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Background Real-world evidence on the preference for and effectiveness of third- or later-line (3L +) monotherapy for HER2-positive gastric cancer is limited in Japan. This study evaluated the utility of nivolumab, irinotecan, and trifluridine/tipiracil (FTD/TPI) monotherapy as 3L + treatment in Japanese patients with HER2-positive gastric/gastroesophageal junction (G/GEJ) cancer who were previously treated with trastuzumab. Methods In this multicenter, retrospective, observational study (20 centers), data of eligible patients were extracted from medical records (September 22, 2017–March 31, 2020), with follow-up until June 30, 2020. Outcomes included overall survival (OS), real-world progression-free survival (rwPFS), time to treatment failure (TTF), objective response rate (ORR; complete response [CR] + partial response [PR]), and disease control rate (DCR). Results Of 127 enrolled patients, the overall analysis population comprised 117 patients (median [range] age, 71 [38–89] years). The most commonly prescribed 3L + monotherapy was nivolumab (n = 100), followed by irinotecan (n = 12) and FTD/TPI (n = 5). The median (95% confidence interval [CI]) OS, rwPFS, and TTF were 6.2 (4.5–8.0), 1.9 (1.5–2.3), and 1.8 (1.5–2.2) months, respectively, at median (range) 150 (25–1007) days of follow-up. The ORR (CR + PR) and DCR were 9.0% (1% + 8%) and 32.0%, respectively. Factors such as higher neutrophil–lymphocyte ratio (≥ 2.54), Glasgow prognostic score (≥ 1), Eastern Cooperative Oncology Group performance status (ECOG PS; ≥ 2), and hepatic metastasis significantly impacted OS. Conclusions The observed OS in this study for HER2-positive G/GEJ cancer was shorter than that reported previously, suggesting that the effectiveness of nivolumab, irinotecan, or FTD/TPI as 3L + therapy may be limited.

Despite having once been extensively used for cosmetics or pain reduction, the use of single-incision laparoscopic cholecystectomy (SILC) has declined in recent years due to technical difficulties and a reported increase in complications. Since the introduction of SILC in 2009, our hospital has been actively involved with this technique. Our experience suggests that SILC is not a difficult procedure and can be safe and useful, with particularly excellent cosmetic outcomes. This study retrospectively details the outcomes of SILC at our hospital.Data on 1469 cases of SILC performed on a waitlist basis at Osaka Police Hospital from May 2009 to December 2020 were collected and retrospectively analysed.The median operative time and blood loss were 96 min and 0 mL, respectively. A total of 46 patients (3.1%) required conversion surgery, including 36 needing additional ports and 10 requiring laparotomy. Intraoperative complications included common bile duct injury in 1 patient (0.07%) and right hepatic artery injury in 1 patient (0.07%), with no other organ injury. Postoperative Clavien-Dindo 3 or higher complications were observed in 18 patients (1.2%). Incisional hernias occurred in 15 patients (1.0%). The median postoperative hospital stay was 3 days.This study showed that SILC can be performed safely without any increase in complications, as reported previously. Granted that it is performed safely, SILC may be a useful technique due to its superior cosmetic outcomes or pain reduction.

Aim Osteoporosis in patients after gastrectomy is increasing with the aging of gastric cancer patients. Bisphosphonates are effective treatments for osteoporosis; however, their safety or efficacy in postgastrectomy patients has not been established. The purpose of this multicenter prospective intervention study was to investigate the impact of monthly minodronate on osteoporosis after gastrectomy. Methods Of the 261 enrolled gastric cancer patients, 164 patients were diagnosed with osteoporosis based on criteria of the Japan Society of Osteoporosis. They were randomly assigned 1:1 to groups treated with active vitamin D (VD group) or monthly minodronate (MIN group). The primary endpoint was changes in lumbar bone mineral density (L‐BMD) 12 mo after the start of administration. The secondary endpoints were changes in bone metabolism markers, adverse events (AEs), or treatment completion rates. Results There was no significant difference in patient background between the VD (n = 82) and MIN (n = 82) groups. In the MIN group, the increase in L‐BMD was significantly higher than that in the VD group (4.52% vs 1.72%, P = .001), with a significant reduction in bone metabolism markers; blood NTX (−25.6% vs −1.6%, P, Monthly minodronate is safe and effective for osteoporosis after gastrectomy.

Background Application of laparoscopic gastrectomy (LG) to advanced gastric cancer is still controversial due to lack of sufficient surgical and oncological outcomes. The purpose of this study was to elucidate the feasibility of LG for advanced gastric cancer by multicenter prospective cohort study. Methods A total of 98 patients with clinical stage II or III gastric cancer from 8 institutes were analyzed in this study. The primary endpoint was incidence of severe postoperative complications of Clavien-Dindo classification grade Ⅲa or higher. Results Sixty-six patients underwent laparoscopic distal gastrectomy (LDG), 10 patients laparoscopic proximal gastrectomy (LPG), 21 patients laparoscopic total gastrectomy (LTG), and 1 patient received gastro-jejunostomy. Seven patients had positive lavage cytology (CY1) and R0 rate was 90.8%. Three patients (3.1%) required conversion to open surgery. The incidence of overall postoperative complications and severe postoperative complications were 17.3% and 9.2%, respectively, those were comparable to the data of open surgery for advanced gastric cancer previously published. By surgical procedure, the incidence of severe postoperative complications of LDG, LPG, and LTG were 4.6, 0, and 28.6% and the rate of severe anastomotic leakage of LDG, LPG, and LTG were 0, 0, and 9.5%, respectively. Total gastrectomy was an only independent risk factor of severe postoperative complications in LG for advanced gastric cancer (odds ratio 8.75; 95% confidence interval 1.70-56.69, P = .0092). Discussion The incidence of severe postoperative complications after LG performed by qualified surgeons was acceptable even in cases of advanced gastric cancer; however, careful attention is required to adopt LTG. (UMIN000025733).

Background: About twice as many boys as girls undergo growth hormone (GH) therapy in GH deficiency (GHD). However, this sex difference may not correctly reflect a real incidence. Objectives: We analyzed the evidence of a selection bias whereby more boys seek treatment at short stature clinics. Subjects and Methods: The present study included 3,902 children who visited 17 short stature clinics with a height SD score of −2 SD or less. The percentage of children who underwent the GH stimulation test was compared between boys and girls, as was the percentage of children ultimately diagnosed with GHD. Results: The children comprised 2,390 boys (61.3%) and 1,512 girls (38.7%), with a boy:girl ratio of 1.58:1. The percentage of children who underwent the GH stimulation test did not differ between boys (45.7%) and girls (49.8%). Among the children who underwent the GH stimulation test, the percentage diagnosed with GHD did not differ significantly between boys (22.0%) and girls (20.1%). The boy:girl ratio of children diagnosed with GHD was 1.59:1. Conclusions: The boy:girl ratio of children with short stature (1.58:1) did not differ significantly from that of children diagnosed with GHD (1.59:1). These results indicate that the predominance of boys in GHD does not reflect a real incidence, but rather a selection bias whereby a higher proportion of boys with short stature seek treatment at clinics. This difference arises because parents are more concerned about boys’ height, and because boys reach adult height at an older age.

Aim We previously reported in a randomized controlled trial that Billroth I and Roux‐en‐Y reconstructions were generally equivalent regarding body weight change and nutritional status 1 year after distal gastrectomy for gastric cancer. We describe the long‐term follow‐up data 5 years after distal gastrectomy. Methods We analyzed consecutive gastric cancer patients who were randomly assigned to undergo Billroth I or Roux‐en‐Y reconstruction after distal gastrectomy. We evaluated body weight change, nutritional status, late complications, quality of life (QOL) using the European Organization for Research and Treatment of Cancer Core QOL Questionnaire, and dysfunction using the Dysfunction After Upper Gastrointestinal Surgery for Cancer, 5 years after surgery. Results A total of 228 patients (Billroth I = 105; Roux‐en‐Y = 123) were eligible for efficacy analyses in this study. Body weight loss 5 years after surgery did not differ significantly between the Billroth I and Roux‐en‐Y groups (10.0% ± 7.9% and 9.6% ± 8.4%, respectively; P = .70). There were no significant differences in other aspects of nutritional status between the two groups. Reflux esophagitis occurred in 19.0% of the patients in the Billroth I group vs 4.9% in the Roux‐en‐Y group (P = .002). Regarding QOL, Billroth I was significantly inferior to Roux‐en‐Y on the diarrhea scale (Billroth I: 28.6, Roux‐en‐Y: 16.0; P = .047). Regarding dysfunction, no score differed significantly between the two groups. Conclusions Billroth I and Roux‐en‐Y reconstructions were generally equivalent regarding body weight change, nutritional status, and QOL 5 years after distal gastrectomy, although Roux‐en‐Y more effectively prevented reflux esophagitis and diarrhea., Billroth I and Roux‐en‐Y reconstructions were generally equivalent regarding body weight change, nutritional status, and quality of life 5 years after distal gastrectomy, excluding reflux esophagitis and diarrhea.

Background/aim The rate of lymph node metastasis (LNM) of colorectal carcinoma (CRC) with a submucosal (SM) invasion depth of 1000 µm or more can reach 12.5%, which is the most common reason for additional resection in daily practice. Other studies have reported that the rate of LNM is less than 2%, regardless of the depth of invasion, if the lesions show good histology, lymphovascular infiltration is negative, and tumor budding is limited. The purpose of this study was to investigate new risk factors for LNM in T1b colorectal cancer. Patients and methods The 239 patients who were diagnosed with pathological T1b CRC after colorectal surgical resection at the Osaka Police Hospital in Japan between January 2008 and December 2018 were retrospectively reviewed in this study. Results The LNM rate was 11.3% (27/239). The variables identified as being significant factors using multivariate analysis were: i) lymphatic invasion (Ly)-positive [odds ratio (OR)=5.97; 95% confidence interval (CI)=2.27-15.74], ii) female gender (OR=3.49; 95%CI=1.38-8.85), and iii) left-sided colorectal involvement (OR=4.98; 95%CI=1.22-20.39). If none of these risk factors were present with T1b, the LNM rate was 0% (0/28). Conclusions Ly-positive, female gender, and left-sided colorectal involvement could be risk factors for LNM in T1b CRC.

The appropriate surgical procedure for patients with upper third early gastric cancer is controversial. We compared total gastrectomy (TG) with proximal gastrectomy (PG) in this patient population. A multicenter, non-randomized trial was conducted, with patients treated with PG or TG. We compared short- and long-term outcomes between these procedures. Between 2009 and 2014, we enrolled 254 patients from 22 institutions; data from 252 were included in the analysis. These 252 patients were assigned to either the PG (n = 159) or TG (n = 93) group. Percentage of body weight loss (%BWL) at 1 year after surgery, i.e., the primary endpoint, in the PG group was significantly less than that of the TG group (− 12.8% versus − 16.9%; p = 0.0001). For short-term outcomes, operation time was significantly shorter for PG than TG (252 min versus 303 min; p

Osteoporosis leads to fragility fractures and is a major public health problem. We conducted this study to analyze the prevalence of and risk factors for osteoporosis after gastrectomy in older patients.This multicenter prospective trial comprised older patients without recurrence of gastric cancer for 3 years after curative surgery. The prevalence of osteoporosis was identified using the World Health Organization bone mineral density (BMD)-based definition. Univariate and multivariate analyses were performed to identify the risk factors for osteoporosis.BMD values were measured in 267 of the 271 enrolled patients. The prevalence of osteoporosis was 38.2% (men 24.0%; women 60%). Analysis using FRAXThe prevalence of osteoporosis in older patients after gastrectomy was 38.2%. Moreover, female sex, age, low body mass index after gastrectomy, and a history of fracture were risk factors significantly associated with osteoporosis. Thus, older patients undergoing gastrectomy should have proactive surveillance and receive treatment for osteoporosis.

With the advancement of endoscopic resection(ER)of colorectal cancer, surgical resection after ER has been increasing. This study evaluated the effects of initial ER on short- and long-term outcomes in T1b colorectal cancer. This retrospective cohort study enrolled patients with pathological T1b colorectal cancer who underwent colorectal surgical resection between 2008 and 2018. A total of 239 eligible patients were divided into 2 groups: patients initially treated using surgical resection with lymph node dissection(LND)(surgery alone, n=142)and patients treated using initial ER and additional surgical resection with LND(surgery after ER, n=97). No significant differences were observed in short-term outcomes(ie, operative time, blood loss, or postoperative complications)or the long-term outcomes(ie, recurrence rate, overall survival rate, or recurrence free survival rate)between groups.

We investigated whether growth hormone (GH) treatment could accelerate the onset of puberty in patients with isolated GH deficiency (GHD). Of the 135 boys and 89 girls who started GH treatment before the onset of puberty and were followed up at Tanaka Growth Clinic, 83 boys and 51 girls who started GH treatment sufficiently earlier than the average age at onset of puberty of GHD patients (

Simple Summary The screening methods and therapeutic strategies for gastrointestinal cancer (GIC) have improved, but mortality in GIC patients remains high. Early detection and precise evaluation of GIC are required to further improve treatment outcomes in GIC patients. MicroRNAs (miRNAs), which do not encode proteins, have attracted attention as biomarkers of various diseases. Since the first report revealing the strong correlation between miRNAs and cancer in 2002, numerous studies have illustrated the changes in the expression and the biological and oncological effects of miRNAs in GIC. Furthermore, miRNAs circulating in the blood are reported to be associated with GIC status. These miRNAs are thought to be useful as noninvasive biomarkers because of their stability in blood. Herein, we discuss the potential of miRNAs as noninvasive biomarkers for each type of GIC on the basis of previous reports and describe perspectives for their future application. Abstract Gastrointestinal cancer (GIC) is a common disease and is considered to be the leading cause of cancer-related death worldwide; thus, new diagnostic and therapeutic strategies for GIC are urgently required. Noncoding RNAs (ncRNAs) are functional RNAs that are transcribed from the genome but do not encode proteins. MicroRNAs (miRNAs) are short ncRNAs that are reported to function as both oncogenes and tumor suppressors. Moreover, several miRNA-based drugs are currently proceeding to clinical trials for various diseases, including cancer. In recent years, the stability of circulating miRNAs in blood has been demonstrated. This is of interest because these miRNAs could be potential noninvasive biomarkers of cancer. In this review, we focus on circulating miRNAs associated with GIC and discuss their potential as novel biomarkers.

Aim The present study aimed to evaluate the efficacy of short‐term nutritional intervention with an oral elemental diet (ED; Elental; EA Pharma Co., Ltd, Tokyo, Japan) at 300 kcal/day for 6‐8 weeks in the early post‐gastrectomy period on postoperative long‐term body weight loss (BWL). Methods We analyzed consecutive patients who were randomly divided to receive the regular diet with or without ED. The control group received regular diet alone post‐gastrectomy, whereas the ED group received 300 kcal ED plus regular diet for 6‐8 weeks. Primary endpoint was percentage (%) BWL (body weight loss; body weight before surgery minus that at postoperative 1 year) by surgical type. Secondary endpoints included changes in nutrition‐related blood parameters. Results Of the patients in the original trial, 106 were eligible for efficacy analyses. %BWL at postoperative 1 year was significantly lower in the ED group than in the control group among patients who underwent total gastrectomy (TG) (n = 19 and n = 17, respectively; 9.66 ± 5.98% [95% confidence interval, CI: 6.77‐12.54] vs 15.11 ± 6.78% [95% CI: 11.63‐18.60], P = .015), but not in patients who underwent distal gastrectomy (n = 38 and n = 32, respectively; 5.81 ± 7.91% [95% CI: 3.21‐8.41] vs 5.96 ± 6.20% [95% CI: 3.72‐8.19], P = .933). In multivariate analysis, ED was the only factor affecting %BWL at postoperative 1 year among patients who underwent TG. Conclusions Daily nutritional intervention (300 kcal/day ED) for 6‐8 weeks reduced %BWL not only at postoperative 6‐8 weeks but also at 1 year in patients who underwent TG., Daily nutritional intervention (300 kcal/day elemental diet) for 6‐8 weeks reduced %body weight loss not only at postoperative 6‐8 weeks but also at 1 year in patients who underwent total gastrectomy.

Pancreatic cancer (PC) is a highly aggressive disease with dismal prognosis. Although only a surgical resection can offer the chance of a cure, the 5-year survival rate after a potentially curative resection have been reported to be a low as 10-30%. Peritoneal recurrence is a major recurrence pattern after surgery for PC. Peritoneal lavage cytology (CY) is employed widely in the diagnosis and staging of PC to rule out patients with occult peritoneal metastasis. However, the prognostic significance of CY+ in potentially resectable PC is still controversial. We rise the question of whether CY+ status in PC has predictive value for survival and early peritoneal recurrence. We conducted this study to evaluate use of a new genetically modified telomerase-specific replication-selective adenovirus, expressing GFP (TelomeScan F35) in rapid detection of viable peritoneal tumor cell (v-PTC) dissemination of PC. This human clinical trial sought to determine if the presence of virally-detected, rare v-PTC predict peritoneal recurrence and patient outcome. This study was approved by the IRB in Osaka Police Hospital and Rinku General Medical Center. Patients with resectable cytologically or histologically proven ductal adenocarcinoma of the pancreas were enrolled. 100ml of saline as peritoneal lavage fluid was harvested just after a laparotomy in 53 patients with PC. Half of the fluid was examined by cytology with papanicolau staining and MOC-31 immunostaining and the remaining half was analyzed to detect v-PTC with TelomeScan F35. To distinguish between leucocyte and cells with epithelial origin, cells were stained with anti-CD45 Ab. To further distinguish cells with primary tumor origin, cells were labeled with anti-CEA, anti-CA19-9 and EpCAM Abs. GFP-positive and CD45-negative, and either CEA-, CA19-9- or EpCAM-positive cells were counted as v-PTC by automatic detection system using NIS Elements imaging software. Patients were followed after surgery to evaluate its clinical significance. Among 53 patients aged 53-87 years (30 males and 23 females), 6 were cytologically positive (CY+), other 12 were virally positive by TelomeScan F35 (v-PTC+). All 53 patients underwent a surgical resection (PD/DP/TP=32/14/7). 2 patients were double positive (CY+/v-PTC+), and peritoneal recurrence early occurred at 7 month after surgery despite adjuvant chemotherapy. 4 were CY+, but v-PTC-, and no peritoneal recurrence were observed (0%). On the other hand, other 10 were CY-, but v-PTC+, and 4 of these 10 patients occurred peritoneal recurrence (40%). Remaining 37 patients were double negative (CY-/v-PTC-), peritoneal recurrence were observed in only 4 patients. In conclusion, the TelomeScan F35-based v-PTC detection may be an independent prognostic factor in patients with resectable PC and had close association with peritoneal recurrence. Citation Format: Masahiro Tanemura, Kenta Furukawa, Manabu Mikamori, Tadafumi Asaoka, Yasuo Urata, Kentaro Kishi, Daisaku Yamada, Shogo Kobayashi, Hidetoshi Eguchi. Development of modified telomerase-specific adenovirus-based identification for viable-peritoneal tumor cells in peritoneal lavage fluid in resectable pancreatic cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5107.

Nodular lymphocyte-predominant Hodgkin lymphoma(NLPHL)is a subtype of Hodgkin lymphoma. It is uncommon in Japan, and only a few cases of NLPHL originating from the mesentery have been reported. Most patients with NLPHL present in the early stage, but some patients have malignancy at initial presentation. We should perform staging laparotomy for the diagnosis and treatment of cases in which a lymph node biopsy is difficult.

Robot-assisted laparoscopic surgery(RALS)for rectal cancer has been covered by National Health Insurance in Japan since April 2018. We launched RALS in our hospital in October 2019 and now report the short-term results(up to January 2020). Altogether, 15 consecutive patients(12 men, 3 women: median age 70 years)with rectal cancer underwent RALS during that period. For the first 2 cases, we performed RALS under the instruction of an experienced proctor from another institution. Among the 15 patients, 6 underwent high anterior resection and 9 low anterior resection. Median operating time was 358 min, median intraoperative blood loss was 0 mL, and there were no apparent intraoperative complications. Median postoperative length of hospital stay was 13 days, and only 1 patient developed a high-grade complication(Clavien-Dindo Grade Ⅲb)postoperatively. Hence, RALS for rectal cancer was launched successfully in our institution.

A phase-Ⅱtrial of TAS-102 plus bevacizumab(Bev)combination therapy showed a progression-free survival(PFS)of 3.7-4.6 months. Here, we report 12 cases of unresectable advanced recurrent colorectal cancer treated with TAS-102 plus Bev therapy at our hospital between June 2017 and February 2020. The median PFS was 6 months(2-12). Adverse events greater than Grade 3 were neutropenia(33.3%), febrile neutropenia(8.3%), thrombocytopenia(8.3%), and vomiting (8.3%). The frequency of non-hematotoxicity was low. In conclusion, the TAS-102 plus Bev therapy may be a useful option for the late-line treatment of unresectable advanced recurrent colorectal cancer.

Long-term outcomes of single-incision laparoscopic colectomy (SILC) for colon cancer (CC), as practiced in real-world settings, especially in relation to disease stage, have not been established. We examined, retrospectively, both short- and long-term outcomes of SILC versus those of multiport laparoscopic colectomy (MPLC) performed for CC in a propensity-score-matched cohort. The study involved 263 patient pairs matched 1:1 from among 691 patients who, between January 2008 and May 2014, underwent either SILC or MPLC for a primary solitary CC at our hospital. Short-term and long-term operative outcomes were compared between the two groups. Operation time was the only surgical outcome that varied significantly between the two groups (p = 0.0004). Overall 5-year cancer-specific survival (CSS) in the SILC group was 93.7 (95% CI 89.6–96.2)%, and CSS per pathological stage (I, II and III) was 98.5 (90.0–99.8)%, 96.0 (88.2–98.7)%, and 88.3 (79.6–93.6)%, respectively, whereas overall 5-year CSS in the MPLC group was 93.3 (89.4–95.9)%, and CSS per pathological stage was 100%, 95.4 (88.3–98.3)%, and 84.1 (74.1–90.8)% (p = 0.5278, 0.2679, 0.7666, and 0.9073), respectively. Overall 3-year disease-free survival (DFS) in the SILC group was 94.0 (90.2–96.4)%, and 3-year DFS per pathological stage was 98.6 (90.4–99.8)%, 90.1 (81.4–95.0)%, and 79.0 (69.4–86.2)%, respectively, whereas overall 3-year DFS in the MPLC group was 93.2 (89.4–95.7)%, and 3-year DFS per pathological disease stage was 100%, 94.5 (87.4–97.7)% and 75.5 (64.7–83.8)% (p = 0.2829, 0.7401, 0.4335 and 0.8518), respectively. Thus, oncological outcomes did not differ significantly between groups. Incisional hernia occurred in 21 (8.0%) SILC group patients and 17 (6.5%) MPLC group patients, without a significant between-group difference (p = 0.6139). Our data indicate that perioperative and oncological outcomes of SILC performed for CC are comparable to those of MPLC performed for CC.

The standard treatment for unresectable or recurrent gastrointestinal stromal tumor(GIST)is tyrosine kinase inhibitor(TKI). It is reported that resection of metastatic lesions after TKI administration prolongs progression free survival, but its influence on overall survival is not clarified. We experienced a case of GIST with peritoneal dissemination for which TKI administration and 2 local resections were effective. The patient was a man in his 70's. We started chemotherapy with imatinib for GIST with peritoneal dissemination. However, it was discontinued due to the occurrence of interstitial pneumonia. Dissemination was evaluated as radically resectable on the images. After the interstitial pneumonia was alleviated, surgery was performed. Although sunitinib was introduced at 2 months postoperatively, recurrent peritoneal dissemination was detected at 32 months postoperatively, and treatment was then changed to regorafenib. Regorafenib treatment reduced the tumor size; however, Grade 3 albuminuria was detected 16 months after treatment initiation and, thus, this treatment was discontinued. Subsequently, the tumor enlarged again. Because there was only 1 recurrent lesion, we performed radical resection. Postoperatively, a reduced dose of regorafenib was re-administered. At present, 9 months after the re-surgery, the patient is alive without recurrence.

A 67-year-old woman presented with bloody stools to a local physician. Lower gastrointestinal endoscopy revealed a type 3 all-circumferential tumor at descending colon. She was diagnosed with descending colon cancer and referred to our hospital for surgery. Preoperative computed tomography(CT)revealed a horseshoe kidney. We performed single-incision laparoscopic colectomy for descending colon cancer(cT3cN0cM0, cStageⅡa)complicated by a horseshoe kidney. The surgery was performed safely without any additional injuries. In patients with horseshoe kidneys, abnormalities have been reported in the running of the blood vascular system and the renal pelvis and ureter systems. Thus, sufficient understanding of the anatomic abnormality by preoperative examinations, such as 3D-CT, is essential for performing surgery safely.

A 66-year-old woman admitted for nausea was found to have a type 2 tumor with stenosis at the fourth portion of the duodenum by upper gastrointestinal series and endoscopy, which was diagnosed as an adenocarcinoma by endoscopic biopsy. Abdominal computed tomography(CT)showed an irregular thick wall at the fourth portion of the duodenum but without metastasis or invasion to the adjacent vessels. We examined the lymph nodes around the pancreatic head intraoperatively and partially resected the duodenum and jejunum based on the diagnosis of negative swollen nodes. The definitive diagnosis was primary tubular adenocarcinoma of the fourth portion of the duodenum, T3, N0, M0, Stage ⅡA. Reports of primary cancer of the fourth portion of the duodenum are very rare, and we include a discussion of the current literature.

Chemoradiation was performed at Osaka Police Hospital's department of respiratory medicine on a 70-year-old male with small cell lung carcinoma(cT4N3M0, cStage ⅢC). Subsequent to secondary chemotherapy for multiple bone metastases that had been observed, he received care to control the disease. He arrived at the hospital complaining of epigastric pain. He got CT-scan and was referred to our department because of a suspected hematoma around the right gastroepiploic artery. He was treated conservatively because circulatory dynamics were steady and there was no indication that anemia had progressed. However, when a test laparotomy was performed the day after the start of treatment because he presented with decreased blood pressure and progressive anemia, a massive hematoma was found around the right gastroepiploic artery. The hematoma was removed, and hemostasis was performed. Based on the pathological findings of the excised specimen, he was diagnosed with abdominal metastasis of small cell lung carcinoma. This is a report on our experience and a literature review on a case of mesenteric hematoma caused by abdominal metastasis of small cell lung carcinoma.

A 75-year-old man presented with a fever. Computed tomography revealed a 10 cm solid tumor under the duodenum. A pre-operative diagnosis of liposarcoma was established using biopsy. Pancreaticoduodenectomy was performed, and the pathological examination led to the diagnosis of dedifferentiation type liposarcoma. Two years later, the liposarcoma recurred at the remnant pancreas. A total remnant pancreatectomy was performed. The pathological examination revealed dedifferentiated type liposarcoma and positive surgical margins. Therefore, radiotherapy of 59.4 Gy in 33 fractions was performed at the recurrence area. The patient has been recurrence-free from 1 year 6 months since the second operation.

277 Background: The real-world effectiveness of third- or later-line (3L+) therapies in patients (pts) with HER2-positive gastric cancer remains unknown. We report a multicenter, retrospective, observational study at 20 centers in Japan to investigate the outcomes of 3L+ therapy in pts with HER2-positive advanced gastric/gastroesophageal junction (G/GEJ) cancer previously receiving trastuzumab (UMIN000040853). Methods: Pts aged ≥20 years with HER2-positive advanced G/GEJ cancer who were previously treated with trastuzumab and newly initiated on nivolumab, irinotecan, or trifluridine/tipiracil monotherapy as 3L+ therapy (Sep 2017 to Mar 2020) were evaluated for overall survival (OS), progression-free survival (PFS), duration of response (DOR), time to treatment failure (TTF), objective response rate (ORR), and disease control rate (DCR). An exploratory analysis for factors affecting OS was conducted using a multivariate Cox regression model, with HER2 status as a covariate. Results: The overall analysis population was 117 pts (median: age, 71 years; number of prior treatment lines, 2; days since the initiation of first-line treatment, 431 days). Median (95% confidence interval) OS, PFS, and TTF were 6.2 months (4.5–8.0), 1.9 months (1.5–2.3), and 1.8 months (1.5–2.2), respectively, at a median follow-up of 150 days. Outcomes by treatment groups are shown in the Table. ORR and DCR in 100 pts with evaluable target lesions were 9.0% and 32.0%, respectively, and median DOR was 8.4 months. A higher neutrophil-lymphocyte ratio (≥2.540), Glasgow prognostic score (≥1), ECOG PS (≥2), and hepatic metastasis significantly impacted OS. Conclusions: The real-world effectiveness of 3L+ therapies was limited in this study. New HER2 treatment agent is expected to improve outcomes in pts with HER2-positive G/GEJ cancer.[Table: see text]

Patient: Male, 82 Final Diagnosis: Intrahepatic squamous cell carcinoma Symptoms: None Medication: — Clinical Procedure: — Specialty: Oncology Objective: Rare disease Background: Cholangiocarcinoma is a rare, aggressive biliary tract malignancy. On histopathology, most tumors are adenocarcinomas, while squamous cell carcinoma of the biliary tract is extremely rare. Case Report: An 82-year-old male was admitted due to the detection of a space-occupying lesion at S6 of the liver. On abdominal dynamic computed tomography, there was an irregular mass with inhomogeneous density associated with mild delayed enhancement in the tumor’s peripheral zone, measuring approximately 22×25 mm, at S6, with secondary dilated biliary ducts of B6. Endoscopic retrograde cholangiopancreatography showed a severe stricture at B6. Brush cytology of B6 was positive for both adenocarcinoma and squamous cell carcinoma. Furthermore, mucous brushing cytology of the papilla of Vater was also positive for adenocarcinoma. Finally, the preoperative diagnosis of primary intrahepatic cholangiocarcinoma, combined with a cancer of the papilla of Vater, was made. The patient underwent both extended right lobectomy and pancreaticoduodenectomy. Histological examination showed that the majority (>99%) of this liver tumor was composed of keratinizing squamous cell carcinoma. Conclusions: Squamous cell carcinoma of the biliary tree is very rare, since the majority of biliary tree tumors are adenocarcinomas. Cholangiocarcinoma containing a squamous cell component has a poor prognosis. To the best of our knowledge, this is the first case report of a primary intrahepatic squamous cell carcinoma that presented as a solid tumor showing clear histological collision between adenocarcinoma and squamous cell carcinoma and was successfully treated with hepatic resection and achieved disease-free survival of more than one year.

Introduction In intraperitoneal-onlay-mesh repair with hernia defect closure (IPOM-plus), the abdominal cavity can be reliably approached through the hernial orifice. Adhesions can then be detached, and the hernial orifice can be closed by direct visual manipulation. Presentation of cases IPOM-plus via the hernial orifice approach was performed in 49 patients. First, an incision is made just above the hernial orifice to reach the abdominal cavity. Under direct visualization, the adhesions are dissected, and the mesh is inserted after laparoscopic manipulation. After closing the hernial orifice under direct visual manipulation, the mesh is fixed again under laparoscopic guidance. Conclusions This technique has the advantages of an easy intra-abdominal approach and direct visual manipulation. No mesh infections were observed in this study, suggesting that it may be useful as a hybrid procedure.

Introduction To evaluate the feasibility and safety of single-incision laparoscopic cholecystectomy (SILC) for uncomplicated gallbladder in elderly patients. Materials and Methods A retrospective analysis of 810 patients undergoing SILC from May 2009 to October 2016 at Osaka Police Hospital was performed, and the outcomes of the patients aged, Highlights • The operative time and the conversion rate of patients ≥80 years after single-incision laparoscopic cholecystectomy were comparable to those of patients

Introduction The aim of this study was to evaluate the feasibility and safety of SILS for totally extraperitoneal inguinal hernia repair for patients on antithrombotic therapy. Methods A total of 365 patients who underwent SILS for totally extraperitoneal inguinal hernia repair between January 2011 and November 2015 were analyzed retrospectively. Antithrombotic drugs were stopped preoperatively, and bridging intravenous heparin therapy was given according to the operative risk of each patient. Data on the patients' characteristics and perioperative outcomes were collected from their medical records. Results Ninety-two patients (25%, 92/365) were treated with antithrombotic drugs preoperatively. The mean operative times for unilateral and bilateral hernia repairs were 96 min and 94 min (P = 0.5), respectively, in the antithrombotic therapy group and 140 min and 130 min (P = 0.2), respectively, in the control group. Bleeding volume was minimal in all patients. There was no significant difference in the conversion rate. The mean postoperative hospital stay was 2.5 days in the antithrombotic therapy group and 2.1 days in the control group (P = 0.1). Postoperative complications were seen in 16% (15/92) of patients in the antithrombotic therapy group and in 11% (29/273) of patients in the control group (P = 0.2). Pulmonary embolism was seen in one patient (0.4%, 1/273) in the control group. Conclusions SILS for totally extraperitoneal inguinal hernia repair with bridging heparin therapy can be performed safely for patients on antithrombotic therapy.

Background Rectal metastasis from pulmonary adenocarcinoma is rare, and it has been regarded as an end-stage phenomenon. Recently, however, advances in lung cancer treatment have improved the chance of long-term survival of patients with unresectable distant metastases. We describe the occurrence and management of metastatic spread of a pulmonary carcinoma to the rectum. Case presentation The patient was a 79-year-old woman who had undergone thoracoscopic left lobectomy for pulmonary adenocarcinoma and then, over the next 11 years, various drugs (carboplatin + paclitaxel (as adjuvant therapy), gefitinib, gemcitabine + vinorelbine, S1 (an oral 5-fluorouracil-based drug), carboplatin + pemetrexed + bevacizumab, erlotinib, nivolumab, afatinib, and carboplatin+ S1) were administered, especially for hilar and mediastinal lymph node recurrences. During the eleventh postoperative year, left and right iliac bone metastases were detected, and radiation therapy was undertaken for local control of these lesions. When 18F-fluorodeoxyglucose positron emission tomography was performed for evaluation of the disease, tracer accumulation in the upper rectum was seen. Colonoscopic examination of the rectum revealed an intramural mass with central ulceration, and the mass was diagnosed histologically as an adenocarcinoma. The bone metastases appeared to be controlled, and the patient’s performance status was good, but she had suffered constipation for about a year and desired treatment. Thus, laparoscopic low anterior resection was performed. Histopathologic analysis revealed a moderately differentiated adenocarcinoma existing mainly between the submucosa and serosa, and immunohistochemical analysis showed the tumor to be positive for cytokeratin (CK) 7, negative for CK20, positive for thyroid transcription factor-1, and negative for special AT-rich sequence-binding protein 2 and caudal type homeobox 2, confirming the diagnosis of rectal metastasis from the primary pulmonary adenocarcinoma. The patient recovered well without any change in her functional status. Systemic chemotherapy was resumed, and she continues to do well, now 6 months after surgery. Conclusions Surgery may be a good option for the management of an isolated rectal metastasis from pulmonary cancer in patients whose functional status is good.

We report a case of myeloid sarcoma(MS)that primarily developed in the spleen. The patient was a 60s man with a chief complainant of low-grade fever following a dental implant. Although he underwent intensive antibiotic treatment, including levofloxacin, meropenem, and vancomycin, no significant decline in fever was observed. Abdominal contrast-enhanced CT revealed an LDA occupying the majority of his spleen, which was diagnosed as a splenic abscess. Although a CT-guided biopsy and drainage for the spleen were considered, a puncture of the spleen was not performed due to the substantial concern of bleeding. Subsequently, a splenectomy was performed and HE staining revealed mitosis of tumor cells and massive necrosis. Immunohistochemical analysis revealed that the tumor cells were positive for myeloperoxidase, CD43, CD45, and CD68. Finally, the splenic LDA was diagnosed as MS instead of a splenic abscess. He was treated with systemic chemotherapy. MS primarily develops in the spleen is quite rare: we found only 2 case reports of this disease. The prognosis of MS is poor due to the complications of AML. Accordingly, MS should be considered as a differential diagnosis for accurate diagnosis and treatment of splenic LDA.

Small bowel obstruction (SBO) arises on various backgrounds, and the surgical procedure is often modified intraoperatively as needed. Single-incision laparoscopic surgery (SILS) is less invasive than conventional multiport laparoscopic surgery (MPS) and reported to be equally safe and efficient. We have been applying SILS to SBO requiring surgical treatment, and we conducted a retrospective study to clarify the role of SILS in the management of SBO. Thirty-four consecutive patients were identified for inclusion in the study through a review of hospital records of patients having undergone surgery for SBO between May 2013 and June 2018. Patients with tumor- or hernia-related SBO were excluded. We also identified, for comparison, a group of patients who had undergone open surgery for SBO during the preceeding 5-year period. The primary study endpoint was the SILS completion rate, and analyses were performed to identify risk factors for conversion to open surgery and perioperative complications. The SILS completion rate was 70.6% (24/34 patients), with conversion open surgery required for the remaining 10 (29.4%) patients. Conversion was necessitated by limited working space in 5 (50%) patients, discovery of massive necrosis in 3 (30%), and non-detection of the responsible lesion in 2 (20%). Univariable analysis showed an American Society of Anesthesiologists Physical Status score (p = 0.020) and severe intra-abdominal adhesions (p = 0.007) to be risk factors for conversion. Conversion to open surgery (vs complete SILS) was significantly associated with increased operation time (p = 0.018), blood loss (p = 0.021), postoperative stay (p = 0.010), and postoperative complications (p = 0.004). Open surgery was significantly associated with increased postoperative stay (p = 0.026) and postoperative complications (p = 0.011). SILS appears to be a reasonable surgical treatment option for selected patients with SBO.