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Although sigmoid volvulus (SV) causes acute obstruction, its pathogenesis and mechanism of torsion are unknown, and few reports have described its pathological findings. Here, we evaluated the clinicopathological characteristics of volvulus and factors contributing to volvulus of the sigmoid colon.We compared 14 patients with SV (10 men and 4 women; median age, 78.5 years) with 14 age- and sex-matched control patients for differences in clinical characteristics, focusing on dysmotility (enteric visceral myopathy, neuropathy, and mesenchymopathy).Of the 14 SV patients, 7 had recurrent volvulus, 11 had an associated condition, and 5 required emergency surgery. Atrophy and fibrosis of the inner muscle were more prevalent in the SV than control patients (p = 0.041). Median extent (per centimeter of muscularis propria) of the myenteric plexus (12.5 versus 17.5, p 0.001) and submucous plexus (15.0 versus 25.5, p 0.001) was lower in the SV patients, as were the median numbers of myenteric (9.7 versus 30.4, p 0.001) and submucous ganglion cells (10.0 versus 23.2, p 0.001). Inflammatory neuropathy was more prevalent in the SV than control patients (p = 0.046); whereas, the prevalence of mesenchymopathy did not differ (p = 0.481).A decrease in the extent of enteric plexus and ganglion cells precedes the clinical manifestation of SV. Although further elucidation is needed, this decrease may play an important role in the diagnosis of SV and in identifying the mechanism leading to torsion in SV.

We reviewed 21 patients with locally advanced breast cancer with distant metastasis.The median age was 61 years.The median time to presentation at hospital was 13 months, and the median neoplasm diameter on the first visit was 10 cm.The main histological type was scirrhous carcinoma.Sixteen cases tested positive for hormone receptor(76%), 4 tested positive for HER2(19%), and 3 were triple negative(14%).Four patients underwent surgery.The techniques performed included mastectomy and axillary lymph node dissection.Three patients experienced local recurrence.The first-line treatment was surgery for 1 patient, chemotherapy for 12 patients, hormonal therapy for 7 patients, and trastuzumab for the HER2 positive patients.The median follow-up period was 49 months.The patients for where an operation was performed were 49 months and the operation not- enforcement patients were 54 months.If treatment is possible for patients with locally advanced breast cancer with distant metastasis, multidisciplinary treatment according to individual patient characteristics is recommended. In the case of surgical treatment, careful consideration must also be given to these characteristics.

Intramural metastasis (IM) in gastric cancer is rare. However, it often occurs with esophageal squamous cell carcinoma and has been reported to have a poor prognosis.In 4,714 cases of gastric cancer that underwent gastrectomy, the clinicopathological features and postoperative prognoses of 29 cases with IM were evaluated and compared with 2,770 cases of advanced gastric cancer without IM.Of the 4,714 cases, 29 (0.6 %) were histopathologically diagnosed with gastric cancer with IM. There were significant differences in the number of lymph node metastases, capillary invasion, and stage grouping between cases with IM and advanced gastric cancer without IM. Metastasis size was approximately within 2 cm, and many metastases occurred within 2 cm of the primary lesion. Multiple metastases were observed in 38 % of cases and occurred mainly in the submucosa and muscularis propria. IM was detected preoperatively in 17.2 % of cases and was present equally on both sides of the primary lesion. Nine cases had IM outside the stomach. The median survival time with IM was significantly less than in cases of advanced gastric cancer without IM (p0.0001). A subgroup of cases with IM within 1 cm of the primary lesion had a relatively favorable prognosis.The presence of IM is thought to be one of the most important prognostic factors in gastric cancer. Aggressive resection is recommended to increase long-term survival if curative resection is possible.

Gastrectomy with D2 lymphadenectomy is the standard treatment for curable gastric cancer in eastern Asia. Whether the addition of para-aortic nodal dissection (PAND) to D2 lymphadenectomy for stage T2, T3, or T4 tumors improves survival is controversial. We conducted a randomized, controlled trial at 24 hospitals in Japan to compare D2 lymphadenectomy alone with D2 lymphadenectomy plus PAND in patients undergoing gastrectomy for curable gastric cancer.Between July 1995 and April 2001, 523 patients with curable stage T2b, T3, or T4 gastric cancer were randomly assigned during surgery to D2 lymphadenectomy alone (263 patients) or to D2 lymphadenectomy plus PAND (260 patients). We did not permit any adjuvant therapy before the recurrence of cancer. The primary end point was overall survival.The rates of surgery-related complications among patients assigned to D2 lymphadenectomy alone and those assigned to D2 lymphadenectomy plus PAND were 20.9% and 28.1%, respectively (P=0.07). There were no significant differences between the two groups in the frequencies of anastomotic leakage, pancreatic fistula, abdominal abscess, pneumonia, or death from any cause within 30 days after surgery (the rate of death was 0.8% in each group). The median operation time was 63 minutes longer and the median blood loss was 230 ml greater in the group assigned to D2 lymphadenectomy plus PAND. The 5-year overall survival rate was 69.2% for the group assigned to D2 lymphadenectomy alone and 70.3% for the group assigned to D2 lymphadenectomy plus PAND; the hazard ratio for death was 1.03 (95% confidence interval [CI], 0.77 to 1.37; P=0.85). There were no significant differences in recurrence-free survival between the two groups; the hazard ratio for recurrence was 1.08 (95% CI, 0.83 to 1.42; P=0.56).As compared with D2 lymphadenectomy alone, treatment with D2 lymphadenectomy plus PAND does not improve the survival rate in curable gastric cancer. (ClinicalTrials.gov number, NCT00149279.)

腎細胞癌は数年を経て転移再発することがある疾患であり, 転移臓器は肺・肝・骨・脳に多いとされる. 今回われわれは, 左腎細胞癌に対し腎摘出後2年目に, 孤立性に胃転移をきたした稀な症例を経験した. 症例は77歳, 男性. 2003年9月, 他院にて左腎細胞癌に対し左腎摘出術を施行された. 2005年12月, 黒色便を認め近医を受診し, 著明な貧血を指摘された. 当院に紹介となり精査したところ, 上部内視鏡検査で胃体上部に約5cmの1型の腫瘍を認めた. 生検組織検査で免疫組織学的にビメンチン染色陽性であり, 左腎摘出時の腎細胞癌と同様の所見であったことから, 腎細胞癌胃転移と診断した. 2006年2月, 胃全摘術, D2郭清を施行した. 病理組織検査では, 好酸性の細胞質を持つ腫瘍細胞が線維血管性間質を交え偽腺管状となって増殖していた. 摘除された左腎細胞癌と同一の細胞像であり, 胃転移に矛盾しない所見であった.

Use of a standard open stent or self-expanding metal stent for patients with malignant dysphagia is associated with a risk of gastroesophageal reflux especially when placed across the esophagogastric junction. We report 3 cases of malignant esophageal stenosis treated with a long cover-type Niti-STM stent with an antireflux mechanism. Case 1: A 87-year-old man presented with dysphagia due to esophageal cancer at the middle thoracic esophagus. Two months after surgery using a standard open stent, the dysphagia relapsed because of tissue overgrowth. Case 2: A 73-year-old woman presented with lung cancer and severe dysphagia due to enlarged mediastinal lymph nodes. Case 3: A 66-year-old man presented with dysphagia due to esophageal cancer at the lower thoracic esophagus. All 3 patients received an antireflux stent across the esophagogastric junction. In cases 1 and 2, dysphagia was relieved immediately without complications. In case 3, the patient experienced severe reflux and chest pain associated with stent placement and could not ingest any solid food. We conclude that the antireflux stent may be useful for palliation in patients with severe malignant esophageal obstruction; however, patients should be informed about the risk of failure to prevent reflux.

Stage IV gastric cancer has poor prognosis, and median survival time (MST) is reported to range from 6 to 13 months. We report a case of long-term survival in a Stage IV gastric cancer patient who was successfully treated with multi combination chemotherapy with S-1. A 73-year-old woman presenting with gastric cancer with pyloric stenosis and peritoneal dissemination at the sigmoid colon underwent distal gastrectomy with D2 lymphadenectomy and sigmoidectomy. She received adjuvant chemotherapy with S-1 and CDDP after surgery. During the twelfth administration of S-1 and CDDP, she developed an anaphylactic reaction against CDDP; therefore, only S-1 was administered for the next 6 courses. Thirty one months postgastrectomy, a left ovarian metastasis (about 4 cm) was detected by computed tomography. Two courses of S-1 and CPT-11 were administered; however, the ovarian metastasis grew to twice its initial size. She underwent hysterectomy and bilateral ovariectomy. The pathological diagnosis was metastatic tumors in the uterus and ovary(Krukenberg tumor). After the second surgery, S-1 and docetaxel therapy was initiated. A metastasis (S2, 5mm diameter) appeared in the right lung around 65 months after the gastrectomy. The patient received a total of 28 courses, up until 69 months post-gastrectomy. At present, she hopes to finish the chemotherapy and is consulting a palliative care facility. At 80 months post-gastrectomy, she has no symptoms because the lung metastasis exhibits slow growth (15 mm diameter), and is maintaining her quality of life (QOL).

A 61-year-old man was diagnosed with rectal cancer with multiple liver metastases in December 2009, and low anterior resection of the rectum was performed. Postoperative adjuvant chemotherapy with 6 courses of oxaliplatin, Leucovorin, and 5-FU (FOLFOX4) and bevacizumab was initiated, followed by 5 courses of fluorouracil, Leucovorin, and irinotecan (FOLFIRI) and bevacizumab. Right posterior segment (S6, S7) hepatectomy with enucleation of S2, S3 and S5 was performed, and chemotherapy with FOLFOX4 (11 courses) was administered. New metastases in the S5 segment were observed in August 2011 and right hepatic lobectomy was performed. The patient then underwent 8 courses of adjuvant chemotherapy with FOLFOX4. However, left hepatic lobe lateral segment and caudate lobe metastases then appeared. Subsequent repeated chemotherapy with FOLFIRI plus cetuximab (3 courses) and irinotecan plus cetuximab was interrupted in August 2013 owing to adverse events resulting in rapid growth of hepatic metastases. The patient underwent hepatic left lateral segmentectomy and left caudate lobectomy. The postoperative course was uneventful and the patient has currently survived 4 years and 7 months after the initial surgery.

目的:根治切除を行ったstage II, III大腸癌の再発症例を解析し,再発時期と再発後の生存に関連する因子について検討した. 方法: 1991年1月から1996年12月までの間に当科で根治切除を行った470例を対象とした.この内,再発した96例を初回手術時の病理学的因子と再発時期で解析し,再発時期を予測する因子と再発後の生存期間に影響する因子について検討した. 結果:再発時期の中央値は初回手術後17.7カ月であった.初回手術後2年以内の肝再発は68.9%, 局所再発は58.8%, 肺再発は25.0%であった.単変量解析では,初回手術時の組織型(高分化腺癌以外),リンパ節転移あり,初回手術後18カ月以内の再発, stage III, 高リンパ管侵襲が予後不良因子であった.さらに,高リンパ管侵襲のみが多変量解析でも予後不良因子であった. 結論:初回手術後2年以内は特に肝,局所再発に注意が必要であった.さらに,再発した場合はリンパ管侵襲を確認し,低リンパ管侵襲であった場合は手術を含めた積極的な治療の効果が得られると考えられた.

症例は45歳の男性で, 1986年, 発熱, 皮疹, リンパ節腫脹にて発症し, 全身性エリテマト-デス (systemic lupus erythematosus: 以下, SLE) と診断された. 2003年1月17日より発熱・嘔吐・腹痛を認め, 1月24日の腹部CT検査にて, 腹腔内遊離ガスを認め, 消化管穿孔, 汎発性腹膜炎と診断し, 同日, 緊急開腹手術を施行し, 壊死した直腸S状部に穿孔を認めた. 組織標本より, 壊死型虚血性腸炎と診断した. 術後, エンドトキシン吸着療法・持続的血液濾過を導入し, 集学的治療にて軽快した. 自験例のように, SLEに消化管穿孔を伴った症例は, 本邦で過去28年間に23例報告されている. なかでも23例中9例が死亡し, そのうち5例が下部消化管穿孔であった. SLEの経過中みられる消化器症状として穿孔はまれではあるが, 発症すると致死率は高く, SLE患者が腹部症状を訴えてきた際には, その存在と危険性を十分に理解する必要があると考える.

A 55-year-old woman underwent low anterior resection for sigmoid colon cancer with multiple bilobar metastases. She then received 23 courses of Leucovorin, fluorouracil, and oxaliplatin (mFOLFOX) plus bevacizumab and 13 courses of Leucovorin, fluorouracil, and irinotecan (FOLFIRI) plus bevacizumab as down staging chemotherapy. A two-stage hepatectomy was planned to avoid the risk of hepatic failure due to radial resection of bilobar metastases. Therefore, a right lobectomy was performed, and curative resection was achieved 54 days after the first hepatectomy. Two-stage hepatectomy as well as a combination of induction chemotherapy and portal vein embolization may have contributed to the improved prognosis of the initially unresectable multiple bilobar liver metastases.

Background: The regression tree method is a useful statistical technique that has been little used in the analysis of prognosis. Methods: The prognostic factors of gastric cancer were investigated, using the regression tree method, in 555 patients who had undergone curative resection for serosa-negative gastric cancer and who were enrolled in a randomized controlled trial of postoperative adjuvant chemotherapy (JCOG [Japan Clinical Oncology Group] 8801 study). Results: By the regression tree method, the first divided prognostic factor (the most important factor) was lymph node metastasis; in particular, extent of lymphatic spread had the greatest impact on prognosis. In addition, age, tumor size, depth of invasion, and individual dose intensity were found to be significant prognostic factors, whereas sex, tumor location, macroscopic tumor type, and extent of lymph node dissection were not. The resulting tree structure consisted of nine terminal nodes with different prognostic factors, and four clusters were obtained by the merging of terminal nodes that showed a similar prognosis. The cluster which showed the best survival rate (5-year survival rate, 0.986) consisted of two terminal nodes: node 12, which contained N0T1 patients who were younger than 62 years and had a tumor size of less than 7.5 cm, and node 14, which contained N1 patients who were younger than 46 years. Conclusion: In serosa-negative gastric cancer, lymph node metastasis was the most important prognostic factor. Utilization of the regression tree method enabled visual interpretation of the results of statistical analyses through the graphic representation of prognostic factors. It allowed the identification of the optimal combination of these prognostic factors that defined several groups of patients with distinct prognoses and may serve as a useful reference for the individualization of treatment strategy.

In cases of advanced rectal cancer, preoperative chemoradiotherapy( CRT) serves to improve the local control rate, survival rate, radical resection rate, and/or probability of sphincter muscle preservation. According to the Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2010 for the treatment of colorectal cancer, preoperative CRT is the standard treatment for rectal cancer in Europe and the United States. However, there is insufficient evidence in support of its efficacy and safety in Japan, and therefore, CRT needs to be evaluated in properly designed clinical trials. Recently, several studies have reported on the efficacy of preoperative CRT in Japan. Herein, we report a case of rectal cancer in which radical resection was successfully performed with neo-adjuvant CRT.

In the present study, we evaluated the outcome of preoperative treatment with S-1 and CDDP for the treatment of advanced gastric cancer. Fifty-five cases of advanced gastric cancer received pre-operative treatment with S-1 and CDDP. The tumor control rate( PR and CR according to RECIST criteria) was 55%. The clinical response and histological response to the treatment and curative resection were closely related to favorable postoperative survival. We noted that patients who demonstrated CR or PR received S-1 as postoperative treatment, whereas those with SD or PD were more likely to receive paclitaxel as postoperative treatment. Preoperative treatment with S-1 and CDDP was not only an effective initial treatment, but also demonstrated favorable results in a S-1 in vivo sensitivity test.

We report a case of gastric cancer accompanied by disseminated carcinomatosis of the bone marrow treated with S-1 and cisplatin( CDDP) combination chemotherapy. The patient was a 68-year-old woman who was detected as having disseminated intravascular coagulation( DIC) during an examination for gastric cancer and she was diagnosed as having disseminated carcinomatosis of the bone marrow by lumbar puncture. She was immediately treated with S-1 and CDDP combination chemotherapy( S-1, 80 mg/body orally administered[ po] on days 1-21 and CDDP, 60 mg/body intravenously [iv] administered on day 8) and her DIC improved on the fourth day. Subsequently, the patient was treated with 3 courses of combination chemotherapy and she survived for 184 days from the initiation of the treatment. Although disseminated carcinomatosis of the bone marrow is associated with a poor prognosis, we believe that the duration of survival of our patient was extended due to initiation of chemotherapy at an early stage.

The patient was an 87-year-old woman who was diagnosed with atrial fibrillation, which was treated with an anticoagulant, and with chronic kidney disease. The patient was diagnosed as having liver dysfunction and lower cholangiocellular carcinoma (cStage I) on ultrasonography and magnetic resonance cholangiopancreatography. Since it was impossible to perform curative resection owing to the patient's decreased cardiac and renal function, we performed palliative endoscopic retrograde biliary drainage (ERBD) with a plastic stent (PS), and the patient was discharged 11 days later. However, the patient was readmitted because of fever (38.0°C) and vomiting 124 days after ERBD. We assumed that the patient had developed cholangitis due to PS obstruction. Moreover, her blood culture was positive for Klebsiella pneumoniae. We were unable to replace the PS as the tumor had increased in size and hemorrhage from the papilla of Vater continued after the stent had been removed. The signs of inflammation improved after treatment of sepsis with antibiotics and immunoglobulins, and we performed percutaneous transhepatic cholangio drainage( PTCD) and eventually inserted a percutaneous transhepatic biliary endoprosthesis (PTBE) with an expandable metallic stent (EMS). The patient died 2 months later; no stent occlusion was observed. Our experience suggests that endoscopic biliary stents should be selected bearing in mind the patency of the stent and the prognosis.

We measured serum concentrations of hapatocyte growth factor (HGF) in patients with gastric cancer and compared these with the histological findings and conventional tumour markers, including CEA, CA19-9 and CA125, for evaluation of the significance of serum HGF levels as a tumour marker. The HGF levels were measured by an enzyme-linked immunosorbent assay (ELISA) system. The average levels of serum HGF in 89 healthy control subjects, 104 patients with primary gastric cancer and 15 patients with recurrent gastric cancer were 0.31 +/- 0.11 ng ml(1), 0.42 +/- 0.50 ng ml(-1) and 0.92 +/- 0.39 ng ml(-1) respectively. The average level in patients with recurrent disease was significantly higher than in healthy control subjects and in primary cancer patients (P< 0.001 and P< 0.003 respectively). Of 104 patients with primary gastric cancer, 35 (33.7%) showed an aberrant increase in the circulating level of HGF. The increased HGF levels were significantly associated with the degrees of histological tumour invasion and venous invasion. Of 15 patients with recurrent gastric cancer, 14 (93.3%) showed an aberrant increase. No correlation was found between serum HGF levels and CEA levels, CA19-9 levels and CA125 levels. However, the rate of the aberrant increase in HGF levels was significantly higher than that of any other tumour markers, including CEA, CA19-9 and CA125, in primary gastric cancer patients. In conclusion, the circulating levels of HGF were elevated in approximately one-third of patients with primary gastric cancer, particularly in those with high grades of histological tumour invasion and venous invasion, and frequently in patients with distant metastases, suggesting that HGF might play important roles in the tumour progression of gastric cancer. Furthermore, serum HGF levels may be of value as a tumour marker in patients with gastric cancer.

Four hundred and one cases of submucosal gastric carcinoma were divided into three groups according to the extent of submucosal invasion and the possibility of limited operation such as surgical local resection or D1+No. 7 lymph node dissection was examined. The groups consisted of carcinomas of microscopic invasion (sm1: 137 cases), those of macroscopic moderate invasion (sm2: 165 cases), and those of macroscopic massive invasion (sm3: 99 cases). In each group, histological nodal involvement was analyzed according to tumor location, macroscopic type and tumor size. As a result, the surgical local resection could be indicated for 1) sm1 tumors located at upper third, 2) elevated lesion of sm1 and 3) all sm tumors within 1 cm in size. And D1+No. 7 dissection was indicated for 1) all sml tumors, 2) all sm tumors located at upper third, 3) all elevated lesions and 4) all sm tumors within 2 cm in size, whereas the sum satisfying with D1+No. 7 dissection were 101 cases (sm1: 59, sm2: 26, sm3: 16) excluding the high risk cases with nodal involvement such as undifferetiated type and lesions accompanying with ulcer or ulcer scar. As the lymphatic permiation markedly increased in sm2 (83%) compared with sm1 (37%) cases, limited operation would be theoretically applyed to sm1 carcinomas with safety. However, D2 dissection should be recommended in cases which were suspected of sm invasion, because the accuracy rate of preoperative or operative diagnosis of sm1 was not sufficient in the present time.

No.16郭清の功罪を転移例の予後と術後のQOLの面から検討した. No.16郭清343例のうち79例 (23.0%) に転移を認めた.この率は深達度, 3型・4型および低分化型と相関し高率であった. P0, H0のNo.16転移例の5生率は18.8%であるが, このうちn3 (-) 群の予後は31.6%と良好であった. No.16郭清とQOLとの関係では, D2郭清に比べ出血量が有意に多く (p

Radiofrequency ablation(RFA) is minimally invasive and is easy to perform. In the RFA procedure, puncture and passing of the electrical current are painful. Therefore, some facilities use general anesthesia for RFA. In order to evaluate the use of general anesthesia for RFA of hepatocellular carcinoma, a questionnaire survey was conducted.With the cooperation of Tokyo liver-tomo-no-kai(Tokyo Liver Association), a questionnaire survey was conducted for patients who underwent RFA. In the survey, data on the following were obtained "type of anesthesia used", "number of RFA treatment points", "duration of treatment", "length of impact of pain", and "if you need to receive RFA treatment again, how would you feel about this."The ratio of local anesthesia (LA) to general anesthesia (GA) was 113:24. The ratios of the numbers of patients who felt pain to those who felt no pain were 64:49 (LA) and 0:24 (GA). The ratios of the patients who wished to not receive RFA again to the patients who were comfortable with receiving RFA were 65:45 (LA) and 4:20 (GA).GA achieves better pain control compared to LA, and the patients who receive GA have greater tolerance of RFA.

It is common to use systemic chemotherapy, instead of hepatic arterial infusion (HAI) of 5-fluorouracil (5-FU) or other cytotoxic agents, for unresectable hepatic metastases in colorectal cancer patients. Nevertheless, systemic administration of anticancer agents such as FOLFOX or FOLFIRI is sometimes difficult to continue for infirm patients. A 71-year-old female who had undergone sigmoidectomy for sigmoid colon cancer received HAI for 12 months because of big bilobar hepatic metastases and poor performance status. Thereafter, a two-stage hepatectomy(first, left lobe: second, S7+8 and S5) was performed successfully. She has been alive for 2.5 years after the first operation but with two small lung metastases in the left lobe. Because of bad performance status and her weak social and familial conditions, treatment with standard systemic chemotherapy could not be continued. In such cases, HAI should be performed if the metastases are limited to the liver.

At present, fluorouracil and cisplatin combination therapy is the standard chemotherapy against esophageal cancer, but the choice of second-line chemotherapy is controversial. Furthermore, the effect of radiation therapy against lung metastasis from esophageal cancer is unclear. We report a case of lung metastasis from esophageal cancer resistant to fluorouracil and cisplatin combination therapy but responsive to radiation therapy. The patient was a 55-year-old woman who had undergone an operation for esophageal cancer at another hospital. A single right lung metastasis appeared 1 year after the operation. Combined fluorouracil and cisplatin therapy was administrated for 5 courses, but the lung metastasis increased in size. Afterwards, she was admitted to our hospital. We treated her with 14 courses of S-1 and docetaxel combination therapy administered over 13 months. The lung metastasis was decreased for a period. Furthermore, radiofrequency ablation under computed tomography was performed against the lung metastasis re-growth at another hospital. Although the lung metastasis increased in size, no further metastases were detected during the clinical course. The patient was treated with radiotherapy for the lung metastasis re-growth. The tumor had almost disappeared by 10 months after the completion of radiotherapy. Currently, she is receiving palliative care as an outpatient and the lung metastasis has not been evident for 2 years since the completion of radiotherapy.

We report 4 cases of malignant airway obstruction treated by airway stenting. Three cases were caused by esophageal cancer and the fourth case by malignant lymphoma. Two patients with esophageal cancer received chemoradiotherapy after airway stenting and survived for 24 months and 54 months, respectively (without cancer recurrence). One patient with esophageal cancer died of airway bleeding 2 months after stent placement. The malignant lymphoma patient was treated by cyclophosphamide+doxorubicin+vincristine+prednisolone(CHOP) with rituximab. Airway obstruction due to malignancy is an urgent oncological situation that should be treated immediately. Airway stenting shows a marked and immediate improvement in dyspnea. Consequently, the induction of chemoradiotherapy or chemotherapy is possible. Two patients were successfully treated by chemoradiotherapy, of which 1 survived for more than 4 years without any evidence of cancer recurrence. Additional chemoradiotherapy for patients who receive esophageal stenting is controversial because of the high frequency of adverse events. However, chemoradiotherapy after airway stenting may demonstrate acceptable anti-cancer effects with fewer adverse events. Airway stenting was an effective treatment for airway obstruction, and additional treatment is essential for longer survival.

胃癌の外科治療をリンパ節転移の実態と予後の面から検討した.早期胃癌のリンパ節転移・肉眼型・大きさの検討から, その程度に応じてm癌ではEMR (9%), 外科的局所切除 (35%), R1+No.7郭清 (56%) の術式が可能である.しかしsm癌ではほとんどがR2郭清術式が必要である.第2群の郭清効果はA領域癌で最も大きく, M, Cとなるに従い低下した.第3群リンパ節の郭清効果はA群のNo.12で最も大きく, その5年生存率は35%であり, ついでNo.11, No.14Vの順であった.M領域癌でもNo.12転移例の5年生存率は27%と良好な予後を示した.No.16リンパ節転移の郭清効果ではP (-), H (-) 症例の5年生存率は19%であった.これらの転移例のなかでn3 (-) 例の5年生存率は27%と良好であり, 予防的郭清効果を期待しうると考えられた.今後この郭清効果については適応を一定にしたprospectiveな比較試験が必要である.

We have experienced a case of esophageal carcinoma developing esophago-bronchial fistula that was successfully treated by esophageal bypass surgery followed by chemo-radiation. A man aged 64 years old with developed esophago- bronchial fistula after initial chemo-radiation was undergone a gastric bypass surgery to separate esophagus and bronchus. Though closure of fistula was just 4 months after definitive chemo-radiation, an oral feeding was possible until the death of the patient. Stent placement for esophageal carcinoma was less invasive treatment though chemo-radiation after a stent placement was accompanied by high incidence of stent associated morbidity. Since esophageal bypass surgery can definitely separate airway from esophagus, chemo-radiation with oral feeding can be easily carried out. Esophageal bypass surgery was a treatment recommendation for the patient with esophageal carcinoma invading trachea or bronchus.

A 69-year-old male was operated on sigmoidectomy for sigmoid colon cancer (SS, N2, H0, P0, M0, stage IIIb) 7 years ago. Two years later, he was diagnosed for rectal cancer and bilateral lung metastases by TBLB. We performed Mile's operation, and the rectal focus was pathologically diagnosed with a recurrence of sigmoid colon cancer. After surgery, chemotherapy with FOLFOX was started for bilateral lung metastases, resulting in CR during the 22 months. But bilateral lung metastases were exacerbated, and then we administered several other chemotherapies. Five years have passed since chemotherapy started, although the focuses tended to progress. Right now, he has been a chemotherapy outpatient for last 5 years.

A 37-year-old female, who had undergone a low anterior resection for lower rectal cancer, had been received chemotherapy (FOLFOX4, FOLFIRI) for 2 years because of right ovarian metastasis occurred and removed 9 months after the first operation. One month after 2 years of continued chemotherapy, progressive metastases happened to occur successively (rt lunge, left ovarium, liver, para-aortic lymphonode, Virchow lymphonode and bone). Right upper lobe pnemonectomy was performed first, then, peritonectomy, total hysterectomy with left oophorectomy and a partial resection of the small bowel were done. IRIS, as postoperative chemotherapy, performed with hepatic arterial infusion (HAI) of CPT-11 and 5- FU resulted in getting a minimal response for about 10 months. Because of the hepatic arterial thrombosis at 10 months after the previous operation, we could not continue HAI with systemic chemotherapy, that was resulted in the progresion of mutiple metastases, and that the patient died 62 months after the first surgery. Immunohistochemical analyses with MIB-1 stainning of four surgical specimens revealed 80% positive cells in the cancerous tissues.

We report a case of encephalopathy that was suspected to be caused by chemotherapy for liver metastasis from sigmoid colon cancer. A 72-year-old male was suspected that he had drug-induced eukoencephalopathy because he was presented with physical disorders during the FOLFOX/bevacizumab therapy. Although a brain MRI revealed Alzheimer disease, leukoencephalopathy was not excluded from the diagnoses due to a fact that his findings could not be compared before and after the chemotherapy. If leukoencephalopathy was suspected, chemotherapy should have been discontinued as soon as possible. Although a partial response was achieved, chemotherapy had to be discontinued in this case. The cases whose physical and neurological disorders were at risk due to a past history need an examination for nervous system in order to make a comparison with the findings before and after chemotherapy.

The treatment of hepatic metastasis of colon cancer was in progress by new biochemical agents. Generally, a resection was the first alternative treatment against hepatic metastasis of colon cancer, but new antitumor agents were more effective than conventional antitumor agents. Disappearance of metastasis for colon cancer treated with only antitumor agents was commenced to report. We were experienced a case of transverse colon cancer without a recurrence lesion after five years from the resection of hepatic metastasis. A case was a 77-year-old man. He was operated against transverse colon cancer in February 2003. Pathological stage was ss, n0, Stage II. In April 2004, serum CEA was increased. CT examination was not detected a hepatic metastasis but ultrasound examination and MRI detected the metastasis at S7 lesion in the liver. In July 2004, he was admitted to S-1 and PSK until October 2004. In December 2004, the lesion of hepatic metastasis was reduced and serum CEA was decreased. But in September 2005, the metastatic lesion was re-grown. A resection for hepatic metastasis was executed in November 2005. After the resection for hepatic metastasis, he was admitted to UFT/ UZEL from January 2006 to October 2006. Present time( June 2011), the lesion of recurrence was not detected by several examinations (CT, MRI, Ultrasound etc).

Although combination of S-1 and cisplatin (CDDP) is a standard therapy for advance or recurrent gastric cancer patients, there are some cases where a CDDP administration is difficult for patients. We here report three such cases of gastric cancer treated by S-1 and docetaxel (DOC) combination therapy. Based on our three cases, we believe that S-1 and DOC combination therapy could be suitable for outpatients showing safety and efficacy.

A-75 year-old man, diagnosed as ascending colon cancer with large bowel obstruction, multiple hepatic, lunge metastases and peritoneal dissemination, was treated with neoadjuvant chemotherapy (FOLFOX4: 2 courses) and subsequent ileocecal resection. Postoperative systemic chemotherapy with hepatic arterial infusion (HAI) of 5-FU was performed in the following fashion: FOLFOX4, FOLFIRI with or without bevacizumab or cetuximab was administered every 4 weeks and a weekly HAI twice every 4 weeks. By those treatments, the patient could maintain a 30-month long NC effect and a good performance status.

Frequently advanced or recurrent esophageal cancer was invasive trachea and often causing hemoptysis, stenosis and dyspnea. Occasionally, these cases were treated by a placement of tracheal stent. The placement effect was quickly and a main symptom of dyspnea was improved dramatically. However, the most of the cases were in poor prognosis with advanced cancer treated by chemo-radiotherapy (CRT). We experienced a case of recurrent esophageal cancer with tracheal invasion treated by placement of tracheal expandable metallic stent (EMS). A case was a 73-year-old man (at first admission). He was performed esophagectomy with tracheotomy against esophageal carcinoma at cervical portion. Eighteen month later, a local recurrence with tracheal invasion was appeared. The tracheal covered stent was inserted at the recurrent site. After stenting, CRT was performed with 5-FU and docetaxel. The effect of CRT was complete response (CR). Hence, a stent was removed from trachea. No recurrence was observed at the site and maintained a CR condition for two years after CRT.

A 68-year-old male patient with mediastinal node metastasis 40 months after total gastrectomy for advanced gastric cancer, and a 72-year-old male patient with para aortic node metastasis were treated with concurrent chemo-radiotherapy of 1.8 Gy × 5 × 6 week with S-1 (100 mg/body, days 1-14 and 22-35) + docetaxel (30 mg/body, days 1, 8, 22, 29). Although two patients developed a lymph node recurrence during multiple chemotherapies including S-1, they have responded well and demonstrated complete response after chemo-radio therapy. Grade 3 esophagitis was sole adverse side effect. In contrast to the western countries, chemo-radio therapy was not recognized as a standard treatment for gastric cancer in Japan. However, our report suggested that chemo-radio therapy can be an option for the treatment of advanced gastric cancer.

To evaluate the survival benefit of adjuvant chemotherapy after curative resection in serosa-positive gastric cancer, a multicenter phase III clinical trial was conducted in Japan. From January 1993 to March 1998, 268 patients were randomized to adjuvant chemotherapy (135 patients) or surgery alone (133 patients). All patients underwent gastrectomy with D2 or greater lymph node dissection. The chemotherapy regimen consisted of intraperitoneal cisplatin soon after abdominal closure, postoperative intravenous cisplatin (day 14) and 5-fluorouracil (day 14–16), and daily oral FU (UFT) starting 4 weeks after surgery for 12 months. The primary endpoint was overall survival. Relapse-free survival and site of recurrence were secondary endpoints. Fifty-two patients (38.5%) in the adjuvant chemotherapy arm completed the chemotherapy regimen. There were 4 (1.49%) treatment-related deaths, 1 in the surgery-alone and 3 in the adjuvant chemotherapy arm (2 did not receive chemotherapy). Grade 4 toxicity was observed in 3 patients in the surgery-alone and 2 patients in the adjuvant chemotherapy arm. There was no significant difference in 5-year overall survival (62.0% adjuvant chemotherapy vs. 60.9% surgery-alone, P = 0.482) and 5-year relapse-free survival rates (57.5% adjuvant chemotherapy vs. 55.6% surgery-alone; P = 0.512). There was no benefit in overall and relapse-free survival with this adjuvant chemotherapy regimen for patients with macroscopically serosa-positive gastric cancer after curative resection.

多発早期胃癌145例のうち微小癌 (最大径5mm以下の癌) を有する60例 (86病巣) を対象に臨床病理学的特徴を検討し, 早期胃癌に対する縮小手術 (limited operation;LOP) と内視鏡的粘膜切除術 (endoscopic mucosal resection;EMR) の問題点について考察した.多発早期胃癌と微小癌症例の頻度は, それぞれ早期胃癌の18.9%, 7.8%であり増加傾向にあった.微小癌の特徴はIIb (61.6%), tub1 (80.2%), 粘膜内癌 (m) が多く (98.8%), 占居部位ではM>A>C領域の順で, 主癌巣と同一か隣接した領域に多かった.主癌巣からの平均距離は, 長軸距離で4cm以内であった.主癌巣以外がすべて微小癌であった症例は35例にみられた.EMRの適応条件を満たす症例 (大きさ2cm未満, 深達度m) は9例存在し, これらを単発癌と誤認しEMRを行うと取り残しとなると考えられた.早期胃癌に対するLOPやEMRは, リンパ節転移の有無からだけではなく多発癌, 特に微小癌の存在を考慮し慎重に行う必要がある.

80歳以上の高齢者および35歳以下の若年者胃癌を対象として臨床病理学的特徴と手術成績を比較検討した.5年ごとに両群の頻度をみると, 若年者群では増加傾向を示さないが, 高齢者群では最近の5年間で著明な増加を示した.臨床病理学的には, 高齢者は早期癌が19%と少なく, 進行癌は2型の癌が35%と多く, 4型は少なかった.手術術式はR1郭清, 胃亜全摘が多く, リンパ節転移は高齢者群でn1 (+) が多かった.組織型は分化型が77%と多くを占め, 若年者群では未分化型が88%であった.高齢者の早期癌は隆起型を主体とする分化型を示すのに対して, 若年者では陥凹型を中心とした未分化型であった.胃内の早期癌の多発病巣は高齢老に多かった.他病死を除いた高齢者の治癒切除例の5年生存率は63.3%で若年者の81.3%と比較し不良であった.死因をみると高齢者では他病死が多いのに対して若年者では癌死が多くを占めた.

A case of malignant lymphoma of the stomach with invasion to the middle third of the esophagus is reported. A 57-year-old woman was seen at the hospital because of epigastric pain. The X-ray examination of the esophagus and the stomach revealed a tumor centering on the upper gastric body with invasion as far as the middle of the esophagus. Abdominal CT scanning showed marked thickening in the lower part of the esophagus, suggesting invasion to the esophagus. There was no swelling of lymph nodes in the mediastinum and para-aorta. Surgical procedures of total gastrectomy combined with splenectomy and subtotal esophagectomy were done through the thoracoabdominal approach, and the left side segment of the colon was interposed. The tumor was 18×14 cm in size with the esophageal invasion of 11 cm. Histological type was the diffuse and mixed type lymphoma. The tumor had serosal infiltration histologically and lymph node metastasis was not recognized (0/72). Patient has not relapsed in 16 postoperative months. If there are no distant metastases but an invasion into other organs, the patient with malignant lymphoma of the stomach can have a favorable prognosis by aggressive combined resection of surrounding organs and lymphadenectomy. Because the nutrition of these patients can be maintained in a relatively favorable state and the tumor growth is expansive differing from gastric cancers.