Reactivation of hepatitis C virus caused by steroid monotherapy for sudden deafness

Hepatitis C virus (HCV) reactivation has been reported to be caused due to several anticancer drugs and immunosuppressive agents; however, HCV reactivation after steroid monotherapy has rarely been reported. Here, we report the case of a 65-year-old Japanese man with HCV infection who developed HCV reactivation after the administration of prednisolone (PSL) for 6 days for sudden deafness. In the patient history, the positivity for anti-HCV antibody was observed, but serum level of HCV RNA was not measured. Two months after PSL administration, the patient experienced an alanine aminotransferase (ALT) flare and the serum level of HCV RNA was observed to be 6.2 log IU/mL; then, the patient was admitted to our hospital for hepatitis treatment. Based on the clinical course and laboratory findings, the patient was diagnosed with HCV reactivation. Although the ALT levels decreased spontaneously during follow-up, they did not drop to normal range; subsequently, sofosbuvir and ledipasvir treatments were started. A sustained virological response 24 weeks after the end of treatment was achieved. This case study suggests that HCV reactivation with hepatitis flare can occur even after a steroid monotherapy, and doctors should pay attention to HCV reactivation when administering PSL for patients with HCV infection.

Long-term follow-up and exploratory analysis of lenvatinib in patients with metastatic or recurrent thymic carcinoma: Results from the multicenter, phase 2 REMORA trial

OBJECTIVES

The main objective of this report was to detail the long-term follow-up data from the REMORA study, which investigated the safety and efficacy of lenvatinib in patients with thymic carcinoma. In addition, an exploratory analysis of the association between relative dose intensity (RDI) and the efficacy of lenvatinib is presented.

MATERIALS AND METHODS

The single-arm, open-label, phase 2 REMORA study was conducted at eight Japanese institutions. Forty-two patients received oral lenvatinib 24 mg once daily in 4-week cycles until the occurrence of intolerable adverse events or disease progression. The REMORA long-term follow-up data were evaluated, including overall survival (OS). RDI was calculated by dividing the actual dose administered to the patient by the standard recommended dose. This trial is registered on JMACCT (JMA-IIA00285) and on UMIN-CTR (UMIN000026777).

RESULTS

The updated median OS was 28.3 months (95 % confidence interval [CI]: 17.1-34.0 months), and the OS rate at 36 months was 35.7 % (95 % CI: 21.7 %-49.9 %). When grouped by RDI of lenvatinib, the median OS was 38.5 months (95 % CI: 31.2-not estimable) in patients with ≥ 75 % RDI and 17.3 months (95 % CI: 13.4-26.2 months) in patients with < 75 % RDI (hazard ratio 0.46 [95 % CI: 0.22-0.98]; P = 0.0406) at 8 weeks. Patients who maintained their lenvatinib dose over 8 weeks had a higher objective response rate than patients whose doses were reduced (75.0 % vs 29.4 %; P = 0.0379). No new safety concerns or treatment-related deaths were reported, and lenvatinib had a tolerable safety profile.

CONCLUSION

This follow-up report updated OS in patients with metastatic or recurrent thymic carcinoma. A higher RDI of lenvatinib at 8 weeks could be associated with improved outcomes.

Preliminary comparative study of lower extremity pressure measurements under the conditions using former models and new lithotomy stirrups in rectal cancer surgery

BACKGROUND

This study aimed to investigate the effect of the use of new lithotomy stirrups-2 on the pressure dispersal on lower limbs, which may lead to the prevention of well-leg compartment syndrome (WLCS) and deep venous thrombosis (DVT), which are the most commonly associated adverse events with laparoscopic and robot-assisted rectal surgery.

METHODS

A total of 30 healthy participants were included in this study. The pressure (mmHg) applied on various lower limb muscles when using conventional lithotomy stirrups-1 and new type stirrups-2 was recorded in various lithotomy positions; 1) neutral position, 2) Trendelenburg position (15°) with a 0° right inferior tilt, and 3) Trendelenburg position (15°) with a 10° right inferior tilt. Using a special sensor pad named Palm Q®, and the average values were compared between two types of stirrups.

RESULTS

The use of new lithotomy stirrups-2 significantly reduced the pressure applied on the lower limb muscles in various lithotomy positions compared with the use of lithotomy stirrups-1. The most pressured lower limb muscle when using both lithotomy stirrups was the central soleus muscle, which is the most common site for the development of WLCS and DVT. In addition, when using the conventional lithotomy stirrups-1, the pressure was predominantly applied to the proximal soleus muscle; however, when using lithotomy stirrups-2, the pressure was shifted to the more distal soleus muscle.

CONCLUSION

These results suggest that the new lithotomy stirrups-2 is useful in reducing the pressure load on leg muscles, especially on the proximal to central soleus, and may reduce the incidence of WLCS and DVT after rectal surgery performed in the lithotomy position. Further clinical studies are needed to determine whether the use of lithotomy stirrups-2 prevents these complications in various clinical settings.

Dose-Finding and Efficacy Confirmation Trial of the Superselective Intra-arterial Infusion of Cisplatin and Concomitant Radiation Therapy for Locally Advanced Maxillary Sinus Cancer (JCOG1212): Results of the Efficacy Confirmation Phase in Patients with T4aN0M0

PURPOSE

Locally advanced maxillary sinus cancers require radical surgery as a standard treatment, but this often results in significant disfigurement and impairment of function. JCOG1212 seeks to evaluate the safety and efficacy of the superselective intra-arterial infusion of cisplatin and concomitant radiation therapy (RADPLAT) for T4aN0M0 and T4bN0M0 maxillary sinus squamous cell carcinomas. We herein report the results of the efficacy confirmation phase in the T4a cohort.

METHODS AND MATERIALS

Patients received 100 mg/m2 cisplatin intra-arterially weekly for 7 weeks with concomitant radiation therapy (total 70 Gy) as determined by the results of the preceding dose-finding phase. The trial aimed to evaluate the primary endpoint of 3-year overall survival (OS), comparing RADPLAT with the historical control for 3-year OS in surgery (80%).

RESULTS

From April 2014 to August 2018, 65 patients were registered in the T4a cohort from 18 institutions, consisting of 54 men and 11 women with a median age of 64 years (range, 40-78 years) and Eastern Cooperative Oncology Group performance status 0/1 (58/7). After excluding 1 ineligible patient, 64 patients were included in the primary analysis of efficacy and safety. The median follow-up was 4.5 years in all eligible patients, and the primary endpoint for 3-year OS was 82.8% (90% CI, 73.4%-89.2%). With regard to acute adverse events, mucositis (grade ≥3), neutropenia (grade ≥3), increased creatinine (grade ≥2), hearing impairment (grade ≥2), and stroke (grade ≥2) were observed in 20.3%, 14.1%, 3.1%, 3.1%, and 1.6% of patients, respectively. One treatment-related death due to a thromboembolic event was reported.

CONCLUSIONS

We demonstrated that RADPLAT showed favorable results for patients with T4aN0M0 maxillary sinus squamous cell carcinomas compared with the historical control for 3-year OS in surgery, which was from an earlier period, and showed some specific toxicities. Therefore, RADPLAT, as well as surgery, can be regarded as a possible treatment option for these patients.

Dabrafenib and trametinib administration in patients with BRAF V600E/R or non-V600 BRAF mutated advanced solid tumours (BELIEVE, NCCH1901): a multicentre, open-label, and single-arm phase II trial

Background

BRAF V600 mutations are common in melanoma, thyroid, and non-small-cell lung cancers. Despite dabrafenib and trametinib being standard treatments for certain cancers, their efficacy across various solid tumours remains unelucidated. The BELIEVE trial assessed the efficacy of dabrafenib and trametinib in solid tumours with BRAF V600E/R or non-V600 BRAF mutations.

Methods

Between October 1, 2019, and June 2022, at least 50 patients with measurable and seven without measurable diseases examined were enrolled in a subcohort of the BELIEVE trial (NCCH1901, jRCTs031190104). BRAF mutated solid tumour cases other than BRAF V600E mutated colorectal cancer, melanoma, and non-small cell lung cancer cases were included. Patients with solid tumours received dabrafenib (150 mg) twice daily and trametinib (2 mg) once daily until disease progression or intolerable toxicity was observed. The primary endpoint was overall response rate (ORR), and secondary endpoints included progression-free survival (PFS), 6-month PFS, and overall survival (OS). Bayesian analysis was performed using a prior distribution with a 30% expected response rate [Beta (0.6, 1.4)].

Findings

Fourty-seven patients with measurable disease, mainly with the BRAF V600E mutation (94%), and three others with non-V600E BRAF mutations (V600R, G466A, and N486_P490del) were enrolled. The primary sites included the thyroid gland, central nervous system, liver, bile ducts, colorectum, and pancreas. The confirmed ORR was 28.0%; the expected value of posterior distribution [Beta (14.6, 37.4)] was 28.1%, although the primary endpoint was achieved, not exceeding an unexpectedly high response rate of 60% obtained using Bayesian analysis. The disease control rate (DCR) was 84.0%. The median PFS was 6.5 months (95% confidence interval [CI]; 4.2-7.2 months, 87.8% at 6 months). Responses were observed across seven tumour types. Median OS was 9.7 months (95% CI, 7.5-12.2 months). Additional patients without measurable diseases had a median PFS of 4.5 months. Adverse events (AEs) were consistent with previous reports, with 45.6% of patients experiencing grade ≥3 AEs.

Interpretation

This study reported promising efficacy against BRAF V600-mutant tumours. Dabrafenib and trametinib would offer a new therapeutic option for rare cancers, such as high-grade gliomas, biliary tract cancer, and thyroid cancer.

Funding

This study was funded by the Japan Agency for Medical Research and Development (22ck0106622h0003) and a Health and Labour Sciences Research Grant (19EA1008).

Totally laparoscopic surgery for a hydrocele of the canal of Nuck extending from the abdominal cavity to the subcutaneous space: a case report

BACKGROUND

Hydrocele of the canal of Nuck (HCN) is a rare disease, and its indications for laparoscopic surgery are not well-established.

CASE PRESENTATION

A 53-year-old woman was referred to our hospital due to an uncomfortable thumb-sized inguinal mass. Preoperative computed tomography scan and magnetic resonance imaging revealed a hydrocele extending from the abdominal cavity around the left deep inguinal ring via the inguinal canal to the subcutaneous space. The patient was diagnosed with HCN protruding into the abdominal cavity and extending to the subcutaneous space. Laparoscopy can easily access the hydrocele protruding into the abdominal cavity. Furthermore, laparoscopic hernioplasty can be superior to the anterior approach for females. Hence, laparoscopic surgery was performed. After transecting the round ligament of the uterus, a tense 3-cm hydrocele was dissected with it. In order to approach the hydrocele distal to the deep inguinal ring, the transversalis fascia was incised medially to the inferior epigastric vessels. The subcutaneously connected hydrocele was excised from the incision. Then, the enlarged deep inguinal ring was reinforced using a mesh with the laparoscopic transabdominal preperitoneal approach. The patient was discharged 2 days postoperatively. Laparoscopic resection can be more effective for a hydrocele protruding into the abdominal cavity as it facilitates an easy access to the hydrocele. Moreover, laparoscopic resection of a hydrocele extending from the inguinal canal to the subcutaneous space via a transversalis fascia incision can be safer, with low risk of injury to the inferior epigastric vessels. The incised transversalis fascia and the enlarged deep inguinal ring due to the HCN were simultaneously repaired with the laparoscopic transabdominal preperitoneal repair. There are two reports on laparoscopic resection via a transversalis fascia incision for HCNs located between the inguinal canal and the subcutaneous space, which does not require intraperitoneal hydrocelectomy. However, this is the first report on laparoscopic resection of large HCNs protruding into the abdominal cavity and extending beyond the inguinal canal into the subcutaneous space via intraperitoneal hydrocelectomy and a transversalis fascia incision.

CONCLUSIONS

Laparoscopic surgery with transversalis fascia incision can be useful for HCNs extending from the abdominal cavity to the subcutaneous space.

Progress report of a cross-organ and biomarker-based basket-type clinical trial: BELIEVE Trial

Cancer genomic medicine using next-generation sequencers has been developing. However, the number of patients who could receive genomically matched therapy is limited because off-label use or patient-oriented compassionate use was not permitted under National Health Insurance in Japan. To improve patient drug accessibility, we initiated a biomarker-based basket-type clinical trial (NCCH1901) in October 2019 under patient-proposed healthcare services. We listed the drugs that had high medical needs but were not covered by National Healthcare Insurance. Then we included these drugs before patient proposal so that they could access off-label drugs soon after they had the results of CGP tests. All drugs were provided free of charge by pharmaceutical companies. The objective was to administer off-label drugs and to collect efficacy and safety data for these drugs. The primary endpoint was the response rate based on the best overall response for up to 16 weeks. As of January 31, 2022, we included 18 drug cohorts and 295 patients were treated in this study. The most common cancer was brain tumor, followed by carcinoma of endocrine organs and colorectal cancer. BRAF mutations and ERBB2 amplifications were the frequent genomic abnormalities to be enrolled. This study was one way to access off-label drugs, and contributed significantly to providing treatment opportunities for patients in Japan.

Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer with radiologically pure-solid appearance in Japan (JCOG0802/WJOG4607L): a post-hoc supplemental analysis of a multicentre, open-label, phase 3 trial

BACKGROUND

Although segmentectomy was better than lobectomy in terms of overall survival for patients with non-small-cell lung cancer (NSCLC) with a pure-solid tumour appearance on thin-section CT in the open-label, multicentre, randomised, controlled, phase 3 JCOG0802/WJOG4607L trial, the reasons why segmentectomy was associated with better overall survival were unclear. We aimed to compare the survival, cause of death, and recurrence patterns after segmentectomy versus lobectomy in trial participants with NSCLC with a pure-solid appearance METHODS: We conducted a post-hoc supplemental analysis of the JCO0802/WJOG4607L randomised, controlled, non-inferiority trial for the patients (aged 20-85 years) with small-sized NSCLC with radiologically pure-solid appearance on thin-section CT (≤2 cm, consolidation tumour ratio 1·0). The primary aim was to compare the overall and relapse-free survival, cause of death, and recurrence patterns associated with segmentectomy and lobectomy for patients with radiologically pure-solid NSCLC to determine why the overall survival of segmentectomy was superior to that of lobectomy, even for oncologically invasive lung cancers. JCO0802/WJOG4607L is registered with the UMIN Clinical Trials Registry, UMIN000002317, and is complete.

FINDINGS

Between Aug 10, 2009, and Oct 21, 2014, 1106 patients were randomly assigned to undergo either lobectomy or segmentectomy. Of these participants, 553 (50%) had radiologically pure-solid NSCLC and were eligible for this post-hoc supplemental analysis. Of these 553 participants, 274 (50%) patients underwent lobectomy and 279 (50%) underwent segmentectomy. Median patient age was 67 years (IQR 61-73), 347 (63%) of 553 patients were male and 206 (37%) were female, and data on race and ethnicity were not collected. As of data cutoff (June 13, 2020), after a median follow-up of 7·3 years (IQR 6·0-8·5), the 5-year overall survival rate was significantly higher after segmentectomy than after lobectomy (86·1% [95% CI 81·4-89·7] in the lobectomy group, with 55 deaths vs 92·4% [88·6-95·0] in the segmentectomy group, with 38 deaths; hazard ratio (HR) 0·64 [95% CI 0·41-0·97]; log-rank test p=0·033), whereas the 5-year relapse-free survival was similar between the groups (81·7% [95% CI 76·5-85·8], with 34 events vs 82·0% [76·9-86·0], with 52 events; HR 1·01 [95% CI 0·72-1·42]; p=0·94). Deaths after a median follow-up of 7·3 years due to lung cancer occurred in 20 (7%) of 274 patients after lobectomy and 19 (7%) of 279 after segmentectomy, and deaths due to other causes occurred in 35 (13%) patients after lobectomy compared with 19 (7%) after segmentectomy (lung cancer death vs other cause of death, p=0·19). The locoregional recurrence was higher after segmentectomy (21 [8%] vs 45 [16%]; p=0·0021). In subgroup analyses, better 5-year overall survival after segmentectomy than after lobectomy was observed in the subgroup of patients aged 70 years or older (77·1% [95% CI 68·2-83·8] with lobectomy vs 85·6% [77·5-90·9] with segmentectomy; p=0·013) and in male patients (80·5% [73·7-85·7] vs 92·1% [87·0-95·2]; p=0·0085). By contrast, better 5-year relapse-free survival after lobectomy than after segmentectomy was observed in the subgroup younger than 70 years (87·4% [95% CI 81·2-91·7] with lobectomy vs 84·4% [77·9-89·1] with segmentectomy; p=0·049) and in female patients (94·2% [87·6-97·4] vs 82·2% [73·2-88·4]; p=0·047).

INTERPRETATION

This post-hoc analysis showed improved overall survival after segmentectomy in patients with pure-solid NSCLC compared with lobectomy. However, survival outcomes of segmentectomy depend on the patient's age and sex. Given the results of this exploratory analysis, further research is necessary to determine clinically relevant indications for segmentectomy in radiologically pure-solid NSCLC.

FUNDING

Japanese National Cancer Center Research and Development Fund and Practical Research for Innovative Cancer Control Fund, and a Grant-in-Aid for Scientific Research from the Ministry of Health, Labor, and Welfare of Japan.

Impact of the quality of resected thyroid cancer tissue sample on next-generation sequencing testing

Activating rearranged during transfection (RET) proto-oncogene alterations can be identified using next-generation sequencing (NGS) of tumor DNA/RNA. We assessed factors associated with NGS (Oncomine Dx Target Test [ODxTT]) success for resected thyroid cancer (TC) specimens, including sample age, processing conditions, and DNA/RNA quality. TC samples were from three Japanese hospitals, with sample age <1-<10 years, fixative 10%/15% neutralized buffered formalin (NBF), and fixation time ≤48 h/>48 h-≤72 h. NGS success rate was defined as the percentage of samples returning validated NGS results (RET fusion-positive/negative [RNA] or RET mutation-positive/negative [DNA], detected using ODxTT). DNA/RNA quality was assessed with indexes based on electrophoresis (DNA/RNA integrity number, DV200 ) and quantitative polymerase chain reaction (DNA/RNA integrity score [ddCq/ΔCq]). NGS success rate (N = 202) was 90%/93% (DNA/RNA) overall, 98%-100% (DNA and RNA) for samples <3 years old, and 91% (DNA and RNA) for samples ≥3-<5 years old fixed in 10% NBF for ≤48 h. Multivariate logistic regression analysis identified ddCq and ΔCq as significant predictors of DNA and RNA NGS success rates, respectively. Quality assessment of nucleic acid extracted from archival tissue samples is important for achieving high NGS success rates in clinical practice, especially for samples ≥3 years old.

Platform trial for off-label oncology drugs using comprehensive genomic profiling under the universal public healthcare system: the BELIEVE trial

BACKGROUND

Precision medicine has transformed cancer treatment by focusing on personalized approaches based on genomic abnormalities. However, comprehensive genomic profiling (CGP) and access to targeted therapies are limited in Japan. This study investigates the BELIEVE trial, which aims to improve drug accessibility for patients with actionable genetic abnormalities through off-label drug administration.

METHODS

The BELIEVE trial is a platform trial with a single master protocol, conducted under the Clinical Trials Act and the patient-proposed health services (PPHS) scheme. Eligible patients with solid tumors exhibiting actionable alterations were enrolled, and CGP tests covered by national health insurance were employed. Treatment selection, study drugs from collaborating pharmaceutical companies, and treatment schedules adhered to predefined protocols. Primary and secondary endpoints were evaluated, and statistical analysis was conducted based on patient response rates.

RESULTS

The BELIEVE trial offered treatment opportunities for patients with relapse/refractory disease who lacked standard therapies or clinical trial options. This study addresses unmet medical needs and contributes to the establishment of precision medicine systems. Similar trials like NCI-MATCH and TAPUR are being conducted globally. The BELIEVE trial provides a platform for off-label drug administration, collects essential clinical data, and contributes to drug approval applications.

CONCLUSION

The BELIEVE trial provides hope for patients with actionable genetic abnormalities by facilitating access to targeted therapies through off-label drug administration. It establishes a regulatory framework and promotes collaboration between industry and academia by expanding organ-specific and cross-organ biomarker-based treatments.

Phase II Trial of Nivolumab in Metastatic Rare Cancer with dMMR or MSI-H and Relation with Immune Phenotypic Analysis (the ROCK Trial)

PURPOSE

Mismatch repair deficiency (dMMR)/microsatellite instability-high (MSI-H) are positive predictive markers for immune checkpoint inhibitors. However, data on the activity of nivolumab in advanced dMMR/MSI-H rare cancers and more accurate biomarkers are worth exploring.

PATIENTS AND METHODS

We conducted a multicenter phase II, open-label, single-arm clinical trial to explore the effectiveness and safety of nivolumab monotherapy in patients with advanced rare cancers with dMMR/MSI-H, in parallel with immune phenotype analysis, to explore new biomarkers. A Bayesian adaptive design was applied. Characterization of peripheral blood mononuclear cells (PBMC) was characterized by multicolor flow cytometric analysis and CyTOF using samples collected before and after the intervention. The dMMR was identified by the complete loss of MLH1/MSH2/MSH6/PMS2.

RESULTS

From May 2018 to March 2021, 242 patients were screened, and 11 patients were enrolled, of whom 10 were included in the full analysis. Median follow-up was 24.7 months (interquartile range, 12.4-31.5). Objective response rate was 60% [95% confidence interval (CI), 26.2-87.8] by central assessment and 70% (95% CI, 34.8-93.3) by local investigators. Median progression-free survival was 10.1 months (95% CI, 0.9-11.1). No treatment-related adverse events of grade 3 or higher were observed. Patients with a tumor mutation burden of ≥10/Mb showed a 100% response rate (95% CI, 47.8-100). Responders had increased T-bet+ PD-1+ CD4+ T cells in PBMC compared with nonresponders (P < 0.05).

CONCLUSIONS

The trial met its primary endpoint with nivolumab, demonstrating clinical benefit in advanced dMMR/MSI-H rare solid cancers. Besides, the proportion of T-bet+ PD-1+ CD4+ T-cells may serve as a novel predictive biomarker.

Inflammatory Hepatocellular Adenoma Mimicking Focal Nodular Hyperplasia That Grew during Pregnancy and Changed Its Appearance on Magnetic Resonance Imaging after Delivery

We reported a notable case of inflammatory hepatocellular adenoma that grew during pregnancy, consequently changing its appearance on magnetic resonance imaging remarkably. A 5-months-pregnant 35-year-old woman presented with a 37-mm liver nodule that had been diagnosed as focal nodular hyperplasia 3 years earlier. She had never used oral contraceptives. After 2 months, the nodule grew to 57 mm. The patient delivered a full-term infant without complications. Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging performed after delivery revealed markedly different findings compared with the first images. A liver biopsy was performed, and the tumor was diagnosed as inflammatory hepatocellular adenoma.

A case of non-ampullary duodenal adenosquamous carcinoma with successful emergency pancreaticoduodenectomy for gastrointestinal hemorrhage

BACKGROUND

Although most duodenal carcinomas are pathological adenocarcinomas, a small number of cases have been reported of adenosquamous carcinoma, characterized by variable combinations of two malignant components: adenocarcinoma and squamous cell carcinoma. However, owing to the small number of cases of non-ampullary duodenal adenosquamous carcinoma, there have been no reported cases of emergency pancreaticoduodenectomy for gastrointestinal hemorrhage due to non-ampullary duodenal adenosquamous carcinoma.

CASE PRESENTATION

A 66-year-old Japanese male presented to the referring hospital with a chief complaint of abdominal pain, diarrhea, and dark urine that had persisted for 1 month. The patient was referred to our hospital because of liver dysfunction on a blood examination. Laboratory results of the blood on the day of admission showed that total and direct bilirubin levels (12.0 mg/dl and 9.6 mg/dl) were markedly increased. An endoscopic retrograde biliary drainage tube was inserted for the treatment of obstructive jaundice, and imaging studies were continuously performed. Contrast-enhanced computed tomography and endoscopy revealed an ill-defined lesion involving the second portion of the duodenum, predominantly along the medial wall, and measuring 60 mm in diameter. No metastases were observed by positron emission tomography. Pancreaticoduodenectomy was planned based on the pathological findings of poorly differentiated adenocarcinoma. However, 2 days before the scheduled surgery, the patient experienced hemorrhagic shock with melena. Owing to poor hemostasis after endoscopic treatment and poor control of hemodynamic circulation despite blood transfusion, radiological embolization and hemostasis were attempted but were incomplete. An emergency pancreaticoduodenectomy was performed after embolizing the route from the gastroduodenal artery and pseudoaneurysm area to reduce bleeding. The operation was completed using an anterior approach without Kocherization or tunneling due to the huge tumor. The operation time was 4 h and 32 min, and blood loss was 595 mL The pathological diagnosis was adenosquamous carcinoma. The postoperative course was uneventful with 17 day hospital stay and the patient is currently well, with no signs of recurrence 9 months after surgery.

CONCLUSIONS

This report presents an extremely rare case of successful emergency pancreaticoduodenectomy for gastrointestinal hemorrhage caused by non-ampullary duodenal adenosquamous carcinoma.

Role of reduction gastrectomy in patients with gastric cancer with a single non-curable factor: Supplementary analysis of REGATTA trial

Background

REGATTA trial failed to demonstrate the survival benefit of reduction gastrectomy in patients with advanced gastric cancer with a single non-curable factor. However, a significant interaction was found between the treatment effect and tumor location in the subset analysis. Additionally, the treatment effect appeared to be different between Japan and Korea. This supplementary analysis aimed to elucidate the effect of reduction surgery based on tumor location and country.

Methods

Multivariable Cox regression analyses in each subgroup were performed to estimate the hazard ratio (HRadj), including the following variables as explanatory variables: country, age, sex, incurable factor, cT, cN, primary tumor, performance status, histological type, and macroscopic type.

Results

Patients (95 in Japan and 80 in Korea) were randomized to chemotherapy alone (86 patients) or gastrectomy plus chemotherapy (89 patients). The subgroup analysis according to the country revealed a worse overall survival in gastrectomy plus chemotherapy arm in Japan (hazard ratio: 1.32, 95% confidence interval: 0.85-2.05), but not in Korea (hazard ratio: 0.85.95% confidence interval: 0.52-1.40). Overall survival was better in distal gastrectomy plus chemotherapy compared with chemotherapy alone (hazard ratio = 0.69, 95% confidence interval: 0.42-1.13), and worse in total gastrectomy plus chemotherapy compared with chemotherapy alone (hazard ratio = 1.34, 95% CI: 0.93-1.94), which was more remarkable in Korea than in Japan.

Conclusions

Primary chemotherapy is a standard of care for advanced gastric cancer; however, the survival benefits from reduction by distal gastrectomy remained controversial.

[Now and Future of the ATLAS Project]

The National Cancer Center Hospital in Japan has established the Asia Cancer Clinical Trial Network, otherwise known as the ATLAS project, which began in September 2020 with government support. The goal of the ATLAS project is to foster a robust research platform for international clinical trials in Asia by developing research institutions' network and providing educational opportunities. The ATLAS project also aims to concurrently conduct multiple international clinical trials. Participating countries include not only longstanding collaborators such as Korea, Taiwan, and Singapore, but also rapidly developing nations such as Thailand, Malaysia, the Philippines, and Vietnam. Each country's top-tier research institutions have joined as participating facilities in the ATLAS project. Currently, 5 international clinical trials are ongoing with several more in preparation. While academia lacked an infrastructure to support such a lot of international research previously, the National Cancer Center Hospital has been addressing this by establishing the Department of International Clinical Development in November 2020, and operating the Asian Partnerships Office in Bangkok, Thailand from December 2021. This strategy is aimed at creating an in-house research support function to conduct affordable, swift, and convenient Asian collaborative clinical trials. Furthermore, to increase commitment to ATLAS across Asian countries, an ATLAS board has been established as a decision- making body as the clinical trial group. This mechanism, constructed to make decisions on a pan-Asian basis, is represented by 2 delegates from each country.

Successful treatment with laparoscopic extended posterior sectionectomy for inflammatory pseudotumor in the liver with para-aortic lymphadenitis

Inflammatory pseudotumor (IPT) is a rare disease that requires a differential diagnosis from malignancies. We describe a case of hepatic IPT with para-aortic lymphadenopathy, treated with a stepwise strategy of laparoscopic surgery. A 61-year-old woman was referred with a liver lesion. Computed tomography revealed a 13 cm well-defined lesion in segments VII-VI. The patient also had bead-like enlarged lymph nodes from the perihilar to the para-aortic regions. Although percutaneous lymph node biopsy showed no evidence of malignancy, 18 F-fluorodeoxyglucose positron emission tomography revealed accumulation in the lesion and lymph nodes. Lymph nodes were harvested laparoscopically for intraoperative pathological examination. With no evidence of malignancy, laparoscopic liver resection was continuously performed as a diagnostic treatment. The patient was given a pathological diagnosis of IPT and was discharged on the 16th day and is well 2 years after surgery. The minimally invasive laparoscopic approach to diagnostic treatment could be useful with secure advantages.

Clinical activity and exploratory resistance mechanism of milademetan, an MDM2 inhibitor, in intimal sarcoma with MDM2 amplification: an open-label phase 1b/2 study

Intimal sarcoma is an extremely rare life-threatening malignant neoplasm. Murine double minute 2 (MDM2) amplification is observed in > 70% of intimal sarcomas. Milademetan, an MDM2 inhibitor, may provide a clinical benefit in this patient population. We conducted a phase 1b/2 study in patients with MDM2-amplified wild-type TP53 intimal sarcoma as a sub-study of a large nationwide registry for rare cancers in Japan. Milademetan (260 mg) was administered orally once daily for three days every 14 days, twice in a 28-day cycle. Of 11 patients enrolled, 10 were included in the efficacy analysis. Two patients (20%) showed durable responses for >15 months. Anti-tumor activity correlated with TWIST1 amplification (P = 0.028) and negatively with CDKN2A loss (P = 0.071). Acquired TP53 mutations were detected in sequential liquid biopsies as a novel exploratory resistance mechanism to milademetan. These results suggest that milademetan could be a potential therapeutic strategy for intimal sarcoma.

Real-world clinical profile, treatment patterns and patient-reported outcomes for thyroid cancer in Japan

Aim: To provide a real-world snapshot of the clinical profile, management, and patient-reported outcomes (PRO) for advanced medullary and papillary thyroid cancer prior to the availability of rearranged during transfection (RET) inhibitors in Japan. Materials & methods: Physicians completed patient-record forms for eligible patients seen during routine clinical practice. Physicians were also surveyed about their routine practice and patients were asked to provide PRO data. Results: RET testing patterns varied by hospital type; no therapeutic relevance was a commonly cited reason to not carry out testing. Multikinase inhibitors were the main systemic therapies prescribed, although timing to start multikinase inhibitors varied; adverse events were reported as challenges. PROs revealed high disease/treatment burden. Conclusion: More effective and less toxic systemic treatment targeting genomic alterations is needed to improve long-term outcomes of thyroid cancer.

Trastuzumab Deruxtecan for Human Epidermal Growth Factor Receptor 2-Expressing Advanced or Recurrent Uterine Carcinosarcoma (NCCH1615): The STATICE Trial

PURPOSE

To investigate the efficacy and safety of trastuzumab deruxtecan, an antibody-drug conjugate targeting human epidermal growth factor receptor 2 (HER2) with a topoisomerase I inhibitor payload, in patients with uterine carcinosarcoma (UCS) expressing HER2.

PATIENTS AND METHODS

Patients with recurrent UCS with HER2 immunohistochemistry scores ≥1+ previously treated with chemotherapy were included. Patients were assigned to the HER2-high (immunohistochemistry score ≥2+; n = 22) or low (immunohistochemistry score of 1+; n = 10) groups for primary and exploratory analyses, respectively. Trastuzumab deruxtecan 6.4 or 5.4 mg/kg was administered intravenously once every 3 weeks until unacceptable toxicity or disease progression. Dose modification was based on the updated recommended phase II dose for breast cancer to be 5.4 mg/kg. The primary end point was the objective response rate by central review in the HER2-high group. Secondary end points included the overall response rate (ORR) in the HER2-high group by investigator assessment, ORR in the HER2-low group, progression-free survival (PFS), overall survival (OS), and safety.

RESULTS

The ORR by central review in the HER2-high and HER2-low groups were 54.5% (95% CI, 32.2 to 75.6) and 70.0% (95% CI, 34.8 to 93.3) and those by investigator assessments were 68.2% and 60.0%, respectively. The median PFS and OS in the HER2-high and HER2-low groups were 6.2 and 13.3 months and 6.7 months and not reached, respectively. Grade ≥ 3 adverse events occurred in 20 patients (61%). Grades 1-2 and 3 pneumonitis/interstitial lung disease occurred in eight (24%) and one (3%) patient, respectively.

CONCLUSION

Trastuzumab deruxtecan has efficacy in patients with UCS, regardless of HER2 status. The safety profile was generally consistent with that previously reported. Toxicities were manageable with appropriate monitoring and treatment.

[RET Gene Alterations in Thyroid Cancer-Towards Treatment with Selective RET Inhibitors]

Rearranged during transfection(RET)is one of the driver genes in thyroid cancer, which encodes a receptor tyrosine kinase. There are 2 types of genomic alterations of RET seen in thyroid cancer. Fusions of the RET tyrosine kinase domain region with partner genes are observed in papillary thyroid cancer, whereas RET mutations are observed in hereditary and sporadic medullary thyroid cancers. These alterations constantly activate downstream signaling pathways, leading to oncogenesis. Recently, selective RET inhibitors have been developed and approved overseas and in Japan for the treatment of RET-altered thyroid and lung cancers, and it will be important to detect genomic alterations in the RET gene using methods including companion diagnostics in the future.

A new era of the Asian clinical research network: a report from the ATLAS international symposium

This report summarizes the presentations and discussions in the first Asian Clinical Trials Network for Cancers (ATLAS) international symposium that was held on 24 April 2022, in Bangkok, Thailand, and hosted by the National Cancer Center Hospital (NCCH), co-hosted by the Pharmaceuticals and Medical Devices Agency (PMDA), Clinical Research Malaysia (CRM) and the Thai Society of Clinical Oncology (TSCO), and supported by Embassy of Japan in Thailand. Since 2020, the NCCH has conducted the ATLAS project to enhance research environments and infrastructures to facilitate international clinical research and cancer genomic medicine in the Asian region. The purpose of the symposium was to discuss what we can achieve under the ATLAS project, to share the latest topics and common issues in cancer research and to facilitate mutual understanding. Invitees included stakeholders from academic institutions, mainly at ATLAS collaborative sites, as well as Asian regulatory authorities. The invited speakers discussed ongoing collaborative research, regulatory perspectives to improve new drug access in Asia, the status of phase I trials in Asia, the introduction of research activities at the National Cancer Center (NCC) and the implementation of genomic medicine. As the next steps after this symposium, the ATLAS project will foster increased cooperation between investigators, regulatory authorities and other stakeholders relevant to cancer research, and establish a sustainable pan-Asian cancer research group to increase the number of clinical trials and deliver novel drugs to patients with cancer in Asia.

Molecular pathology quality control in Southeast Asia: Results of a Multiregional Quality Assurance Study from MASTER KEY Asia

Tissue specimen quality assurance is a major issue of precision medicine for rare cancers. However, the laboratory standards and quality of pathological specimens prepared in Asian hospitals remain unknown. To understand the methods in Southeast Asian oncology hospitals and to clarify how pre-analytics affect the quality of formalin-fixed paraffin-embedded (FFPE) specimens, a questionnaire surveying pre-analytical procedures (Part I), quality assessment of immunohistochemistry staining (IHC) and DNA/RNA extracted from the representative FFPE specimen from each hospital (Part II), and quality of DNA/RNA extracted from FFPE of rare cancer patients for genomic sequencing (Part III), were conducted. Quality measurements for DNA/RNA included ΔΔCt, DV200, and cDNA yield. Six major cancer hospitals from Malaysia, Philippines, and Vietnam participated. One hospital showed unacceptable quality for the DNA/RNA assessment, but improved by revising laboratory procedures. Only 57% (n=73) of the 128 rare cancer patients' specimens met both DNA and RNA quality criteria for Next-Generation Sequencing. Median DV200 was 80.7% and 64.3% for qualified and failed RNA, respectively. Median ΔΔCt was 1.25 for qualified and 4.89 for failed DNA. Longer storage period was significantly associated with poor DNA (fail:qualify = 1579:321 days, p<0.001) and RNA (fail:qualify = 1070:280 days, p<0.001). After improvement of pre-analytical factors, the qualification rate increased for hospitals A and E from 41.5% to 70.5% and 62.5% to 86%, respectively. This is the first report to elucidate the pre-analytical laboratory procedures of main Southeast Asian oncology hospitals. An external quality assessment program may improve factors associated with tumor FFPE specimen quality.

Patient-reported outcome and quality of life research policy: Japan Clinical Oncology Group (JCOG) policy

Assessments of patient-reported outcomes and health-related quality of life in cancer clinical trials have been increasingly emphasized recently because patient and public involvement in cancer treatment development has been promoted by regulatory authorities and academic societies. To assess patient experiences during and after cancer treatment, there is interest in implementing patient-reported outcome and health-related quality of life assessments into cancer clinical trials. The Japan Clinical Oncology Group quality of life ad hoc committee previously created a version of the Quality of Life Assessment Policy in 2006. Recently, there has been increasing demand from Japan Clinical Oncology Group researchers to assess patient-reported outcome/health-related quality of life in clinical trials. Although guidelines are available regarding planning and reporting clinical trials that include patient-reported outcome/health-related quality of life as an endpoint, there are still issues regarding the lack of consensus on standardized methods for analysing and interpreting the results. Hence, it was considered necessary to reorganize the Japan Clinical Oncology Group patient-reported outcome/quality of life research committee and to revise the former patient-reported outcome/quality of life research policy to promote patient-reported outcome/health-related quality of life research in future Japan Clinical Oncology Group trials. The purpose of this Japan Clinical Oncology Group patient-reported outcome/quality of life research policy is to define patient-reported outcome/health-related quality of life research and provide guidelines for including patient-reported outcome/health-related quality of life as an endpoint in Japan Clinical Oncology Group trials.

Muscle mass ratio in male gastric cancer patients as an independent predictor of postoperative complications after minimally invasive distal gastrectomy

BACKGROUND

The current study aimed to investigate the relationship between muscle mass proportion and the incidence of total complications in male gastric cancer (GC) patients after minimally invasive distal gastrectomy (MIDG).

METHODS

Between March 2017 and March 2020, 152 male GC patients with clinical stage III or lower GC who underwent MIDG were enrolled in this study. The muscle mass ratio (MMR) was calculated by dividing the total muscle weight obtained from bioelectrical impedance analysis by the whole-body weight. Thereafter, the association between MMR and surgical outcomes was determined.

RESULTS

Based on the optimal MMR cutoff value of 0.712 obtained using the receiver operating characteristic (ROC) curve, patients were divided into two groups (69 and 83 patients in the MMR-L and MMR-H groups). The MMR-L group had a significantly higher total complication rate compared to the MMR-H group (MMR-L, 24.6% vs. MMR-H, 7.2%; P = 0.005). Multivariate analysis also identified MMR-L as a significant independent risk factor for total complications and intra-abdominal infectious complications after MIDG.

CONCLUSIONS

The MMR calculated using bioelectrical impedance analysis can be a useful predictor for postoperative complications after MIDG in male GC patients.

Diagnostic and Therapeutic Challenges in Disseminated Mycobacterium colombiense Infection Caused by Interferon-γ Neutralizing Autoantibodies

Adult-onset immunodeficiency due to interferon-γ-neutralizing autoantibodies (nIFNγ-autoAbs) can remain underdiagnosed. We present a case of severe Mycobacterium colombiense infection with nIFNγ-autoAbs. To ensure early diagnosis, clinicians should have a high index of suspicion in patients of Asian descent with opportunistic infections and perform QuantiFERON-TB assay for disease screening.

[A case of invasive liver abscess syndrome caused by Klebsiella pneumoniae causing endophthalmitis-induced blindness]

An 82-year-old female patient was admitted to our hospital for visual acuity loss in both eyes. The patient was diagnosed with invasive liver abscess syndrome and bilateral endophthalmitis due to Klebsiella pneumoniae 4 days after the onset of ocular symptoms. The liver abscess improved by broad-spectrum antibiotics and intravitreal injection, but bilateral blindness occurred. Most literature reported fever as the first symptom of invasive abscess syndrome, but this case had no fever at the onset of ocular symptoms. Delayed invasive liver abscess syndrome diagnosis might cause poor visual acuity prognosis.

Docetaxel+Cisplatin+5-FU (DCF) Therapy as a Preoperative Chemotherapy to Advanced Esophageal Squamous Cell Carcinoma: A Single-center Retrospective Cohort Study

Objective The aim of this study was to determine the safety and clinical efficacy of docetaxel+cisplatin+5-fluorouracil (DCF) as neoadjuvant chemotherapy (NAC). Methods In this single-center study, patient background and treatment outcomes (NAC efficacy assessment, NAC adverse events, short-term postoperative outcomes, and one-year postoperative outcomes) in patients treated with preoperative DCF and preoperative cisplatin+5-FU (CF) were compared retrospectively. Patients Seventeen patients diagnosed with esophageal squamous cell carcinoma (ESCC) and treated with preoperative DCF therapy and 50 patients treated with preoperative CF therapy between January 2013 and July 2019 were included in this study. Results There were significant differences in clinical T factor and clinical stage between the CF and DCF groups (p<0.05). All patients in the DCF therapy group were above clinical T3 and clinical stage III. The clinical response after NAC was partial response (PR) for 23 patients (46.0%) in the CF group and 13 patients (76.5%) in the DCF group (p=0.030). Regarding adverse events in NAC, neutropenia, febrile neutropenia (FN), diarrhea, and stomatitis were observed more frequently in the DCF group than in the CF group (p<0.05). The postoperative results [overall survival (OS), recurrence-free survival (RFS), one-year OS, one-year RFS] of the DCF group were comparable to those of the CF group. Conclusion DCF therapy has been recognized as an effective treatment option for advanced ESCC. However, the indication for DCF therapy should be chosen carefully because of the high incidence of adverse events.

Circular-stapled esophagogastrostomy using the keyhole procedure after radical esophagectomy for esophageal cancer

BACKGROUND

Anastomotic leakage of cervical esophagogastrostomy following radical esophagectomy for esophageal cancer has reduced over time; however, postoperative anastomotic stricture still occurs at a considerably high rate. We developed a novel method of circular-stapled esophagogastrostomy by employing the keyhole procedure, which uses a linear stapler to enlarge the anastomotic opening made with a circular stapler (CS).

METHODS

We retrospectively reviewed 70 patients with esophageal cancer who underwent transthoracic esophagectomy and reconstruction via cervical CS-mediated anastomosis with or without the keyhole procedure between 2018 and 2020. The primary outcome was postoperative anastomotic stricture incidence within 180 days after surgery.

RESULTS

Among 70 patients, 22 underwent the keyhole procedure (CS + K group) and the remaining did not (CS group). No differences were observed in patients' age, sex, body mass index, performance status, American Society of Anesthesiologists physical status, Charlson's comorbidity index, tumor histological type, tumor location, clinical stage, or preoperative treatment. A smaller stapler was used in the CS + K group (p < 0.001). Incidence of anastomotic stricture was significantly different (CS vs. CS + K, 18.8 vs. 0%, p = 0.049), especially when a 21 or 23 mm CS was used (CS vs. CS + K, 50.0 vs. 0%, p = 0.005). Univariate analysis confirmed that CS ≤ 23 without keyhole was a significant risk factor (p = 0.001).

CONCLUSIONS

The keyhole procedure could be a simple and useful alternative technique that reduces the risk of stricture formation in cervical esophagogastric anastomosis, especially when using the smaller-sized CS.

Orchiectomy due to delayed severe scrotal hematocele after laparoscopic transabdominal preperitoneal repair for a giant inguinoscrotal hernia: a case report

BACKGROUND

A giant inguinoscrotal hernia is a rare inguinal hernia that extends below the midpoint of the inner thigh while standing. Although reports of laparoscopic surgery for giant inguinoscrotal hernias have increased, the risk of delayed hematocele has not yet been clarified.

CASE PRESENTATION

A 68-year-old man was evaluated for a left giant inguinoscrotal hernia, and laparoscopic transabdominal preperitoneal repair (TAPP) was performed. In the procedure, the distal hernia sac was not resected. The postoperative course was uneventful for 3 months postsurgery, after which he complained of giant scrotal swelling, which gradually grew to 13 cm. It did not improve with several punctures and caused dysuria because of increased pressure on the urethra. Thus, reoperation was performed 9 months after surgery. The hematocele consisted of a thickened hernia sac, which was tightly adhered to the spermatic cord and testicle. The hernia sac including the hematocele was removed from the scrotum through an anterior approach, preserving the spermatic cord and testicle. On the third postoperative day, an orchiectomy was performed due to poor testicular perfusion caused by spermatic cord injury. There was no hematocele or hernia at the 3-year follow-up. The remnant sac after laparoscopic TAPP for a giant inguinoscrotal hernia possibly caused refractory hematocele. Additionally, the removal of the hernia sac, including hematocele, from the spermatic cord and testicle has a risk of inducing injury, leading to orchiectomy.

CONCLUSION

Surgeons should be aware of the possibility of delayed refractory hematoceles after laparoscopic TAPP for giant inguinoscrotal hernias when the hernia sac is not resected.

[A Case of Curative Resection for Gastric Cancer with Single Giant Lymph Node Metastasis]

A 79-year-old male presented with epigastric discomfort and appetite loss. A type 1 advanced gastric tumor was detected by upper gastrointestinal endoscopy. Contrast-enhanced CT revealed a 7 cm mass with contrast effect at the greater curvature of the lower body of the stomach. No distant metastases were found. Staging laparoscopy confirmed gastric cancer with single giant lymph node metastasis, which was resectable, although the metastatic node possibly invaded the transverse colon. We performed total gastrectomy and partial colectomy. Pathological examination revealed the tumor was pT3N1; the mass was #4sa lymph node metastasis of gastric cancer. The postoperative course was uneventful. No tumor recurrence has been found for 12 months postoperatively.

[A Case of Gastric Granular Cell Tumor Resected by a Surgical Robot]

A 46-year-old man was referred to further treatment for a 20 mm submucosal tumor at the gastric angle found during a medical check-up. Endoscopic ultrasonography and chest abdominal contrast-enhanced CT revealed the tumor was located at the 4th(proper muscular)layer of the posterior wall of the gastric antrum and slightly enhanced. No metastasis was found. Although a biopsy failed to reveal an accurate diagnosis, GIST was clinically suspected. A robotic distal gastrectomy was planned to manage the residual gastric stricture. The intraoperative findings indicated possible passage of the remnant stomach; therefore, local resection was performed. The patient's postoperative course was uneventful, and he was discharged on postoperative day 9. A histopathological examination confirmed the diagnosis of a PAS-positive, S100-positive granular cell tumor with no nuclear atypia. These findings suggest that use of the robotic approach could help determine the stomach resection extent.

[A Case of Robotic Distal Pancreatectomy for Pancreatic Metastasis of Gastric Cancer]

A 78-year-old male who had received laparoscopic total gastrectomy for upper gastric cancer 30 months ago(pT3N0, pStage ⅡB)was referred for further treatment for a 30-mm in size mass at the splenic hilum. The mass was suspected of lymph node metastasis was suspected. Two courses of SOX therapy failed to achieve the tumor response. Since there was no other metastasis, surgical treatment was indicated. Robot distal pancreatectomy with splenectomy was performed. There was no finding of peritoneal metastasis during the operation. The operative time was 384 min, the blood loss 22 mL, respectively. The postoperative course was uneventful, and he was discharged on the 12th postoperative day. The histopathological examination found that the resected mass was pancreatic metastasis of gastric cancer. Despite 3 courses of SOX therapy after the operation, the tumor recurred at the liver and paraaortic lymph nodes 2 months later. The second-line ramucirumab plus paclitaxel was started and has continued for 11 months with partial response. Although oncological benefit of surgical resection for isolated metastasis of gastric cancer, including pancreatic metastasis, was unclear, the robotic approach for such an atypical case was safe and feasible, leading to smooth initiation of postoperative systemic therapy.

Clinical factors associated with noncurative endoscopic submucosal dissection for the expanded indication of intestinal-type early gastric cancer: Post hoc analysis of a multi-institutional, single-arm, confirmatory trial (JCOG0607)

OBJECTIVES

The multi-institutional, single-arm, confirmatory trial JCOG0607 showed excellent efficacy of endoscopic submucosal dissection (ESD) for the expanded indication of intramucosal intestinal-type early gastric cancer (EGC), which consists of two groups: lesions >2 cm if clinical finding of ulcer (cUL)-negative, or those ≤3 cm if cUL-positive because of the expected low risk of lymph node metastasis. However, the proportion of noncurative resections (NCR) requiring additional surgery was high (32.4%). This post hoc analysis aimed to explore the clinical factors associated with NCR.

METHODS

As the expanded indication includes two different groups, we explored the clinical factors associated with NCR separately in cUL-negative (>2 cm) and cUL-positive (≤3 cm) groups using the log-linear model.

RESULTS

Two hundred and sixty cUL-negative and 206 cUL-positive EGCs were analyzed. The proportions of NCR were 33.8% in the cUL-negative group and 29.6% in the cUL-positive group. A multivariable analysis demonstrated that moderately differentiated predominant histology diagnosed in pretreatment biopsy (risk ratio [RR] 1.93, 95% confidence interval [CI] 1.34-2.77, P < 0.001) and lesion in the upper stomach (RR 1.75, 95% CI 1.03-2.96, P = 0.038) in the cUL-negative EGCs, and tumor size >2 cm (RR 1.78, 95% CI 1.22-2.58, P = 0.003) and female sex (RR 1.62, 95% CI 1.07-2.44, P = 0.021) in the cUL-positive EGCs were independent factors associated with NCR.

CONCLUSIONS

Clinical risk factors associated with NCR were different between cUL-negative and cUL-positive EGCs. To avoid NCR, we need to take these factors into account when deciding expanded indications for ESD.

Establishment of a new practical telesurgical platform using the hinotori™ Surgical Robot System: a preclinical study

Aim

The recent development of new surgical robots and network telecommunication technology has opened new avenues for robotic telesurgery. Although a few gastroenterological surgeries have been performed in the telesurgery setting, more technically demanding procedures including gastrectomy with D2 lymphadenectomy and intracorporeal anastomosis have never been reported. We examined the feasibility of telesurgical robotic gastrectomy using the hinotori™ Surgical Robot System in a preclinical setting.

Methods

First, the suturing time in the dry model was measured in the virtual telesurgery setting to determine the latency time threshold. Second, a surgeon cockpit and a patient unit were installed at Okazaki Medical Center and Fujita Health University, respectively (approximately 30 km apart), and connected using a 10-Gbps leased optic-fiber network. After evaluating the feasibility in the dry gastrectomy model, robotic distal gastrectomies with D2 lymphadenectomy and intracorporeal B-I anastomosis were performed in two porcine models.

Results

The virtual telesurgery study identified a latency time threshold of 125 ms. In the actual telesurgery setting, the latency time was 27 ms, including a 2-ms telecommunication network delay and a 25-ms local information process delay. After verifying the feasibility of the operative procedures using a gastrectomy model, two telesurgical gastrectomies were successfully completed without any unexpected events. No fluctuation was observed across the actual telesurgeries.

Conclusion

Short-distance telesurgical robotic surgery for technically more demanding procedure may be safely conducted using the hinotori Surgical Robot System connected by high-speed optic-fiber communication.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-022-02710-6.

Totally laparoscopic resection using delta-shaped anastomosis of jejunal leiomyosarcoma with intussusception at the angle of Treitz: a case report

Background

A leiomyosarcoma of the gastrointestinal tract is extremely rare. We report a case of jejunal leiomyosarcoma with intestinal intussusception at the angle of Treitz that was successfully treated with laparoscopic resection followed by intracorporeal reconstruction using a delta-shaped anastomosis.

Case presentation

A 54-year-old man was referred to our hospital due to fatigue and loss of appetite. Blood tests showed anemia. Enteroscopy and subsequent enterography using meglumine sodium amidotrizoate showed easily hemorrhagic tumor (10 cm in diameter) in the jejunum just beyond the angle of Treitz. Contrast-enhanced computed tomography revealed jejunojejunal intussusception. Histopathological examination of a biopsy specimen revealed a leiomyosarcoma. Laparoscopic resection of the tumor without reduction of the intussusception was performed. The resected line of the proximal intestine was very close to the ligament of Treitz in the present case. Intracorporeal jejunojejunostomy was completed using a delta-shaped anastomosis, wherein anastomosis was performed between the posterior walls of the proximal and distal jejunums after minimal mobilization around the ligament of Treitz. The patient’s postoperative course was uneventful, and he was discharged at 10 days postoperatively. No recurrence has been observed within 2 years after surgery.

Conclusions

We present a case in which a totally laparoscopic surgery for leiomyosarcoma located at the angle of Treitz with jejunojejunal intussusception was performed successfully.

Liver abscess in advanced hepatocellular carcinoma after atezolizumab plus bevacizumab treatment: A case report

RATIONALE

Hepatocellular carcinoma (HCC) is the sixth most common type of cancer globally. Since 2020, combination treatment with atezolizumab and bevacizumab were approved in patients with unresectable HCC in Japan, and atezolizumab plus bevacizumab is the first-line treatment for unresectable HCC.

PATIENT CONCERNS

A 73-year-old Japanese man diagnosed with a large HCC was treated with atezolizumab plus bevacizumab. After 2 cycles, he had fever and fatigue and was admitted to the hospital.

DIAGNOSIS

Abdominal contrast-enhanced computed tomography revealed tumor necrosis in HCC with gas formation in the necrotic area. Laboratory examination revealed a white blood cell (WBC) count of 16,340/μL and C-reactive protein (CRP) level of 33.0 mg/dL. Based on the above findings, he was diagnosed with a liver abscess.

INTERVENTIONS

Percutaneous transhepatic liver abscess drainage and broad-spectrum antibiotics treatment were performed.

OUTCOMES

Despite liver abscess drainage, persistent fever and no improvement in the WBC count or CRP level was observed. The patient's respiratory condition and renal function gradually worsened; The patient's general condition did not improve despite the ventilator support and continuous hemodiafiltration, and he died on day 37.

LESSONS

We report the first case of liver abscess after atezolizumab plus bevacizumab treatment for unresectable HCC.

BRAF and MEK Inhibitor Treatment for Metastatic Undifferentiated Sarcoma of the Spermatic Cord with BRAF V600E Mutation

An 18-year-old Japanese man was diagnosed with an undifferentiated sarcoma of the spermatic cord, with multiple distant metastases to the lungs and bones. The patient received doxorubicin-based standard chemotherapy. Although the chemotherapy was effective, it induced severe adverse events, which led to treatment discontinuation. A comprehensive genomic profiling test using resected tumor tissue revealed the BRAF V600E mutation. Based on the result, the patient received combination therapy with dabrafenib and trametinib. The combination therapy achieved a good response with few adverse events. However, 6.5 months later, pleural metastases and meningeal dissemination had emerged. A liquid comprehensive genomic profiling test was performed after the progression to identify the resistance mechanism, which resulted in the detection of no actionable gene alterations other than BRAF V600E. This report shows that the BRAF V600E mutation may be a promising therapeutic target and that resistance to the targeted therapy could also occur in soft tissue sarcoma. The significance of BRAF mutations across different types of cancer should be validated, and it is necessary to apply targeted therapies and develop methods to overcome resistance based on the optimal use of comprehensive genomic profiling tests.

A multicenter investigator-initiated Phase 2 trial of E7090 in patients with advanced or recurrent solid tumor with fibroblast growth factor receptor (FGFR) gene alteration: FORTUNE trial

Background

Aberrant fibroblast growth factor receptor (FGFR) signaling can substantially influence oncogenicity. Despite that FGFR gene abnormality is often detected by cancer genome profiling tests, there is no tumor-agnostic approval yet for these aberrations. E7090 (tasurgratinib) is an orally available selective tyrosine kinase inhibitor of FGFR1-3. Specific FGFR alterations were previously reported to be highly sensitive to E7090 based on a high-throughput functional evaluation method, called mixed-all-nominated-mutants-in-one (MANO) method, narrowing down the most promising targets. This trial was focused on the alterations identified by the MANO method and was performed under the nationwide large registry network for rare cancers in Japan (MASTER KEY Project).

Methods/Design

This single-arm Phase 2 trial was designed to evaluate the safety and efficacy of E7090 in patients with advanced or recurrent solid tumors harboring FGFR alterations. Three cohorts were set based on the type of FGFR alterations and the results of MANO method. A maximum of 45 patients will be enrolled from 5 institutions over 2.5 years. E7090 will be administered once daily as an oral single agent in 28-day cycles. The primary endpoint is the objective overall response rate; whereas, the secondary endpoints include progression-free survival, overall survival, disease control rate, safety, duration of response, and time to response. Ethics approval was granted by the National Cancer Center Hospital Certified Review Board. Patient enrollment began in June 2021.

Discussion

A unique investigator-initiated multicenter Phase 2 trial was designed based on the results of preclinical investigation aiming to acquire the approval of E7090 for solid tumors harboring FGFR gene alterations. The findings may serve as a novel model for the development of tumor-agnostic molecular targeted therapies against rare genetic abnormalities.

Trial registration

Japan Registry of Clinical Trial: jRCT2031210043 (registered April 20, 2021) ClinicalTrials.gov: NCT04962867 (registered July 15, 2021).

A Single-Arm Confirmatory Study of Definitive Chemoradiotherapy Including Salvage Treatment for Clinical Stage II/III Esophageal Squamous Cell Carcinoma (JCOG0909 Study)

PURPOSE

Definitive chemoradiotherapy (CRT) is the standard treatment for patients with locally advanced esophageal cancer (EC) who refuse surgery as the initial therapy. However, poor survival, a high incidence of late toxicities, and severe complications after salvage surgery remain issues to be resolved. This single- arm multicenter trial (Trial name XXXX) aimed to confirm the efficacy of CRT modifications, including salvage treatment, for reducing CRT-related toxicities and facilitating salvage treatment for improved survival.

METHODS AND MATERIALS

Patients with clinical stage II/III EC (UICC 6th, non-T4) were eligible. Chemotherapy comprised cisplatin (75 mg/m2 on days 1and 29) and 5- fluorouracil (1,000 mg/m2/d on days 1-4 and 29-32). Radiotherapy was administered at a total dose of 50.4 Gy. Good responders received 1-2 additional cycles of chemotherapy. For residual or recurrent disease, salvage endoscopic resection (ER) or salvage surgery was performed based on specific criteria. The primary endpoint was the 3-year overall survival (OS). The calculated sample size was 95 patients, with a one-sided alpha of 5% and a power of 80%. The expected and threshold 3-year OS were 55% and 42%, respectively.

RESULTS

Overall, 96 patients were enrolled, and 94 were included in the efficacy analysis. A complete response was achieved in 55 patients (59%). Salvage ER and salvage surgery were performed in 5 (5%) and 25 patients (27%), respectively. R0 resection by salvage surgery was achieved in 19 patients (76%). Five patients (20%) showed grade 3 or 4 early operative complications, and 9 patients (9.6%) showed grade 3 late toxicities during the long-term follow-up. The 3-year OS was 74.2% (90% CI, 65.9%-80.8%).

CONCLUSION

The combination of definitive CRT and salvage treatment has lower CRT- related toxicities and yields good OS, thus making it a promising novel treatment option for patients with locally advanced EC.

A case of direct inguinal hernia incarceration after transperitoneal robot-assisted radical prostatectomy

In this study, we report a case of incarcerated direct inguinal hernia (DIH) after robot-assisted radical prostatectomy (RARP) in a patient with concomitant DIH. The 71-year-old man underwent RARP. Six days later, he developed a right DIH incarceration. His laparoscopy findings revealed an incarcerated intestine that was adherent to the hernia orifice. After reducing the hernia, the peritoneum was found to be defective in the right DIH orifice. The DIH was then repaired via the Lichtenstein method. The patient was discharged without complications on postoperative day 13. No recurrence was observed at 3-year follow-up. When repair and peritoneum closure for concomitant DIH are not performed in RARP, it should be kept in mind that the nonrepaired concomitant DIH orifice may develop intestinal incarceration and adhesion to the hernia orifice without the peritoneum immediately after RARP.

Clinical advantage of standardized robotic total gastrectomy for gastric cancer: a single-center retrospective cohort study using propensity-score matching analysis

BACKGROUND

Although recent studies have shown that robotic gastrectomy offers clinical advantages over laparoscopic gastrectomy in decreasing gastric cancer (GC) morbidity, studies focusing on robotic total gastrectomy (RTG) remain limited. The current study aimed to clarify whether the use of a robotic system could clinically improve short-term outcomes.

METHODS

Between January 2009 and June 2021, 371 patients diagnosed with both clinical and pathological Stage III or lower GC and underwent RTG or laparoscopic total gastrectomy (LTG) were enrolled in this study. The primary outcome was the incidence of intra-abdominal infectious complications over Clavien-Dindo classification grade IIIa. Demographic characteristics of those who underwent the RTG and LTG were matched using propensity-score matching (PSM), after which short-term outcomes were compared retrospectively.

RESULTS

After PSM, 100 patients were included in each group. The RTG group had a significantly shorter duration of hospitalization following surgery [RTG 13 (11-16) days vs. LTG 14 (11-19) days; p = 0.032] and a greater number of dissected LNs [RTG 48 (39-59) vs. LTG 43 (35-54) mL; p = 0.025], despite having a greater total operative time [RTG 511 (450-646) min vs. LTG 448 (387-549) min; p < 0.001]. In addition, the RTG group had significantly fewer total complications (3% vs. 13%, p = 0.019) and intra-abdominal infectious complications (1% vs. 9%; p = 0.023).

CONCLUSIONS

The current study showed that robotic surgery might improve short-term outcomes following minimally invasive radical total gastrectomy by reducing intra-abdominal infectious complications.

Multicenter phase II trial of trastuzumab deruxtecan for HER2-positive unresectable or recurrent biliary tract cancer: HERB trial

Trastuzumab deruxtecan (DS-8201) is an antibody-drug conjugate composed of a humanized monoclonal anti-HER2 antibody, a cleavable tetrapeptide-based linker and a potent topoisomerase I inhibitor. The drug's efficacy has been proven in HER2-positive breast and gastric cancers. The rate of HER2 positivity in biliary tract cancer (BTC) has been reported to be 5-20%, and case reports and clinical trials have suggested that HER2 inhibitors might be active in HER2-positive BTC. Here we describe the rationale and design of the phase II HERB trial that will evaluate the efficacy and safety of trastuzumab deruxtecan in patients with HER2-expressing unresectable or recurrent BTC. The primary end point will be the centrally assessed objective response rate in HER2-positive patients.

Clinical trial and translational research for cancer immunology in Asian countries: Understanding the new frontier

e14510

Background: Among the major advances in cancer treatment is the progress in cancer immunotherapy; however, despite the strides, there is few information specific to the Asian population. It is unclear to what extent clinical trial and translational research in cancer immunology are conducted in Asian institutions. Methods: This questionnaire-based survey was conducted among researchers and healthcare professionals who are involved in cancer immunology research and therapeutics in Asia-Pacific countries. The study identified the involvement of respondents in various phases of clinical trials, and immunotherapy research. In addition, the current capabilities of the institutions to conduct translational research were surveyed. Results: We received a total of 122 responses from 20 Asia-Pacific countries. More than half (58%) of the responders are currently conducting clinical trials on cancer immunology with 25% having performed more than 10 Phase 3 trials in the last 3 years. In clinical trials and clinical practice, immune checkpoint inhibitors were performed in most countries (81.8% and 88.6%, respectively). Clinical trials and clinical practice of CAR-T and TCR-T were performed only in some countries (CAR-T; 22.7% and 15.9%, TCR-T; 2.3% and 0%, respectively). In the absence of novel therapeutics in their institution, 18% of the responders refer their patient to facilities that have ongoing clinical trials. Among the institutions that perform Hematopoietic stem cell transplant (55.1%), the most common type offered include autologous (81.3%) and allogenic (70.8%) peripheral blood stem-cell transplantation. About 51.7% of the respondents have institutions that can conduct early drug phase development studies with only 11.2% capable of utilizing their own immunotherapeutic agents. Less than half of the respondents (40.7%) belong to institutions that have conducted translational researches using patient-derived samples for the last three years. Furthermore, more than half of the respondent institutions have no personnel that is experienced to handle and/or run patient-derived fresh peripheral blood or fresh tumors. Collaboration among neighboring countries can allow send out of specimens to other institutions that have such capability, however, 56.9% of countries have regulations or restrictions in transporting lymphocytes or tumor tissues. Conclusions: Oncologists and researchers in Asia recognize the importance of cancer immunology researches for patients. There were institutional and inter-country differences particularly in the conduct of early phase clinical drug development and translational research.

A phase II, multicenter, single-arm trial of eribulin in patients with bevacizumab-resistant recurrent glioblastoma

2036

Background: Glioblastoma (GBM) is one of the worst prognostic cancers and there is no effective treatment after failure of bevacizumab. Eribulin is a microtubule inhibitor used for the treatment of patients with metastatic breast cancer and liposarcoma. We previously reported that eribulin strongly inhibits the RNA-dependent RNA polymerase (RdRP) activity of TERT protein in cancer cells, and has a strong anti-tumor effect against GBM cells with TERT promoter mutation. In this study we aim to investigate the efficacy and safety of eribulin in patients with bevacizumab-resistant recurrent GBM. Methods: This is an open-label, multicenter, single-arm phase II trial. Eligible patients aged 20-75 years with bevacizumab-resistant recurrent GBM were enrolled from 2018-2020. Patients received eribulin 1.4 mg/m2 on days 1 and 8 of 21-day cycle until disease progression or intolerable toxicity was observed. The primary endpoint was one-year overall survival rate (1yOS%). The 35 patients are needed to achieve an 80% power at a one-sided alpha of 10%, under threshold 1yOS% of 10% and expected 1yOS% of 25%. Results: Thirty-seven patients aged 26-73 (median: 54) years were treated. Twenty-six of 37 (70.3%) patients were diagnosed as IDH-wildtype GBM, 4 (10.8%) were with IDH-mutant GBM and 7 (18.9%) were GBM, NOS. Thirty-four (91.9%) patients had a Karnofsky performance status of 70 or 80 at the registration. Thirty-one (83.8%) patients received additional treatments, including 28 (75.7%) bevacizumab, 11 (29.7%) re-irradiation and 3 (8.1%) resection after failure of eribulin. Among 37 subjects, 32 surgical specimens were analyzed for TERT promoter mutation and 15 for RdRP activity. 1yOS% was 29.7% [80% CI: 20.5 to 39.5 (p < 0.0001), 95% CI: 16.1 to 44.6]. Median OS was 9.0 months [95% CI: 6.2 to 11.0] and median progression-free survival was 1.5 months [95% CI: 1.4 to 1.7]. Neither TERT nor RdRP statuses was associated with prolonged OS. Among all the target lesions evaluated, two lesions decreased more than 50% in size and the patients survived more than one year, however no obvious PR was confirmed at the final evaluation. The disease control rate was 25.7% [95% CI: 12.5 to 43.3]. Common ≥ grade 2 AEs were neutropenia (70.3%), leukopenia (56.8%), lymphopenia (27.0%), elevation of γ-GTP (13.5%), elevation of ALT (10.8%), elevation of AST (8.1%), alopecia (8.1%). Treatment-related grade 3 or 4 AEs occurred in 59.5% of subjects. There were no AEs leading to death. Conclusions: Eribulin was safely applied for the patients with recurrent GBM. This phase II study met its primary endpoint of 1yOS%, although no obvious response was observed. Further investigation to reveal the biomarkers related to longer survival is underway. Clinical trial information: UMIN000030359.