta. Chemoradiotherapy was initiated, followed by chemotherapy. Two months after the completion of chemoradiotherapy, the patient developed epigastric pain and anorexia because of the necrotic lymph node penetrating the gastric tube with cavity formation. Upper gastrointestinal endoscopy revealed a 25- mm-sized ulcer with central necrotic slough on the posterior wall of the stomach. Abdominal symptoms alleviated after conservative treatment with fasting and administration of antibiotics, and the inflammatory reaction improved. Oral nutritional supplements were started on hospitalization day 7, and abdominal symptoms or inflammatory reactions did not recur after resuming diet. The patient was discharged on hospitalization day 39 when the general condition stabilized. Subsequently, chemotherapy was restarted, and no regrowth of metastatic lesions was observed on endoscopy or CT examination 4 months later. Three years and 8 months after the recurrence, the recurrent disease has been controlled.

A 67-year-old man was admitted with melena. A colonoscopy detected advanced rectal cancer, and a CT scan revealed invasion of the seminal vesicle and prostate. Given the wild-type RAS status of the tumor, we administered 6 courses of XELOX plus cetuximab as neoadjuvant chemotherapy. After treatment, the tumor had shrunk, and the rectum had narrowed. Later, following a diagnosis of coronary artery disease, colostomy was performed. The patient was treated for the coronary artery disease for 2 months. Following treatment, tumor progression was detected, and hence, the patient was treated with the same chemotherapy regimen for 4 more courses. We performed a laparoscopic assisted abdominoperineal resection of the rectum with combined resection of the seminal vesicle and prostate. Pathological examination revealed a complete response to treatment. Six months after the operation, no recurrence was observed without further adjuvant chemotherapy.

The patient was a 17-year-old woman. An abnormal urinalysis was observed, and abdominal echography showed a pancreatic cystic mass. At the first examination, computed tomography(CT)and endoscopic ultrasound(EUS)showed a unilocular cystic mass of 60mm in size in the pancreatic body and tail, and no malignant findings were observed. After 14 months, CT and positron emission tomography-computed tomography(PET-CT)showed that the cystic mass had a mural nodule with FDG accumulation, and presence of a tumor in hepatic S8 with FDG accumulation. Laparoscopic distal pancreatectomy and hepatic subsegmentectomy of S8 were performed for diagnostic and therapeutic purposes. The pathological diagnosis was mucinous cystadenocarcinoma(MCC)and metastatic liver cancer in the form of MCC. S-1 was administered after surgery. Nine months after resection, multiple metastatic liver tumors were found, and GEM plus nab-PTX was administered. After 2 courses of treatment, the patient is still alive without new lesions.

A 64-year-old man presented with dysphagia. Esophagogastroduodenoscopy revealed a submucosal tumor of 52mm in size at the lower thoracic esophagus. Biopsy yielded a pathological diagnosis of c-kit-positive esophageal gastrointestinal stromal tumor(GIST). We started neoadjuvant therapy with imatinib to avoid excessive surgical invasion. After 6 months of treatment, CT revealed a reduction in tumor size to 27 mm. We performed laparoscopic lower esophagectomy, proximal gastrectomy, double-tract reconstruction, and complete tumor resection. Neoadjuvant imatinib therapy was effective for the esophageal GIST.

The patient was a 66-year-old man presenting with epigastric pain and jaundice. PET-CT demonstrated limited-accumulation on the tumor at the head of the pancreas, diagnosed as borderline resectable adenosquamous carcinoma. The patient was treated with preoperative chemoradiation therapy with 2 courses of gemcitabine followed by administration of S-1 and gemcitabine for 13 months, which reduced the tumor size. After preoperative therapy, pancreaticoduodenectomy was performed. Histopathological examination revealed that no viable tumor cells were detected in the pancreas or lymph nodes, and the patient had achieved a pathological complete response. Postoperative adjuvant chemotherapy was not performed, and the patient is still alive without recurrence for 66 months after surgery.

A questionnaire survey was conducted on the administration of secondary chemotherapy for unresectable or recurrent gastric cancer by 43 doctors involved in gastric cancer treatment in the Yamaguchi prefecture. Seventy-one percent of doctors replied that the secondary chemotherapy transfer rate was more than 60%, and 29% of doctors replied that the secondary chemotherapy transfer rate was less than 60%. The reasons why patients could not be transferred to secondary chemotherapy included inferior performance status, poor general condition, and elderly age, among others. Weekly paclitaxel plus ramucirumab therapy was used as the major regimen of secondary chemotherapy by 95% of doctors. In addition, 93% of doctors indicated that weekly nab-paclitaxel would be an option for gastric cancer secondary chemotherapy. Secondary chemotherapy for gastric cancer in the Yamaguchi prefecture has a standard regimen selection according to guidelines.

We have performed a combination therapy of hepatic arterial infusion chemotherapy(HAIC), radiation therapy(RT), and surgical resection for the treatment of hepatocellular carcinoma(HCC)with portal vein tumor thrombosis(PVTT)since 2013. We retrospectively analyzed 36 patients with HCC with PVTT who underwent hepatectomy between 1995 and 2016 to evaluate the clinical outcomes. Ten patients received preoperative HAIC, 7 underwent RT, and 14 received postoperative HAIC. The median survival time(MST)was 19.3 months, and the MST was significantly longer in the patients who underwent curative resection than those in patients who did not. In the non-curative resection group, postoperative HAIC prolonged the survival.

A 77-year-old man underwent a follow-up examination after distal gastrectomy. Contrast-enhanced computed tomography revealed a tumor of the pancreatic body and tail that contacted the common hepatic artery/celiac artery. Subsequently, the tumor was diagnosed as a borderline resectable pancreatic cancer. After chemoradiation therapy, the tumor was considered resectable. Preoperative angiography with intraoperative contrast-enhanced ultrasonography and indocyanine green fluorescence imaging confirmed blood flow in the residual stomach. Postoperatively, ischemic necrosis of the residual stomach was not observed. After distal gastrectomy, distal pancreatectomy with en bloc celiac axis resection was performed to safely and curatively address the cancer of the pancreatic body and tail.

A 65-year-old woman with cecum cancer underwent laparoscopic right colectomy.After 3 years, she was diagnosed with a local recurrence with small bowel invasion and underwent tumor resection.One year later, she had a re-recurrent lesion involving her right iliac bone.After one year of chemotherapy, a PET-CT showed no other abdominal lesions suggestive of malignancy.She underwent resection of the re-recurrent tumor involving the right iliac bone and R0 resection was achieved. She was able to ambulate postoperatively and returned home.In selected cases, extended surgery including bone resection can be an option for the local recurrence of advanced colon cancer.

Case 1: A 64-year-old man with a chiefcomplaint ofbloody stools was seen in our hospital. He underwent an extended right lobe resection for hilar cholangiocarcinoma 3 years ago and was in the middle of chemotherapy for multiple metastases. Case 2: A 69-year-old man with a chiefcomplaint ofbloody emesis and stools was seen. He underwent left hepatic trisegmentectomy for hilar cholangiocarcinoma and ligation of the right portal vein for postoperative portal venous thrombus 6 months ago. After careful examination, the patients in both cases were diagnosed with bleeding of the jejunal varices formed at the site ofhepaticojejunostomy. The patient in Case 1 underwent percutaneous transhepatic obliteration ofvarices and the patient in Case 2 underwent transileocolic vein obliteration ofvarices. After hepatobiliary pancreatic surgery with biliary tract reconstruction, we should be aware of ectopic varices during differential diagnosis of gastrointestinal bleeding.

We report 3 cases of obstructive left-sided colon cancer that could be treated with laparoscopic resection.Case 1: A 25- year-old man was given a diagnosis of colonic obstruction due to transverse colon cancer.Twenty -four days after decompression by a nasointestinal tube, we performed a laparoscopic partial colectomy.Case 2: A 75-year-old woman was given a diagnosis of colonic obstruction due to sigmoid colon.Forty -nine days after decompression by a laparoscopic transverse colostomy, we performed a laparoscopic sigmoidectomy.Case 3: A 48-year-old man was given a diagnosis of colonic obstruction due to sigmoid colon cancer.Twenty -two days after decompression by colonic stent, we performed a laparoscopic sigmoidectomy.In these 3 cases, decompression was sufficient when resecting the primary lesions, and the operations could be completed laparoscopically.Elective radical surgery was possible by resolution of oncologic emergency state.

A 56-year-old man with HCV infection was referred to our hospital for further evaluation and treatment of hepatic tumor. Abdominal enhanced computed tomography demonstrated an S8 hepatic tumor, about 15mm in maximal diameter. The tumor showed enhancement on the arterial phase and washout on equilibrium phase. EOB-MRI scan also showed the hepatic tumor with enhancement in the early phase and washout in the delayed phase. Liver function was normal. Serum AFP and PIVKA- II were normal and CEA and CA19-9 were elevated. However, no other tumor was detected by the colonoscopy, esophagogastroduodenoscopy and PET-CT. Under the diagnosis of HCC, partial hepatectomy was performed. Histologically, the tumor was composed of neoplastic glands with irregularly dilated lumen of adenocarcinoma, resembling ductal plate malformation(DPM). And Von Meyenburg complexes and foci of ordinary intrahepatic cholangiocarcinoma(ICC)were also found. ICC with this histologic features reported as a new subtype of ICCs.

The patient was a 46-year-old woman with left lower abdominal pain.Abdominal dynamic CT revealed a 40 mm, gradually- enhanced pancreatic head mass.The interior of the tumor was heterogeneous and partly low in density.Endoscopic ultrasonography showed a well-defined and heterogeneous tumor with an echoic area in the pancreatic head.Therefore, the cystic lesion with solid components was suspected to be a solid pseudopapillary neoplasm(SPN), considering the age of the patient.Subtotal stomach-preserving pancreaticoduodenectomy was performed.The postoperative course was uneventful, and she was discharged on the 13th day after surgery.Postoperative pathology confirmed a diagnosis of pancreatic acinar cell carcinoma.SPNs often show an image very similar to pancreatic acinar cell carcinoma and it is difficult to distinguish between the two only by imaging findings.Due to the divergence between clinical findings such as age and image findings, it was difficult to confirm a diagnosis of pancreatic acinar cell carcinoma in this case.

We report a case of colorectal cancer with peritoneal dissemination and liver metastasis that achieved R0 resection by preoperative chemotherapy and CRS plus HIPEC. A 33-year-old man presented with a complaint of abdominal bloating. After further examination, he was diagnosed with transverse colon cancer with peritoneal dissemination and liver metastasis. After 9 courses of preoperative XELOX plus cetuximab and 4 courses of preoperative XELIRI plus bevacizumab, he underwent transverse colon resection, peritoneal resection, and HIPEC(MMC 20mg/4,000mL physiological saline, 40mins). There was little histological evidence of peritoneal dissemination around the region of the primary tumor. Moreover, no tumor cells were found in other peritoneal disseminations or in the liver metastasis. As a result, he was able to undergo curative resection. Colorectal cancer with peritoneal dissemination still has a poor prognosis, but combination therapy with chemotherapy and CRS plus HIPEC is expected to improve prognosis.

A 50-year-old man with complaints of epigastralgia, pyrexia, and malaise was diagnosed with sigmoid colon cancer, descending colon cancer, and unresectable colorectal liver metastases. Because the prognosticator was liver metastases, he went through chemotherapy(biweekly CapeOX plus cetuximab)as soon as possible. After 6 courses of this regimen, multiple liver metastases were markedly reduced in size(partial response[PR]), resulting in conversion therapy with complete resection. Recently, some reports showed that patients who had R0 resection after conversion chemotherapy could expect favorable long-term prognosis. It is important to select the appropriate first-line chemotherapy and the timing of the conversion resection.

We report 2 cases of laparoscopic simultaneous resection for synchronous liver metastasis of colon cancer. Case 1: A 76- year-old woman was diagnosed with advanced cecum cancer(type 3)with synchronous liver metastasis(segment 5: 23mm), Laparoscopic ileocecal resection and partial liver resection were performed for 414 minutes, with 20 mL of blood loss. The patient was discharged 11 days after the operation. Case 2: A 78-year-old woman was diagnosed with advanced sigmoid colon cancer(type 2)with synchronous liver metastasis(segment 2: 70mm). Laparoscopic sigmoidectomy and extrahepatic resection were performed for 382 minutes, with 10 mL of blood loss. Portal vein thrombus(umbilicus)was recognized but relieved with warfarin. The patient was discharged 15 days after the operation. Simultaneous laparoscopic colon and hepatectomy for synchronous liver metastasis of colorectal cancer can be safely performed for selected indications.

A 51-year-old woman was seen in our hospital because an ascending colon tumor with extensive abdominal wall abscess was detected on computed tomography(CT). On the same day, we performed open drainage and laparoscopic assisted ileocolostomy. Postoperative day 35, we performed right hemicolectomy with abdominal wall resection and closure of the colostomy as a radical surgery. After surgery, we started(negative pressure wound therapy: NPWT)to the surgical wound site; hence, the abdominal wall defect could be healed without a musculocutaneous flap. Laparoscopic assisted open drainage, a two-stage operation, and NPWT are useful in a case of colon cancer with abdominal wall abscess.

Case 1: A 57-year-old woman with chronic hepatitis related to the hepatitis B virus was found to have a liver tumor on ultrasonography(US). Computed tomography(CT), magnetic resonance imaging(MRI), and angiography revealed 2 tumors in the liver. The patient underwent right anterior sectorectomy, and histopathologic analysis revealed mucosa-associated lymphoid tissue(MALT)lymphoma. Thirty months later, recurrence was confirmed using liver biopsy. CR was confirmed after radiation and chemotherapy, and the patient has survived. Case 2: A 71-year-old woman came to our hospital for rheumatism treatment. US, CT, and MRI revealed a tumor in the left lateral segment of the liver. The patient underwent laparoscopic partial liver resection and histopathologic analysis revealed MALT lymphoma. The patient has survived.

A 65-year-old woman who was diagnosed with unresectable Stage IV sigmoid colon cancer underwent transverse colostomy with double orifices. Although KRAS gene mutation was observed, we could not administer bevacizumab because of the risk of bleeding from the primary tumor and peritumoral abscess. We started bi-weekly XELOX therapy but bloody bowel discharge continued. We planned extended resection of the primary tumor in order to control the bleeding and perforation. Sigmoidectomy, partial resection of the left ureter and small intestine, partial hysterectomy, bilateral salpingo-oophorectomy, and umbilical tumor resection were performed and the patient was discharged on the 10th day after surgery. After surgery, bloody bowel discharge disappeared and bevacizumab was administered in the 55th day. Extended resection for a primary tumor may contribute to bleeding control and broaden treatment options.

We report a case of heterochronic cervical esophageal cancer with a subcutaneous abscess successfully treated using chemoradiation. A 68-year-old man underwent esophagectomy for middle thoracic esophageal cancer 13 years ago. In April 2015, upper gastrointestinal endoscopy revealed advanced residual cervical esophageal cancer. Enhanced CT showed a massive tumor with a subcutaneous abscess, and the tumor had invaded the left internal jugular vein and the 8th cervical spine. We firstly performed abscess drainage and administered antibiotics. After the inflammation decreased, we started chemora- diation. Chemotherapy consisted of 70mg/m / 2 cisplatin(day 1)and 700 mg/m2 5-FU(days 1-5)combined with almost 60 Gy radiotherapy(1.8 Gy/day, 5 days/week, days 1-49). We administered cisplatin and 5-FU only once because renal dys- function occurred. Consequently, we changed the regimen to weekly 100mg/m2 paclitaxel administration(day 1). After 2 months, a clinical complete response(CR)was obtained and we stopped chemotherapy. Eight months after chemotherapy cessation, the patient shows no sign of recurrence. These results suggest that chemoradiation is an effective treatment for cervical esophageal cancer with a subcutaneous abscess.

An asymptomatic 35-year-old man visited our hospital because of an esophageal abnormality identified on a medical check-up. Gastrointestinal endoscopic examination revealed a 4 cm diameter submucosal tumor(SMT)in the upper esophagus. endoscopic ultrasound fine-needle aspiration biopsy(EUS-FNAB)was performed. Histopathological examination showed that it was strongly positive for a-SMA and partially positive for c-kit. An esophageal leiomyoma was suspected but esophageal gastrointestinal stromal tumor(GIST)could not be completely ruled out. After considering the patient's age and the location of the tumor, we performed thoracic enucleation of the esophageal SMT. Immunostaining findings showed that it was a-SMA positive and S-100 negative. Mast cells, but not tumor cells were partially stained with c-kit. The final pathological diagnosis was leiomyoma. The postoperative course was uneventful. We report this case together with a review of the literature.

We report a case of borderline resectable(BR)pancreatic cancer, which was eligible for R0 resection following preoperative chemotherapy with GEM plus nab-PTX. A 77-year-old woman presented with brown urine and clay-colored stool. After further examination, she was diagnosed with obstructive jaundice due to pancreatic head cancer. Because the tumor was in contact with the region attached to the SMA nerve plexus, she was also diagnosed with BR-A pancreatic cancer. After 6 courses of preoperative GEM plus nab-PTX combination chemotherapy, she underwent subtotal stomach-preservingpancreaticoduodenectomy with SMV resection and right semicircular SMA nerve plexus dissection. In the histopathological diagnosis, malignant cells were observed at low levels in both the pancreatic parenchyma and duodenal mucosa. There were no findings of residual malignant cells in the wall of the SMV or in the nerve plexus around the SMA. Since the final diagnosis was pT3,(DU+), pN0, cM0, fStage III , we concluded that the R0 resection as complete. Histological therapeutic evaluation with the Evans classification concluded that the disease was Grade III . GEM plus nab-PTX combination chemotherapy could be considered for preoperative chemotherapy, which may allow R0 resection for BR pancreatic cancer.

The patient was 66-year-old woman with anemia. A 6 cm GIST was diagnosed in the fourth portion of the duodenum using abdominal CT. Duodenal-jejunal segmental resection was performed for the GIST. Four years after surgery, multiple liver metastatic recurrences ofGIST were diagnosed using abdominal CT. The metastatic tumor was treated with imatinib, but the treatment caused adverse events such as leukocytopenia(Grade 2)and anemia(Grade 3). The treatment continued for 41 months while reduced or discontinued during the administration period. Sunitinib was administered, but the treatment caused a reduced platelet count(Grade 3), anemia(Grade 2), and melena(Grade 3). The treatment continued for 12 months while reduced or discontinued during the administration period. Regorafenib was administered and continued for 9 months. Thereafter, trancecatheter arterial embolization(TAE)was performed 5 times. The patient is alive 8 years and 3 months after recurrence.

We present a case of Fournier's gangrene secondary to rectal cancer that was managed with perineal reconstruction using a posterior thigh flap after debridement and tumor resection. A 67-year-old man was admitted with disturbed consciousness as well as hip and right thigh pain. His perineal and gluteal skin was necrotic. CT revealed subcutaneous emphysema that had spread from the rectum to the gluteal region and right thigh. We diagnosed him with Fournier's gangrene, and then removed the necrotic tissue and constructed a sigmoidostomy. A diagnosis of rectal cancer was later confirmed. Fifty-nine days after the initial operation, a laparoscopic abdominoperineal resection was performed. The perineal defect was repaired using a posterior thigh flap with the gluteus maximus. There were no postoperative complications, and the patient was discharged ahead of schedule. We concluded that the use of a posterior thigh flap is a good choice for perineal reconstruction, because it is simple to perform, can cover a large area, and has a low risk of infection.

A 56-year-old man who underwent a radical operation and adjuvant chemotherapy for recurrent rectal cancer had been followed-up and had no recurrence for one and a half years. Thereafter, CT and upper endoscopy showed a submucosal tumor with a central recess developing in the stomach wall. It was suspected that the gastric tumor was either a metastasis of rectal cancer or a submucosal tumor-like gastric cancer. We performed a radical operation to remove the lesion. In the resected specimen, immunohistopathological findings including HER2 status suggested that the gastric tumor was a primary gastric cancer resembling a submucosal tumor.

We report a case of hepatocellular carcinoma (HCC) with a Vp4 tumor thrombus treated successfully with multidisciplinary therapy. A 59-year-old woman who complained of abdominal distension was diagnosed as having HCC associated with hepatitis B virus (HBV) infection. The tumor was located in the left lobe, caudate lobe, and S6, and the tumor thrombus extended into the main portal and right portal veins. Extended left lobectomy with thrombectomy and S6 partial hepatectomy were performed after intrahepatic arterial infusion chemotherapy with radiation. During the surgery, the collateral circulation was preserved for bleeding control and residual liver function preservation. The patient was alive 12 months after surgery. Cases of advanced HCC with Vp4 can be successfully treated by multidisciplinary therapy.

Background and Objectives: Cetuximab has shown efficacy in patients with metastatic colorectal cancer (mCRC). Recent studies have demonstrated that cetuximab induces antibody-dependent cell-mediated cytotoxicity (ADCC), mediated via the fragment c gamma receptors(FcgR)in mCRC. Since the establishment of KRAS mutations as a major negative predictor of efficacy, additional biomarkers have been found to be useful for the improvement of selection of patients likely to be responsive to cetuximab. We investigated the relationship between polymorphisms and the outcome of mCRC patients treated with cetuximab., Methods: In this study, 57 patients were evaluated. The relationships of FcgR polymorphisms with response rate (RR), progression-free survival (PFS), and overall survival (OS) were analyzed., Results: The FcgR polymorphisms were not significantly related to RR, PFS, and OS. Compared with the other haplotypes, the haplotype containing the 131H and 158V alleles was related to a lower RR (p=0.018). The diplotypes containing 131H and 158V alleles had significantly lower RR than the other diplotypes (p=0.038)., Conclusion: Our data suggest that FcgR polymorphisms may be associated with the outcome of mCRC patients treated with cetuximab and FOLFIRI. However, these results are currently controversial, and detailed investigations are needed to confirm the relationship between FcgRs polymorphisms and cetuximab efficacy.

The use of hepatectomy for the treatment of liver metastasis from gastric cancer has been controversial. We report a case of metachronous liver metastasis from gastric cancer, which we successfully treated with hepatectomy. A 59-year-old man underwent laparoscopy-assisted total gastrectomy with D1 plus lymphadenectomy for gastric cancer. The histopathological findings revealed that the tumor was a well-differentiated tubular adenocarcinoma, T2(MP), N1(#1 2/3), M0, fStage II, according to the 14th edition of the Japanese Classification of Gastric Carcinoma. TS-1 was administered as adjuvant chemo- therapy for 1 year after the operation. About 5 years after the gastrectomy, a recurrent tumor was detected in S5/8-7 of the liver. Although chemotherapy with TS-1 plus Lentinan was administered, the liver tumor increased in size. Percutaneous transhepatic portal embolization was performed to improve liver function followed by resection of the right lobe of the liver. Paclitaxel plus doxifluridine (5'-DFUR) was administered for 6 months as adjuvant chemotherapy. No recurrence was observed for 17 months after hepatectomy.

A 60-year-old man was diagnosed as having type 3 advanced gastric cancer in the gastric antrum and multiple liver metastases( S2, S3, S4, and S7)( cT3[ SS] N0M0H1, Stage IV). The patient received combined neoadjuvant chemotherapy with S-1 and cisplatin( CDDP). S-1( 80 mg/body/day) was administered orally for 3 weeks followed by 2 drug-free weeks as a course, and CDDP (60 mg/m2) was administered by intravenous infusion on day 8. The gastric tumor reduced in size and the liver metastases improved after 5 courses of treatment. Distal gastrectomy, D2 lymph node dissection, and partial liver resection( 4 sites) were performed. S-1 alone was continued as adjuvant chemotherapy; no recurrence was detected in 2 years and 2 months after surgery. Although there is insufficient evidence to support the benefit of surgical resection in patients with advanced gastric cancer with liver metastases, chemotherapy combined with surgical resection would improve the survival time without deterioration of quality of life of these patients. This case suggests that neoadjuvant chemotherapy is effective against advanced gastric cancer even with multiple liver metastases.

A 61-year-old man who complained of right hypochondralgia was diagnosed as hepatocellular carcinoma (HCC) associated with hepatitis B virus (HBV) infection. The tumor was located in the right lobe and S3, and the tumor thrombus extended into the main portal and left portal veins. Preoperatively, real-time tumor-tracking radiation therapy was performed on the tumor thrombus (20 Gy/4 Fr),after vessel coils were placed at the anterior hepatic artery as a marker for the radiation. Ten days after radiation therapy, extended right hepatectomy with thrombectomy and S3 partial hepatectomy were performed. There were no postsurgical complications, and intrahepatic artery infusion chemotherapy was performed. The patient was alive with no recurrences 20 months after surgery. Radiation therapy before hepatectomy is an effective treatment for portal venous tumor thrombus in HCC.

We report a case of a patient who developed cytomegalovirus colitis during chemotherapy for esophageal cancer. A 62- year-old man was admitted to our hospital complaining of epigastralgia and dysphagia. He was diagnosed as having esophageal cancer( Mt, type 3, cT3, cN2, cM0, cStage III). Neoadjuvant chemotherapy with 5-fluorouracil( 5-FU) and cisplatin (CDDP) was initiated. However, after 1 course of chemotherapy, the patient experienced a stroke. Subsequently, he was treated with radical chemoradiotherapy. Chemoradiotherapy with low-dose docetaxel was administered. However, he developed interstitial pneumonia, and thus received pulse corticosteroid therapy with methylprednisolone. On the 26th day after steroid therapy, he developed melena. Colonoscopy revealed multiple punched-out ulcers in the transverse colon, and the patient was diagnosed as having cytomegalovirus colitis on the basis of positive cytomegalovirus antigenemia. Intravenous ganciclovir therapy was initiated. On the 13th day after ganciclovir therapy, the patient required an emergency surgery because of perforation-related peritonitis. We identified a perforation in the ascending colon and performed ileocecal resection. Although he was treated with paclitaxel, he died of esophagotracheal fistula and aspiration pneumonitis. We should be aware of cytomegalovirus colitis during chemotherapy and corticosteroid therapy.

A 69-year-old man with a history of distal gastrectomy for early gastric cancer consulted our department concerning a possible diagnosis of sigmoid colon cancer. After detailed examination, he was diagnosed with type 3 advanced sigmoid colon cancer with colonic stenosis and large type 3 gastric cancer in the residual stomach with gross infiltration of the adjacent organs. The patient first underwent sigmoidectomy and then received a regimen of neoadjuvant combination chemotherapy with S-1, cisplatin( CDDP), and Lentinan( LNT)( S-1 80 mg/m2, CDDP 60 mg/m2, and LNT 2 mg/body twice weekly for 2 weeks) for gastric cancer( cT4b[ SI, liver, pancreas], N2M0H0, Stage IIIC). After 2 courses of treatment, the gastric tumor had reduced in size but had penetrated the transverse colon. We performed total resection of the gastric remnant, D2 lymph node dissection, and en bloc resection of the transverse colon, partial liver, pancreas body and tail, partial diaphragm, and pericardium. S-1/CDDP (a total of 11 courses) followed by single-agent S-1 therapy was continued as adjuvant chemotherapy. With a follow-up time of 3 years and 10 months, no recurrence was noted following total resection of the gastric remnant.

A 65-year-old man was diagnosed with a rectal carcinoid tumor (10 mm in diameter) in July 2007. We performed low anterior resection with lymph node dissection. Histological depth of penetration of the rectal wall by the primary tumor was up to the submucosa, and lymph node metastasis was observed at station 251 (Japanese Classification of Colorectal Carcinoma, seventh Edition). Five years later, abdominal enhanced computed tomography (CT) revealed multiple liver tumors and swelling of the right obturator lymph nodes. During surgery, ultrasonography revealed 10 hypoechoic masses in both hepatic lobes. We performed right pelvic lymph node dissection, partial hepatectomy (S5/6, S7, and S8), and microwave coagulation therapy. After surgery, the patient was treated with octreotide long-acting repeatable( LAR). The patient remained disease-free for 10 months after surgery. Our findings suggest that careful monitoring is necessary for metachronous lymph node and liver metastasis during follow-up treatment for rectal carcinoid tumors.

Here, we report a case of a patient with overlap syndrome (systemic lupus erythematosus[SLE]and polymyositis[PM]) whose condition improved following treatment for coexisting descending colon cancer. A 75-year-old man experienced Raynaud symptoms and arthralgia. He was diagnosed as having overlap syndrome (SLE/PM) and was treated with steroids. However, the symptoms did not improve. Descending colon cancer was diagnosed by colonoscopy. After surgery, overlap syndrome improved immediately. Overlap syndrome was considered as a paraneoplastic event caused by the coexisting descending colon cancer.

We herein report the case of a patient with intestinal gastrointestinal stromal tumor(GIST) who was refractory to molecular targeted therapy but showed improvement in quality of life(QOL) after palliative surgery. A 60-year-old man with a high-risk diagnosis underwent an incomplete resection for multiple abdominal tumors. He was treated with molecular targeted therapy after the operation, but he acquired secondary resistance to imatinib and intolerance to sunitinib. Although the patient was treated with imatinib again, he experienced vomiting, abdominal pain, and leg edema because of tumor regrowth 7 months after the re-treatment. His general condition deteriorated, and his Eastern Cooperative Oncology Group (ECOG) performance status(PS) was 3. After 35 months of the first treatment, palliative resection of tumors was performed to control the symptoms. After the operation, the general condition of the patient improved, and his ECOG PS was maintained as 1 for at least 4 months. Palliative resection may improve QOL.

We report a case of GIST successfully treated with resection after a long-term control medication by molecular targeted drugs. A 59-year-old man underwent an un-complete resection for multiple abdominal tumors. The patient was treated with imatinib at a dose of 400 mg/day for high risk GIST. Since he had PD 22 months after the treatment, sunitinib was administered at a dose of 50 mg/day. However, abdominal tumor grew, and melena and intra-abdominal hemorrhage were appeared. After 27 months from the first treatment, a resection of tumors was performed to control abdominal hemorrhage. After the operation, abdominal tumor was successfully controlled with the treatment of imatinib.

The combination treatment of non-specific immunomodulator Lentinan (LNT) and OK-432 is effective for controlling Th1/Th2 balance and inducing Th1 dominant status in cancer patients. According to this rationale, we tried an administration of LNT and OK-432 in the pleural or peritoneal cavity for patients with malignant effusion. In all 21 lesions of the 20 cases, 10 revealed a complete disappearance and 7 revealed diminution of the effusion. The efficacy of this treatment is 81%. All patients developed a clinical efficacy in 1 to 3 courses of this treatment, and 9 lesions developed clinical efficacy in only 1 course. None of patients developed toxic symptoms LNT, and 10 developed a low grade fever by OK-432. The combination of LNT and OK-432 is effective and for QOL conserving loco-regional treatment.

We report a patient with unresectable advanced gastric cancer who was successfully treated with chemotherapy after gastrojejunostomy. A 64-year-old man was admitted to our hospital complaining of appetite loss and body weight loss. Abdominal enhanced CT revealed a gastric wall thickening and swelling of lymph nodes in the lesser curvature. Upper gastrointestinal endoscopy showed a gastric cancer in the antrum of the stomach. He underwent laparotomy, which revealed a T4 tumor invading the pancreas. Gastrojejunostomy was performed. After the operation, intake therapy of 80-100 mg S-1 was started for four weeks followed by two weeks rest as one course. After 2 courses of the therapy, abdominal enhanced CT showed a partial response of the lymph nodes. He is alive for 19 months after the operation. Abdominal enhanced CT showed a stable disease. This case suggested that S-1 chemotherapy after gastrojejunostomy was effective for unresectable advanced gastric cancer because of the long-term survival and an improvement of the patient's quality of life.

It is very important for immunotherapy to release Th2-dominated and Treg-dominated immunological conditions in patients with malignant diseases. In the present study, we assessed the population of CD4+IL-10+T-cells and CD4+Foxp3+T-cells in peripheral blood in patients with colorectal cancer using a flow cytometric analysis, and we investigated whether Th2-dominated and Treg-dominated condition could be modulated by PSK. Peripheral blood samples were collected preoperatively from 40 patients with colorectal cancer before and after oral administration of PSK (3 g/day × 1 week). After PSK treatment, CD4+IL-10+T-cell percentages decreased in 63% of patients and CD4+Foxp3+T-cells percentages decreased in 63% of patients. However, no correlation was found between the ratio of CD4+IL-10+T-cell percentages and that of CD4+Foxp3+T-cell percentages after/before PSK treatment. These results suggest that PSK could release Th2-dominated and Treg-dominated immunological condition in patients with colorectal cancer. Further examinations are needed to investigate the after/before percentage ratio of CD4+Foxp3+T-cells can be useful predicting parameters for the selection of responders of PSK.

Purpose: Recently, in drug therapy for patients with advanced digestive cancer, S-1 (tegafur x gimeracil x oteracil potassium) alone or S-1 combined with other chemotherapeutic agents (S-1+alpha) is prescribed. However, many patients are often forced to give up long-term S-1 treatment owing to high incidence rates of adverse effects. The purpose of this study was to evaluate the efficacy of superfine dispersed lentinan (SDL) for the suppression of adverse effects of S-1 or S-1+alpha., Subjects and Method: The subjects were 72 patients who had unresectable or recurrent advanced digestive cancer. The subject group consisted of 45 men and 27 women, with a median age of 64 (31-85) years; 29 gastric, 25 colorectal, 10 pancreatic and 8 other digestive cancer patients. Thirty -one patients were administered S-1 alone and 41 patients were administered S-1+alpha. SDL (15mg of lentinan/bag/day) was orally administered to all patients for 12 weeks. Adverse events and overall survival time were evaluated according to the CTCAE ver 3.0 and the Kaplan-Meier method, respectively., Results: Seventy-two patients were enrolled in this study. Adverse events which had an undeniable causal relationship to SDL were observed in 2 patients (2.7 %, constipation [Grade 2] and nausea [Grade 1]) out of 72 patients; all of the events were not severe and disappeared when the SDL administration was discontinued. Adverse events associated with S-1 or S-1+ alpha were observed in 9 patients (12.5% ) (11 events) out of 72 patients. Grade 3 adverse events were observed in 3 patients (4.2% ) (leukopenia, 2; thrombocytopenia, 1). Incidence rates of both hematological and nonhematological adverse events were very low. In no gastrointestinal toxicity associated with S-1 or S-1+alpha was observed, which was estimated to be an effect of SDL combination. Mean survival times in gastric cancer and colorectal cancer patients were 9. 5 months (95%confidential interval [CI], 7.0-22.4 months) and 18.4 months (95% CI, 13.2 -28.5 months), respectively., Conclusions: From the results of the present study, SDL is considered completely free of anything harmful to advanced digestive cancer patients and is effective for the suppression of adverse effects of S-1 or S-1+alpha therapy. It is suggested that SDL can prolong the administration period of S-1 and, as a result, contribute to prolongation of survival in patients with advanced digestive cancer.

The standard chemotherapy regimen for esophageal cancer is cisplatin and 5-fluorouracil (5-FU). We herein report a case of esophageal cancer associated with colon cancer, which was treated with combination chemotherapy of FOLFOX. The patient received chemotherapy of modified FOLFOX6 (mFOLFOX6) at dosages of 80% of standard regimen (oxaliplatin 68 mg/m2, levofolinate calcium 160 mg/m2, bolus 5-FU 320 mg/m2, and followed by continuous 5-FU 1,920 mg/m2/ 46 hr) in combination with radiotherapy (total 61.6 Gy). He developed grade 3 leukopenia after 2 courses of mFOLFOX6 and the 3rd course was started at dosages of 70% of standard regimen with 1 week delay. After that, no other adverse event without grade 2 esophagitis was appeared. Esophagogram revealed a partial response in primary tumor of the esophagus after 3 courses of chemotherapy with radiotherapy and blood chemistry examination showed negative squamous cell carcinoma antigen. One month after chemoradiotherapy, esophagogram revealed tracheoesophageal fistula, but tumor of the esophagus was well controlled. FOLFOX regimen combined with radiotherapy is well tolerated and effective for inoperable esophageal cancer. FOLFOX cannot be used for esophageal cancer in Japan, so clinical trial of FOLFOX for esophageal cancer should be conducted in the near future in Japan.

We report a case of rapid growth GIST successfully treated with resection, which imatinib controlled it as a stable disease for three years. A 68-year-old woman underwent simple hysterectomy and bilateral oophorectomy for the pelvic tumor. In the operation, there were multiple disseminations in the greater omentum and peritoneum. After diagnosed as high risk GIST, the patient was treated with imatinib at a dose of 400 mg/day, and the tumor was controlled as a stable disease for 3 years. At the end of 2008, lower abdominal tumor grew rapidly and intra-abdominal hemorrhage appeared. Although sunitinib was administered at a dose of 37.5 mg/day, the tumor was enlarged, and sunitinib was stopped because the patient developed grade 3 diarrhea. IVR was tried to control abdominal hemorrhage, but it was unsuccessful. The patient's general condition was getting worse, ECOG performance status 3. In January 2009, the resection of main tumor was performed to control abdominal hemorrhage. After the operation, a general condition of the patient was getting better, ECOG performance status 1. The resection for drug resistant GIST may contribute to improve the patient's quality of life.

Imatinib is a standard treatment for metastatic GIST. Surgery is an optional treatment for local recurrence and resectable liver metastasis. We report a case of high risk group rectal GIST with local recurrence, liver metastases and mediastinal pleural metastasis. Long-term survival (7 years and 10 months) was achieved with imatinib after resection. A 63-year-old man underwent a surgery for undifferentiated esophageal cancer and simultaneously was diagnosed a rectal submucosal tumor of 3 cm by digital examination in 2001. After 2 years, he underwent Miles' operation because of an increase of the rectal submucosal tumor. The histological examination revealed a high risk group GIST. PET-CT and CT pointed out a local recurrence and liver metastases that were resected in 2004. Adjuvant imatinib at a dose of 300 mg/day was started but the dose was reduced to 300 mg/2 days due to a side effect. Resumption and discontinuation of imatinib had been repeated. In 2008, he received a resection of mediastinal pleural metastasis. Imatinib started again at a dose of 200 mg/2 days and no recurrence has been pointed out. Combined modality therapy with surgery and chemotherapy for the metastatic GIST may contribute to a long-term survival.