Search

Esophagectomy and pancreatectomy are recognized as highly invasive procedures with relatively high complication rates; therefore, careful indication decisions are required. The depth of tumors invading adjacent organs, such as the aorta, vertebral body, and trachea, is defined as T4, and are estimated to have a low survival rate even after treatment. Conversely, pancreatic invasion of esophageal cancer is uncommon and not clearly defined as T4. Thus, it is often difficult to decide on a treatment strategy for locally advanced esophageal cancer. In this study, we describe three cases of esophagectomy with combined resection of the pancreas and spleen for esophageal cancer or esophagogastric junction cancer with invasion of the pancreatic body or tail. To the best of our knowledge, this is the first report of esophagectomy and combined resection of the pancreas and spleen in multiple patients from a single institution.

Undifferentiated pleomorphic sarcoma (UPS) in the gastrointestinal tract is rare. According to the diagnostic criteria after the World Health Organization 2013 reclassification, there has been only one case of UPS with perforation of the gastrointestinal tract. A 71-year-old man who was undergoing outpatient chemotherapy at the department of respiratory medicine of our hospital for lung cancer and brain metastasis, was admitted to our hospital with sudden high fever and abdominal pain. A computed tomography scan showed free air in the abdominal cavity with thickening of part of the jejunal wall. We suspected jejunal metastasis of lung cancer and performed emergency surgery for acute peritonitis due to gastrointestinal perforation in the same area. A Bormann type 2 tumour was found in the jejunum with perforation. The histopathological diagnosis was UPS. Ten months have passed since the surgery, and there has been no recurrence of UPS and no significant change in lung cancer. Primary UPS of the gastrointestinal tract is rare, and cases with perforation are extremely rare. Currently, ten months have passed since the surgery, and no recurrence has been observed. We encountered a case of UPS in which it was difficult to distinguish metastasis from lung cancer to the jejunum, and the emergency surgery gave us the chance to confirm the definitive diagnosis and save the patient's life.

Esophageal gastrointestinal stromal tumors (GISTs) are very rare, accounting for 2–5% of all GISTs. As with other GISTs, the principle of surgical treatment is complete resection with negative margins. In addition to biological grades of GISTs itselves, local recurrence due to capsular damage is a known risk. We describe two cases of massive esophageal GISTs that were successfully resected thoracoscopically after 2 months administration of 400 mg imatinib, with some discussion of the literature. Case 1, the patient was a 51-years-old man. After treated with 400 mg of imatinib as preoperative chemotherapy for 2 months, we performed surgery that included right thoracoscopic subtotal esophagectomy, gastric tube reconstruction, and jejunostomy. The resection specimen and histopathology were esophageal GIST-LtMtAeG, 110 × 95 mm. The postoperative course was uneventful, and was discharged on postoperative day 14. The patient has been recurrence free for 11 months postoperatively. Case 2, the patient was a 70-years-old man. After treated with 400 mg of imatinib as preoperative chemotherapy for 2 months, we performed surgery that included right thoracoscopic subtotal esophagectomy, gastric tube reconstruction, and jejunostomy. The resection specimen and histopathology were esophageal GIST-LtAeG, 90 × 52 mm. The postoperative course was uneventful, and was discharged on postoperative day 14. The patient has been recurrence free for 9 months postoperatively.

Background Barrett's esophagus (BE) is characterized by presence of columnar epithelium in the lower esophageal mucosa, which originally comprises stratified squamous epithelium. Gastroesophageal reflux disease causes BE and BE adenocarcinoma (BEAC); further, the incidence of BEAC is increasing, especially in developed countries. Long-segment BE (LSBE) has a particularly high carcinogenic potential and necessitates treatment, surveillance, and prevention. Case presentation Herein, we report three cases of BEAC originating from LSBE larger than 15 cm. All three patients underwent surgery for the diagnosis of BEAC. A 66-year-old man with advanced esophageal cancer underwent neoadjuvant chemotherapy and subsequent subtotal esophagectomy. The postoperative pathological diagnosis was of poorly differentiated adenocarcinoma with lymph node metastasis (pT3 pN3 pM0 pStage III based on the Union for International Cancer Control TNM Classification 8th edition). Two years after the operation, the patient was diagnosed with recurrence around the celiac artery and underwent chemotherapy. An 83-year-old woman with advanced esophageal cancer underwent subtotal esophagectomy. The postoperative pathological diagnosis was of well-differentiated adenocarcinoma with supraclavicular lymph node metastasis (pT3 pN3 pM1 pStage IV). Two months after the operation, the patient was diagnosed with recurrence in the neck lymph nodes and underwent chemotherapy; however, she died. A 66-year-old man with early-stage esophageal cancer underwent subtotal esophagectomy. A superficial early cancerous lesion was seen over BE. The postoperative pathological diagnosis was of well-differentiated adenocarcinoma without lymph node metastasis (pT1a pN0 pM0 pStage 0). The patient was found to be alive and recurrence-free 3 months after the operation. Conclusions BEAC might show good prognosis if detected and treated early. Extremely LSBE is associated with a high incidence of BEAC; therefore, early detection and treatment with close surveillance is essential.

Background Anomalous bifurcation of the right superior pulmonary vein is an important anomaly that should be recognized not only in respiratory and cardiac surgeries, but also in esophageal surgery for the safe performance of surgery. We report a case in which thoracoscopic esophagectomy was safely performed using preoperative three-dimensional computed tomography (3D CT) imaging. Case presentation An 81-year-old male patient received an upper gastrointestinal endoscopy, which revealed a 20-cm incisor at the entrance, 43-cm EGJ, and 30-mm large type 1 + IIc lesion between the 23-cm and 26-cm incisors; biopsy showed squamous cell carcinoma (SCC). Contrast-enhanced CT showed wall thickening in the anterior wall of the upper thoracic esophagus, without evidence of multi-organ invasion or lymph node metastasis. In addition, a break in the right pulmonary vein passing dorsal to the right main bronchus and flowing directly into the left atrium was observed, and 3D CT was performed preoperatively to confirm the 3D positioning. Positron emission tomography (PET)–CT showed a high degree of accumulation (SUVmax 19.95) in the upper thoracic esophagus. The patient was diagnosed with upper thoracic esophageal cancer, cT2N0M0 cStage II, and underwent thoracoscopic subtotal esophagectomy (three-region dissection) and gastric tube reconstruction. The dorsal inflow of the pulmonary vein in the right main bronchus, which was recognized on preoperative CT, was confirmed and preserved. The pathological diagnosis was basaloid squamous cell carcinoma, pT1b(SM1)N0(0/58)M0 pStage I. The postoperative course was uneventful, and the patient was discharged on postoperative day 20. Conclusions The anomalous bifurcation of the pulmonary vein in the right upper lobe area required attention because of its potential to cause massive bleeding and difficulty in securing the operative field if misidentified and damaged during surgery. Although it is not frequently encountered, it is the bifurcation anomaly that esophageal surgeons must bear in mind due to its severe consequences. Preoperative image-reading and intraoperative manipulation of this vessel are imperative for surgical safety.

Background The esophagus has no serosa; therefore, esophageal cancer may quickly invade its adjacent organs. In recent years, reports of conversion surgery (CS) and salvage surgery (SS) have described resection of esophageal cancer previously considered unresectable, with the addition of intensive preoperative chemotherapy or chemoradiotherapy. Currently, there is no established method for determining whether tumor excision is possible. Additionally, differences in surgical approaches between facilities may influence outcome after resection. However, the option for resection is considered a significant factor in determining a patient’s prognosis. Methods Patients who were diagnosed with advanced-stage (T3 or higher) squamous cell carcinoma of the esophagus and subsequently underwent resection with CS or SS were included in the study. Resection was performed through a small thoracotomy using a thoracoscope. Clinicopathologic factors, such as complete resection rate (R0) and prognosis, were investigated. Results A total of 49 surgeries were conducted: 39 CS and 10 SS cases. The male-to-female ratio was 37:12. R0:R1:R2 equals 42:3:4, and the R0 resection rate was 85.7%. The 5-year survival rates for CS and SS cases were 69.2% and 32.1%, respectively. The 5-year survival rates for R0, R1, and R2 resections were 63.4%, 0.0%, and 25.0%, and those for R0 and R1 + 2 resections were 63.4% and 14.3%, respectively, indicating that the prognosis for R0 resection cases was significantly better (P = 0.001 and P = 0.001, respectively). Regarding chemotherapy for CS, 29 patients received 5-FU and cisplatin therapy, whereas 10 patients received 5-FU, cisplatin, and docetaxel (DCF) therapy. After 2015, the ratio of DCF was significantly high, and the R0 resection rate was 100% in patients who received DCF therapy. Conclusions In this study, a satisfactory R0 rate was achieved using the magnifying effect of the thoracoscope while ensuring safety during thoracotomy. Trial registration This was a single-center cohort study wherein clinical data were retrospectively registered. This study was approved by the Chiba Cancer Center review board (H29-262). All procedures adhered to the ethical standards of the responsible committee on human experimentation and the Helsinki Declaration of 1964 and its later amendments.

Background Although there are many studies on primary esophageal adenocarcinoma arising from Barrett's esophagus or ectopic gastric mucosa, reports on adenocarcinoma arising from esophageal cardiac glands are extremely rare. Herein, we report a case of mid-thoracic cancer antigen 19-9 (CA 19-9)-producing primary esophageal adenocarcinoma, which presumably originated from the cardiac glands. Case presentation A 74-year-old man was referred to our department with advanced esophageal cancer, which initially presented with dyspepsia. Serum levels of cancer antigen 19-9 (CA 19-9) were elevated (724.89 U/ml). Upper gastrointestinal endoscopy revealed a type 2 tumor on the posterior wall of the mid-thoracic esophagus approximately 29–32 cm from the incisor. Mucosal biopsy was consistent with a diagnosis of adenocarcinoma. Contrast-enhanced computed tomography showed a circumferential wall thickening in the mid-thoracic esophagus without enlarged lymph nodes or distant metastasis. Positron emission tomography–computed tomography showed accumulation in the primary tumor, but no evidence of lymph node or distant metastasis. According to these findings, the adenocarcinoma was staged as cT3N0M0, thereby, requiring subtotal esophagectomy with lymph node dissection. Postoperative course was uneventful. Histopathologic analysis revealed a 50 × 40 mm moderately differentiated adenocarcinoma with invasion to the thoracic duct and lymph node metastasis at #108(1/4), #109R(1/3), and #109L(1/3). After surgery, the stage was revised to moderately differentiated pT4apN2pM0 (pStage III). Immunostaining revealed expression of CA19-9 and suggested esophageal cardiac gland origin of the tumor. Three months after the surgery, the patient showed no recurrence and is undergoing outpatient observation. Conclusions We experienced a case of mid-thoracic CA19-9-producing primary esophageal adenocarcinoma, which was presumed to have originated in the esophageal cardiac glands. Due to the scarcity of studies regarding this condition, specific management needs to be further clarified.

We verified the significance of intestinal blood flow evaluation by indocyanine green(ICG)fluorescence during intracorporeal anastomosis in laparoscopic colectomy which was performed from July 2019 to December 2019 in our institute. For 11 cases of intracorporeal anastomosis, we examined the patient background, surgical results such as operation time and blood loss, evaluation of intraoperative ICG blood flow, and perioperative complications. In all cases, after the mesentery treatment in the abdominal cavity and before the intestinal incision, the blood flow of the planned anastomosis site was evaluated by ICG fluorescence observation. No cases were required to be changed the anastomosis site. The average operation time was 240 minutes and the average blood loss was 10 mL. There were no perioperative complications such as anastomotic leakage, stenosis, bleeding, nor wound infection. It was suggested that the intraoperative evaluation of ICG blood flow during intracorporeal anastomosis in laparoscopic colectomy may contribute to the suppression of complications such as anastomotic leakage.

There are few reports on laparoscopic stoma creation; we report here our experience with laparoscopic stoma creation.Seven patients who underwent laparoscopic stoma creation between April 2019 and December 2019 were studied and their clinical outcome was evaluated retrospectively. Operation approach: We performed a colostomy in the transverse colon. At first, we insert a 12 mm first port into the site of stoma marking. And more, we insert three 5 mm ports on the opposite side of the first port. We remove the adhesions of the intestinal tract and create a colostomy.We changed open method 2 cases out of 7 cases due to extensive adhesion. In laparoscopically, we had an operation time of 97 (42-130) minutes and a blood loss of 5(2-40) mL. We had no postoperative complications or stoma problems.Laparoscopic stoma creation was useful due to few postoperative complications and can be rapidly transferred to chemotherapy.

Background: Undifferentiated pleomorphic sarcoma (UPS) in the gastrointestinal tract is rare. According to the diagnostic criteria after the World Health Organization 2013 reclassification, there has been only one case of UPS with perforation of the gastrointestinal tract.Case presentation: A 71-year-old man who was undergoing outpatient chemotherapy at the department of respiratory medicine of our hospital for lung cancer and brain metastasis, was admitted to our hospital with sudden high fever and abdominal pain. A computed tomography scan showed free air in the abdominal cavity with thickening of part of the jejunal wall. We suspected jejunal metastasis of lung cancer and performed emergency surgery for acute peritonitis due to gastrointestinal perforation in the same area. A Bormann type 2 tumor was found in the jejunum with perforation. The histopathological diagnosis was UPS. Ten months have passed since the surgery, and there has been no recurrence of UPS and no significant change in lung cancer.Conclusions: Primary UPS of the gastrointestinal tract is rare, and cases with perforation are extremely rare. Currently, ten months have passed since the surgery, and no recurrence has been observed. We encountered a case of UPS in which it was difficult to distinguish metastasis from lung cancer to the jejunum, and emergency surgery gave us the chance to confirm the definitive diagnosis and save the patient's life.

Neoadjuvant chemotherapy has been performed for locally advanced colorectal cancer with invasion to other organs or lateral lymph node metastasis in to control local recurrence and distant metastasis. We evaluated the treatment results and the significance of surgery in 53 patients(36 rectal cancer cases and 17 sigmoid colon cancer cases)who underwent surgery after chemotherapy by XELOX plus bevacizumab for 3 months. As pretreatment diagnosis, 42 cases were T4b and 39 cases were lymph node positive. Combined resection was performed in 34 cases including 12 cases of total pelvic exenteration. Pathological diagnosis showed 27 cases of ypT4b and 34 cases of ypN0. Pathological curative resection was performed in 90.4%. Histological effect by chemotherapy was 31 cases in Grade(Gr)1a, 10 cases in Gr 1b, 8 cases in Gr 2, and 4 cases in Gr 3, respectively. The 5-year survival rate was 60.9% in Gr 1a or lower and 100% in Gr 1b or higher. Tumor markers( CEA and CA19-9)were reduced into normal range after neoadjuvant chemotherapy in all 4 patients with Gr 3. Pathological CR could not be predicted from clinical findings after neoadjuvant chemotherapy. It was suggested that neoadjuvant chemotherapy for locally advanced rectal cancer with invasion to other organs or lateral lymph node metastasis is useful for improving the prognosis, surgical resection is indispensable as a multidisciplinary treatment, and that the pathological therapeutic effect leads to prognosis prediction.

We report a case of transverse colon cancer resected by laparoscopic partial colectomy, followed by open gastrectomy. A man in his 70s was diagnosed with transverse colon cancer. He had a history of open gastrectomy for gastric lymphoma; thus, postoperative adhesions were expected in the upper abdomen. We performed a laparoscopic partial colectomy with gentle adhesiotomy, without injury. After preparation of the marginal vessels, blood flow towards the planned anastomotic line was confirmed by infrared observation after venous injection of indocyanine green. However, the initially planned oral anastomotic line did not show a blood supply; therefore, the anastomotic line was altered to a site of sufficient blood flow. In postlaparotomy cases, delicate handling and careful adhesiotomy are necessary in the laparoscopic approach due to the possibility of severe intraoperative injury resulting in conversion to open surgery. Furthermore, blood flow confirmation by fluorescence angiography is recommended in cases in which anatomical alterations might have occurred due to the previous operation.

Neoadjuvant chemotherapy(NAC)with S-1 plus CDDP(SP)followed by gastrectomy has been used for the treatment of patients with locally advanced gastric cancer. We examined the number of treatment courses, histologic effects, ypStage, and prognosis to estimate the utility and define the best treatment course of SP NAC. The patients were divided into 1 course(A: 54 cases), 2 courses(B: 50 cases), and incomplete first course(C: 12 cases). The rates of Grade 2 or more in histological effect were 24.1% in group A, 34.0% in B, and 0% in C. Four patients achieved pathological CR(1 case in group A and 3 cases in group B). The pathological response by NAC was more effective in group B than in group A. In down-staging cases by NAC, survival curves were obtained according to ypStage. The 5-year survival rates in R0 cases were 67.0%in the effective therapeutic group and 51.0%in the non-effective group; the results being significantly different. According to the number of therapeutic courses of NAC, the 5-year survival rates were 57.9% in group A, 65.2% in group B, and 20.0% in group C, demonstrating a significantly better prognosis in group B. Although the pathological response appeared in 1 course, it was significant in 2 courses of NAC. The results indicate that the completion of at least 2 courses of NAC are necessary in locally advanced gastric cancer.

A 66-year-old man was diagnosed with advanced esophagogastric junction cancer and referred to our institution (Department of Gastroenterological Surgery, Chiba Cancer Center) for treatment. Computed tomography imaging confirmed the presence of a tumor, extending from the lower thoracic esophageal to the esophagogastric junction, with swelling of the upper mediastinal lymph nodes. Based on the criteria of the International Union against Cancer Committee (UICC, 8th Edition), the staging was confirmed as follows: 101R, 107 and 106 pre. Based on these findings, a clinical diagnosis of EGJ cancer was made, with a UICC 8th classification of cT3N1M0 c-stage-III. Preoperative chemotherapy was performed, with tumor shrinkage obtained after three courses of chemotherapy (using S-1 plus oxaliplatin). Subsequently, esophagectomy with three-field lymph node dissection and gastric tube reconstruction, via the intrathoracic route, was performed. On postoperative day 2, the patient developed an idiopathic pneumothorax, with brown-green drainage from the chest tube. A repeat thoracotomy was performed, confirming the presence of brown-green pleural fluid and necrosis of esophageal tissue. The area of necrosis was situated 4 cm on the oral side of the anastomosis, with greater necrosis of the right than left side. There was no evidence of necrosis of the gastric tube. The necrotic residual esophagus was excised and reconstructed, as an external fistula on the left side of the neck. On day 38, after the second surgery, reconstruction of the esophageal conduit and gastric tube, via the jejunum, was performed. At 7 months after discharge, the patient was symptom free, with no evidence of cancer recurrence.

With the aging population, the number ofearly gastric cancer patients aged 80 years or older is increasing. We clarified the outcome ofgastrectomy among early gastric cancer patients aged 80 years or older and examined the significance ofadditional gastrectomy for non-curative ESD cases. 1 ) Surgical outcomes in 90 cases ofearly gastric cancer patients aged 80 years or older with gastrectomy were analyzed. Gastrectomy was performed for patients up to 88 years of age and 84 cases (93.3%)were pStageⅠA. Three years and 5 years survival rates were 83.9% and 60.4%, respectively. The causes ofdeath included other disease in 28 cases, other cancer in 4 cases, and death associated with hospital stay in 1 case. 2 ) There were 28 non-curative ESD cases, including 6 T1a, 9 T1b1, and 13 T1b2. Among them, 8 additional gastrectomies were performed, but none were lymph node metastases and cancer residue at the proper muscle layer was identified in only 1 case. Three years and 5 years survival rates ofthe additional gastrectomy group were 100% and 60%, respectively. Although 2 years survival rate ofthe group without additional gastrectomy was 83.3%, there were no deaths due to gastric cancer. In elderly patients with early gastric cancer, considering the increasing the proportion deaths due to other diseases and the decreased quality of life after gastrectomy, the usefulness of additional gastrectomy for non-curative ESD is limited.

We report a case of synchronous cancer of the kidney and ascending colon that was resected concurrently using roboticassisted partialnephrectomy and laparoscopic ileocecalresection. A man in his 70s was diagnosed as having renaland ascending colon cancers. Thus, simultaneous resection was planned. First, robotic partial nephrectomy was performed via a transabdominalapproach by the urologicalsurgeon. After changing the position from semi-lateraldecubitus to supine, severalports were added and laparoscopic ileocecal resection was performed. Robotic and laparoscopic surgery was performed simultaneously, and the benefits of minimally invasive surgery were obtained.

The common type carcinoma of gastric cancer is divided into 3 groups, papillary adenocarcinoma(pap), well differentiated tubular adenocarcinoma(tub1)and moderately tubular adenocarcinoma(tub2). In this study, we tried to individualize treatments of them by evaluating their clinicopathological features.Examined resected specimens were collected from 2000 to 2016. We compared among pap, tub1, and tub2 as the clincopathological features retrospectively.Histological diagnosis was confirmed to 55 cases with pap, 639 cases with tub1 and 718 cases with tub2. Comparing the ratio of lymph node metastasis(LNM)according to the depth of invasion, tub2 and pap show higher incidence of LNM than tub1 in T1b, T2, and T4(a+b). Tub2 and pap patients have larger number of LNM and worse 5 year survival rates than tub1 patients.We demonstrated that tub2 and pap may have higher malignancy and show earlier LNM than tub1. When we consider of endoscopic treatment, individualizataing tub1, tub2 and pap is important.

Preoperative chemotherapy has been performed for locally advanced colorectal cancer, to achieve cytoreduction, local control, and prevention of distant metastasis. The regimens of mFOLFOX6/XELOX plus bevacizumab for 3 months have been adopted to succeed curative resection for borderline resectable colorectal cancer. We examined treatment results for locally advanced colorectal cancer without distant metastasis. Thirty-four patients were examined and the mean age was 62.7 years old. The cohort comprised of 23 cases of rectal cancer and 11 of sigmoid colon cancer. Thirty cases were diagnosed as cT4b and 25 cases were as cN+before chemotherapy. Stoma creations were performed in 26 patients before preoperative chemotherapy. Reduction ratio of the tumor diameter was 33.6±28.2%. The reduction in CEA was 38.5±39.4%, and the reduction in CA19-9 was 62.8±42.3%. There were 23 extended resections combined with involved organs including 8 total pelvic exenterations. Chemotherapeutic effect was diagnosed as Grade 1a or less, 20 cases; Grade 1b, 6 cases; Grade 2, 5 cases; Grade 3, 3 cases. Recurrence was found in 9 cases and 8 of them were Grade 1a or less. Overall 5-year survival rate was 74.6%. The utility of preoperative chemotherapy for locally advanced rectal cancer is suggested not only for local treatment but also systemic therapy, especially in chemotherapeutic effective cases.

We report a case of locally advanced rectal cancer invading toward sacrum treated by laparoscopic low anterior resection. A man in his 60's was diagnosed with rectal cancer expanding near to sacrum. The circumferential resection margin was assessed to be scarce. After preoperative chemotherapy, we performed laparoscopic low anterior resection. In order to obtain surgical margin, we had to cut into presacral venous plexus. With prepared sufficient devices, hemostasis was safely acquired. Pathological findings revealed clear surgical margin. It is important to prepare appropriate hemostasis devices in managing cases with high risks of intraoperative hemorrhage. Laparoscopic approach may contribute to these cases, making hemostasis easier than laparotomy with the magnified view, pneumoperitoneum and Trendelenburg position.

This study aimed to survey treatment ofgastric cancer via gastrectomy or endoscopic submucosal dissection(ESD)in patients aged 85 years or older and to clarify the risks and benefits of gastrectomy in terms of postoperative complications and prognosis. The analysis included 40 patients who were treated via gastrectomy and 41 who were treated via ESD. All patients were aged 85 years or older. Although most ofthe patients who had gastrectomy had good performance status(PS), comorbidities were found in 72.5%, and limited operation was often performed. In the gastrectomy group, R0 tumor-free resection margins were achieved in 75%, and postoperative complications occurred in 45%. Despite R0 surgery, the 2-year overall survival rate was 61.7% and the 3-year overall survival was 42.9%. Seven patients(17.1%)in the ESD group were diagnosed with T1b tumors, and no patients were shifted to surgery. Treatment decisions for super-elderly gastric cancer patients are made with regard to age, PS, and comorbidities. There is a limit to survival time after radical gastrectomy. It is necessary to examine the negative effect of gastrectomy on survival time. Selected patients aged 85 years or older with T1b gastric cancer should be given the option of ESD.

We report a case of mucinous adenocarcinoma of the appendix with peritoneal dissemination diagnosed by laparoscopic abdominal exploration and appendectomy. A man in his 60's was diagnosed with peritoneal dissemination of mucinous adenocarcinoma incidentally during an operation for an inguinal hernia. Carcinoma of the appendix was suspected as the primary lesion after further examination. We performed laparoscopic abdominal exploration and appendectomy. The purpose of the operation was to detect the primary lesion, make a pathological diagnosis, and to evaluate the extent of peritoneal dissemination. Laparoscopic findings revealed wide spread peritoneal dissemination and the pathological findings confirmed mucinous adenocarcinoma of the appendix. These laparoscopic procedures lead to a precise diagnosis and allowed for adequate treatment selection.

Background Salvage surgery for esophageal cancer (squamous cell carcinoma) patients with locoregional failure after definitive chemoradiotherapy (dCRT) is high risk, and no surgical consensus has been established. We evaluated our 2 procedures of salvage surgery for failure which was confirmed by GS, CT, and PET: [SE] esophagectomy followed by reconstruction for patients ≤ 80 yo, without cT4 at the initial presentation, and whose recurrent/residual tumor can be removed as a R0 resection, and [SL] dissection of only metastatic abdominal lymph nodes for patients without any other failure. Methods All patients received dCRT ≥ 50 Gy followed by salvage surgery. In 17 patients who underwent SE from 2009 to 2014, prophylactic dissection of cervical or 106 tbL nodes was often omitted, poststernal route was preferred, LigasureTM was routinely used, and aggressive nutritional intervention with enteral nutrition was perioperatively supplied. In SL for 5 patients until 2016, No. 3 and 7 nodes were removed. Results [SE] Sixteen patients received R0 resection. Postoperative complications were noted in 6 patients (35%), and pleural effusion was the most common (24%). However, neither anastomotic leakage nor in-hospital death developed. Median overall survival (OS) time is 44 months, and provisional 5-year OS rate is 41%. While 7 patients died of esophageal caner, one died from another caner and 3 died from other illness. Tentative 5-year disease-free survival (DFS) rate is 54%. Between cases with relapse after CR and cases with residual tumor, no significant difference was found in postoperative recurrence (2/8 vs. 5/9, P = 0.33) and survival (provisional 5-year OS rate: 50 vs. 33%, P = 0.45/provisional 5-year DFS rate: 70 vs. 40%, P = 0.22), while the relapsed patients after CR showed a little better outcome. [SL] Three patients have no relapse for 60/36/18 months after SL. One developed bone metastasis in 54 months after SL. One patient developed repeated abdominal recurrence and underwent SL again. Conclusion SE can be safely performed with strict planning, secure surgery and appropriate perioperative care. SL can also be beneficial as a less invasive salvage surgery to selected patients. Strict decision-making and appropriate postoperative follow-up method with attention to other diseases should be established based on further studies. Disclosure All authors have declared no conflicts of interest.

Background We tried integrated analysis of epigenomic information (Epigenomics) and image information (Radiomics) as Ragioepigenomics for esophageal cancer. Methods 1, Expression analysis of miR, evaluation as prognostic predictor (Epigenomics), 2, Image information analysis (Radiomics): a, Normalization of contrast CT images, feature quantities by 3D gray level co-occurrence matrix extraction. b, Normalization of SUV of FDG-PET image. Extraction of feature quantity by 3D gray level co-occurrence matrix. c, Image analysis of features. 3, Integrated analysis of Epigenomics and Radiomics information: We analyzed the relationship between miR expression level and variables obtained from image analysis. Results As a result of Cox regression by the selection method using elastic net, three variables were selected from contrast CT, and the results of both were consistent. Furthermore, when the survival curve and the log rank test were performed by the Kaplan-Meier method for the cluster shade high value group and the low value group, a significant difference was observed in the 2 groups. Conclusion A multimodal approach so called Radioepigenomics, which is a system for analyzing molecular information from image analysis will be applied to future Precision Medicine. Disclosure All authors have declared no conflicts of interest.

We report a case of anal canal cancer with inguinal lymph node metastasis treated with laparoscopic abdominoperineal resection combined with inguinal lymph node dissection. A 52-year-old woman was diagnosed with anal squamous carcinoma after excision of an anal canal tumor. Further examination revealed right inguinal lymph node metastasis. Chemoradiotherapy was administered but was discontinued because of serious adverse events. We therefore performed laparoscopic abdominoperineal resection combined with inguinal lymph node dissection. The pathological findings revealed residual squamous cell carcinoma at the lymphatic vessels in the rectal wall and lymph nodes, including the right inguinal region. Therapeutic effect of Grade 1a was achieved in spite of interruption of the chemoradiotherapy. She was discharged 17 days after the operation, and no recurrence was observed for 11 months. Radical resection was performed for the anal canal squamous cell carcinoma with the metastasis to the right inguinal lymph node, even after interruption of the chemoradiotherapy.

The patient was a 59-year-old woman with advanced double cancers of the stomach and endometrium with peritoneal metastasis. Abdominal computed tomography revealed that the endometrial cancer was more advanced than the gastric cancer; therefore, the peritoneal metastasis was diagnosed as arising from the endometrial cancer. Treatment of the endometrial cancer with cytoreductive surgery followed by adjuvant chemotherapy was performed first. She underwent total hysterectomy, bilateral salpingo-oophorectomy, and omentectomy. Disseminated nodules were found throughout her abdomen. The histopathological findings indicated carcinosarcoma of the uterus, pT3bNXM1, Stage Ⅳb. One month after surgery, she received 6 courses of adjuvant chemotherapy with paclitaxel plus carboplatin. After the adjuvant chemotherapy, abdominal computed tomography revealed that both the ascites and the disseminated nodules had disappeared. Therefore, a second-look surgery for the endometrial cancer and definitive surgery for the gastric cancer were planned. At the laparotomy, no disseminated nodules were found, so distal gastrectomy and D2 lymphadenectomy were performed. The histopathological findings were pT4aN1M0P0Cy0, Stage ⅢA. She received adjuvant chemotherapy with S-1 for 1 year, and has been alive with no evidence of recurrence for 2 years and 7 months after the initial surgery.

A 65-year-old woman complaining of fetor ex vagina was diagnosed with endometrial adenocarcinoma of the uterus based on the pathological findings of an endometrial biopsy. Sigmoid colon cancer was found on a pre-operative CT scan. Diagnosis of double cancer was made and we performed sigmoidectomy and panhysterectomy with associated resection of both adnexa. Histopathological examination found that the tumor accounted for almost all of the uterine mucosa and over half of the muscular layer. Immunostaining showed CK7 (-), CK20 (+), CDX2 (+), ER (-), and PgR (-), and we diagnosed it as a metastasis to the uterus of the sigmoid colon cancer. The pathological diagnosis was a moderately differentiated adenocarcinoma, pT4b (SI: urinary bladder), pN0 (0/12), H0, P1,M1a (uterus), pStage Ⅳ. As adjuvant chemotherapy, she was administered XELOX for 6 months. Although colorectal cancer rarely metastasizes to the uterus, due to the increase in the prevalence of colorectal cancer, it may be also increase. To choose the best treatment course, it is necessary to diagnose whether it is a primary uterine cancer or a metastatic uterine cancer.

We evaluated the difference in effectiveness between preoperative radiotherapy (RT) and chemotherapy (C) as part of multimodal therapy for locally advanced rectal cancer. In the RT group, 43 patients were enrolled and preoperative radiotherapy was performed with 42.6 Gy for 4 weeks. In the C group, 16 patients were treated with preoperative chemotherapy consisting of mFOLFOX6/XELOX plus bevacizumab for 3 months. All 43 tumors in the RT group were located in the lower rectum. The C group was composed of 9 in the lower rectum and 7 in the middle or upper rectum. The C group was more advanced than the RT group in terms of depth of invasion, lymph node metastasis, and tumor diameter. The histological treatment response was better after RT (7 with little, 10 with a minor, 24 with a major, and 2 with a complete response) than after C (10 with little, 4 with a minor, 1 with a major, and 1 with a complete response). The tumor reduction ratio by colonography showed 36.5% after RT and 28.7% after C. CEA was reduced by 47.2% after RT and 45.2% after C. Though RT is more effective for local lesions than C, C is expected to be preferred as the local and systemic therapy for locally advanced rectal cancer with pelvic organ involvement or lateral lymph node metastases.

Gastric carcinoma with lymphoid stroma (GCLS) is a histological type with severe lymphocytic infiltration. GCLS is very rare and few cases have been reported. We examined the clinical features, problems of preoperative diagnosis, and treatment of 14 cases (1.8%) that were diagnosed as GCLS out of 790 gastric cancers surgically resected in our hospital. The mean age was 69 years. Six, 8, and 0 cases were located in the upper, middle, and lower fields of the stomach, respectively, and 8, 1, 4, and 1 cases were macroscopically 0-Ⅱc, 0-Ⅰ, type 2, and type 3, respectively. The depth of invasion was M, SM1, SM2, MP, and SS in 0, 0, 9, 3, and 2 cases, respectively. There were 12 cases(86%)with infection by Epstein-Barr virus, and just 1 case with lymph node metastasis. All cases have had no evidence of recurrence. There were no cases that were diagnosed as GCLS before surgery. GCLS is recognized as having a more favorable prognosis compared with other types of gastric carcinoma, so an aggressive surgery might achieve good outcomes. However, preoperative diagnosis is very difficult and there is a compelling need for new techniques or criteria for diagnosis of GCLS.

症例は42歳，男性．歯状線より1.5cmの下部直腸に30mm大の2型腫瘍を認め，生検にて高分化腺癌であった．内肛門括約筋切除術（以下ISR），3群リンパ節郭清，transverse coloplasty，横行結腸人工肛門造設術を施行．病理組織検査では，高分化腺癌，固有筋層までの浸潤でリンパ節転移を認めなかった．術後21日目に退院し，1カ月目に注腸造影を施行しtransverse coloplasty部より骨盤内に造影剤の漏出を認めた．保存的に経過をみるも術後11カ月でも瘻孔の治癒を認めず術後15カ月目に大殿筋膜皮弁充填術を施行．この手術後12カ月目に注腸造影にて瘻孔閉鎖を確認し，人工肛門閉鎖術を施行した．現在人工肛門閉鎖後4年4カ月経過し，再発を認めず，排便機能も良好である．これまでにISR後の骨盤内瘻孔に対して大殿筋膜皮弁充填術を施行し治癒した報告例はなかった．大殿筋膜皮弁充填術は有用な術式であると考えられた．

悪性線維性組織球腫（MFH）は主に成人の四肢軟部組織に好発する非上皮性悪性腫瘍である．通常，腹腔内実質臓器や後腹膜を原発とすることは稀であるが，小腸間膜を原発とする炎症性MFHの切除例を経験したので報告する．症例は61歳，男性．下腹部膨満感を主訴に近医受診．採血検査で炎症反応を認め，腹部単純CT検査で下腹部骨盤内に腫瘤性病変を認めた．後腹膜腫瘍の疑いで当科紹介入院．造影3D-CT検査で回結腸動脈より栄養を受ける小腸間膜腫瘍の診断となり，回腸部分切除術を施行した．病理組織検査で回腸腸間膜原発の炎症性MFHと診断された．術後経過は良好で，術後9日目に退院した．現在外来で経過観察中であり，術後約2年が経過するが明らかな再発所見は認めていない．文献的考察を含めて症例報告する．

症例は86歳，女性．繰り返す総胆管結石の発作に対し，内視鏡的逆行性胆道ドレナージ（ERBD）チューブを挿入した．チューブ挿入後29日目に突然腹膜炎を伴う腹痛を呈し当科受診した．CTにてfree air，腹水の他にS状結腸に多数の憩室とERBDチューブを認めた．以上よりERBDチューブ逸脱によるS状結腸穿孔の診断で緊急手術を行った．開腹所見はS状結腸に穿孔部を認め同部にERBDチューブの先端を触知した．周囲S状結腸にも憩室を認め，穿孔部を切除してハルトマン手術を施行した．術後経過は良好で，術後31日目に退院となった．ERBDチューブは逸脱しても通常は便とともに排泄されるが，本症例のように稀ではあるが憩室穿孔をきたす可能性があるので注意深い観察が必要である．

症例は62歳，男性．胃体上部2型胃癌に対し，胃全摘術施行．術後UFTを1年間内服．胃切除後15カ月後，肝S4の6.0×5.0cmの肝転移に対し肝部分切除施行．術後，肝動注化学療法（5-Fu，ADM，MMC）施行．肝切除後26カ月後，右肺2.3×2.0cmの転移に対し，右肺部分切除施行．肺切除後90カ月たった現在無再発生存中である．異時性，単発の胃癌肝転移，肺転移症例に対しては切除により，治癒の可能性も十分あり，積極的に切除すべきと思われた．胃癌肝転移，肺転移ともに切除しえた症例の報告は少なく，今回5年以上の長期無再発生存の1例を経験したので，文献的考察を加えて報告する．

A 78-year-old man presented with a chief complaint of dysphagia. He was diagnosed with an esophageal squamous cell carcinoma and referred to our hospital. A type 3 tumor was identified in the lower thoracic esophagus on endoscopy. A CT scan revealed lymph node metastases at the No. 3 station. The clinical stage of the tumor was T3N1M0, Stage III. The patient was treated with neoadjuvant chemotherapy consisting of2 courses of5 -FU and nedaplatin. He had a partial response and underwent a radical esophagectomy. Histopathological examination revealed a complete response of the primary lesion and viable cancer cells in only one lymph node at the No. 3 station. No adjuvant chemotherapy was administered. Three months after the operation, recurrences in the upper abdominal multiple para-aortic lymph nodes were detected. Although he was treated with chemotherapy, he died 7 months after the operation. Even after a complete response of the primary lesion was achieved using neoadjuvant chemotherapy, esophageal cancer with lymph node metastasis has the potential for an early recurrence. Therefore, we should consider adjuvant therapy in such cases.

We evaluated the efficacy of intraperitoneal chemotherapy with cisplatin (CDDP) for peritoneal recurrent gastric cancer following surgical intervention. Twelve patients were enrolled. The combination systemic chemotherapy was S-1 or S-1 plus paclitaxel (S-1+PTX). PTX was administered intravenously at 80 mg/m² on day S-1 and 15. S-1 was administered at 80 mg/ m²/ day for 7 consecutive days, followed by 7 days of rest, and the cycle was repeated. CDDP was administered intraperitoneally at 40 mg/body on day 8. This treatment was repeated every 4 weeks until disease progression was diagnosed. The survival time(ST)and time to treatment failure(TTF)were estimated. The surgical interventions were gastrectomy in 3 patients, colostomy in 8 patients, and enterostomy in 1 patient. Overall, the median TTF and ST were 294 days and 455 days, respectively. When stratified by surgical method and combination chemotherapy, the median TTF and ST were not statistically significant. However, when stratified by performance status (PS), the median TTF was 352 days for patients with PS 0 and 218 days for those with PS 1, 2 (p=0.0029), whereas the median ST was 553 days for patients with PS 0 and 331 days for those with PS 1, 2 (p=0.0198). In conclusion, the data suggest that intraperitoneal CDDP chemotherapy with systemic chemotherapy is effective for the treatment of extensive peritoneal recurrent gastric cancer, especially in patients with good PS.

We report a case of gastrointestinal stromal tumor (GIST) locally resected after long-term chemotherapy with imatinib mesylate. A 78-year-old woman was diagnosed with GIST in the lower rectum on screening colonoscopy for anemia. The tumor was 7 cm in diameter, and the anal sphincter was considered to be difficult to preserve due to the extent of the tumor. The patient refused surgery, so she was administered imatinib mesylate chemotherapy. The medication was continued for 5 years without any major adverse events, and the status of the tumor was stable. Five years later, she underwent transanal local resection for anal prolapse and incarceration of the tumor. Pathological findings revealed a 7 cm sized high-risk GIST. The long-term stable status of the tumor was maintained, and the anal function was preserved by the local resection.