[A Case of Local Remnant Esophageal Cancer after Chemotherapy Getting Complete Response by Radiotherapy]

This is a case of a 72-year-old woman who presented without anymajor complaint. An anemia was indicated during follow-up for diabetes at the internal medicine unit and an upper gastrointestinal endoscopy(GS)was performed. A type 2 tumor was detected in the middle thoracic esophagus and biopsyrevealed a squamous cell carcinoma. A tumor was detected in the middle thoracic esophagus bycervical thoracoabdominal computed tomography(CT)scan and no invasion of surrounding organs was noted. The lymph node 104R had enlarged significantlybut no distant metastasis was observed. The patient was diagnosed with advanced esophageal cancer, Mt, type 2, cT2N2M0, stage Ⅱ. For preoperative chemotherapy, CDDP plus 5-FU(FP)therapywas administered. Lung metastasis was found on CT examination and surgical resection was not indicated. Hence, 4 courses of docetaxel plus CDDP plus 5-FU(DCF)therapywere administered. Following treatment, lung and lymph node metastases disappeared on the image. However, the main tumor remained at the GS. Radiotherapy was administered as a local additional treatment. Thereafter, GS showed mucous membrane redness and white spots of the lesion. Biopsyfrom the same site showed no malignant findings. The patient has remained malignancy-free since 18 months.

Long-Term Survival After Multidisciplinary Treatment Including Surgery for Metachronous Metastases of Small Intestinal Gastrointestinal Stromal Tumors after Curative Resection: A Case Report

Patient: Male, 56-year-old

Final Diagnosis: Metachronous metastases of small intestinal gastrointestinal stromal tumors

Symptoms: Abdominal and/or epigastric pain

Medication: —

Clinical Procedure: Operation • chemotharapy

Specialty: Gastroenterology and Hepatology

[Stereotactic Body Radiotherapy for Liver Metastasis of Gastric Cancer]

Case 1: A 69-year-old man underwent distal gastrectomy in September 2007 for type 2 gastric cancer with liver metastasis (S5). After the operation, we administered chemotherapy. After that, we performed partial hepatectomy in July 2008. After hepatectomy, liver metastases appeared as 2 lesions in February 2009. Thus, we administered another type of chemotherapy. The effect of the chemotherapy was not favorable. Therefore, SBRT was performed for the liver metastases in December. After SBRT, he did not present with any recurrent tumors. Case 2: A 67-year-old woman underwent distal gastrectomy in March 2015. In August 2015, hepatic metastasis(S5 single shoot)was confirmed. Although chemotherapy was administered and SD was continued, it was ceased due to the patient's request. Thus, SBRT was performed in July 2016. However, from October 2016, multiple liver metastases developed and she died in January 2017.

[Efficacy of Partial Resection for Stomach Cancer in the Elderly]

We examined the effectiveness of partial gastrectomy in the elderly. Twelve patients who underwent partial gastrectomy for gastric cancer in our hospital had an average of 2.75 comorbidities before surgery. Two patients relapsed, and 2 patients died from other diseases. The depth of the gastric tumor was T2 in patients with recurrence. Partial gastrectomy should be considered carefully for advanced stage cancer. There were only small changes in weight, PS, and nutrition before and after surgery, suggesting that partial gastrectomy is effective.

[A Case of Gastric Cancer Responding to Neoadjuvant Chemotherapy Leading to Histological Change to Grade 3]

A 70-year-old man with cStage III A(cT3N2H0P0CYXM0)advanced gastric cancer in the lesser curvature with esophageal invasion and bulky lymph nodes was treated with S-1/CDDP. After 4 courses of chemotherapy, the tumor and lymph nodes were found to be reduced in a CT examination. Total gastrectomy with lymph node dissection(D2)was performed. Histopathological examination revealed no cancer cells in the stomach or lymph nodes, indicating Grade 3.

[Pathological Complete Response in 3 Patients with Esophageal Cancer Treated with Neoadjuvant Chemoradiation Therapy]

Neoadjuvant chemotherapy(NAC)for esophageal cancer is standard in Japan. However, the value of neoadjuvant chemoradiation therapy(NACRT)is unknown. Thirteen patients with cStage II and III squamous cell carcinoma of the esopha- gus were treated with NACRT(CDDP 70mg/m2/day on day 1, 5-FU 70 mg/m2/day on days 1-4, radiation 30 Gy/15 Fr). We report 3 pathological CR cases and 10 non-CR cases of esophageal cancer. Between the CR and non-CR group there was no difference in the incidence of postoperative complications. No serious adverse events were observed. There were no significant differences in OS and RFS. Five cases relapsed in the non-CR group. There were no relapsed cases in the CR group.

Effects of a planned preoperative exercise program on body composition in early gastric cancer patients with metabolic syndrome

206

Background: Visceral fat obesity and skeletal muscle depletion were reported to be both risk factors for complications in abdominal cancers surgery. Preoperative exercise may reduce morbidity by modifying body composition. Methods: We conducted an exploratory study attached to a prospective study (AEGES) to examine the effects of a 4-weeks exercise in stage I gastric cancer patients with metabolic syndrome. The AEGES enrolled 50 patients between 2007 and 2013, of which 18 were assigned to the exercise arm. The exercise program consisted of aerobic training 3-7 days a week, resistance training once or twice a week, and stretching. The expected energy expenditure of exercise was set at 30 kcal/kg/week. The total energy expenditure was measured using a calorie counter. After completion of the exercise, the patients received CT and endoscopy for re-staging, then underwent curative gastrectomy. Total skeletal muscle cross-sectional area (cm2) was evaluated on the average of two adjacent axial images at L3. Muscle area was expressed as lumber skeletal muscle index (cm2/m2). Total visceral fat volume was evaluated at the level of umbilicus. The changes of parameters before and after the exercise were assessed by paired Wilcoxon sign test. Results: A total of 15 patients with evaluable CT image were examined. Body weight, body mass index, and abdominal circumference were significantly decreased (-1.5 kg, -0.52 kg/m2, and -3.3 cm, respectively). The median skeletal muscle index was 48.06 cm2/m2 before and 46.85 cm2/m2 after the exercise, which was not statistically significant (p=0.41), while the median visceral fat volume was 205.2 cm2 before and 169.0 cm2 after the exercise, which was statistically significant (p=0.001). There was a weak correlation between total energy expenditure and amount of skeletal muscle index change (r=0.22 by Spearman’s correlation and p=0.427). No patient demonstrated progression of clinical cancer stage during 4 weeks. Conclusions: Preoperative exercise for 4 weeks could significantly modify body composition without progression of gastric cancer. More intensive or personalized exercise would be required to increase skeletal muscle.

Perioperative management of esophageal cancer surgery based on a modified ERAS protocol

99

Background: We have performed perioperative management using modified ERAS protocol after esophageal cancer surgery. Our protocol includes plaque control in collaboration with dental clinic, breathing training, nutrition support for low-nutrition, preoperative oral rehydration, pain control, early mobilization, early enteral nutrition and intestinal peristalsis monitoring by abdominal Xp with contrast agents after surgery, and so on. Methods: The aim of the study is to clarify the safety of our modified ERAS protocol as perioperative management of esohphageal surgery. 136 cases of thoracic esophageal cancer patients were performed with 3 field lymph node dissection between January 2011 and July 2014 using modified ERAS protocol(group A). 29 cases were performed classical postoperative management between September 2008 and November 2009(group B). We compared ventilator weaning dates, start dates of postoperative ambulation, start dates of enteral feeding, start dates of oral intake, length of hospital stay, the number of hospital death between group A and group B. Results: In group A, except two cases was extubated in POD1, start dates of postoperative ambulation was POD1(median), start dates of enteral feeding was POD1(median), start dates of oral intake was POD6(median), length of hospital stay was 15days(median), and the number of hospital death was 1case. On the other hand, in group B, dates of extubation was POD4(median), start dates of postoperative ambulation was POD2(median), enteral feeding was not sued for postoperative management, start dates of oral intake was POD15(median), length of hospital stay was 29days(median), and the number of hospital death was 2case. After introduction of this protocol, all these values were significantly reduced in group A rather than in group B. Walking distance were 130m(POD1), 322m(POD2), 509m(POD3), completion rate of enteral feeding was 90%, and the safety of enteral nutrition was also confirmed by peristalsis monitor using abdominal Xp with contrast agents or defecation state. Conclusions: It was considered that perioperative management of esophageal cancer surgery based on modified ERAS protocol is contribute to the early recover of postoperative status.

Long-term survival results of the patients who were enrolled to the feasibility study of laparoscopy-assisted distal gastrectomy for c-stage I gastric cancer

166

Background: We introduced laparoscopy-assisted distal gastrectomy (LADG) as multi-institutional feasibility study, and already reported that the overall morbidity rate was 1.6% in the study (Gastric Cancer 2012). The aim of this study is to evaluate the long-term survival results of the patients who were enrolled to the study and finished 5-year follow-up. Methods: A total of 165 c-stage I gastric cancer patients who were registered from Kanagawa Cancer Center were included to the study. The Kaplan-Meier method was used to evaluate overall survival and recurrence-free survival. Results: Median follow-up period of the patients was 1901 days. The reconstruction methods were either B-I (n=150), R-Y (n=14), or B-II (n=1). The accuracy for preoperative diagnosis of stage I was 87.2% (144/165). Among 14 patients with p-stage II/III excluding T3N0/T1N2-3, eight patients received postoperative adjuvant chemotherapy. The recurrence rates by pathological stage were 0% (0/123) for stage IA, 4.7% (1/21) for stage IB, 6.2% (1/16) for stage II, and 60% (3/5) for stage III/IV, respectively. The organ of recurrence was mainly observed in liver (n=3), followed by bone, lymph node, peritoneum (n=1). The 5-year recurrence-free survival rates were 94.5% for all patients, 97.2%/92.3%/60% for pT1/pT2/pT3/4, 98.5%/82.4%/71.4%/66.7% for pN0/pN1/pN2/pN3, 97.9%/81.3%/40% for p-stage I/p-stage II/p-stage III/IV. Conclusions: LADG for c-stage I gastric cancer was feasible in long-term result, as well as in short-term outcome.

Surgery for solitary pulmonary metastasis after curative gastrectomy for gastric cancer: Contribution to the long-term survival

102

Background: Surgical resection is rarely indicated for pulmonary recurrence after curative gastrectomy for gastric cancer because most tumors recurred as multiple nodules or carcinomatous lymphangitis / pleuritis and prognosis is extremely poor. However, some investigators reported a sporadic case developing a solitary pulmonary metastasis which was surgically resected and resulted in a relatively favorable clinical outcome. The present study aimed to clarify contribution of surgery for solitary pulmonary recurrence to the long-term survival. Methods: We performed a systematic review of the literature by searching the words of “stomach”, “neoplasms”, “lung”, and “metastasis” in the Pubmed and Japanese ICHUSHI database, and analyzed the cases reporting on resection of solitary pulmonary metastasis after curative gastrectomy for gastric cancer together with our cases treated at our hospital. Overall survival was estimated by Kaplan-Meier method. Results: A total of 45 patients, 42 from a systematic review and 3 from our cases, were examined. Median age (range) was 67 years (31–84 years). Primary gastric cancer had the following characteristics; histologically differentiated type in 30 patients, undifferentiated type in 2, and unknown in 13 patients and tumor depth of T1 in 3, T2 in 6, T3 in 13, T4 in 9, and unknown in 6. Surgery for the primary gastric cancer was total gastrectomy in 30 patients and distal one in 15. The median (range) disease-free survival (DFS) between initial gastric resection and the detection of pulmonary metastasis was 28.0 months (5-128 months). Surgery for pulmonary tumor was lobectomies in 20 patients, segmentectomies in 3, wedge resections in 18, and unknown in 4. Only 4 patients received adjuvant chemotherapy after pulmonary resection. The median (range) follow-up period after pulmonary surgery was 20 months (3-98 months). The overall survival after pulmonary resection was 86% at 1-year, 62% at 3-year, and 56% at 5-year with the median (range) survival time of 67 months (3-98 months). Conclusions: Surgery for solitary pulmonary recurrence could contribute to the long-term survival.

Risk factors for severe weight loss after gastrectomy for gastric cancer

38

Background: Body weight loss (BWL) is frequently observed in gastric cancer patients who underwent gastrectomy for gastric cancer. Recently, we reported that severe BWL after gastrectomy was a significant risk factor for continuation of S-1 adjuvant chemotherapy. However, risk factors of BWL after surgery remain unclear. Methods: The present study retrospectively examined the patients who electively underwent curative gastrectomy for gastric cancer between January of 2012 and June of 2014. All patients received peri-operative care of ERAS protocol. %BWL was calculated by percentile of body weight at one month after surgery to preoperative body weight. Severe BWL was defined as %BWL over 10%. Risk factors for severe BWL were determined by both univariate and multivariate logistic regression analyses. Results: Two-hundred seventy eight patients were examined. Median age (range) was 68 years (27-86). Median body mass index (range) was 22 (13.4-33.5). Thirty patients had received neoadjuvant chemotherapy. Operative procedure was total gastrectomy (TG) in 97 patients (Open in 61 and laparoscopic in 36) and distal gastrectomy (DG) in 181 patients (Open in 94 and laparoscopic in 87). Median operation time (range) was 268.5 minutes (95-554). Median blood loss (range) was 115 mL (0-1600). Morbidity of grade 2 or more defined by Clavien-Dindo classification was observed in 37 patients including pancreatic fistula in 8, anastomotic leakage in 5, and abdominal abscess in 3. No mortality was found. Completion of ERAS protocol without any variance was 95.3%. Median %BWL was 6% (-4.3% to 19.5%). Both univariate and multivariate logistic analyses demonstrated that morbidity (odds rate 3.56, p=0.001), blood loss over 300ml (odds rate 2.04, p=0.0356), and total gastrectomy (odds rate 2.1, p=0.0258) were significant risk factors for severe BWL. Conclusions: Nutritional intervention trial to inhibit BWL after gastrectomy should be focused on the patients who developed morbidity, showed blood loss over 300ml, or received total gastrectomy.

[The case of a solitary pulmonary tumor which could be diagnosed as early gastric cancer recurrence by detailed pathological examinations]

We report the case of a solitary pulmonary tumor, which was diagnosed as recurrent early gastric cancer by detailed pathological examinations. A 59-year old man initially underwent total gastrectomy for gastric adenocarcinoma located at the esophago-gastric junction. A pathological examination indicated a papillary adenocarcinoma (pap ) that had invaded the submucosal layer (sm²), but had not metastasized to the regional lymph nodes (n0). The final diagnosis was P0H0M0T1bN0, Stage IA. Chest computed tomography (CT) 30 months after primary surgery indicated a solitary tumor with a diameter of 9 mm at S3 of the left lung. A positron emission tomography (PET)-CT scan showed an accumulation of ¹⁸F-fluordeoxy-glucose (FDG18) at the same location. Lung cancer was suspected and the patient was given a left upper lobectomy. The resected tumor was diagnosed as gastric cancer metastatic adenocarcinoma by permanent pathological examination. The tumors showed similar histology and immuno histochemical findings for CK7, CK20, TTF-1, SP-A, CDX-2, and HER2 . Early gastric cancer is an almost curable disease and recurrence is very rare. We report the details of this case and review the literature.

Prediction of nodal metastasis in clinical T1 gastric cancer

21

Background: Clinical T1 gastric cancer sometimes metastasizes to regional lymph nodes. Standard surgery is D2 gastrectomy for clinical T1N+ gastric cancer patients, however, clinical detection of nodal metastasis by Computed Tomography is unreliable, with only 4% sensitivity in our previous study. The present study aimed to predict pathological nodal metastases in clinical T1 gastric cancer. Methods: Patients were selected from the prospective database of Kanagawa Cancer Center between Oct 2000 and Oct 2007 based on the following criteria; (1) histologically proven adenocarcinoma of the stomach, (2) patients were diagnosed with clinical T1 by gastrointestinal endoscopy, (3) patients received radical surgery with D1 or more lymphadenectomy as a primary treatment. First, univariate logistic-regression model was used to select risk factors for prediction of pathological nodal metastasis by analyzing clinical factors of tumor location, clinical depth (cT1a or cT1b), macroscopic type, maximal tumor diameter, and pathological type. Then, the optimal cut-off value and predictive accuracy was determined by ROC curve using significant factors selected in logistic regression. Results: A total of 511 patients were entered into this study. Among these, pathological N+ was observed in 46 patients (9.0%). Clinical depth (p=0.002), tumor diameter (p<0.001) and pathological type (p=0.002) were significant risk factors for pathological nodal metastasis. Using these factors in multivariate logistic regression, the AUC was calculated to be 0.75. Cut-off value was different depending on the histology and clinical depth; 7.9 cm for differentiated type and 4.8 cm for undifferentiated type in cT1a and 4.3 cm for differentiated type and 1.1 cm for undifferentiated type in cT1b. Using these criteria, sensitivity and specificity for prediction of pathological nodal metastasis were 67.4% and 71.6%, respectively. Conclusions: Pathological nodal metastasis in clinical T1 gastric cancer was predictable by clinical depth, pathological type, and tumor size, however, specificity was not so high. D2 surgery is highly recommended for clinical T1 when the tumors satisfy these criteria.

Colorectal cancer recurrence in the liver: detection by PET

Positron emission tomography (PET) has been successfully used in the imaging of various cancers. In this retrospective study, we examined clinical utility of PET in the imaging of liver metastasis from colorectal cancer. Results of PET were compared with those of ultrasonography (US) and contrast-enhanced computer tomography (CT) in 11 liver metastases seen in eight patients with recurrent colorectal cancer. The detection rates were 73% (8 of 11 metastases) by US, 73% (8 of 11 metastases) by CT, and 82% (9 of 11 metastases) by PET. PET correctly identified US-negative and CT-negative liver metastases. However, PET was negative in one patient with minute metastases. The findings in our preliminary study were in agreement with those of previous reports. A prospective study is warranted to determine the optimum role of PET in the management of patients with colorectal liver metastasis.