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Background: Laparoscopically assisted pylorus-preserving gastrectomy (LAPPG) is introduced as a function-preserving operation with minimal invasion for early gastric cancer (EGC). This study aimed to investigate the long-term outcome and survival with LAPPG. Methods: From January 2005 to July 2008, 188 patients with EGC underwent LAPPG. The surgical and long-term outcomes and survival were assessed retrospectively. Results: The accuracy of the preoperative EGC diagnosis was 92.6%. The median follow-up period was 38 months (range, 2-63 months). Two patients experienced gallstones, and three patients experienced a second primary EGC. One patient with T3N0 gastric cancer died of peritoneal metastasis, and four patients died of other causes. The overall 3-year survival rate was 97.8%, and the disease-specific 3-year survival rate was 99.3%. Conclusions: The LAPPG procedure is safe in terms of satisfactory long-term outcome and survival for patients with EGC in the middle third of the stomach. [ABSTRACT FROM AUTHOR]

A case of primary sarcomatous tumor of the liver in a 61-yr-old man is reported. The tumor, which measured 8.5 X 8 X 8 cm, was located in the right lobe of the liver and consisted of spindle cells in a storiform pattern intermingled with bizarre giant cells. Immunohistochemically, most tumor cells expressed vimentin. Cytoplasmic immunoreactivity with α1-antitrypsin and lysozyme was documented in the giant cells. Ditrastructurally, cells with fibroblastic and histiocytic features were present. The morphological and immunohistochemical findings justify the conclusion that the tumor should be classified as a malignant fibrous histiocytoma. Reported cases of hepatic malignant fibrous histiocytoma were reviewed and compared with similar tumors observed in other body sites. [ABSTRACT FROM AUTHOR]

Background: Acetaminophen is used in multimodal therapy for postoperative pain management. However, the additional effects of acetaminophen in combination with thoracic epidural analgesia (TEA) are not well understood. This prospective, multicenter randomized study was conducted to evaluate the efficacy of routine intravenous (i.v.) acetaminophen in combination with TEA for the management of postoperative pain in gastric cancer surgery.Methods: A total of 120 patients who underwent distal gastrectomy were randomly assigned in a 1:1 ratio to receive i.v. acetaminophen every 6 h and TEA during the first 3 postoperative days (acetaminophen group) or TEA alone (control group). The primary endpoint was the sum of TEA rescue doses during the first 2 postoperative days.Results: Final analysis included 58 patients in the acetaminophen group and 56 patients in the control group. The median number of TEA rescue doses was significantly lower in the acetaminophen group compared with the control group (3.0 vs. 8.0, p = 0.013). The median area under the curve (AUC) of the pain scores at coughing was significantly less in the acetaminophen group compared with the control group (285 vs. 342, p = 0.046) without an increase in postoperative complications. TEA rescue doses and pain score AUCs were significantly reduced by acetaminophen in patients who underwent open gastrectomy (p = 0.037 and 0.045), whereas there was no significant difference between patients who underwent laparoscopic gastrectomy in the two groups.Conclusions: In gastric cancer surgery patients, routine i.v. acetaminophen in combination with TEA provides superior postoperative pain management compared with TEA alone. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of our study was to evaluate the efficacy of a new combination antiemetic therapy consisting of palonosetron, aprepitant, and dexamethasone in gastric cancer patients undergoing chemotherapy with S-1 plus cisplatin. Methods: This prospective, multi-institutional observational study assessed patient-reported nausea, vomiting, use of rescue therapy, change of dietary intake, and Functional Living Index-Emesis (FLIE) questionnaire results. The percentages of patients showing complete response (CR; no emesis and non-use of any rescue antiemetics) and complete protection (CP; no significant nausea and non-use of any rescue antiemetics), change of dietary intake, and impact of chemotherapy-induced nausea and vomiting on daily life during the overall (0-120 h after cisplatin administration), acute (0-24 h), and delayed (24-120 h) phases were examined. These findings were compared with our previous study, which used granisetron, aprepitant, and dexamethasone, to assess the relative effectiveness of palonosetron versus granisetron in combination antiemetic therapy. Results: Of the 72 included patients, 66 (91.6 %), 70 (97.2 %), and 50 (69.1 %) achieved CR, and 48 (66.7 %), 61 (84.7 %) and 49 (68.1 %) achieved CP during in the overall, acute, and delayed phases of cisplatin administration, respectively. Approximately half of the patients had some degree of anorexia. FLIE results indicated that 78.6 % of patients maintained their quality of life. Palonosetron was not superior to granisetron in combination antiemetic therapy. Conclusions: Three-drug combination antiemetic therapy with palonosetron, aprepitant, and dexamethasone was tolerable in gastric cancer patients undergoing treatment with S-1 plus cisplatin. The predominance of palonosetron to granisetron was not demonstrated in this study. [ABSTRACT FROM AUTHOR]

Background: Pylorus-preserving gastrectomy (PPG) is performed in some patients for the treatment of early gastric cancer. The aim of this study was to investigate longterm survival for patients having PPG with extensive lymph node dissection, except for the suprapyloric nodes, for early gastric cancer. Study Design: From January 1995 to December 2006, 305 patients underwent PPG if they met the following criteria: cT1 (mucosa or submucosa), cN0 gastric cancer in the middle body of the stomach. Overall 5-year survival, cancer-related mortality, and freedom from recurrence were assessed retrospectively. Results: The median followup period was 61 months (range 27 to 144 months). Seven patients died, and the overall 5-year survival probability was 98%. Gastric cancer-related mortality was 0% and none of the patients had evidence of tumor recurrence. The accuracy of the preoperative diagnosis of T1 gastric cancer using endoscopy or endoscopic ultrasonography was 95.7%. Conclusions: PPG may provide a longterm survival benefit for patients with clinically diagnosed T1 (mucosa or submucosa), cN0 gastric cancer in the middle body of the stomach, only when the accuracy of preoperative diagnosis can be assured. [Copyright &y& Elsevier]

Background: Neurofibromatosis type 1 (NF1) is known to be associated with the frequent occurrence of unique gastrointestinal stromal tumors (GISTs), preferably occurring in the small intestine, with no mutations in the c-kit proto-oncogene or platelet-derived growth factor receptor-alpha (PDGFRA), with a high tendency for multifocal development, indolent nature, with low proliferation activity and favorable prognosis., Case Presentation: A woman in her forties visited her local doctor complaining of menstrual pain; a large mass was detected in her lower abdomen, and she was referred to our hospital. The patient had hundreds of skin warts and café au lait spots. The patient's mother had been diagnosed with type 1 neurofibromatosis. The patient met the diagnostic criteria for NF1 and was diagnosed with NF1. Ultrasonography showed a large heterogeneous cystic mass with various echo patterns, solid compartments and multiple septations. Magnetic resonance imaging showed a multilocular cystic mass with liquid content exhibiting various intensities, including that of blood. A small round solid mass was also observed close to the cystic tumor. Contrast-enhanced computed tomography showed that the round solid mass showed strong enhancement in the early phase, unlike the cystic tumor component. Open laparotomy revealed a multicystic exophytic tumor measuring 11.5 cm originating from the jejunal wall, 20 cm distal to the duodenojejunal flexure. A solid tumor measuring 2.1 cm was also found on the anal side of the large tumor. We resected the short segment of the jejunum, including the two lesions. Microscopic findings revealed that the cystic and solid tumors consisted of spindle-shaped tumor cells showing little atypia with a fascicular or bundle arrangement. Nuclear mitosis was scarce. Immunostaining of the tumor cells showed positive staining for KIT and DOG1 and negative staining for S100 and desmin. The NF1 patient was diagnosed with multiple GISTs accompanied by intratumoral hemorrhagic denaturation arising from the jejunum. The TNM staging was pT4N0M0, stage IIIA., Conclusion: We report a case of GISTs associated with NF1 that showed a jejunal origin, multifocal development and few mitotic figures. The recurrence risk, survival prognosis and need for adjuvant chemotherapy, particularly in cases where the initial GIST exhibits a very indolent pathology in NF1-related GISTs, remain to be elucidated., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Alteration of chemosensitivity or tumor aggressiveness in response to chemotherapy has been reported, and liquid biopsy assessment during chemotherapy for colorectal cancers has confirmed the acquisition of mutations in various oncogenes. However, the occurrence of histological transformation seems to be extremely rare in colorectal cancers, and the few existing case reports of this transformation are from lung cancer and breast cancer. In this report, we describe the histological transformation of clinically aggressive scirrhous-type poorly differentiated adenocarcinoma of the ascending colon to signet-ring cell carcinoma in almost all recurrent tumors that were confirmed by autopsy after response to chemotherapy plus cetuximab., Case Presentation: A 59-year-old woman visited our hospital with whole abdominal pain and body weight loss and was diagnosed with scirrhous-type poorly differentiated adenocarcinoma of the ascending colon with aggressive lymph node metastases. The intrinsic chemosensitivity of the tumors was evident upon initiation of mFOLFOX6 plus cetuximab therapy, and right hemicolectomy was performed, and the tumor obviously remained in the peripancreatic area, paraaortic region, or other retroperitoneal areas. The ascending colon tumors mainly consisted of poorly differentiated adenocarcinoma and were not associated with signet-ring cell components except for minute clusters in a few lymphatic emboli in the main tumor. Chemotherapy was continued, and metastases were eliminated at 8 months after the operation; this response was maintained for an additional 4 months. Discontinuation of chemotherapy plus cetuximab resulted in immediate tumor recurrence and rapid expansion, and the patient died of the recurrent tumor 1 year and 2 months after the operation. Autopsy specimens revealed that almost all of the recurrent tumors exhibited transformation and consisted of signet-ring cell histology., Conclusion: This case might suggest that various oncogene mutations or epigenetic changes resulting from chemotherapy, especially regimens that include cetuximab, contribute to the transformation of non-signet-ring cell colorectal carcinoma to signet-ring cell carcinoma histology and can promote the aggressive clinical progression characteristic of signet-ring cell carcinoma., (© 2023. The Author(s).)

A 40-year-old man complaining of abdominal distention was referred to our hospital. Computed tomography of the abdomen demonstrated a very large abdominal mass with fat and calcification. The size of the mass rapidly increased from 30cm to 40cm over two weeks. The tumor was removed and diagnosed by pathological examination to be a retroperitoneal mature cystic teratoma that contained a 40-cm long, mature intestinal tract-like cyst, together with bone marrow and fat. The rapid growth of the tumor may have been caused by an increased secretion in the cyst.

Background: Although postoperative adjuvant chemotherapy with S-1, an oral fluoropyrimidine, has become a standard of care for gastric cancer in Japan, nonresponders may suffer from the cost and adverse reactions without clinical benefit. This multicenter exploratory phase II trial was conducted to see whether a chemosensitivity test, the collagen gel droplet embedded culture drug sensitivity test (CD-DST), can adequately select patients for chemotherapy., Methods: The CD-DST using four different concentrations of 5-fluorouracil was conducted with resected specimens from preregistered patients who underwent gastrectomy with D2 or more extensive lymphadenectomy. Patients who were histopathologically confirmed to have stage II or greater disease without distant metastasis were eligible for final enrollment. All patients underwent protocol-specified adjuvant chemotherapy with S-1. Three-year relapse-free survival was compared between patients determined as sensitive by the CD-DST (responders) and those deemed insensitive (nonresponders). Appropriate cutoff values for in vitro growth inhibition were defined when the hazard ratio for relapse in responders and the log-rank P values were at their minimum., Results: Of the 311 patients enrolled, 14 were ineligible and 27 failed to start the protocol treatment. The CD-DST failed in 64 other patients, and survival analyses were conducted with the remaining 206 patients (39 stage II disease, 155 stage III disease, and 12 stage IV disease). The outcome of patients who were determined to be responders was significantly superior to that of nonresponders regardless of the 5-fluorouracil concentrations, although no differences in clinicopathologic characteristics were observed between the two groups, except for age., Conclusions: The CD-DST identified those who benefit from adjuvant chemotherapy. It deserves further evaluation in the setting of a prospective randomized trial. ClinicalTrials.gov identifier: NCT00287755.

Background/aims: Although pylorus-preserving gastrectomy (PPG) is performed as a function preserving surgery, patients sometimes suffer from postoperative stasis of the gastric contents after the procedure. Preservation of blood flow and both celiac and pyloric branches of the vagal nerve may decrease the incidence of the stasis., Methodology: Patients who underwent PPG at the Cancer Institute Hospital between April 2005 and December 2007 were included in the study. Early surgical results and the incidence of stasis were investigated and compared between patients in whom the celiac branch had been preserved (PPG-CBP group) and those in whom it had not (PPG-nCBP group)., Results: Patients in the PPG-nCBP group had a higher body mass index than patients in the PPG-CBP group (23.9 vs. 22.3 kg/m2; p=0.004), as well as a longer operation time (249.3 vs. 227.0 min; p=0.010). There was no significant difference in the incidence of stasis between the groups (13% vs. 8%; p=0.523)., Conclusions: There was no correlation between preservation of the celiac branch and the incidence of stasis in the first 30 days after PPG. A large randomized control trial investigating both short- and long-term outcomes after PPG is required to elucidate the primary cause of postoperative stasis.

Background/aims: Although laparoscopy is accepted for treatment of colon cancer, its use for rectal cancer still has technical limitations. Whether a laparoscopic approach for rectal cancer is safe and beneficial remains unknown when simultaneous open upper major abdominal surgery is planned., Methodology: Eight patients underwent laparoscopic rectal resection for primary rectal cancer combined with open upper major abdominal surgery., Results: All laparoscopic rectal resections were successful, with no conversion to open surgery. Surgical procedures included two anterior, four low or super-low anterior, and two abdominoperineal resections. There were five simultaneous liver resections for suspected synchronous liver metastasis and three gastrectomies for advanced gastric cancer. Mean operating time was 517 (377-745) min, including 235 (165-330) min for rectal resection. Mean estimated blood loss was 398 (45-1200) mL, including 78 (0-550) mL for rectal resection. There was no postoperative morbidity. Overall morbidity was lower (0 vs. 47%) and time to flatus and liquid diet was faster (2.1 vs. 3.4 and 3.5 vs. 5.6 days, respectively) in the laparoscopic resection group compared with the open group with synchronous open upper major abdominal surgery., Conclusions: This preliminary report suggests that laparoscopic rectal resection for rectal cancer combined with open upper major abdominal surgery is a safe and feasible option in selected patients.

Background/aims: Gastric cancer in the remnant stomach after proximal gastrectomy has not been studied in detail. The aim of this study was to clarify the incidence of this type of cancer., Methodology: From 478 cases of radical proximal gastrectomy followed prospectively, those that developed gastric cancer in the remnant stomach were identified. The incidence of gastric cancer in the remnant stomach in the cohort was compared with the expected incidence of gastric cancer in the general population., Results: Gastric cancer in the remnant stomach occurred in 8 (6 males, 2 females) of 478 patients (1.7%). The duration from primary gastrectomy to gastric cancer in the remnant stomach detection was over 10 years in 3 cases. In males, the rate of the incidence of gastric cancer in the remnant stomach was lower than the expected incidence for all durations. In females, the rate was also low, but appeared slightly elevated from 6 to 10 years and from 16 to 20 years after the primary gastrectomy., Conclusions: The incidence of proximal gastrectomy after proximal gastrectomy is not high, and the risk in males is especially low. However, proximal gastrectomy may develop over 10 years after surgery, and long-term follow-up is essential.

Laparoscopic surgery is increasingly applied to the treatment of gastrointestinal disease. However, the insertion of secondary trocars following pneumoperitoneum carries the risk of serious complications such as major vascular and bowel injuries. Such injury can arise when the force required for the trocar insertion is such that it causes the operator to have impaired control over the entry. There is a need for a procedure of secondary trocar insertion that is safe and easy to perform for training clinicians in laparoscopic surgery. We have developed the "cut-and-screw" insertion method for secondary trocar insertion using a specially developed laparoscopic cannula with a sharp edge and housing. Our procedure is simple, rapid, and safe. In this chapter, we describe the technique and present our initial clinical results.

To proceed with more patient-oriented cancer medicine, the development of a new medical system is necessary in Japan. In Ariake Hospital of the Japanese Foundation for Cancer Research, a new medical system has been developed, which is composed of a common outpatient clinic and a conference system. The core conference system is called "Cancer Board". The practice of patient-oriented medicine in gastroenterological cancer has been introduced as a sample of the Cancer Board system in our hospital.

Intra-abdominal or retroperitoneal liposarcomas are huge, and local recurrence is a common event. There is still no consensus concerning debulking or repeated resection. Twelve patients who had surgery for intra-abdominal or retroperitoneal liposarcomas at the Cancer Institute Hospital (Tokyo, Japan) during 1981-2002 were enrolled. Eight patients underwent complete resection, for a resectability rate of 67%. Combined resection of adjacent organs was necessary to obtain clear margins in 10 of the 12 patients (83%). A patient who underwent R2 resection survived 13.2 years in a dormant state without tumor regrowth. Resection of second (five patients), third (three patients), or seventh (one patient) for local recurrence or regrowth tumors was successfully performed. A patient survived 21.5 years after four R0 resections and three R2 resections. Our experience suggests that both near-total and repeated resection might improve survival benefit.

The outcome after resection of hepatic metastases from colorectal cancer is influenced not only by factors of metastatic lesions but also those of primary disease. To clarify whether primary disease factors are predictive of post-resection outcome of colorectal liver metastases, 180 patients (male : female = 114 : 66; 61.1 +/-10.5 yrs; synchronous: metachronous = 95 : 85; colon: rectum = 124 : 56 who underwent surgery of colorectal liver metastases in Cancer Institute Hospital from 1995 to 2005 were recruited for analysis. Post-resection outcome of the patients with colorectal liver metastases was significantly influenced by 1) depth of invasion, 2) grade of lymph node metastasis , 3) number of metastatic lymph nodes and 4) Dukes stage of primary disease. The patients with lymph node metastases further than grade 3 showed median survival time of less than 2 years and did not survive longer than 5 years. Thus such condition seemed not warrant resective treatment for liver metastases. In case of synchronous metastatic disease, primary disease information, such as lymph node metastases, depth of invasion, and Dukes stage, were significant predictive factors after hepatectomy. Meanwhile, such factors did not show significant influence in the patients with metachronous liver metastases. In conclusion, influence of primary disease factors should be considered for deciding the indication of hepatectomy for colorectal liver metastases, especially when patients have synchronous lesions.

Tiny duodenal carcinoid is easily treated by endoscopic mucosal resection method. On the other hand, this tumor develops in the deeper layer of the mucosa, therefore it invades like a submucosal tumor. The resection of the total layer is sometimes needed to get a tumor-free margin. Moreover, lymph node metastasis is not predicted only by tumor size. Laparoscopic surgery is less invasive compared with conventional open surgery. We describe a new method, endoscopic total layer resection with laparoscopic sentinel node dissection and defect closure. This type of combined method should be performed in order to help decide whether to convert to conventional lymph node dissection, or not.

Although in recent years hepatic resection has become a safe procedure, there are few data on repeat liver resection for hepatic metastases from gastrointestinal stromal tumor. A 60-year-old Japanese man underwent partial gastrectomy and extended right hepatectomy for gastrointestinal stromal tumor of the stomach with liver metastasis. However, liver metastasis recurred at the interval of less than 1 year. Therefore, the patient underwent a total of six liver resections. The liver resections comprised four R0, one R1 and one R2 resection. To our knowledge, six times for liver resection performed on one patient is a maximum. This patient survived 43 months after the first surgery. Despite frequent recurrence of hepatic metastasis from gastrointestinal stromal tumor, repeated hepatectomy provides a survival benefit if complete removal of all tumorous masses appears possible.

Clinical trials of adjuvant chemotherapy after surgery of gastric cancer have a long history dating since the late 1950s, but no standard regimen is yet established. Early studies included 5-FU- or TSPA-based regimens, sometimes combined with Me-CCNU or BCNU in Western countries, and resulted in a negative survival benefit, whereas 5-FU or MMC alone, or in combinations such as with MFC, were tried in Japan, and resulted in marginal survival benefit in the subset of moderately locally advanced diseases. Oral administration of 5-FU or its derivatives characterized Japanese trials in 1980s, though no definite benefit is yet established. Recent reports from Western countries regarding ELF, MMC + TGF, and FEM suggest significant or subsignificant survival benefit after curative gastrectomy. Meta-analysis of randomized trials also suggested marginal significant survival benefit, and these results encourage future trials with new drugs. The same regimens administered following surgery with different technical skill may result in different outcomes, and treatments in our country should be established based on our trials.