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We report 2 cases of neuroendocrine carcinoma(NEC)of colon and rectum with distant metastasis. The treatment of NEC with distant metastasis is based on the treatment of small cell lung cancer, but that is controversial because NEC is relatively rare. Case 1: A 75-year-old man who was admitted for anal pain. Physical examination showed the anal tumor and swelling inguinal lymph nodes. CT showed rectum tumor and multiple lymph node metastases to the pelvis and inguinal region. Colonoscopy showed a Type 3 tumor in the rectum. He was diagnosed with NEC based on biopsy and immunostaining. Colostomy was performed for pain relief and etoposide/cisplatin(EP)therapy was introduced. After 6 courses of the chemotherapy, CT showed progression of the tumor, then we made the shift to palliative treatment. Case 2: A 69-year-old man who was admitted for abdominal pain and back pain. CT showed transverse colon tumor with multiple metastases to the liver, lung, and lymph nodes. Colonoscopy showed a circumferential tumor in the transverse colon. He was diagnosed with NEC based on biopsy and immunostaining. He refused chemotherapy and died 2 months later.

We report a case of advanced gastric cancer with right gastroepiploic vein tumor thrombus treated using preoperative S-1 plus cisplatin(CDDP)in which pathological complete response was achieved. A 78-year-old man was diagnosed with type 2 gastric cancer located at the greater curvature of the antrum, accompanied by right gastroepiploic vein tumor thrombus. Four courses of S-1 plus CDDP were administered as neoadjuvant chemotherapy. After 2 courses, computed tomography(CT) revealed the disappearance of the tumor in the right gastroepiploic vein thrombus. Distal gastrectomy with D2 lymphadenec- tomy was performed, and the diagnosis was pathological complete response(CR). Eight courses of S-1(100mg/day on days 1-28, followed by 2 weeks of rest)were administered as adjuvant chemotherapy. During the 1-year postoperative follow up, the patient showed no recurrence. An S-1 plus CDDP regimen can be a useful preoperative chemotherapy option for advanced gastric cancer with tumor vein thrombus.

We experienced a successful case in which the patient was treated with a combination of operation and transcatheter arterial chemoembolization for a hypervascular tumor of unknown primary origin in the liver; we report this case with a literature review. A 76-year-old man noticed an upper abdominal tumor and he visited our department for detailed examination. Enhanced CT scan showed multiple hypervascular tumors scattered across both lobes of the liver, and the pattern of contrast effect implied that the tumors were primary neuroendocrine tumors or endocrine metastases. Gastroscopy and colonoscopy showed no tumor in the intestine. TACE was performed mainly for the tumors in the right lobe. One month later, we performed left lateral segmentectomy and partial hepatectomy for segment 6. Histopathological findings showed that the tumors in the left lateral segment had neuroendocrine properties, and the tumor in segment 6 was necrosed. One year has passed since the surgery without recurrence of neuroendocrine tumors in the liver or other organs.

We report 2 successful cases treated with trans-catheter arterial embolization(TAE)for hemorrhagic shock due to pseudoaneurysm rupture at the primary tumor site in advanced colorectal cancer. Case 1: A 73-year-old female underwent Hartmann surgery at another hospital for rectal perforation and peritonitis. Six months later, she had a massive bloody stool and was transferred to our hospital. She was diagnosed with bleeding from advanced rectal cancer that remained following the first surgery. Contrast computed tomography(CT)showed that a branch of the superior rectal artery(SRA)developed an aneurysm at the primary tumor site, and TAE was performed to stop bleeding on hospital day 3. Case 2: A 79-year-old male with type 2 sigmoid colon cancer and simultaneous multiple liver metastases developed copious blood in the stool before primary tumor resection and was transferred to our hospital. Contrast CT showed that a branch of the SRA developed an aneurysm at the primary tumor site, and TAE was immediately performed to stop bleeding.

We report a case of colon cancer with simultaneous liver metastases successfully treated with multidisciplinary therapy including two-stage hepatectomy. This is a case of a 72-year-old woman diagnosed with type 1 cecal cancer with 2 simulta- neous liver metastases(S4/8: 98mm, S3: 63mm). At first, laparoscopic resection of the primary site was performed to prevent colon ileus. Liver metastases rapidly grew and became unresectable; fortunately, 11 courses of mFOLFOX6 and bevacizu- mab were effective and liver metastases shrunk(S4/8: 85mm, S3: 67mm). At last, two-stage hepatectomy was performed as conversion surgery, and the patient survived without recurrence for more than 2 years.

We report a case where resection was performed for pancreatic metastasis from renal cell carcinoma 21 years after nephrectomy. A 72-year-old man had undergone total gastrectomy with distal pancreatomy and splenectomy for gastric cancer, and right nephrectomy for primary renal cell carcinoma in 1993. Incidentally, a CT scan performed in 2014 revealed a tumor in the head of the pancreas. Enhanced MRI suggested that the tumor contained some fat tissue. The tumor in the pancreatic body had sharp margins; therefore, we performed subtotal pancreatectomy. The tumor was considered pancreatic metastasis from renal cell carcinoma. Pathological findings indicated clear-cell type carcinoma(G1-G2), which is very similar to renal cell carcinoma. We diagnosed pancreatic metastasis from renal cell carcinoma. The patient has remained well, with no recurrence 20 months after the pancreatectomy.

To better understand the pathogenesis of biliary tract carcinoma (BTC) and to increase the accuracy of predicting outcomes for patients with this disease, we performed molecular cytogenetic analyses of BTC cell lines and tumors to identify non-random amplification(s) and target gene(s) within the amplicons. Among several non random chromosomal aberrations detected in BTC cell lines by comparative genomic hybridization, gain/ampli-fication of DNA at 5p was the most frequently observed alteration. We assessed the copy number and expression status of the possible target gene SKP2 for 5p amplification in cell lines and 33 primary stage II or III tumors of BTC. SKP2 was amplified, and subsequently overexpressed in both cell lines and primary tumors of BTC. However, levels of Skp2 and p27Kip1 proteins were not correlated inversely. Heightened expression of Skp2 and reduced expression of p27Kip1 were both associated with a shorter disease-free and/or overall survival in univariate analyses. In multivariate regression analyses, Skp2 and p27Kip1 were independent predictive factors. Those results suggest that (a) overexpression of Skp2 through an amplification mechanism may contribute to the progression of BTC, (b) not only each molecule, but also the combination of Skp2 and p27Kip1, might be a useful predictor of the prognosis of BTC, and (c) molecular targets of Skp2 other than p27Kip1 may also be important factors in the pathogenesis of this disease.

The patient was a 73-year-old woman with hematemesis, who was brought to our hospital by an ambulance. Emergency upper gastrointestinal endoscopy was performed, and a thickened wall and multiple ulcers were noted in the middle- lower region of the stomach body. The biopsy revealed gastric cancer (por), and the macroscopic depth of invasion was up to the subserosal layer. Multiple white granular protruding lesions were observed in the duodenal bulb and were diagnosed as follicular lymphoma by biopsy. As follicular lymphoma generally takes a long time to progress in many cases, the vital prognosis would be determined by the gastric cancer. Thus, total gastrectomy was performed for gastric cancer. For reconstruction, the double-tract method was used. Duodenal follicular lymphoma was continuously monitored by upper gastrointestinal endoscopy. Here, we describe the case of a patient with a complication of follicular lymphoma arising from duodenal and gastric cancer, which is very rare, and report this case along with a literature review.

Vaginal metastasis is extremely rare, as is metastatic colorectal cancer. A 78-year-old woman was diagnosed with rectal cancer and uterine fibroid. Low anterior resection and simple hysterectomy was performed and the final diagnosis was fStage IIIa. Adjuvant chemotherapy was not performed. One year after the surgery, she was referred to our hospital with the chief complaint of hematuria. A tumor was observed in the posterior wall of the vagina. We performed vaginal mucosal resection and the pathological diagnosis was metastasis of rectal cancer. One year and 5 months after the surgery, we performed left inguinal node dissection and the pathological diagnosis was metastasis of rectal cancer. The patient has remained disease-free for 3 years and 5 months without adjuvant chemotherapy after resection of the vaginal metastasis.

A 67-year-old man visited our hospital for further check-up of biliary tract disease since his two brothers suffered from biliary tract cancer. Abdominal CT scan revealed a wall thickning at the fundus of gallbladder and its vascularity was rich. Chronic cholecystitis was diagnosed, however, cancer was highly suspected. Cholecystectomy was performed and the frozen section of the gallbladder was compatible for cancer. Therefore, segment-4a and -5 liver resections with regeonal lymph node dissection were added. Although preoperative radiological findings were free of liver metastasis, the resected liver specimen included a nodule of 1 cm in segment-5. Extrahepatic bile duct was not resected because the stump of the cystic duct was free from cancer. The final pathological diagnosis according to the TNM classification was pT3N1M1, Stage IV. We considered the patient to be in the high-risk group of recurrence, adjuvant chemotherapy using both gemcitabine and S-1 was performed. S-1 (80 mg/body/day) was scheduled on day 1-14, and gemcitabine (1,000 mg/body) was scheduled on day 8, day 15. The treatment was continued for two years (a total of 28 courses) without experiencing advese events. The patient is cancer free by means of radiological and hematological studies. Gallbladder cancer with liver metastasis in segment-4a and/or -5 can be considered as "local" metastasis, which a liver resection and adjuvant therapy may lead to a good prognosis.

A 79-year-old woman was reffered to our hospital with the chief complaint of hematochezia. Type-2 tumor was found on anal canal by colonoscopy, and pathologic examination revealed a poorly differentiated squamous cell carcinoma. Computed tomography of the abdomen demonstrated obturatory node metastasis. The patient was diagnosed as having squamous cell carcinoma of the anal cana (l cStage III). After four months from chemoradiation (66 Gy/33 Fr plus S-1), the ulcer side was improved completely to epithelization, and abdominal CT scan showed a remarkable reduction of obturatory node metastasis. She was obtained a complete response. Now the patient is disease-free for ten months after chemoradiation.

A 69-year-old woman visited our emergency room because of sudden right lower quadrant abdominal pain. Abdominal CT revealed a ruptured tumor in the anterior segment of the liver. Emergency laparotomy was selected due to interventional radiology was not available. As the patient was in shock status with massive intraabdominal hemorrhage, ligation of the right hepatic artery and suturing of the tumor bleeding point was carried out. Given the patient's history and liver biopsy report, we concluded as hepatocellular carcinoma derived form NASH. Anterior resection of the liver was performed after the patient became stable. About one year later, tumor was detected in the lateral segment and was removed. The patient is free of disease for two and a half years after the initial operation. Carcinogenesis of the hepatocellular carcinoma within NASH is not well described. We herein report a case of ruptured hepatocellular carcinoma originated from NASH.

We report two cases of advanced pancreatic cancer whose prognoses are fairly good with surgery and chemotherapy. Case 1: A 71-year-old male patient was diagnosed as pancreatic head cancer by abdominal ultrasound. The tumor size was about 2 cm in diameter. Whipple's procedure and regional lymphadenectomy were conducted. Pathological diagnosis was pT3N2 with s0 and rp1. Gemcitabine (GEM) was administered in a routine fashion at out-patient clinic. He is free of disease after three years and eight months. Case 2: A 63-year-old male patient was diagnosed as pancreatic head cancer although the mass was not so clearly visible by CT. Pylorus preserving pancreaticoduodenectomy was performed with D2 lymph node dissection. Pathological report was pT3N1 with s0 and rp0. GEM was started six months after the operation but continued for only six months. After the non-treatment interval of six months, GEM was restarted due to the sudden elevation of CA19-9. Soon the number dropped but instead of reaching normal range, it began to increase again. S-1 was added to the regimen which gave a great response. He is well after three and a half years. CA19-9 was almost being normal. Both patients had cancer within the pancreas without an invasion to the surrounding tissue. GEM is a standard regimen for adjuvant chemotherapy. However, S-1 may contribute to the outcome when GEM becomes powerless.

A 75-year-old woman had an operation for gallstone ileus without cholecystectomy in other hospital and she was admitted to our hospital because of duodenal adenoma with severe atypia and small carcinoid in proximal duodenal wall. Distal gastrectomy and cholecystectomy were performed. Histological studies revealed the existence of cholecystoduodenal fistula and suggested the existence of gallbladder carcinoma progressed to the duodenal wall through the fistula. Cystic duct dissection and lymph nodes dissection were performed. It has been theorized that a cholecystoduodenal fistula may represent a significant risk factor in the development of gallbladder carcinoma because of the chronic reflux of duodenal contents which includes pancreatic juice. Our case may support this theory. In this case, we thought that the formation of gallbladder cancer could have been avoided if the cholecystectomy was performed in the first operation for gallstone ileus. It is very important that cholecystectomy should be performed when an existence of cholecystoduodenal fistula is highly suspected.

The jejunostomy catheters were placed with needle catheter jejunostomy (NCJ) kits at the time of gastrectomy for the gastric cancer patients. When the oral intake of the post-operative patient is insufficient, home enteral nutrition (HEN) was introduced to the patient. Forty seven cases out of the 278 gatrectomy patients with jejunostomy were applied to HEN (400-1,200 kcal/day in the night). Twenty nine HEN gastric cancer cases received the chemotherapy in the outpatient clinic. The mean age was 71 years old, the number of total gastrectomy and distal gastrectomy were 21 and 8, respectively, and the number of Stage III and IV were 21 and 8, respectively. The chemotherapy for these 29 cases was continued for a long period unevenly in the outpatient clinic, even though the oral intake of the cases was insufficient. HEN is a good arm for keeping the chemotherapy secure and efficient in the outpatient clinic.

We report two cases of metastatic liver carcinoma with the treatment of radiofrequency ablation (RFA) and intraarterial chemotherapy. The 57-year-old man of Case 1 had resectable multiple liver metastases of rectal carcinoma in November 2007. He refused a liver resection, but accepted a low anterior resection of the rectum and RFA and intraarterial chemotherapy (5-FU 1,000 mg WHD). After this treatment, he had accepted systemic chemotherapy and found no liver recurrence within a year. The 66-year-old man of Case 2 had unresectable multiple liver metastases of locally-advanced esophageal carcinoma in July 2006. He had accepted radiochemotherapy (FP+65 Gy), and then RFA and intraarterial chemotherapy (5-FU 1,000 mg WHD). After this treatment, solitary brain metastasis and lymph node metastasis of mediastinum were found and treated, and now he has been alive with systemic chemotherapy.

The intraperitoneal administration of anti-cancer drug is a rationale route to adjuvant chemotherapy. We applied adjuvant MTX-5-FU intraperitoneal chemotherapy for 60 advanced gastric cancer cases which had undergone gastrectomy (Stage II 18, Stage III A 19, Stage IIIB 13, and Stage IV 10 cases). A 5-year survival rate of Stage II, III A, IIIB and IV was 66.2%, 60.7%, 46.5% and 18.8%, respectively. Five-year survival rates of both Stage III A and IIIB on this study were likely to be higher than the rates of Stage III A and IIIB of other institutions. The 24 out of 42 cases with the serosal surface exposure of cancer demonstrated a cancer recurrence. Seventy percent (17 cases) of the 24 recurred cases developed a peritoneal recurrence, which means that the intraperitoneal chemotherapy did not touch a pattern of the recurrence of the gastric cancer with the serosal surface exposure.

We analyzed a recurrence pattern and prognosis of 42 gastric cancer cases with histological serosal exposure of cancer and without macroscopical residual cancer in the operation. These cases received adjuvant MTX-5-FU chemotherapy intraperitoneally. Twenty four patients showed a recurrence of gastric cancer. Twenty two patients died of recurrence, and two patients were still alive with recurrence. Seventeen patients (71%) developed peritoneal seeding, which means intraperitoneal chemotherapy made no influence to the pattern of recurrence of gastric cancer with serosal invasion. All of the recurred patients with Stage II and IIIA gastric cancer and about 60% of the recurred patients with Stage IIB and IV developed peritoneal metastasis. The prognosis of recurred 24 patients showed that 9 patients (38%) were kept alive for more than 3 years, and 5 patients (21%) were kept alive for more than 5 years. Intraperitoneal chemotherapy of MTX-5-FU did not touch the pattern of recurrence of gastric cancer with serosal invasion, but the analysis of the prognosis revealed a possibility of improvement of the prognosis.