Search

Background/aim The chemokine receptors C-X-C chemokine receptor type 4 (CXCR4) and C-C chemokine receptor type 7 (CCR7) play an important role in the invasion and metastasis of cancer. This study investigated the relationship between relative expression of CXCR4 and CCR7 mRNA, clinicopathological factors, and outcomes in patients with colorectal cancer (CRC). Patients and methods We studied 202 patients who underwent surgery for CRC. The expression levels of CXCR4 and CCR7 mRNA in cancerous tissue were measured using quantitative real-time reverse-transcriptase polymerase chain reaction. Results High CCR7 mRNA expression levels in CRC tissues were positively associated with tumour size and were more frequently associated with cancer of the rectum than of the colon. Moreover, outcomes were significantly poorer in patients with high CCR7 mRNA expression than in those with low expression. On multivariate Cox regression analysis, a higher CCR7 mRNA expression level was a significant independent predictor of poorer overall survival in patients with CRC. Conclusion Overexpression of CCR7 mRNA may be a useful independent prognostic factor in patients with CRC.

This prospective multi-central randomized phase II trial evaluated the efficacy and safety of oral Vitamin B12 500 μg/day replacement compared with oral Vitamin B12 1,500 μg/day in patients with Vitamin B12 deficiency after total gastrectomy for gastric cancer.Patients were randomly assigned to receive oral Vitamin B12 500 μg/day or Vitamin B12 1,500 μg/day in a 1:1 ratio with a minimization method. The primary endpoint was the incidence of a normal serum Vitamin B12 level at three months after treatment.From January 2018 to December 2021, 3 institutions collaborated with the present study, and 74 patients were registered from these 3 institutions. The study was prematurely closed due to poor accrual after reaching almost 50% of its goal. Among the 74 recruited patients, 36 were allocated to the Vitamin B12 500 μg/day arm and 38 to Vitamin B12 1,500 μg/day arm. The incidences of patients with a normal Vitamin B12 level at 3 months (serum Vitamin B12 level200 pg/ml) were 91.7% (33/36) in the Vitamin B12 500 μg/day arm and 100% (38/38) in the Vitamin B12 1,500 μg/day arm (p=0.3587). The types of clinical symptoms with Vitamin B12 deficiency that improved with Vitamin B12 treatment and the degree of improvement were also similar.Although the primary endpoint of the present study was not met, it was found that oral Vitamin B12 500 μg/day replacement is as effective and safe as oral Vitamin B12 1,500 μg/day replacement for Vitamin B12 deficiency.

Gastrojejunostomy has been performed as a palliative treatment for unresectable, advanced gastric cancer patients with gastric outlet obstruction (GOO). However, its role before neoadjuvant chemotherapy (NAC) has not been established. We present the case of a 72-year-old man with distal advanced gastric cancer with GOO. Computed tomography showed para-aortic lymph node (PAN) metastasis without other distal metastasis. We performed laparoscopic stomach-partitioning gastrojejunostomy (LSPGJ), which avoided new gastrojejunostomy reconstruction when performing distal gastrectomy after NAC. His oral intake improved after surgery and NAC was successfully administered on postoperative day 14, without surgical complications. After completion of NAC, the patient underwent radical distal gastrectomy with gastrojejunostomy reused as Billroth-II reconstruction. A histological examination revealed no residual cancer cells. LSPGJ, with partitioning on the expected resection line in distal gastrectomy after NAC, can be useful for treating advanced gastric cancer with GOO when NAC followed by curative gastrectomy is planned.

Laparoscopic/robotic distal gastrectomy (LDG/RDG) as a treatment for early gastric cancer has become increasingly and widely accepted for its minimal invasiveness and proportionate outcomes. Over the years, in addition to the LDG/RDG technique and the lymphadenectomy and gastrectomy procedures, various reconstruction methods have been developed and further improved upon. In particular, the number of minimally invasive intracorporeal anastomosis reconstruction techniques has been increasing.The medical records of 445 patients with gastric cancer who underwent reconstruction following LDG/RDG via either trapezoidal-shaped gastroduodenostomy (TAPESTRY; n=126) or delta-shaped anastomosis (DSA; n=319) at our hospital between April 2012 and May 2021 were retrospectively reviewed. Short-term surgical outcomes, including the operation time, blood loss, length of hospital stay, and complications, were compared between the 2 groups. Anastomosis-related complications, namely leakage, bleeding, stricture, and delayed gastric emptying, were monitored and graded using the Clavien-Dindo classification.All operations were either performed or supervised by qualified surgeons. Patients' characteristics in the TAPESTRY group and the DSA group were biased in terms of the surgical approach, but they were well-balanced after propensity score matching. Overall anastomosis-related complications (Clavien-Dindo grade II or above) within 30 days after surgery in the TAPESTRY group were comparable with those in the DSA group, either all patients (1.5% vs. 5.0%, P=0.115) or after propensity score-matching analysis (2.1% vs. 6.5%, P=0.134). There were no records of reoperation or mortality during hospitalization in either group.TAPESTRY was performed safely, with a low rate of anastomosis-related complications. These findings suggest that trapezoidal-shaped gastroduodenostomy could be a feasible option for reconstruction in patients undergoing LDG/RDG.

Peritoneal metastasis (PM) is one of the most frequent forms of gastric cancer recurrence. In this study, we aimed to use computed tomography (CT) colonography (CTC) to detect signs of PM earlier in patients in whom PM was suspected but not yet diagnosed. CTC was used to evaluate patients with clinical symptoms or general CT findings that were suspicious but not sufficient to confirm PM. In total, 18 patients with suspected PM were enrolled. Ten patients (55.6%) had PM on CTC. Abnormal colonic deformities were identified at locations other than those of the lesions detected by general CT in seven patients. The sensitivity and specificity of CTC for the detection of PM were 83.3% and 100%, respectively. The median overall survival after CTC was 201 days in the CTC-positive group, which was significantly shorter than that in the CTC-negative group (945 days, p = 0.01). In the multivariate analysis, a positive CTC finding was the only factor independently associated with survival (p = 0.005). According to our experience with 18 patients, CTC can be an alternative to conventional imaging for early detection of PM. Further prospective studies with larger sample sizes are warranted to confirm and validate these findings. University hospital Medical Information Network Clinical Trials Registry (UMIN-CTR): Registration number: UMIN000044167.

Here, we report a case of successful surgical resection of expansive-growth acinar cell carcinoma. A 59-year-old man was referred to a local hospital with abdominal distention. CT revealed a large abdominal tumor. Subsequently, he was referred to our hospital. Physical examination showed a large tumor on his left upper abdomen without tenderness. CT revealed an enhanced 18 cm-sized expansive-growth tumor on the left flank, suggesting a primary pancreatic tumor. EUS-FNA yielded a diagnosis of adenocarcinoma. Imaging findings were not typical for pancreatic ductal carcinoma. We performed distal pancreatectomy with splenectomy, transverse colon resection, and proximal gastrectomy. Pathological findings revealed a tumor, measuring 19.5×16.5×15.5 cm, originating from the pancreatic body, positive for trypsin, chymotrypsin, and elastase, consistent with a diagnosis of acinar cell carcinoma, pT3, N0, M0. Four courses of adjuvant chemotherapy with S-1 were provided, and the patient is currently alive without recurrence for 10 months.

Background Renal cell carcinoma (RCC) is a primary tumor with the highest frequency of pancreatic metastasis. Although surgical resection can improve the prognosis of some patients with pancreatic metastasis of RCC (PM-RCC), the role of palliative surgery remains unclear. Herein, we described a case of jejunal limb occlusion caused by a tumor thrombus arising from a PM-RCC which was treated by surgical resection. Case presentation A 75-year-old, male patient with metastatic RCC was admitted to our hospital with new-onset dysphagia and weight loss. Twenty years earlier he underwent a right nephrectomy with an adrenalectomy for the first surgical resection of RCC, and 12 years ago he underwent a left partial nephrectomy for metachronous primary RCC. Nine years later, multiple pancreatic metastases were detected. After discontinuing interferon therapy, he was followed up at his request without anticancer treatment. Multiple, pulmonary metastases developed 3 years ago, and resection of a brain metastasis was performed 6 months ago. He had also undergone a total gastrectomy with Roux-en Y reconstruction and splenectomy for gastric cancer 23 years ago. Computed tomography revealed a metastatic lesion in the pancreatic tail extending into the jejunal limb, which was obstructed by a tumor thrombus. Jejunal limb resection was performed concomitantly with a distal pancreatectomy as palliative surgery. The jejunal limb remnant was approximately 30 cm long and was re-anastomosed to the esophagus using a circular stapler. Blood perfusion at the anastomotic site was confirmed by indocyanine green fluorescence imaging. He was discharged on postoperative day 24 and was followed in the outpatient clinic. He achieved sufficient oral intake at 8 months postoperatively. Conclusions PM-RCC can invade the gastrointestinal tract and cause tumor thrombus formation resulting in bowel occlusion requiring surgical intervention.

Background Post-operative pneumonia is a major complication after general elective surgery in elderly patients and is often caused by aspiration associated with oesophageal reflux. The aim of this study was to identify the risk factors of post-operative pneumonia after gastrectomy in elderly patients with gastric cancer with two potential risk factors of ageing and oesophageal reflux. Methods We retrospectively examined the data of 251 patients ≥75 years old who underwent gastrectomy between January 2014 and December 2018 in our institution. The reconstruction methods were Billroth-I or Roux-Y after distal gastrectomy, jejunal interposition or double tract after proximal gastrectomy and Roux-Y after total gastrectomy. The severity of pneumonia was evaluated by the Clavien–Dindo classification. Results Post-operative pneumonia was identified in 15 patients (5.9%) and was significantly associated with an age ≥80 years old, poor performance status, history of smoking and cardia-non-preserving gastrectomy (total gastrectomy and proximal gastrectomy) in univariate analyses. Multivariate analyses showed that a poor performance status and cardia-non-preserving gastrectomy were independent risk factors for post-operative pneumonia. The patients who suffered post-operative pneumonia required a longer hospital stay than those without post-operative pneumonia (P = 0.002). Conclusion We identified a poor performance status and cardia-non-preserving gastrectomy, which are likely to lead to oesophageal reflux, as risk factors for post-operative pneumonia in elderly patients with gastric cancer. These results warrant further prospective studies to evaluate their utility for reducing the rate of post-operative pneumonia in elderly patients through cardia-preserving gastrectomy or anti-reflux reconstruction.

Background A multi-institutional phase II study was conducted to evaluate the efficacy and safety of preoperative docetaxel, cisplatin and S-1 therapy in marginally resectable advanced gastric cancer. Methods Patients with macroscopic type 4, large macroscopic type 3 and bulky lymph node metastasis received two cycles of preoperative docetaxel, cisplatin and S-1 therapy (docetaxel 40 mg/m2 and cisplatin 60 mg/m2 on day 1, and S-1 80 mg/m2 for 14 days, every 4 weeks). The primary endpoint was the pathological response rate, with an expected value of 65%. Results Thirty-one patients were enrolled in this study. The pathological response rate was 54.8%, and it was higher than the threshold value but lower than the expected rate. The R0 resection rate was 93.5%. The frequencies of grade 3–4 toxicities during docetaxel, cisplatin and S-1 therapy were 41.9% for neutropenia, 6.5% for febrile neutropenia and 32.3% for nausea/vomiting. Grade 2 and 3 surgical morbidities occurred in 23.3 and 6.7% of the patients, respectively. Conclusions Preoperative docetaxel, cisplatin and S-1 therapy was feasible in terms of chemotherapy-related toxicities and surgical morbidity, but the effect did not achieve the expected value. The association between the pathological response rate and survival will be evaluated in the final analysis of this clinical trial., A phase II study of preoperative docetaxel/cisplatin/S-1 therapy for locally advanced gastric cancer was feasible, but the pathological response rate did not achieve the expected value.

The aim of this study was to compare the outcome of using trans-anal ileus tube and self-expandable metallic stent(SEMS) for obstructive colorectal cancer.Between 2014 and 2018, 14 patients received trans-anal ileus tube placement (group I)and 34 received SEMS insertion as bridge to surgery(BTS)and underwent primary resection.The technical success rate was 100%in both groups, and the clinical success rate was 85.7%(12/14 cases)in group I and 91.2%(31/34 cases)in group S. In group S, the CROSS score significantly improved, the rates of stoma construction and postoperative complications were significantly lower, and the period until oral intake and hospital discharge was significantly short.SEMS insertion is more effective than trans-anal ileus tube placement in terms of short-term outcome.

Only a few studies have been conducted regarding the palliative radiation therapy(RT)for gastric cancer(GC)bleeding. Data of 9 patients with gastric cancer requiring blood transfusions due to gastric bleeding who were treated with RT were reviewed. All patients were men with a median age of 83(range, 70-91)years. The clinical stage was ⅡB in 2 patients, Ⅲin 1, ⅣA in 1, and ⅣB in 5. Performing gastrectomy was difficult in 4 patients with distant metastasis or tumor invasion to adjacent organ, 3 with poor performance status, and 2 with advanced age. The median hemoglobin levels before RT was 6.0 (range, 3.3-7.7)g/dL, and all patients received blood transfusions before RT. Seven patients received 30 Gy RT and 2 patients received 50 Gy. Two patients received concurrent chemotherapy. A total of 2 hematological and 4 non-hematological treatment-related adverse events occurred. All patients improved conservatively. Hemorrhage occurred in 8 patients, except for 1. Of the 8 patients who responded to RT, 1 had rebleeding on day 81. The median rebleeding-free survival time from the beginning of RT was 125(range, 21-421)days. Palliative radiation therapy was useful for bleeding control in nonresectable gastric cancer.

Objective: To investigate the prognostic values of the preoperative modified Glasgow Prognostic Score (mGPS) and carcinoembryonic antigen (CEA) alone and combined in elderly patients with colorectal cancer (CRC) planning to receive curative surgery. Methods: We retrospectively analyzed 130 elderly patients (aged ≥80 years) with CRC who received curative surgery between 2008 and 2016. The preoperative mGPS and CEA levels were calculated. Results: Elevated preoperative mGPS or CEA level was significantly associated with shorter relapse-free survival (p = 0.005, both) and cancer-specific survival (p = 0.011 and p < 0.001, respectively). Combined use of these two factors improved the predictive accuracy for tumor recurrence relative to that of either factor. Conclusion: Both mGPS and CEA were independent prognostic factors of CRC in elderly patients receiving curative surgery, but their combination was more accurate.

Perforated gastric cancer reported to be relatively rare and to have a poor prognosis. This study examined 9 patients with perforated gastric cancer. Two-thirds of the patients were male and the median age was 69 years. The timing of the diagnosis of gastric cancer was preoperative clinical findings in 4 cases, intraoperative surgical findings in 3 cases, and postoperative examination in 2 cases. The depths of tumor invasion were T3 in 3 cases, T4a in 4 cases, and T4b in 2 cases and 5 patients were Stage Ⅳ. Four patients underwent palliative gastrectomy and only 1 patient underwent curative(R0)gastrectomy. Four patients underwent repair surgery, 2 of which underwent omental patch repair during the initial surgery. One of patients with omental patch repair received 2-stage curative gastrectomy; the other patient received chemotherapy after recovering from acute peritonitis. The median overall survival was 17.9 months and the prognosis was favorable in cases with curative resection or chemotherapy. For patients with perforated gastric cancer, if curative resection cannot be expected, the initial surgery should be directed toward the treatment of peritonitis and radical oncological surgery or systemic chemotherapy should be planned following patient recovery.

The aim of this study was to clarify the risk factors of severe postoperative complications and prognostic factors in patients who underwent emergent surgery for colorectal cancer perforation. ASA-PSB3 and Mannheim Prognostic Index(MPI)B27 were selected as the independent risk factors for postoperative severe complications on multivariate analysis. Moreover, severe postoperative complications and non-curative surgery were selected as the independent factors of poor prognosis.

Lean body mass loss after surgery, which decreases the compliance of adjuvant chemotherapy, is frequently observed in gastric cancer patients who undergo gastrectomy for gastric cancer. However, the risk factors for loss of lean body mass remain unclear. The current study retrospectively examined the patients who underwent curative gastrectomy for gastric cancer between June 2010 and March 2014 at Kanagawa Cancer Center. All the patients received perioperative care for enhanced recovery after surgery. The percentage of lean body mass loss was calculated by the percentile of lean body mass 1 month after surgery to preoperative lean body mass. Severe lean body mass loss was defined as a lean body mass loss greater than 5 %. Risk factors for severe lean body mass loss were determined by both uni- and multivariate logistic regression analyses. This study examined 485 patients. The median loss of lean body mass was 4.7 %. A lean body mass loss of 5 % or more occurred for 225 patients (46.4 %). Both uni- and multivariate logistic analyses demonstrated that the significant independent risk factors for severe lean body mass loss were surgical complications with infection or fasting (odds ratio [OR] 3.576; p = 0.001), total gastrectomy (OR 2.522; p = 0.0001), and gender (OR 1.928; p = 0.001). Nutritional intervention or control of surgical invasion should be tested in future clinical trials for gastric cancer patients with these risk factors to maintain lean body mass after gastrectomy.

In elderly patients, surgical procesure is decided considering the general condition and surgical invasion. The aim of this study was to clarify the appropriate rage of lymph node dissection for elderly colorectal cancer patients. One hundred forty one colorectal cancer patients aged 75 years or more, who underwent R0 colorectal resection with D2 or D3 lymph node dissection in clinical T3/T4 or clinical N+, were enrolled in this study. The patients whose tumor located in the rectum below the peritoneal reflection(Rb)were excluded. Five-year overall survival(OS)rate and disease specific survival(DSS)rate were 79.1% and 89.4%, respectively. More than 2 preoperative co-morbidities and macroscopic type 3-5 were independent prognostic factors in OS, whereas the rage of lymph node dissection was not risk factor. When comparing the outcomes of D2 and D3 dissections by age, D3 dissection was better tendency in DSS in patients aged under 80, however, D2 dissection was better tendency in patients aged 80 or more. In elderly colorectal cancer patients, there was no difference in prognosis between D2 and D3 dissection, and especially in patients aged 80 years or more, D2 might be sufficient if R0 resection was possible.

A significant body weight loss (BWL) is observed during 1 month after gastrectomy for gastric cancer. However, it remains unclear which body component mainly accounts for the weight loss.Two-hundred forty-four patients who underwent gastrectomy for gastric cancer between May 2010 and October 2013 were examined. Body weight and composition were evaluated by a bioelectrical impedance analyzer within 1 week before surgery (first measurement), at 1 week after surgery (second measurement), and at 1 month after surgery (third measurement). The changes in the early period were defined as the differences until the second measurement, and those in the late period were defined as the differences from the second to the third measurement.Total BWL within 1 month was -3.4 kg, and the rate of body weight at 1 month to the preoperative body weight was 94.1 %. BWL was significantly greater in the early period than in the late period (-2.1 kg vs -1.2 kg, p0.001). In the early period, loss of lean body mass was significantly greater than loss of fat mass (-1.5 kg vs -0.6 kg, p0.001). The same trend was observed when the subset of patients who had surgical morbidities was excluded.BWL during the first week after surgery was significantly greater than that during the subsequent 3 weeks. Furthermore, loss of lean body mass accounted for a significant part of the BWL during the first week.

Compliance with S-1 adjuvant chemotherapy is not satisfactory, and the aim of the present study was to clarify risk factors for the continuation of S-1 after gastrectomy.This retrospective study selected patients who underwent curative D2 surgery for gastric cancer, were diagnosed with stage II/III disease, had a creatinine clearance 60 ml/min, and received adjuvant S-1 at our institution between June 2010 and March 2014. The time to S-1 treatment failure (TTF) was calculated.Fifty-eight patients were selected for the present study. When the TTF curves stratified by each clinical factor were compared using the log-rank test, lean body-mass loss (LBL) of 5 % was regarded as a critical cutoff point. Univariate Cox's proportional hazard analyses demonstrated that LBL was a significant independent risk factor for continuation. The 6-month continuation rate was 91.7 % in patients with an LBL 5 %, and 66.3 % for patients with an LBL 5 % (p = 0.031).The present study demonstrated that LBL might be an important risk factor for a decrease in compliance to adjuvant chemotherapy with S-1 in patients with stage II/III gastric cancer who underwent D2 gastrectomy. A multicenter, double-blinded, prospective cohort study is necessary to confirm whether LBL would affect adjuvant S-1 continuation.

The aim of the present study was to explore the unfavorable subset of patients with Stage II gastric cancer for whom surgery alone is the standard treatment (T1N2M0, T1N3M0, and T3N0M0). Recurrence-free survival rates were examined in 52 patients with stage T1N2-3M0 and stage T3N0M0 gastric cancer between January 2000 and March 2010. Univariate and multivariate analyses were performed to identify risk factors using a Cox proportional hazards model. The recurrence-free survival (RFS) rates of the patients with stages T1N2, T1N3, and T3N0 cancer were 80.0, 76.4, and 100% at 5 years, respectively. The only significant prognostic factor for the survival rates of the patients with stage pT1N2-3 cancer measured by univariate and multivariate analyses was pathological tumor diameter. The 5-year RFS rates of the patients with stage pT1N2-3 cancer were 60.0%, when the tumor diameters measured 30 mm (P = 0.0248). These data may suggest that pathological tumor diameter is associated with poor survival in patients with small T1N2-3 tumors. Because our study was a retrospective single-center study with a small sample size, a prospective multicenter study is necessary to confirm whether small tumors are risk factor for the RFS in T1N2-3 disease.

To evaluate short-term outcomes of laparoscopy-assisted colectomy (LAC) in elderly patients with colorectal carcinoma.A total of 289 colorectal cancer patients underwent LAC between 2008 and 2013. They were divided into an elderly group (80 years of age, group E), and a younger group (80 years of age, group Y). The treatment results, including the surgery-related factors, the perioperative course, and the pre- and postoperative complications, were retrospectively analyzed.There were 49 patients in group E, and 240 patients in group Y. There was no significant difference between the 2 groups considering the operative time, blood loss, rate of transfusion, post-operative hospital stay, rate of conversion to open surgery, or rate of complications, except for the number of patients with an ASA classification of greater than Grade 2 and the degree of lymph node dissection.LAC in elderly patients was found to be relatively safe because it was associated with a reduction in damage to the abdominal wall, and with an early recovery from surgery. These results suggest that the indications of LAC could be expanded for elderly patients.

The aim of this study is to clarify whether TNM-EC or TNM-GC is better for classifying patients with AEG types II/III. The patients who had AEG types II/III and received D1 or more radical lymphadenectomy were selected. The patients were staged both by seventh edition of TNM-EC and TNM-GC. The distribution of the patients, the hazard ratio (HR) of each stage, and the separation of the survival were compared. A total of 163 patients were enrolled in this study. TNM-EC and TNM-GC classified 25 (20 and 5) and 32 (20 and 12) patients to stage I (IA and IB), 15 (4 and 11), and 33 (11 and 22) to stage II (IIA and IIB), 88 (24, 3, and 61) and 63 (14, 26, and 23) to stage III (IIIA, IIIB, and IIIC), and 35 and 35 to stage IV, respectively. The distribution of the patients was substantially deviated to stage IIIC in TNM-EC but was almost even in TNM-GC. A stepwise increase of HR was observed in TNM-GC, but not in TNM-EC. The survival curves between stages II and III were significantly separated in TNM-GC (P = 0.019), but not in TNM-EC (P = 0.204). The 5-year survival rates of stages IIIA, IIIB, and IIIC were 69.0, 100, and 38.9 % in TNM-EC and were 52.0, 43.4, and 33.9 % in TNM-GC, respectively. TNM-GC is better for classifying patients with AEG types II/III than TNM-EC is. These results could impact the next TNM revision for AEG.

This study was undertaken to determine the efficacy of the clinical indications for performing staging laparoscopy for locally advanced gastric cancer to detect peritoneal metastasis or positive cytology findings. The study included 231 patients with T4 gastric cancer without hematogenous or clinically evident peritoneal metastasis. The clinicopathologic features, including T and N factors, were diagnosed by clinical staging. The relation between the clinicopathologic features and the presence of peritoneal metastasis or lavage cytology at surgery was analyzed. A total of 31 patients underwent staging laparoscopy; 200 others underwent open surgery as a primary treatment. Both peritoneal metastasis and lavage cytology were negative in 145 (62.8%) patients, whereas peritoneal metastasis or lavage cytology was positive in 86 patients (37.2%). When calculating diagnostic accuracy in the 23 patients who underwent open laparotomy after staging laparoscopy, the accuracy rate was 95.7%. A multivariate analysis showed that a tumor location involving three portions; macroscopic type 3, 4, or 5; and positive lymph node metastasis to all three is significantly correlated with either peritoneal metastasis or positive cytology. When patients had two or three factors among these three independent risk factors, peritoneal metastasis or positive cytology could be detected with 91.9% sensitivity and 46.7% positive predictive value. The selection of T4 tumors based on clinically evaluable risk factors is therefore considered useful for detecting peritoneal metastasis efficiently and hence avoiding unnecessary staging laparoscopy.

Background Regenerating islet-derived family members (Reg) are superfamily of calcium-dependant lectins that are expressed in the proximal gastrointestinal tract and ectopically at other sites in the setting of tissue injury. The regenerating islet-derived family member 4 (RegIV) gene has been reported in various cancers, associating with diverse functions. This study examined the relation of the relative expression of RegIV gene to clinicopathological factors and outcomes in patients with colorectal cancer (CRC). Methods We studied surgical specimens of cancer tissue and adjacent normal mucosa obtained from 202 patients with untreated CRC. The relative expression levels of RegIV mRNA in cancer and in normal adjacent mucosa were measured by quantitative real-time reverse-transcriptase polymerase chain reaction. Results RegIV gene expression was higher in cancer tissue than in adjacent normal mucosa. The multivariate analysis of clinicopathological factors for 5-year overall survival showed a higher level of RegIV gene expression was a significant independent predictor. Overall survival at 5 years differed significantly between patients with high RegIV gene expression and those with low expression. Conclusions Overexpression of the RegIV gene is considered a useful independent predictor of outcomes in patients with CRC. J. Surg. Oncol. 2011;104:205–209. © 2011 Wiley-Liss, Inc.

A combination of irinotecan with continuous infusional 5-fluorouracil (5-FU) is the standard treatment for advanced colorectal cancer. The aim of this study was to determine the efficacy and safety of combining irinotecan and S-1 (IRIS) in patients with advanced colorectal cancer.Irinotecan was administered as an intravenous infusion at a dose of 120 mg/m(2) on day 1 and 15. And S-1 was administered orally on days 1-14 of a 28-day cycle. S-1 was given orally at a dose that did not exceed 40 mg/m(2) based BSA: BSA1.25 m(2), 40 mg twice daily; 1.25-1.5 m(2), 50 mg twice daily, and BSA1.5 m(2), 60 mg twice daily, for 14 consecutive days.A total of 38 patients were enrolled. An intent-to-treat analysis showed a complete response and partial response to occur in 13.2% and 50.0%, respectively. The disease control rate was 84.2%. The median progression-free survival and overall survival were 10.0 months and 29.1 months, respectively. The rates of grade 3/4 toxicity over 4 cycles were the following: neutropenia, 15.8%; leucopenia, 7.9%; anorexia, 15.8%; diarrhea, 10.5%.IRIS is an effective, well tolerated and convenient treatment regimen for patients with advanced colorectal cancer.

症例は61歳，女性．繰り返す嘔吐と腹部膨満を主訴に当院内科に精査目的にて入院．検索の結果上腸間膜動脈症候群と診断され，保存的治療にて様子をみていたが改善せず，手術目的にて外科紹介となった．手術は腹腔鏡下十二指腸・空腸吻合術施行．術後経過良好にて退院．術後１年２カ月経過するも再発はない．腹腔鏡下十二指腸・空腸吻合術は，低侵襲で本疾患には有用な方法と考えられた．

The aim of this study was to determine the maximum tolerated dose, recommended dose and dose-limiting toxicities of irinotecan (CPT-11) plus S-1 in advanced colorectal cancer.S-1 was administered orally at 80 mg/m(2) per day for 14 consecutive days followed by a 2-week rest. CPT-11 was given intravenously on days 1 and 15 of each course, at an initial dose of 80 mg/m(2) per day, stepping up to 100, 120 or 150 mg/m(2) per day. Courses were repeated every 4 weeks, unless disease progression or severe toxicities were observed.A total of 21 patients were entered in this study. The maximum tolerated dose of CPT-11 was considered to be 150 mg/m(2), because 2 of 3 patients developed dose-limiting toxicities such as leukopenia, neutropenia, diarrhea and anorexia. The recommend dose of CPT-11 was set at 120 mg/m(2). Tumor response rate was 42.8% and median progression-free survival time was 10 months (95% confidential interval, 6.0-14.0 months).A combination of S-1 and CPT-11 showed a good safety profile and can be recommended for further phase II studies in patients with colorectal cancer.

Histological findings of metastatic lymph nodes are important prognosticators in patients with gastric cancer. The aim of this study was to clarify the clinical significance of various pathological characteristics of the early phase of lymph node metastasis in patients with gastric cancer, by selecting patients with tumors that had single lymph node metastases, no serosal invasion, and no metastases to the peritoneum, liver, or distant organs.Seventy-eight patients were eligible and were entered in this study. These patients were subdivided according to the following histological characteristics of the one metastatic lymph node: size of the metastasis (i.e., amount of tumor cells [AT]), proliferating pattern (PP), intranodal location (IL), and the presence or absence of extracapsular invasion (ECI) and/or fibrotic focus (FF). Associations between clinicopathological factors, survival, and the nodal findings were examined.There were no correlations between AT or PP and any clinicopathological factors. IL was significantly correlated with venous invasion and the pathological characteristics of the primary tumor. ECI and FF were observed significantly more frequently in pT2 than in pT1 cancer. Overall survival (OS) differed significantly according to depth of invasion, venous invasion, and the presence or absence of ECI or FF, although OS was not affected by AT, PP, or IL. The 10-year overall survival rates of patients with and without ECI were 50% and 80%, respectively, while these rates for patients with and without FF were 50% and 79%, respectively. Multivariate analysis revealed that ECI and FF were significant prognosticators of survival.These results strongly suggested that the presence of ECI or FF could affect the survival of patients with gastric cancer.

We report 2 cases of signet ring cell carcinoma of the appendix and colon. Case 1: A 61-year-old man was admitted for lower abdominal pain. Colonoscopy revealed an elevated lesion in the orifice of the appendix. Signet ring cell carcinoma was diagnosed on biopsy. The surgical findings showed multiple peritoneal dissemination nodules, while the primary tumor was unresectable owing to extensive invasion into the retroperitoneum. The histopathological findings were signet ring cell carcinoma, T4b (retroperitoneum), NX, P3, Stage Ⅳ. Although the patient received 14 courses of treatment with S-1 as postoperative chemotherapy, he died of his illness at 32 postoperative months. Case 2: A 76-year-old man was admitted for abdominal pain. Perforation of the lower gastrointestinal tract was diagnosed on abdominal CT, and an emergency operation was performed. The surgical findings demonstrated a large number of peritoneal dissemination nodules, cecal invasion of a sigmoid tumor, and perforation of the ascending colon. The primary tumor was thought to be unresectable, and the perforated segment was resected. The histopathological findings were signet ring cell carcinoma, T4b (cecum), NX, P3, Stage Ⅳ. Although 11 courses of treatment using FOLFIRI+Bev were administered as postoperative chemotherapy, the patient died of his illness at 26 postoperative months.

In March 2011, trastuzumab was approved for treating human epidermal growth factor receptor 2 (HER2) positive advanced gastric cancer (AGC) in Japan. Therefore, all patients with AGC should be evaluated for HER2 status. In this study, we analyzed the clinicopathological features and current status of treatment in HER2 positive gastric cancer. One hundred 6 gastric cancer patients were examined for HER2 expression in our hospital between March 2011 and August 2014. Sixteen patients (15.1%) were HER2 positive. There was no correlation between HER2 status and age, sex, and location of tumor; however, HER2 positivity was significantly more frequent in patients with intestinal type tumors and had a tendency towards being more frequent in patients with macroscopic types 0, 1 or 2. Trastuzumab was administered to 10 patients with HER2 positive AGC. The total number of doses of trastuzumab was 1 to 44 (median 7.5), and the therapeutic effect of trastuzumab combination chemotherapy was 1 patient with a complete response and 4 with a partial response. Adverse events due to trastuzumab were not observed. The incidence of HER2 over-expression was 15.1%, and trastuzumab combination chemotherapy was relatively safe and effective.

A 64-year-old woman was diagnosed with Stage IV gastric cancer with lymph node and multiple liver metastases. She was treated with 6 courses of chemotherapy, in 3-week courses, with capecitabine (1,000 mg/m/(2)) plus cisplatin(80 mg/m(2)) administered for 2 weeks, followed by a drug-free week. She underwent curative total gastrectomy with D2 lymph node dissection and reconstruction by using the Roux-en-Y method. The postoperative pathological findings revealed a T3 (SE), N1M1, Stage II B tumor; the tumor was determined to be Grade 1b owing to the chemotherapeutic effect. Postoperatively, only S-1 therapy was administered, because of the development of Grade 3 hand-foot syndrome. The patient is alive 1 year and 8 months after the initial gastrectomy.

We investigated the significance of staging laparoscopy (SL) for clinical Stage III/IVgastric cancer.SL was performed in 60 patients with clinical Stages III/IV gastric cancer.Pre -SL Stages were T3/4a/4b in 3/49/8 patients, N1/2/3 in 14/21/25, M0/ 1 in 38/22, and IIIA/IIIB/IIIC/IV in 16/13/9/22 patients, respectively.After SL, 11 patients were downstaged from T4a to T3, and 3 patients were downstaged from T4b to T4a.Moreover, 14 patients of P0 were identified as P1 or CY1, and 1 patient of H0 was identified as H1 after SL.As a result, post-SL Stages were IIB/IIIA/IIIB/IIIC/IV in 3/17/9/2/29 patients, respectively. In Stage III patients, staging was changed in 17 patients (44.7%) and the treatment strategies were changed in 9 patients (23.7%).In Stage IV cases, none of the patients changed staging and treatment strategies after SL.In conclusion, SL is useful for accurate staging and determining the treatment strategies in Stage III gastric cancer; however, re-evaluation is needed for the indication of SL in Stage IV gastric cancer.

To assess the outcomes of preoperative colonic stent placement for obstructive colorectal cancer.A total of 30 patients with colorectal cancer were treated after preoperative colonic metallic stent placement between July 2012 and March 2014. We reviewed their medical records to assess the usefulness of stent placement and the clinical course. The effects of various clinicopathological variables on post-operative complications were analyzed statistically.Stent insertion was effective in 93% of the 30 patients with obstructive colorectal cancer. Preoperative colonoscopy or enema for proximal colonic survey was possible in 70% of the patients after stent placement; colonic lesions requiring simultaneous resection were noted in 5 patients (24%). The mean interval between stent insertion and operation was 19 days, and 23%of the patients underwent laparoscopic surgery. Statistical analysis revealed that the occurrence of complications was associated with laparoscopic surgery and the amount of operative blood loss.Preoperative stent placement in patients with obstructive colorectal cancer is feasible and laparoscopic surgery can be selected after stent placement.

The ACTS-GC trial showed the efficacy of S-1 adjuvant chemotherapy in patients with pathological Stage II/III gastric cancer who had undergone D2 gastrectomy; however, T1 patients were excluded from this trial.In this study, we compared the prognosis of T1N2/3 gastric cancer with the outcomes of ACTS-GC.From 2000 to 2009, out of 480 patients with resected T1 gastric cancer, 27 patients(5.6%) were pN2/3.Six patients received S-1 adjuvant chemotherapy (group S), whereas 21 patients did not(group N).The 3-year overall survival rates of T1N0/1 and T1N2/3 were 91.7% and 71.3%, respectively. Among T1N2/3 gastric cancer patients, the 3-year survival rate and relapse-free survival rate were 100%/100% in group S and 72.7%/71.1% in group N, respectively. The prognosis of group N was poorer than that of the surgery-alone group in Stage II of ACTS-GC.Furthermore, 5 patients (23.8%) of group N had recurrences; the primary sites of recurrences were lymph nodes in 4 cases, and lymph nodes and liver in 1 case.The prognosis of T1N2/3 gastric cancer is poor; we should, therefore, consider evaluating the efficacy of adjuvant chemotherapy in T1N2/3 gastric cancer patients.

症例1は50歳の女性で, 直腸癌の診断で当院紹介された. 直腸Raに2型病変を認め, CT上傍大動脈リンパ節腫大が見られた. 低位前方切除術施行し, 術中迅速組織診で傍大動脈リンパ節転移陽性であった. 術後化学療法を1クール施行し, 傍大動脈リンパ節腫大は消失したが術後4年9か月のCTで再び傍大動脈リンパ節転移再発を認めた. 化学療法4クール施行後, リンパ節腫大は消失した. 術後8年9か月時点で再発なく経過中である. 症例2は29歳の男性で, 下血にて前医入院し, 精査加療目的で当院転院した. 歯状線に接して粘膜下腫瘍様隆起を認め, 生検で小細胞癌の診断となった. 化学療法3クールと放射線照射を施行し腫瘍の縮小を得た後, 腹会陰式直腸切断術を施行した. 原発巣, リンパ節共に腫瘍細胞を認めず, 加療後19か月現在無再発生存中である. 直腸原発小細胞癌は予後不良だが集学的治療が著効する例もあることから積極的な治療が望まれる.

症例は70歳の女性. 1年前より腹痛が断続的に続くため当院を受診.超音波検査で膵頭部に腫瘤を認めた.次第に食事摂取が困難となり,開腹術を施行.腫瘍は後腹膜に浸潤し,治癒切除は不可能であり,バイパス術および腫瘍生検を施行した.術後,KIT染色のみ行い,弱陽性であったためimatinib mesylate (グリベック®)の投与を開始した.しかし効果なく,他の免疫染色を含め再検すると, KITは陰性, α-SMA・desminが陽性であり,平滑筋肉腫と判明した.すでに腫瘍は進行しており,有効な追加治療が行えぬまま術後3カ月目に原病死した.本症例は画像所見から確定診断することは困難で,治療方針の決定には組織採取が必要であったが, KIT弱陽性の腫瘍では鑑別に苦慮することがあり,その際はすみやかに他の免疫染色やc-kit mutation assayを追加するべきであると考えられた.

内ヘルニアは比較的まれな疾患であり特徴的な所見に乏しく術前診断が困難であるが, しばしば絞扼性イレウスで発症する. 今回われわれは絞扼性イレウスの診断に腹腔鏡が有用であった大網裂孔ヘルニアの1例を経験した. 症例は26歳の男性で, 上腹部痛にて当院内科入院. 徐々に増悪したため翌日当科受診. 腹部CT上,網嚢内に腸管を認め内ヘルニアを疑ったが確定診断には至らなかった. 絞扼性イレウスの診断で緊急手術を施行. まず腹腔鏡で腹腔内を観察したところ, 壊死腸管を認めたため開腹した. 小腸が大網の裂隙を通り網嚢内へ嵌入し, 約60cmの回腸が小網の裂孔により絞扼され壊死しており, 小腸部分切除および裂孔閉鎖を施行した. 本症では壊死腸管を認めたため開腹手術を行ったが, 内ヘルニアを疑った場合, 腹腔鏡は診断および治療に有用な方法であると思われた.

脊髄神経鞘腫および両側腎血管筋脂肪腫(angiomyolipoma: AML)を合併した肺リンパ脈管筋腫症(lymphangioleiomyomatosis: LAM)の1例を経験した.症例は26歳,女性.両側腎AMLの既往あり.平成6年5月より右気胸を5回(2回目に胸腔鏡手術施行),左気胸を2回発症した.今回平成12年9月より左気胸3回目を発症し入院.胸部CT上両肺野に嚢胞性変化が多発しLAMを疑い,平成12年10月胸腔鏡下生検を施行.病理組織所見で細気管支壁および胞隔に平滑筋組織の増生を認め, smooth muscle actin弱陽性, HMB-45陽性,プロゲステロンレセプター陽性によりLAMと診断した.また術後腰痛の増悪があり脊髄MRIで胸部硬膜内髄外腫瘍を認めた.摘出術を施行し神経鞘腫の診断を得た.検索しえた範囲ではLAMと神経鞘腫を合併した報告例はなく,貴重な症例と思われ報告した.