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Several studies have demonstrated that diverse systemic inflammatory-based prognostic parameters predict a poor prognosis in patients with gastric cancer. However, few studies have focused on the relationships between postoperative complications and systemic inflammatory-based prognostic parameters after curative gastrectomy. We investigated the relationships between postoperative complications and these parameters and assessed the clinical utility of the parameters as predictors of postoperative complications in patients with stage I–III gastric cancer. We retrospectively reviewed 300 patients who underwent curative gastrectomy for stage I–III gastric cancer. All postoperative complications were classified as infectious or noninfectious. We evaluated the relationships between postoperative complications and clinical factors, including systemic inflammatory-based prognostic parameters. In total, 101 patients (33.7%) had postoperative Clavien–Dindo grade II–IV complications, and 54 (18.0%) patients developed infectious complications including pancreatic fistula, pneumonia, anastomotic leak, intra-abdominal abscess, and cholecystitis. The relationships between postoperative complications and systemic inflammatory-based prognostic parameters were evaluated by the areas under the receiver operating characteristic curves. Postoperative pneumonia was identified as the most sensitive complication to the systemic inflammatory-based prognostic parameters. Multivariate analysis revealed that preoperative neutrophil-to-lymphocyte ratio (odds ratio, 14.621; 95% confidence interval, 1.160–184.348; p = 0.038) was an independent predictor of pneumonia. Preoperative neutrophil-to-lymphocyte ratio may be a useful predictor of postoperative pneumonia in patients with stage I–III gastric cancer after curative gastrectomy.

Background: Several studies have demonstrated that diverse systemic inflammatory-based prognostic parameters predict poor prognosis in patients with gastric cancer. However, few studies focused on the relationships between postoperative complications and systemic inflammatory-based prognostic parameters after curative gastrectomy. We investigated the relationships between postoperative complications and these parameters to identify parameter-specific postoperative complications, and assessed the clinical utility of the parameters as predictors of postoperative complications in stage I–III gastric cancer patients.Methods: We retrospectively reviewed 300 patients who underwent curative gastrectomy for stage I–III gastric cancer. A postoperative complication sensitive to the systemic inflammatory-based prognostic parameters was identified using a receiver operating characteristic curve, and we evaluated the relationships between the identified postoperative complication and other clinical factors.Results: In total, 101 patients (33.7%) had postoperative Clavien–Dindo grade II–IV complications, namely anastomotic complications, such as leak, stenosis, or hemorrhage (35 patients, 11.7%); pancreatic fistula (16 patients, 5.3%); and pneumonia (14 patients, 4.7%). Postoperative pneumonia had the most sensitive relationship to five systemic inflammatory-based prognostic parameters, and was associated with poor prognosis in stage I–III gastric cancer patients after curative gastrectomy. Multivariate analysis revealed that preoperative neutrophil-to-lymphocyte ratio (odds ratio: 5.228, 95% confidence interval: 1.269–21.541; P=0.022) was an independent predictor of postoperative pneumonia.Conclusions: Preoperative neutrophil-to-lymphocyte ratio may be a useful predictor of postoperative pneumonia in stage I–III gastric cancer patients after curative gastrectomy.

The aim of this phase II study was to evaluate the efficacy and safety of combination therapy with five-cycle CAPOX (capecitabine plus oxaliplatin) plus bevacizumab, followed by five-cycle maintenance therapy with capecitabine plus bevacizumab and reintroduction of CAPOX plus bevacizumab for five cycles, with a preplanned intermittent oxaliplatin strategy in metastatic colorectal cancer (mCRC). Patients with untreated mCRC were administered CAPOX (130 mg/m2 oxaliplatin on day 1, 2000 mg/m2/day capecitabine on days 1–14, every 21 days) + bevacizumab (7.5 mg/kg) every 3 weeks for five cycles, maintenance treatment without oxaliplatin for five cycles, and CAPOX + bevacizumab reintroduction for five cycles or upon tumor progression. The primary endpoint was progression-free survival (PFS), and the secondary endpoints were the time to treatment failure (TTF), overall survival, response rate (RR), and safety. Forty-seven patients who fulfilled the inclusion criteria were enrolled in the evaluation of efficacy and safety. Median PFS was 14.1 months (95% confidence interval [CI], 8.6–19.5), and median TTF was 12.3 months (95% CI, 10.3–14.3). The objective RRs were 51.1% (24/47) during induction therapy, 58.3% (21/36) during maintenance therapy, and 63.6% (14/22) during reintroduction therapy. The frequency of patients with neutropenia, diarrhea, peripheral sensory neuropathy, venous thromboembolism, or grade ≥ 3 allergic reactions was 2.1%. CAPOX plus bevacizumab therapy with a preplanned intermittent oxaliplatin strategy consisting of brief five-cycle induction therapy, five-cycle maintenance therapy with capecitabine plus bevacizumab, and five-cycle reintroduction therapy consisting of CAPOX plus bevacizumab is safe and effective for mCRC patients. UMIN ID: 000,005,732, date of registration: June 7, 2011. https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000006695

We herein describe a case of laparoscopic surgery for an esophageal duplication cyst using a near‐infrared indocyanine green fluorescence system. A 64‐year‐old woman with a cystic tumor adjacent to the esophagogastric junction was referred to our hospital for treatment. Esophagogastroduodenoscopy and abdominal CT revealed a 70‐mm submucosal tumor derived from the abdominal esophagus. We performed laparoscopic resection and then evaluated the tissue perfusion of the abdominal esophagus by using a near‐infrared indocyanine green fluorescence system. A Dor fundoplication was performed to prevent postoperative gastroesophageal reflux disease and reinforce the mucosal layer defect. The postoperative course was uneventful, and pathological evaluation confirmed that the tumor was an esophageal duplication cyst. The patient did not develop recurrence in the 24 months after surgery. We have demonstrated that laparoscopic resection of an esophageal duplication cyst may be performed effectively with intraoperative assessment of tissue perfusion using a near‐infrared indocyanine green fluorescence system.

Approximately 30% patients with stage III colon cancer (CC) develop local recurrence and/or distant metastasis, even if postoperative adjuvant chemotherapy with oxaliplatin plus 5-fluorouracil and leucovorin (5-FU/LV) has been completed. In the present study, molecular analysis was performed to identify molecular markers of tumor recurrence in patients with stage III CC receiving oxaliplatin-based adjuvant chemotherapy. The FACOS study was conducted as a phase II study to evaluate the safety and efficacy of oxaliplatin-based treatment for stage III CC patients. Of the 132 CC patients enrolled in the present study, gene expression analysis using a microarray was conducted in 51 patients. Of these 51 patients, 6 developed recurrence within 5 years. The topmost 5% genes that showed differential expressions between cases that developed/did not develop recurrence were selected, and a set of predictive molecular markers for recurrence was identified. Of the 34,694 genes in the microarray, 1,734 genes were extracted as topmost 5% genes showing differential expressions between cases with and without recurrence. Among these, 10 genes, includingADH1A, ADH1C, CA12, CHP2, HMGCS2, SNAR-A1, TPI1, MS4A12, PLA2G10 and PTPRO, were identified as markers that could clearly divide patients with and without recurrence. Although several prediction models of tumor recurrence have been reported for CC, the set of 10 genes that the present study identified may be useful to predict the risk of recurrence in stage III CC patients receiving oxaliplatin-based adjuvant chemotherapy. Based on these results, high-risk patients with CC should be carefully observed to detect tumor recurrence during the follow-up period.

Background: In the first-line treatment of metastatic colorectal cancer (mCRC) patients with CAPOX plus bevacizumab, the optimal duration of maintenance treatment without oxaliplatin to avoid discontinuation of therapy due to peripheral sensory neuropathy (PSN) remains unknown. The aim of this phase II study was to evaluate the efficacy and safety of combination therapy with five-cycle CAPOX (capecitabine plus oxaliplatin) plus bevacizumab, followed by five-cycle maintenance therapy with capecitabine plus bevacizumab and reintroduction of CAPOX plus bevacizumab for five cycles, with a preplanned oxaliplatin intermittent strategy in mCRC.Methods: Patients with untreated mCRC were administered CAPOX [oxaliplatin 130 mg/m2 and capecitabine (2000 mg/m2 daily) as intermittent treatment for 14 days, followed by a 7-day treatment-free interval, every 3 weeks] + bevacizumab (7.5 mg/kg) every 3 weeks for five cycles, maintenance treatment without oxaliplatin for five cycles, and CAPOX + bevacizumab reintroduction for five cycles or upon tumor progression. The primary endpoint was progression-free survival (PFS), and the secondary endpoints were the time to treatment failure (TTF), overall survival, response rate (RR), and safety.Results: Forty-seven patients who fulfilled the inclusion criteria were enrolled in the evaluation of efficacy and safety. The relative dose intensity and the cumulative dose of oxaliplatin during the overall treatment period were 649.1 mg/m2 and 1132.5 mg, respectively. Median PFS was 14.1 months (95% confidence interval [CI], 8.6–19.5), and median TTF was 12.3 months (95% CI, 10.3–14.3). The objective RRs were 51.1% (24/47) during induction therapy, 58.3% (21/36) during maintenance therapy, and 63.6% (14/22) during reintroduction therapy. The frequency of patients with neutropenia, diarrhea, PSN, venous thromboembolism, or grade ≥ 3 allergic reactions was 2.1%.Conclusion: CAPOX plus bevacizumab therapy with a preplanned intermittent oxaliplatin strategy consisting of brief five-cycle induction therapy, five-cycle maintenance therapy with capecitabine plus bevacizumab, and five-cycle reintroduction therapy consisting of CAPOX plus bevacizumab is safe and effective for mCRC patients.Trial registration: This trial was registered with the University Hospital Medical Information Network on 7 June 2011 (UMIN ID: 000005732).

Diverticular disease of the colon occurs quite frequently in developed countries, and its prevalence has recently increased in Japan. The appearance of diverticulosis increases with age, although mostly remaining asymptomatic. Approximately 20% of cases require treatment. As the Western lifestyle and number of elderly people increase, the need for medical treatment also increases. Computed tomography (CT) is the gold standard for diagnosing diverticulitis. Complicated diverticulitis is classified by the size and range of abscess formation and the severity of the peritonitis. Each case should be classified based on clinical and computed tomography (CT) findings and then treated appropriately. Most patients with uncomplicated diverticulitis (stages 0–Ia) can be treated conservatively. Diverticulitis with a localized abscess (stages Ib–II) is generally resolved with conservative treatment. If the abscess is larger or conservative treatment fails, however, percutaneous drainage or surgery should be considered. Operative treatment is considered standard therapy for severe diverticulitis with perforation and generalized peritonitis (stages III–IV). Colonic diverticulitis treated conservatively frequently recurs. Elective surgery after recovery should be considered carefully and decisions made on a case‐by‐case basis. Because cases of colonic diverticulitis will undoubtedly increase in Japan, it is likely that we will be confronted with increasing numbers of treatment decisions. We therefore need to have a systematic strategy for treating the various stages of colonic diverticulitis appropriately. We herein review the management of complicated diverticulitis.

Perfusion computed tomography (PCT) is a less invasive imaging modality that provides information about tissue hemodynamics at the capillary level. The present study aimed to investigate the correlation between hepatic perfusion and gastric cancer progression. A total of 136 patients with gastric adenocarcinoma were evaluated in the present study. Prior to initial treatment, liver PCT was performed across the hepatic hilar plane and the hepatic blood flow (HBF) was measured using the dual-input deconvolution method. HBF was compared with clinicopathological factors, patient prognosis and circulating serum proangiogenic cytokines. The median HBF was 217 ml/min/100 g tissue. Patients with high HBF had larger tumors (43 mm vs. 71, P

Background The neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) are associated with poor prognoses in patients with gastric cancer; however, few studies have focused on the dynamic changes in these ratios during the treatment of patients with gastric cancer. Here, we assessed the clinical utility of changes in these ratios as prognostic indicators in patients with stage II or III gastric cancer who received adjuvant chemotherapy. Methods We retrospectively reviewed 100 patients who received S-1 adjuvant chemotherapy at ≥70% of the relative dose intensity, and their NLRs and PLRs were evaluated at different times: prior to gastrectomy and upon commencement and termination of adjuvant chemotherapy. To assure the clinical utility of the changes in NLR and PLR as prognostic indicators, other clinical factors were assessed as well. Results Disease recurred in 35 patients as follows: lymph node metastasis (17 patients, 17.0%), peritoneal metastasis (12 patients, 12.0%), and hematogenous metastasis (6 patients, 6.0%); 24 patients died. An increase in the NLR during adjuvant chemotherapy with S-1 was identified as an independent indicator associated with overall survival (hazard ratio [HR] 6.736, 95% confidence interval [CI] 2.420–18.748; P

Ryohei Itagaki, Keiji Koda, Masato Yamazaki, Kiyohiko Shuto, Chihiro Kosugi, Atsushi Hirano, Hidehito Arimitsu, Risa Shiragami, Yukino Yoshimura, Masato Suzuki Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, Japan Purpose: Serotonin (5-hydroxytryptamine [5-HT])3 receptor antagonists are effective for the treatment of diarrhea-predominant irritable bowel syndrome (IBS-D), in which exaggerated intestinal/colonic hypermotility is often observed. Recent studies have suggested that the motility disorder, especially spastic hypermotility, seen in the neorectum following sphincter-preserving operations for rectal cancer may be the basis of the postoperative defecatory malfunction seen in these patients. We investigated the efficacy of 5-HT3 receptor antagonists in patients suffering from severe low anterior resection syndrome. Patients and methods: A total of 25 male patients with complaints of uncontrollable urgency or fecal incontinence following sphincter-preserving operations were enrolled in this study. Defecatory status, assessed on the basis of incontinence score (0–20), urgency grade (0–3), and number of toilet visits per day, was evaluated using a questionnaire before and 1 month after the administration of the 5-HT3 antagonist ramosetron. Results: All the parameters assessed improved significantly after taking ramosetron for 1 month. The effect was more prominent in cases whose anastomotic line was lower, ie, inside the anal canal. Defecatory function was better in patients who commenced ramosetron therapy within 6 months postoperatively, as compared to those who were not prescribed ramosetron for more than 7 months postoperatively. Conclusion: These results suggest that 5-HT3 antagonists are effective for the treatment of low anterior resection syndrome, as in diarrhea-predominant irritable bowel syndrome. The improvement in symptoms is not merely time dependent, but it is related to treatment with 5-HT3 antagonists. Keywords: low anterior resection syndrome, serotonin receptor antagonist, ISR, defecatory malfunction

Background TAS-102 improved overall survival of metastatic colorectal cancer (mCRC) patients with median progression-free survival (PFS) of 2.0 months (RECOURSE trial). Subsequently, the combination of TAS-102 and bevacizumab (BV) has been shown to extend median PFS to 3.7 months (C-TASK FORCE). However, this study included patients with 2nd line and 3rd line chemotherapy. Furthermore, combination chemotherapy of TAS-102 plus BV was reportedly associated with grade ≥3 neutropenia in 72% of treated patients. This study was designed for patients being treated as 3rd line chemotherapy to investigate the clinical impact of this combination and whether neutropenia could be suppressed by altering the TAS-102 administration protocol (biweekly method). Methods This phase II study was conducted in investigator-initiated, open-label, single-arm, multicenter manner in Japan. Eligible patients were 20-80 years old and had to have an ECOG performance status of 0 or 1; had confirmed unresectable mCRC with histologically diagnosed adenocarcinoma; had previously administrated first- and second-line chemotherapy for mCRC and whose tumors were diagnosed as progression of disease (PD). TAS-102 (35 mg/ m²) was given orally twice daily on days 1 -5 and 15 -19 in a 4-weeks cycle, and BV (5 mg/ kg) was administered by intravenous infusion for 30 min in every 2 weeks. The primary endpoint was PFS, and the secondary endpoints were response rate (RR), disease control rate (DCR), overall survival (OS), and safety. This study was registered at the University Hospital Medical Information Network, as UMIN#000030030. Results Between January 1, 2018, and March 31, 2019, 45 patients with mCRC were enrolled in this study (median age, 63; male, 51%). The median PFS was 121 days. The RR and DCR were 4.4% and 73.3%, respectively. Grade 3 or higher adverse events were hypertension (20.0%), neutropenia (15.5 %), leukopenia (6.7 %), fatigue (6.7 %), anemia (4.4 %), anorexia (2.2 %), nausea (2.2 %), creatinine increased (2.2 %) and proteinuria (2.2 %). No treatment-related deaths occurred. Conclusions Biweekly administration of TAS-102 and BV prevents neutropenia and could be one of the treatment options for 3rd line chemotherapy for mCRC. Clinical trial identification UMIN000030030. 2018/March/01. Legal entity responsible for the study The authors. Funding Has not received any funding. Disclosure All authors have declared no conflicts of interest.

Background: It has not been elucidated whether the clinical efficacy of oral fluoropyrimidines for adjuvant chemotherapy of colorectal cancer varies with tumor biological characteristics. Patients and Methods: A multicenter randomized trial was performed comparing oral tegafur/gimeracil/oteracil (S-1) and uracil-tegafur/ leucovorin (UFT/LV) as adjuvant therapy for stage III colorectal cancer. Postoperative survival was compared based on the 5-FU-related mRNA levels in cancer tissues. Results: Among patients with tumor expressing dihydropyrimidine dehydrogenase (DPD) mRNA within the 66.7th percentile (lower 2/3) of all cases, overall survival (OS) was significantly better in the S-1 than in the UFT/LV group. In the S-1 group, patients with low DPD-expressing tumors had significantly better OS than those with highly expressing tumors. Patients with low thymidine synthase (TS)-expressing tumors had significantly better OS than those with highly expressing tumors. Conclusion: The efficacy of oral fluoropyrimidines as adjuvant chemotherapy for colorectal cancer may be influenced by the level of 5-FU-related mRNA in cancer tissues.

Background: Breast-conserving surgery after primary systemic therapy (PST) has become a widely acceptable procedure for locally advanced breast cancers. Sometimes it is difficult to determine the appropriate resection-line at the time of surgical operation because of tumor size reduction or indistinct boundary of the tumor. Moreover we cannot detect tumors in cases with complete response. That was why we developed a new navigation technique using real-time image reconstruction. Materials and methods: Multi-detector row computed tomography (MD-CT) has been performed for all breast cancer patients in our institute. DICOM images of MD-CT were analyzed by image processing software ‘OsiriX'. OsiriX is an open source software which anyone can download from website (http://www. osirix-viewer.com). OsiriX has been specifically designed for navigation and visualization of multimodality and multidimensional images. We used 3D volume rendering images. At the time of surgery, pre-PST volume rendering images ware superimposed directly on the patients’ skin from projector which was connected to a personal computer in the operating room. Results: We could see ‘real-time’ rendering images (from skin to organ by layer to layer) on the patient's body. By using pre-PST imaging data, we could recognize precise tumor area and could perform breast conserving surgery safer and easier than before. Conclusion: Using 3D reconstruction MD-CT images which were obtained before PST, ‘real-time’ virtual navigation was helpful to determine the resection-line for clear surgical margin in breast-conserving surgery after PST. This new technique does not need some expensive equipments and easily performed by surgeon. Ordinary personal computer and projector make it possible to demonstrate a new environment in surgical operation. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-10-11.

はじめに：鼠径ヘルニア根治手術は若い外科医が基本手技を鍛錬する場であり，外科手術の入門編として位置していた．現在，初期研修医制度が実施され，外科系診療科志望でない研修医も外科をローテーションするカリキュラムが組まれている．今回，我々は鼠径ヘルニア根治術を初期研修医に執刀させる是非を検討する．方法：2005年4月から2007年12月に根治手術を施行した139例を対象とした．134例にmesh plug法が，5例にPROLENE hernia system法が行われた．初期研修医執刀例は72例（R群），外科医執刀例は67例（S群）だった．R群とS群において，患者背景，術中，術後因子を検討した．結果：患者背景においてR群とS群で有意差はなかった．術中因子として手術時間においてR群：S群に有意差を認めた（88.0分：64.2分，p＜0.001）．術後因子は，入院期間（3.8±2.1日：4.9±8.3日，p=0.14），合併症（9.8％：6.6％，p=0.64）に統計学的に有意差はなかったが，再発はR群7例（9.7％），S群1例（1.5％）で有意にR群において高かった（p=0.04）．考察：入院期間，合併症には有意差はなく，再発率は初期研修医術者が外科医と比較し有意に高かったが，助手として外科専門医が指導することで，再発率が抑えられる．よって，現在の研修医制度において外科系研修カリキュラムの手術執刀についての指導指診作成が望まれる．

結腸憩室炎に対する治療法は軽∼中等症の場合では絶食·抗生物質投与による治療が行われるが，穿孔ないし穿破をともなう場合，外科的治療が選択されることが多い．今回我々は穿破による膿瘍形成した憩室炎に対し，大腸内視鏡を用いて排膿術を施行，保存的治療にて軽快した2例を経験した．2症例は右側腹部痛，発熱を主訴に当院受診．CTにて上行結腸に広範な壁肥厚像，膿瘍形成を認め，穿破による憩室炎の診断となった．大腸内視鏡施行し上行結腸の広範な炎症を認め，表面に白苔をともなう排膿している憩室に対し，生理食塩水にて洗浄し，膿瘍ドレナージを施行した．術直後に腹痛，発熱が軽減し，保存的治療のみで退院した．結腸憩室炎に対する大腸内視鏡による膿瘍ドレナージは，外科的なサポート下において1つの治療オプションとして考慮できる手技と考えられた．

胆道再建20症例を対象にDIC併用造影MDCT（以下:Dual contrast DIC-CT）を行い肝内胆管から吻合部，挙上空腸および胆管壁とその周囲の形態的観察の可能性につき検討した．胆管から吻合部にかけての胆管短径および長径計測可能は右前枝15/20例（75％），右後枝15/20例（75％），左枝10/18例（55.5％），吻合部16/24吻合（66.6％）で，仮想的内腔面観察可能は順に15/20例（75％），11/20例（55％），10/18例（55.5％），11/20例（55％）であった．胆管径計測，内腔面観察不能の原因はpneumobiliaと造影剤による描出不良であった．Dual contrast DIC-CTによる胆管壁の観察から胆管炎を繰り返す症例で壁厚の測定が可能であった．また術後一過性の原因不明発熱を繰り返す症例で吻合部胆管に接する嚢胞性病変を認めその原因と推察された．Dual contrast DIC-CTを用いた検討により胆道再建後症例の病態解明に役立つ検査の一つになり得るものと思われた．

胆管閉塞を来した好酸球性胆管炎の2症例を経験した. 症例1は53歳の女性で, 検診にて肝異常陰影を指摘された. CT, ERCPで肝左葉の肝内胆管閉塞を認めた. 胆汁細胞診は良性であったが胆管癌も否定できず肝左葉切除術を施行した. 病理組織学的には胆管閉塞部位に多数の好酸球浸潤を認めた. 術後18か月再発の兆候はない. 症例2は87歳の女性で, 主訴は右上腹部痛. ERCPで下部胆管閉塞と総胆管結石を認め, 閉塞部位の組織診で好酸球主体の炎症細胞浸潤を認めた. 内視鏡的胆道拡張術, 切石術により症状は軽快した. 術後17か月再発の兆候はない. 文献上, 好酸球性胆管炎として報告されている症例は18例と少ない. 悪性疾患を念頭に高侵襲な治療が施行された報告もあるが, 近年臨床報告の増加から徐々に病態が解明されつつあり, 内視鏡的治療が主体となっていくと考えられる. 本疾患の知見と的確な診断により治療の低侵襲を維持できると考えられた.

We herein report our experience of performing laparoscopic and endoscopic cooperative surgery for a gastrointestinal stromal tumor with complete situs inversus. A 78-year-old man was referred to our department for treatment of a gastric submucosal tumor. Based on chest X-ray and computed tomography (CT) findings, complete situs inversus was also diagnosed. Upper gastrointestinal endoscopy and imaging showed a 45-mm gastric submucosal tumor in the upper stomach near the esophagogastric junction. We performed local resection of the gastric submucosal tumor by laparoscopic and endoscopic cooperative surgery. Pathological examination revealed that the tumor was an intermediate-risk gastrointestinal stromal tumor, and the patient was discharged on postoperative day 12. The patient is still alive without recurrence or any complications 9 months after surgery.

症例は53歳,女性.検診にて直腸隆起性病変指摘され当院紹介受診.精査により大きさ4×2.5×4cmの仙骨前部類表皮嚢胞腫と診断し,悪性所見を認めなかったため経過観察した. 2年7カ月後のMRI検査にて腫瘤の増大傾向を認めたため悪性化の可能性が考慮され根治術を施行することとなった.術前超音波内視鏡検査にて腫瘤と直腸の明らかな連続性を認めなかったため経仙骨的腫瘤切除術を施行した.腫瘤は大きさ4×3×4.5cmで,病理所見にて腫瘤は扁平上皮に裏打ちされた嚢胞壁構造を有しており,上皮に異型性は認めず,嚢胞壁は線維性結合組織により構成されていた.また皮膚付属器は認めず,類表皮嚢胞腫と診断され,明らかな悪性所見は認めなかった.仙骨前部類表皮嚢胞腫は悪性化の可能性があるため根治術が必要であるが,術式において超音波内視鏡検査にて直腸切除の必要性がないことを事前に知りえたことで経仙骨的切除術が可能であった1例である.

We investigated the feasibility of new carbon dioxide-enhanced virtual multidetector computed tomography (MDCT) cholangiopancreatography (CMCP) for intraluminal exploration in 73 patients with hepatobiliary and pancreatic disease. CMCP was performed via a percutaneous or transpapillary drainage tube, and, synchronously, intravenous contrast material was employed for virtual angiography; three-dimensional (3D) virtual reality was incorporated using OsiriX and Fovia applications. The capability of carbon dioxide to delineate the biliary and pancreatic system was evaluated. All CMCPs showed complete technical success; complications including pancreatitis or pain never occurred. The incidences of visible third- and fourth-order biliary branches were 100 and 86.0%. The capability of carbon dioxide to pass an obstruction through an occluded hilar bile duct malignancy was 80.0%; it provided feasible information on additional bile duct segments. The full extent of the gallbladder was depicted in 72.7% of the studies. Minimum 2-mm lesions of biliary stones or gallbladder polyps were clearly detected. The main or second-order pancreatic ducts were visible in 100 and 83.3% of the studies, respectively. Carbon dioxide enabled the replacement of mucin and pancreatic juice and facilitated the detection of cystic lesions of intraductal papillary-mucinous neoplasm (IPMN) in 75.0% of the studies. We succeeded in achieving 3D spatial recognition of vascular structures in the cholangiopancreatic region, through the fusion of CMCP and 3DCT arteriography and venography in a single image scanning, and radiation time was decreased. This combined modality proved to be feasible for planning operations and for image-guided navigated surgery in the resection of a malignancy. To our knowledge, this is the first report to demonstrate the diagnostic accuracy of carbon dioxide MDCT cholangiopancreatography and the use of this modality for depicting biliary, pancreatic, and fusion blood vessels simultaneously. Carbon dioxide possesses many advantages over conventional iodinated contrast agents, and it might replace more invasive diagnostic measures in the near future.

Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) has been recently introduced, and has demonstrated that it produces rapid future remnant liver (FRL) volumes compared with conventional staged hepatectomy using portal vein embolization (PVE). The correlation between the change of volume and functional capacity in ALPPS is not clear. Furthermore, exact mechanisms of the spectacular regenerative response in ALPPS have not been elucidated. The aim of this study is to evaluate whether FRL volume increases with its change of functional capacity in ALPPS compared with PVE and to elucidate the mechanism of the regenerative response in ALPPS. A retrospective review of all patients with liver metastases undergoing ALPPS or conventional staged hepatectomies using PVE was performed. ALPPS consisted of 2 steps; parenchymal transection between the FRL and the diseased part of the liver with concomitant selective PVL was performed. After that, the diseased deportalized part of the liver was removed 7 - 10 days later. In contrast, the diseased deportalized part of the liver was removed 4 - 6 weeks after PVE for the conventional staged hepatectomy. The fusion data of multi-detector raw CT and 99mTc-GSA dynamic SPECT using the software, SYNAPSE VINCENT (Fujifilm, Japan) was analyzed. FRL volume was measured by CT volumetry at 1 week after 1st step of ALPPS and 4 weeks after PVE. Seven patients with ALPPS were compared with 6 patients with conventional staged hepatectomies. The increasing rate of FRL volume was higher in ALPPS than in PVE (13.7% and 4.6%, respectively), whereas the increasing rate of the functional capacity of FRL was higher in PVE than in ALPPS (18.5% and 10.7%, respectively). This result suggests that the increasing rate of the functional capacity of FRL might be lower compared with the volume, resulting in an overestimation of the functional capacity of FRL for ALPPS. To elucidate the mechanism of the regenerative response and figure out which day is the best time for the diseased liver resection after 1st step of ALPPS, rats were randomly assigned to three experimental groups: selective PVL and ALPPS, sham operation. The hepatic regeneration rate, histopathology, liver biochemical determinations were assessed at 24, 48 and 72h after surgery. The hepatic regeneration rate of ALPPS was much higher than that of the PVL at 72h after surgery. And we successfully established the ALPPS model using rats and demonstrated the accelerated hepatic regeneration in ALPPS compared with PVL. Our model provides a basis for further studies of ALPPS. Citation Format: Daisuke Kawaguchi, Yukihiko Hiroshima, Takashi Murakami, Kenichi Matsuo, Chihiro Kosugi, Kiyohiko Syuto, Akimitsu Yamada, Itaru Endo, Keiji Koda, Kuniya Tanaka. The correlation between the change of future remnant liver volume and functional capacity in ALPPS (associating liver partition and portal vein ligation for staged hepatectomy), and establishment of ALPPS model in rats. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 5272. doi:10.1158/1538-7445.AM2015-5272

Aim: The FOLFOX with bevacizumab regimen has been established as a standard first-line therapy for metastatic colorectal cancer (mCRC), and the OPTIMOX1 study suggested that a stop and go strategy for oxaliplatin reduced peripheral sensory neuropathy. We had already evaluated the efficacy of OPTIMOX1 plus bevacizumab in patients (pts) with mCRC (CRAFT study, Tezuka et al, Invest New Drugs 2013). CapeOx is one of the standard treatments for mCRC that has been proven to be as effective as the FOLFOX regimen. Thus we assessed the efficacy and safety of the combination of intermittent CapeOx + Bevacizumab as a first-line therapy in patients with mCRC in this trial. Methods: Eligibility criteria included ECOG PS: 0–1, no peripheral neuropathy ( Results: Between March 2011 and August 2013, 55 pts were enrolled. Baseline characteristics were median age of 67 years (range, 20–83); PS 0/1 (49/6 pts); male/female(33/22 pts), colon/rectum (28/27pts) and metastatic lesion liver/lung/lymph nodes (32/18/21 pts). A total of 47 pts were evaluated as Par Protocol Set population. 38 pts moved from initial CapeOX to maintenance capecitabine. 20 pts moved to CapeOx reintroduction. Median PFS was 12.4 months (95%CI, 7.7–17.1) and Median TTF was 8.3 months (95%CI, 4.5–12.1). Best overall response rate was 50.9%. Median capecitabine courses were 5 cycles (range 1–5). Oxaliplatin reintroduction rate was 52%. The causes of reintroduction failure were disease progression (3 pts), successful liver resection (2 pts), peripheral sensory neuropathy grade 2 (1 pt). Main grade 3/4 toxicities: neutropenia, anemia, peripheral neuropathy, hand-foot syndrome, and hypertension in 1 patient. Conclusions: This study met its primary endpoint PFS. It was longer than the CRAFT study. CapeOx with intermittent oxaliplatin is indicated to reduce incidence of severe neutropenia and peripheral sensory neuropathy. The results suggested that our treatment strategy was well tolerated and effective for first-line therapy in mCRC, and maintenance of duration for 5 cycles was reasonable. Disclosure: All authors have declared no conflicts of interest.

Rectal neuroendocrine carcinoma is rare with poor prognosis. We report herein a case of advanced moderately differentiated neuroendocrine carcinoma of the rectum with relatively favorable prognosis treated by postoperative adjuvant chemoradiation therapy. A 58-year-old Japanese female was referred and colonofiberscopy revealed an easy-bleeding irregular tumor in the lower rectum, which was pathologically diagnosed as a neuroendocrine carcinoma. Surgical treatment consisted of abdominoperineal resection and lymph node dissection. The tumor invaded deeply into perirectal tissues, and 9 of 11 lymph node metastases were observed. Immunohistochemically, chromogranin A showed diffuse and strong staining, and the MIB-1 labeling index was 18.3 ± 5.6, supporting the high proliferation of the tumor. Some nucleus of the tumor showed positive staining for p21/WAF1. A total dose of 46 Gy of radiotherapy was delivered with 800 mg of daily oral doxifluridine. At 5 years post-surgery, the patient demonstrated no clinical evidence of intrapelvic recurrence or distant metastases.