Rare recurrence pattern after complete response to chemotherapy in a patient with rectal cancer: a case report

BACKGROUND

Colorectal cancer (CRC) often metastasizes to the liver, lungs, lymph nodes, and peritoneum but rarely to the bladder, small intestine, and skin. We here report the rare metastasis of anal cancer in the left bladder wall, followed by metastases to the small intestine and skin, after abdominoperineal resection and left lateral lymph node dissection with chemotherapy in a patient with clinician Stage IVa disease.

CASE PRESENTATION

A 66-year-old man presented with 1-month history of bloody stool and anal pain and diagnosed with clinical Stage IVa anal cancer with lymph node and liver metastases (cT3, N3 [#263L], M1a [H1]). Systemic chemotherapy led to clinical complete response (CR) for the liver metastasis and clinical near-CR for the primary tumor. Robot-assisted laparoscopic perineal rectal resection and left-sided lymph node dissection were performed. Computed tomography during 18-month postoperative follow-up identified a mass in the left bladder wall, which was biopsied with transurethral resection, was confirmed as recurrent anal cancer by histopathologic evaluation. After two cycles of systemic chemotherapy, partial resection of the small intestine was performed due to bowel obstruction not responding to conservative therapy. The histopathologic evaluation revealed lymphogenous invasion of the muscularis mucosa and subserosa of all sections. Ten months after the first surgery for bowel obstruction and two months before another surgery for obstruction of the small intestine, skin nodules extending from the lower abdomen to the thighs were observed. The histopathologic evaluation of the skin biopsy specimen collected at the time of surgery for small bowel obstructions led to the diagnosis of skin metastasis of anal cancer. Although panitumumab was administered after surgery, the patient died seven months after the diagnosis of skin metastasis.

CONCLUSIONS

This case illustrates the rare presentation of clinical Stage IVa anal cancer metastasizing to the bladder wall, small intestine, and skin several years after CR to chemotherapy.

[A Case of Conversion Surgery for Unresectable Advanced Gastric Cancer of Which Metastatic Site Was Disappear by Chemotherapy but the Primary Site Was Enlarged after Five Years]

A 77-year-old man presented to our hospital with a chief complaint of stomachache. He received a diagnosis of unresectable advanced gastric cancer classified as cT3, N+, M1(LYM, HEP, OSS), Stage ⅣB. He underwent first-line chemotherapy with SOX, second-line treatment with PTX plus Ram, and third-line treatment with nivolumab. The primary tumor showed a reduction in size, and liver and lymph node metastases were not detectable. However, after 5 years of chemotherapy, a re- enlargement was observed in the primary gastric lesion without progression of liver and lymph node metastases. Subsequently, conversion surgery was performed. Based on the pathological analysis, the diagnosis was ypT1b2(SM2), N0(0/17), M0, ypStage ⅠA, R0. After nivolumab administration postoperatively for 5 months, chemotherapy was discontinued as there was no recurrence.

[A Case of HER2-Positive Unresectable Advanced Gastric Cancer Showing Long-Term Complete Response Treated by Only Chemotherapy]

A 78-year-old man was diagnosed as HER2-positive unresectable advanced gastric cancer(cT4aN3M1[LYM], Stage Ⅳ). After 2 courses of first-line chemotherapy(S-1 plus oxaliplatin plus trastuzumab), PR was achieved. The treatment could not be continued due to adverse events after 5 courses, thus second-line chemotherapy was conducted. Corresponding to the physical condition. The third-line chemotherapy was also introduced. However, we clinically judged PD because of amount of ascites and chemotherapy was terminated. After that, he has survived for more than 2 years without chemotherapy, and endoscopy and CT showed the disappearance of the tumor, metastatic lymph nodes, and ascites at 41 months after diagnosis. Looking back on the changes in tumor markers, it was possible that he had already achieved CR at the first-line chemotherapy.

[A Case of Lymph Nodes Metastases of Gastric Neuroendocrine Carcinoma Treated with Nivolumab and Showing Complete Response]

A 78-year-old man was diagnosed with lymph node metastasis 2 months after surgery for gastric neuroendocrine carcinoma. He received chemotherapy(CDDP plus CPT-11)and showed partial response(PR)after 3 courses of the regimen. Serum CEA increased 5 months after surgery, thus nab-paclitaxel plus ramucirumab was administered. Although the lymph node kept shrinked after 2 courses of the regimen, the lymph node was detected 12 cm of the size in CT after 5 courses of the regimen. He started to receive nivolumab. The lymph nodes showed PR after 4 courses, and complete response after 6 courses of the regimen for 1 year and 4 months until now.

Aggressive surgical intervention may improve prognosis in patients with ovarian metastasis from colorectal cancer

PURPOSE

The current study aimed to investigate the prognostic clinicopathological factors of synchronous and metachronous ovarian metastasis (OM) from colorectal cancer (CRC) in patients with and without oophorectomy.

METHODS

Female patients with OM from CRC who underwent primary tumor resection at our institution from January 2013 to December 2020 were evaluated.

RESULTS

Of 661 female patients, 22 (3.3%) were diagnosed with OM. Among 22 patients with OM, 12 underwent OM resection. Twenty (91%) patients had extra OM upon diagnosis. Thirteen (59%) patients in the non-surgery group had peritoneal dissemination at surgery or on computed tomography scan or positron emission tomography-computed tomography. Two patients in the OM surgery group had emergency surgery because of abdominal pain. Four patients had postoperative complications, and the median duration of hospital admission was 16.5 days. The median survival time from OM diagnosis to mortality was 20.9 months. Then, the association between the clinicopathological factors and overall survival (OS) was investigated. Tumor location and surgery were found to be related to OS (p = 0.03, 0.006, respectively) in the univariate analysis. However, only surgery was associated with OS (p = 0.02) in the multivariate analysis.

CONCLUSION

Surgery is an important prognostic clinicopathological factor of OM from CRC. OM tumors should be resected because OM surgery is less likely to cause complications and symptoms.

[A Case of Conversion Surgery for Gallbladder Cancer with Para-Aortic Lymph Node Metastasis]

The study presents the case of a 71-year-old woman who visited a nearby hospital for epigastric pain and weight loss. A CT scan showed a mass in the gallbladder, and the CEA level was high, so she was referred to our hospital for further investigation. Abdominal US, CT, and MRI suggested gallbladder cancer with para-aortic metastasis, and the histological findings on the EUS-FNA confirmed the diagnosis. Since surgical resection was not indicated, chemotherapy was performed(gemcitabine plus cisplatin). After 10 courses of chemotherapy, CT and MRI showed downsizing of para-aortic lymph nodes, and no accumulation of FDG was found on FDG-PET. Confirming the downstaging of cancer, conversion surgery, comprising an extended cholecystectomy and a lymph node resection, was performed. The pathological diagnosis showed no lymph node metastasis. No recurrence was observed after 12 months of surgery. Initially, unresectable gallbladder cancer with para-aortic lymph node metastasis was indicated to be compatible with preoperative chemotherapy and conversion surgery.

Perioperative fluid management influences complication rates and length of hospital stay in the enhanced recovery after surgery (ERAS) protocol for patients with colorectal cancer

PURPOSE

To evaluate the efficacy and safety of the enhanced recovery after surgery (ERAS) protocol and quantify the impact of each ERAS item on postoperative outcomes.

METHODS

We used a generalized linear model to compare 289 colorectal cancer patients treated with the ERAS protocol between June, 2015 and April, 2021, with 99 colorectal cancer patients treated with the conventional colorectal surgery pathway between April, 2014 and June, 2015.

RESULTS

The median length of hospital stay (LOHS) was significantly shorter in the ERAS group, at 9 days (range 3-104 days) vs. 14 days (range 4-44 days) (p < 0.001), but the complication rates (Clavien-Dindo grade 2 or more) were similar (16.6% vs. 22.2%; p = 0.227). However, in the ERAS group, the higher the compliance with ERAS items, the lower the complication rate and LOHS (both p < 0.001). Multiple regression analysis demonstrated that "Discontinuation of continuous intravenous infusion on POD1" and "Avoidance of fluid overload" were significantly associated with the LOHS (p < 0.001 and p = 0.008).

CONCLUSION

The ERAS protocol is safe and effective for elective colorectal cancer surgery, and compliance with the ERAS protocol contributes to shorter LOHS and fewer complications. Items related to perioperative fluid management had a crucial impact on these outcomes.

[A Case of Cardiac Tamponade during Multimodal Treatment for Mediastinal Lymph Node Metastasis of Gastric Cancer]

A 52-year-old man underwent total gastrectomy for gastric cancer and chemoradiotherapy for thoracic paraaortic lymph node metastasis. He also underwent esophageal stent implantation for stenosis. He was admitted to our hospital with fever and breathing difficulty and was diagnosed with infectious pericarditis. He showed symptoms of shock due to cardiac tamponade. After pericardial drainage, his vital signs improved. When signs of infection are detected in patients with a history of chemoradiotherapy or stent implantation, we should consider infectious pericarditis due to esophageal pericardial fistula and apply immediate drainage of cardiac tamponade.

[A Case of Long-Term Progress Control of Unresectable Progressive Gastric Cancer with Nivolumab Introduced during Effective Duration of Secondary Treatment]

A 65-year-old man with 1 month of general malaise was admitted to our hospital. Thoracoabdominal CT showed that the supra-clavicular, sub-carina, and para-aortic lymph nodes were swelling. Upper gastrointestinal endoscopy revealed 2 type 1 tumors at the esophagogastric junction, and the biopsy showed Group 5, well to moderately differentiated adenocarcinoma. The clinical diagnosis was cardiac gastric cancer and cStage Ⅳ(cT3N3M1[LYM]). We started capecitabine plus oxaliplatin as the first-line chemotherapy, and weekly paclitaxel plus ramucirumab was administered as the second-line treatment. The second-line treatment was successful, and the effect of PR was obtained. However, considering the period of TTF, while the therapeutic effect continued, we switched to third-line treatment with nivolumab after 7 courses of the second treatment. With the third-line treatment, PR was maintained for 1 year and 3 months, and good quality of life and performance status were obtained for a long period without irAE. However, after 32 courses, because the tumor marker was elevated and lymph nodes were enlarged, we judged PD and switched to the fourth-line treatment with nab-paclitaxel plus ramucirumab. The tumor marker levels decreased, the lymph nodes shrank, and PR was achieved again with the fourth-line treatment. The treatment is still ongoing 2 year and 8 months after the diagnosis.

[Two Cases of Large Gastrointestinal Stromal Tumors Safely and Completely Resected by Laparoscopic Surgery Followed by Neoadjuvant Imatinib Therapy]

Case 1, the patient was a 51-year-old man. Upper gastrointestinal endoscopy revealed a submucosal tumor with delle at the posterior wall of the gastric body, and the biopsy demonstrated a diagnosis of GIST. Abdominal CT scan showed a tumor at the size of 130×110×90 mm. Six months after administration of 400 mg/day of imatinib, the maximum diameter was reduced to 55 mm, then partial gastrectomy was performed by laparoscopic surgery. He continued to take imatinib after the surgery for 3 years, and he is alive without recurrence 4 years postoperatively. Case 2, the patient was a 68-year-old man. An abdominal CT scan showed a tumor at the size of 160×120×85 mm on the posterior outside of the stomach, but no submucosal tumor could be identified by upper gastrointestinal endoscopy. Gastric GIST was suspected and he started taking imatinib 400 mg/day. Because the Grade 3 generalized eruption was appeared, imatinib was discontinued, and then the dose was reduced. Nine months after the initiation of the treatment, the maximum diameter was reduced to 90 mm, and laparoscopic partial gastrectomy was performed. The patient is followed up without administration of imatinib after the surgery, and is alive without recurrence for 1 year and 6 months postoperatively. We report 2 cases that the large gastric GIST was able to be resected safely and completely due to tumor shrinkage by neoadjuvant imatinib therapy.

[Two Cases of Resectable Gastric Cancer with Extensive Nodal Metastasis That Received Preoperative DOS Therapy]

Case 1: A 67-year-old male had a type 1 tumor in the stomach with a lymph node metastasis 50 mm in size. He was diagnosed with cT4aN(+)M0, cStage Ⅲ and received preoperative docetaxel plus oxaliplatin plus S-1(DOS)therapy. After 3 courses of the regimen, the patient underwent laparoscopic total gastrectomy. The final stage was ypT3N1(1/38) M0, ypStage ⅡB, R0, and the pathological response was Grade 2b. Case 2: A 64-year-old male had a type 3 tumor in the abdominal esophagus and a lymph node metastasis 15 mm in size. He was diagnosed with cT3N(+)M0, cStage Ⅲ and received preoperative DOS therapy. After 3 courses, he underwent laparoscopic esophagectomy. The final stage was ypT0N0M0, ypStage 0, R0, and the pathological response was Grade 3. DOS therapy may be effective as a neoadjuvant chemotherapy.

[A Case of Pancreatic Pseudocyst Recurrence after Surgery for Remnant Pancreatic Cancer]

The patient was a 72-year-old man with a history of pancreatic cancer and IPMA treated with distal pancreatectomy. He had recurrence-free period after adjuvant chemotherapy with S-1. But 6 years after the surgery, a diameter of 1 cm mass was noted in the remnant pancreas on MRI examination after hepatocellular carcinoma treatment. The mass was diagnosed as remnant pancreatic cancer, and he had undergone partial pancreatectomy of remnant pancreas. The pathological diagnosis was pancreatic ductal carcinoma with negative margin. However, 6 months after the reoperation, epigastric pain appeared, and CT scan showed a pseudocyst of 10 cm in size. The diagnosis was local recurrence with positive cytology, and then puncture drainage was performed. After repeated drainages, adhesion of the cystic lesion, and chemotherapy, the cytology became negative and the cystic lesion disappeared, but peritoneal dissemination metastasis also appeared. The patient died of the primary disease 7 years and 8 months after the first surgery and 1 year and 11 months after the second surgery. There has been no report of local recurrence in the form of pancreatic pseudocyst after pancreatic cancer surgery, and we report this case with literature discussion.

[A Case of Hepatocellular Carcinoma with Extrahepatic Growth-A Difficult Preoperative Diagnosis]

A 75-year-old man was admitted to our hospital for breathing difficulty. CT showed a 20 cm mass with clear boundaries and internal non-uniformity, which we suspected to be a gastrointestinal stromal tumor(GIST). Surgical resection was been considered to be risky because the mass was close to surrounding organs, such as the stomach, liver and diaphragm. Thus, we chose imatinib therapy. After 2 months, he was admitted to our hospital for anemia. CT showed the size of mass to be smaller, but the area of low density with internal non-uniformity had increased. We diagnosed intratumoral bleeding, and chose surgical resection. The mass was under the omentum, and had infiltrated the extrahepatic area and lesser curvature of the stomach. We diagnosed the mass derived from the stomach, and performed partial gastrectomy with partial liver resection. Pathological diagnosis was extrahepatically growing hepatocellular carcinoma(HCC, pT3N0M0, pStage Ⅲ).

[A Case of Pancreaticoduodenectomy for Vater Papillary Cancer with Celiac Axis Stricture]

During the follow‒up of Vater papillary adenoma, a 74‒year‒old man was admitted to our hospital with a chief complaint of upper abdominal pain and diagnosed as cholangitis with obstructive jaundice. Cholestasis had been considered to be caused by papillary adenoma, however, EUS exam showed continuous bile duct wall irregularity from papilla of Vater. So we diagnosed as papillary carcinoma with extension to the distal bile duct. Preoperative CT showed the stenosis at the root of celiac artery, and hepatic blood flow was considered to be supplied via the pancreatic head arcade from superior mesenteric artery, so an anastomosis of gastroduodenal artery and inferior pancreaticoduodenal artery was performed during pancreaticoduodenectomy( PD). Like this case, when performing PD with celiac artery stricture, it is important to evaluate hepatic blood flow before and during surgery and prepare for the arterial reconstruction.

[Analysis of 16 Cases of Primary Duodenal Carcinoma in Our Hospital]

Primary duodenal carcinoma is a rare disease among gastrointestinal malignancies and has little evidence. We evaluated retrospectively the treatment status of 16 cases of primary duodenal carcinoma in our hospital between 2010 and 2019. The median age was 72(58-88)years and 63% of patients were male, and Each stage were Stage 0 in 4 cases, Stage Ⅰ in 1 case, Stage ⅢA in 2 cases, Stage ⅢB in 3 cases, and Stage Ⅳ in 6 cases(UICC 8th edition). Initial treatment was endoscopic therapy in 3 cases, surgery in 10 cases, chemotherapy in 1 case, and best supportive care in 2 case. The 2-year survival rate was 51.3% and the MST was 25.4 months in all cases. The Stage 0, Stage Ⅰ cases had all recurrence-free survival, while the Stage ⅢA or higher cases, 2-year survival rate was 33.8% and the MST was 20.0 months. Also, XELOX was often selected as the first-line treatment for chemotherapy regimens including recurrence treatment.

[A Long-Survived Case of Gastric Cancer with Multiple Liver Metastases Who Underwent Gastrectomy and Received Chemotherapy]

A 70-year-old man visited our hospital because of a body weight loss. Upper gastrointestinal fiberscope revealed a type 3 tumor and an enhanced MRI showed 30 or more liver metastases. He received docetaxel plus cisplatin plus S-1(DCS)therapy. Although main tumor had shrinked only partially, multiple liver metastases could not be detected. Thus, he was performed distal gastrectomy. After gastrectomy, he received S-1 plus oxaliplatin(SOX)therapy followed by S-1 therapy. Two years and 2 months after surgery, chemotherapy was finished because of no signs of tumor progression. He is alive without recurrence for 2 years and 11 months after gastrectomy.

[A Case Report of Hepatocellular Carcinoma with Complete Spontaneous Regression]

This is the case of a 77-year-old man with hepatitis C. AFP was increased by 95.9 ng/mL, and abdominal computed tomography(CT)revealed a 20 mm mass in the S6 segment of the liver. Therefore, the patient was referred to our hospital for further examination. Abdominal echo at our hospital showed a 10 mm, low echoic lesion in S6, which tended to shrink. Similarly, CT showed a low-concentration nodule of 10 mm in S6, but the contrast effect in the arterial phase was not clear. EOB-MRI showed a 10 mm nodule of DWI hyperintensity and hepatocyte phase hypointensity in S6. Based on these, a diagnosis of hepatocellular carcinoma(T1N0M0, StageⅠ)was made, and we decided to perform surgery. Intraoperative findings showed no tumor on the liver surface, and echo did not reveal a reproducible nodule. The tumor site was estimated using a 3-dimensional image analysis system created preoperatively. Laparoscopic partial resection of the liver S6 segment was performed at a position distant from the estimated tumor site. Rapid pathological examination showed no malignant findings, but no significant lesion was found in the residual liver, and the surgery was completed. The postoperative pathological diagnosis revealed no clear tumor. EOB-MRI was performed again postoperatively, but no tumor was found in the residual liver. The tumor site that had been indicated preoperatively was resected, and we hypothesized that the hepatocellular carcinoma had spontaneously regressed. Although several mechanisms have been reported for the spontaneous regression of hepatocellular carcinoma, few cases of spontaneous regression during surgery have been reported. We do not have a definite opinion on the treatment protocol for hepatocellular carcinoma that regresses spontaneously; therefore, we will report on past cases.

Primary adenosquamous carcinoma of the liver detected during cancer surveillance in a patient with primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is associated with significant risk for hepatobiliary cancers. Primary hepatic adenosquamous carcinoma (ASC), a rare subtype of cholangiocarcinoma, is composed of both adenocarcinoma and squamous cell carcinoma components. We herein report the case of a patient with PSC who was diagnosed with ASC of the liver during cancer surveillance. A 74-year-old male patient was diagnosed with PSC based on blood chemistry and magnetic resonance cholangiopancreatography findings, and regular surveillance for hepatobiliary cancers was initiated. Four years later, the level of carbohydrate antigen 19-9 rapidly increased, and abdominal imaging studies revealed a cystic mass, 40 mm in diameter, containing a solid component in the right liver lobe. Right lobectomy was performed with a pre-operative diagnosis of cholangiocarcinoma; however, the definitive diagnosis was ASC based on the presence of adenocarcinoma and squamous cell carcinoma components in the resected tumor. The patient did not receive post-operative chemotherapy, but was alive for more than 4 years without recurrence at last follow-up. The present case illustrates that regular surveillance and curative resection might achieve long-term survival in hepatic ASC, which has a poor prognosis.

[Case of Gastric Cancer with Para-Aortic Lymph Node Metastases Successfully Treated with S-1/Docetaxel Chemotherapy]

A 78-year-old man diagnosed with advanced gastric cancer and para-aortic lymph node metastases at clinical stage cT3 (SS)N1M1(LYN), Stage Ⅳwas treated with S-1/docetaxel(S-1/DTX)therapy. Eight months later, lymph node metastases resolved on abdominal CT, and the primary lesion appeared scarred when viewed by upper gastrointestinal endoscopy; this was considered to be a complete response(CR). S-1/DTX therapy was administered for a total of 16 courses, followed by 13 courses ofS -1 therapy. During the treatment, CR was maintained. Though chemotherapy was completed 2 years and 2 months after its initiation, the patient's serum CEA level was found to be elevated. As the serum CEA level gradually increased, S-1/DTX therapy was resumed. Three months after chemotherapy was restarted, PET-CT revealed multiple bone metastases. The chemotherapy protocol was changed to paclitaxel/ramucirumab therapy followed by nivolumab therapy. Disease control was difficult, and the patient died 9 months after reinstituting chemotherapy(3 years and 8 months after the first chemo- therapy). This case report summarizes our treatment ofa patient with advanced gastric cancer using S-1/DTX therapy for an extended period of time.

[Two Cases of Liver Metastasis from Gastric Cancer Achieving Long-Term Survival Successfully Treated with Stereotactic Body Radiotherapy(SBRT)]

We report 2 cases with long-term survival following stereotactic body radiotherapy(SBRT)for liver metastasis from gastric cancer. Case 1 was a 65-year-old man. We performed distal gastrectomy for gastric cancer with liver metastasis prior to chemotherapy due to pyloric stenosis. Postoperative S-1 chemotherapy was administered. Two liver metastases observed before the operation were temporarily reduced in size but subsequently enlarged; therefore, SBRT was performed 13 months postoperatively. The liver metastases showed a complete response(CR)and the patient is alive 4 years and 11 months after SBRT(6 years postoperatively). Case 2 was a 71-year-old woman. After performing distal gastrectomy, liver metastasis emerged during postoperative S-1 adjuvant chemotherapy; therefore, SBRT was performed 11 months postoperatively. She was then administered weekly paclitaxel. However, she underwent a right hepatic lobectomy 13 months after SBRT for suspected remnant or marginal recurrence by abdominal enhanced CT. Histopathological examination showed that the tumors contained fibrotic connective tissue with no viable cancer cell remnants; therefore, the therapeutic effect was determined to be of Grade 3. The patient is alive without recurrence in the remnant liver 4 years and 7 months after SBRT(5 years and 6 months after the operation of gastric cancer). Thus, SBRT for liver metastasis from gastric cancer may be considered an effective local treatment.

[A Case of Chemotherapy with Abscess Drainage for Pancreatic Cancer Detected Due to Peritonitis]

A 69-year-old woman was admitted to our hospital because of abdominal pain. Abdominal CT revealed free air, so we performed an emergency operation. Although the perforation site could not be confirmed, pancreatic cancer invading the stomach, spleen, and transverse colon was found. As a splenic abscess and peritoneal dissemination were also found, we created a colostomy and placed drains. Although the postoperative course was good, the splenic abscess continuous with the tumor remained. We thought that early removal of the drain would be difficult, so chemotherapy was introduced while continuing drainage. Fortunately, the pancreatic cancer was controlled, and the abscess tended to shrink, so we removed the tube 137 days after the surgery. After that, we continued chemotherapy, but in the second year after the surgery, the liver metastasis acutely exacerbated and DIC also developed, resulting in cancer death. If surgical intervention is difficult, as in this case, chemotherapy may be considered as an option, keeping in mind the possibility of exacerbation of infection.

[A Case Report of Long Survival in Pancreatic Cancer with Superior Mesenteric Arterial Invasion Following Multimodal Therapy]

The prognosis of pancreatic cancer with superior mesenteric arterial invasion is very poor and judgment of surgical indication is very difficult. We report a case that received multimodal therapy for pancreatic cancer with superior mesenteric arterial invasion. A 43-year-old woman consulted a local doctor because of upper abdominal pain. Ultrasonography revealed a nodule in the pancreatic body and elevated CA19-9 values. She was referred to our hospital for evaluation and therapy. Computed tomography showed a low-density area in the pancreatic body and around the superior mesenteric artery. The clinical diagnosis was pancreatic cancer with superior mesenteric arterial invasion. She received chemoradiation therapy(RT, 50.4 Gy, gemcitabine[GEM]plus TS-1)followed by distal pancreatectomy. She received adjuvant chemotherapy(TS-1)for 6 months. However, follow-up CTperformed 10 months after surgery revealed local recurrence. The patient received chemotherapy( GEM)for 8 months and GEM plus nab-PTX for 22 months. She died from the cancer 50 months after the primary operation.

[A Case of Gastric Cancer with Ramucirumab-Related Colon Perforation after a Subtotal Colectomy]

A 61-year-old man with advanced gastric cancer underwent distal gastrectomy after chemotherapy. Fifteen months later, peritoneal metastasis and colon stenosis were detected. Therefore, subtotal colectomy and ileosigmoidostomy were performed. Three weeks later, paclitaxel(PTX)treatment was initiated, followed by nab-PTX with ramucirumab(Ram)treatment at 7 weeks postoperatively. The patient experienced sudden abdominal pain diagnosed as gastrointestinal perforation 13 weeks postoperatively. Operative findings showed that the anastomosis of the ileosigmoidostomy was perforated, and this was treated using sutures. Angiogenesis inhibitors should be carefully administered even 4 weeks or more after surgery.

[A Case Report of Advanced Gastric Cancer with Synchronous Liver Metastasis Treated with Conversion Surgery after S-1 plus Oxaliplatin Chemotherapy]

Gastroscopy ofa 79-year-old man complaining ofanemia showed a type 3 tumor at the lesser curvature ofthe gastric body. A biopsy revealed poorly differentiated HER2-negative adenocarcinoma. Abdominal CT showed the tumor at the lesser curvature ofthe gastric body, multiple lymph nodes with a maximum diameter of 25mm at the lesser curvature, and a mass measuring 50mm with ring enhancement on S6 ofthe liver. The clinical diagnosis was cT4aN2M1(Hep), cStage Ⅳ. He was treated with chemotherapy comprising 4 courses ofS -1 plus oxaliplatin. Although the tumor had shrunk remarkably, chemotherapy was discontinued because of anorexia. Therefore, we performed total gastrectomy and hepatic partial resection(S6). The final staging was ypT3N0M0, ypStage ⅡA. We achieved R0 resection, and he has shown no recurrence without adjuvant chemotherapy for 3 years.

[Adjuvant Chemotherapy and the Prognosis of ypStageⅠ Gastric Cancer]

The efficacy of postoperative chemotherapy for patients with ypStageⅠgastric cancer has not been evaluated. We investigated the characteristics and prognosis of7 patients with ypStage Ⅰgastric cancer. cStages were ⅡA, ⅡB, ⅢB, and Ⅳin 1, 1, 1, and 4 patients, respectively. S-1 plus cisplatin and docetaxel plus cisplatin plus S-1 were administered in 5 and 2 patients, respectively, for 2-8 courses before gastrectomy. Microscopic curative resection was performed for all patients. ypStage was 0, ⅠA, and ⅠB in 1, 2, and 4 patients. All patients received postoperative chemotherapy with S-1 or docetaxel plus S-1(DS). The 5-year recurrence-free survival was 71% and the 5-year overall survival was 68%. Two patients developed recurrence. One patient developed recurrence 1 year and 1 month after gastrectomy in spite of S-1 treatment for 4 months. Another patient developed recurrence 11 months after gastrectomy after DS treatment for 4 months followed by S-1. The other 5 patients received S-1 for 1-5 years and have survived without recurrence. Although the prognosis ofypStage Ⅰgastric cancer was comparatively good, the regimen and courses ofpostoperative chemotherapy should be evaluated in a prospective study.

[A Case of Esophagogastric Junction Adenocarcinoma with Multiple Esophageal Intramural Metastases]

We experienced a case of multiple esophageal intramural metastasis from adenocarcinoma of the esophagogastric junction. A 58-year-old man was admitted complaining of dysphagia. Upper gastrointestinal endoscopy revealed a type 3 tumor at the esophagogastric junction. Biopsy showed Group 5, poorly differentiated adenocarcinoma. Abdominal CT indicated regional and para-aortic lymph node metastasis. Then the clinical diagnosis was established as Siewert type Ⅲ adenocarcinoma and cT4aN2M1(LYM), cStage Ⅳ. After conducting 4 courses of SP(S-1/cisplatin)therapy, endoscopy showed partial response of the primary tumor and the submucosal nodules in the lower esophagus. We performed lower esophagectomy and total gastrectomy by left thoracotomy and laparotomy. Six esophageal nodules were identified in the lower esophagus, and pathological examination proved the poorly differentiated adenocarcinoma. The esophageal tumors were diagnosed as intramural metastases. The patient showed hepatic and lymphatic recurrence 9 months after surgery, and died 15 months after surgery. Esophageal intramural metastasis from esophagogastric junction adenocarcinoma is relatively rare. We discuss this case along with a review of the literature.

[A Case of Peritoneal Dissemination of Hepatocellular Carcinoma after Laparoscopic Hepatectomy]

A 69-year-old man was found to have a hepatocellular carcinoma of 2.3 cm in diameter, with extrahepatic growth in liver S4 during follow-up for chronic hepatitis C and liver cirrhosis. We performed a laparoscopic partial liver resection, but the tumor capsule was injured by the retractor used to keep the working space at the bleeding site. The pathological diagnosis was moderately differentiated hepatocellular carcinoma(pT2N0M0, pStage Ⅱ). 7 months after the surgery, intrahepatic reoccurrence appeared. Thus, transcatheter arterial chemoembolization(TACE)and radiofrequency ablation were performed. However, a single recurrence ofperitoneal dissemination appeared 8 months after the reoperation. We selected laparoscopic operation this time. Intraperitoneally, we found 4 peritoneal disseminated lesions and resected all the lesions macroscopically. However, even after the resection, peritoneal dissemination recurred and increased. Therefore, we continued treatment with sorafenib and S-1 as systemic therapy, TACE and transcatheter arterial infusion(TAI)for the multiple recurrences in the liver, and radiotherapy for the peritoneal dissemination focuses. However, his general condition worsened, and liver failure occurred. Thus, he was shifted to complete palliative treatment and died 2 years 6 months after the initial operation. The recurrent form ofhepatocellular carcinoma is mainly an intrahepatic recurrence, and recurrence ofperitoneal dissemination is rare. In this case, the intraoperative operation was considered to be the possible cause ofthe recurrence.

[A Case of Urothelial Carcinoma Who Underwent Pancreaticoduodenectomy and Was Diagnosed with Groove Pancreatitis and Preoperatively Suffered from Duodenal Stenosis]

We report a case of a highly advanced urothelial carcinoma accompanied by duodenal stenosis with pancreaticoduodenectomy. A6 6-year-old man presented with upper abdominal pain and vomiting. Acute pancreatitis and hydronephrosis were diagnosed with urgent hospitalization, but jaundice appeared, and stenosis of the duodenum was also found. Thus, we suspected groove pancreatitis or pancreatic cancer, and performed pancreaticoduodenectomy. However, poorly differentiated adenocarcinoma was observed in the retroperitoneal dissection surface in the intraoperative rapid tissue and right hemicolectomy, right nephrectomy, and right ureteral resection were added to the diagnosis. The final diagnosis was urothelial carcinoma. GEM plus CBDCAtherapy was administered as adjuvant chemotherapy. However, obstructive jaundice, acute cholangitis, and acute pancreatitis developed due to occlusion of the intestine due to local recurrence 4 months after surgery. We attempted to reduce yellowing by PTCD; perforation of the small intestine also occurred and a drainage tube was placed in the abdominal cavity. Although a lull condition was obtained, intestinal obstruction due to cancer peritonitis worsened and the patient died 8 months after the operation. In this case, there was no hematuria before surgery and cytology results of urine were negative, so a diagnosis of urinary tract cancer was difficult. There was no report of duodenal stenosis due to urothelial carcinoma.

[Multimodality Therapy for Cecal Cancer with Peritoneal Dissemination]

We report a case of cecal cancer with peritoneal dissemination. A 72-year-old man with cecal cancer(pT4N2M0H0P3, pStage IV )underwent ileocecal resection in 2010. The patient received 106 courses of chemotherapy(FOLFIRI plus Cmab) for peritoneal dissemination after surgery. However, follow-up CT performed 50 months after primary resection detected liver metastasis, which was resected in 2015. The patient received 19 courses of chemotherapy(FOLFIRI plus Cmab)after hepatectomy. The peritoneal dissemination with the diaphragm, retroperitoneal and right inguinal region, were growing 20 months after the 2nd operation. Surgical resection of the peritoneal dissemination was performed in 2016. The patient is alive 81 months after the 1st operation.

[A Case of Alpha-Fetoprotein-Producing Gastric Cancer with Synchronous Liver Metastasis Achieving Recurrence-Free Survival for Five Years by Gastrectomy, Hepatectomy, and Adjuvant Chemotherapy]

a-fetoprotein(AFP)-producing gastric cancer is relatively rare and tends to show a poor prognosis because of hepatic and lymph node metastasis. We experienced a case of AFP-producing gastric cancer with synchronous liver metastasis wherein the patient survived for 5 years without recurrence after undergoing surgery and adjuvant chemotherapy. A 39-year-old woman was admitted to our hospital complaining of tarry stool. Upper gastrointestinal endoscopy revealed a 40mm type 2 tumor in the greater curvature of the lower gastric body, and abdominal CT indicated a 50mm liver metastasis at the S2 segment. The AFP serum level had risen to 71,000 ng/mL. We performed distal gastrectomy and hepatic left lateral segmentectomy. The primary gastric tumor and the hepatic metastasis were both positive for AFP by immunohistochemistry. After conducting 3 courses of S-1/CDDP(SP)therapy as adjuvant chemotherapy, the serum level of AFP had decreased to normal levels. Be- cause the level had risen to 116 ng/mL after a change to S-1 oral administration alone, we decided to re-start SP therapy and carried out 16 courses through the third postoperative year. The patient is still alive without recurrence 5 years after surgery.

[The Experience of the Intensity Modulated Radiation Therapy for Abdominal Lymph Node Metastases from Gastric Cancer]

The recurrence ofgastric cancer has a poor prognosis in spite ofsystemic chemotherapy. We report three cases oflocal control ofdisease after the recurrence owing to intensity modulated radiation therapy(IMRT). The first case was a 66-yearsold man. He was received distal gastrectomy after neoadjuvant chemotherapy for advanced gastric cancer. Abdominal lymph node metastases appeared 1 year and 7 months after the surgery. IMRT was performed and he keeps CR for 1 year and 8 months. The second case was a 72-years-old man. He received proximal gastrectomy for early gastric cancer. Abdominal lymph node metastasis appeared 1 year and 9 months after the surgery. IMRT was performed and he keeps CR for 1 year. The third case was a 71-years-old woman. She received distal gastrectomy for advanced gastric cancer. Abdominal lymph node metastasis appeared 2 years after the surgery. IMRT was performed and she keeps CR for 10 months. We experienced longtime CR after IMRT against abdominal lymph node metastasis. IMRT could be one ofthe strategies ofthe comprehensive treatment for the recurrence of gastric cancer.

[Multidisciplinary therapy for recurrent pancreatic cancer]

We report 2 cases of pancreatic cancer with distant organ metastasis. Case 1: A 67-year-old man with pancreatic cancer (T3N0M0, Stage III) underwent pancreaticoduodenectomy (PD). A follow-up computed tomography (CT) scan performed 48 months after the primary resection detected two masses in his right lung, which were treated by stereotactic body radiotherapy ( SBRT). Twenty-three months after SBRT, the patient is alive. Case 2: A 54-year-old woman with pancreatic cancer (T3N1M0, Stage III) underwent PD. A follow-up CT scan performed 12 months after the primary resection detected 3 masses in her liver, which were treated by SBRT. The patient died because of lymph node metastasis of the pancreatic cancer 32 months after SRT.

[Response to neoadjuvant chemotherapy in breast cancer as assessed by subtype]

The aim of this study was to investigate the responses to neoadjuvant chemotherapy (NAC) in breast cancer according to subtype. The study included 69 women who received NAC at our hospital between January 2004 and January 2013. Complete response( CR) was achieved in 14 patients( 20.3%) and partial response( PR) was achieved in 37 patients (53.6%).CR and PR rates according to subtype were as follows: 0% and 57.1% for the luminal type, 0% and 66.7% for the luminal-human epidermal growth factor receptor (HER)-2 type, 16% and 56% for the triple negative type, and 58.8% and 41.2% for the HER2 type, respectively. The CR rate was the highest among patients with HER2-type breast cancer. Trastuzumab was additionally administered to 12 patients with HER2-type breast cancer, and the CR rate among these patients was significantly higher after trastuzumab treatment( 75%).Thus, it is important to select a treatment strategy for breast cancer on the basis of the subtype diagnosed.

[Clinical significance of neutrophil to lymphocyte ratio in colorectal cancer patients receiving adjuvant chemotherapy combined with polysaccharide-K]

The neutrophil to lymphocyte ratio (N/L ratio) has been reported to be related to the prognosis of various types of cancer. In particular, a high N/L ratio has been suggested to be associated with poor outcome. We investigated the changes in N/L ratio during treatment in 12 patients who had undergone surgery for colorectal cancer and were receiving postoperative adjuvant therapy with a combination of chemotherapy and polysaccharide-K (PSK). The patients were stratified into 2 groups according to the preoperative N/L ratio (cut-off ratio was 2.5): high N/L (≥2.5) and low N/L (<2.5). The changes in N/L ratio and other clinical parameters over time were investigated. In patients with a high preoperative N/L ratio, the use of postoperative PSK-chemotherapy controlled the N/L ratio at low levels. The N/L ratio tended to remain low in patients with low preoperative N/L ratios. No difference in outcome was observed between patients with high and low N/L ratios. In patients who underwent colorectal cancer surgery, postoperative adjuvant therapy with a combination of chemotherapy and PSK succeeded in controlling the N/L ratio at low levels. Further studies with more patients are required to explore the outcomes associated with changing N/L ratios.

[Resection and postoperative multidisciplinary treatment for hepatocellular carcinoma with massive portal venous tumor thrombus-a single-center experience]

BACKGROUND

Patients with advanced hepatocellular carcinoma( HCC) with massive portal venous tumor thrombus (PVTT) face a dismal prognosis as no standard therapy has been defined. A cancer board was established at our hospital 5 years ago.

OBJECTIVE

The aim of this retrospective study was to evaluate our surgical and multidisciplinary treatment for HCC with massive PVTT.

PATIENTS AND METHODS

From July 2007 to June 2012, 8 patients with HCC with PVTT extending into the main portal trunk were treated. Hemihepatectomy and PVTT removal were performed in 4 patients. Postoperative multidisciplinary treatment included transarterial chemoembolization, hepatic arterial infusion therapy, and administration of sorafenib. In 1 patient, intrahepatic recurrence and bilateral adrenal metastases were resected.

RESULTS

There was no in- hospital mortality. The median postoperative hospital stay was 30 days. The overall median survival for patients who underwent surgery and who did not undergo surgery was 344.5 days and 67 days, respectively.

CONCLUSIONS

Resection for HCC with PVTT extending into the main portal trunk is acceptable at medium-scale teaching hospitals in Japan. Surgery and postoperative multidisciplinary therapy may improve the outcome of patients with HCC with massive PVTT.

Predominance of β-cell neogenesis rather than replication in humans with an impaired glucose tolerance and newly diagnosed diabetes

CONTEXT

A decrease in pancreatic β-cell mass is involved in the development of type 2 diabetes.

OBJECTIVE

The purpose of this study was to evaluate the β-cell mass and the incidence of β-cell neogenesis, replication, and apoptosis at both the prediabetic and diabetic stages.

METHODS

We conducted a cross-sectional study of pancreatic tissues obtained from 42 patients undergoing a pancreatectomy who were classified into 4 groups: normal glucose tolerance (n = 11), impaired glucose tolerance (n = 11), newly diagnosed diabetes (n = 10), and long-standing type 2 diabetes (n = 10).

RESULTS

The relative β-cell area decreased and the β-cell apoptosis increased during the development of diabetes. The number of single and clustered β-cells, some of which coexpressed nestin, increased in the patients with impaired glucose tolerance and newly diagnosed diabetes. The prevalence of cells positive for both insulin and glucagon or somatostatin also increased in these patients compared with those with normal glucose tolerance. These double-positive cells were mainly localized in single and clustered β-cells, rather than large islets, and were also positive for Pdx1 or Ngn3. The percentage of insulin-positive cells embedded within ducts increased in the impaired glucose tolerance group. There were no significant differences in the incidence of cells positive for both insulin and Ki67 among the groups.

CONCLUSIONS

These results suggest that β-cell neogenesis, rather than replication, predominates during impaired glucose tolerance and newly diagnosed diabetes in humans and may serve as a compensatory mechanism for the decreased β-cell mass.

[A case of severe subcutaneous emphysema during laparoscopic right-hemicolectomy]

A 76-year-old woman, weighing 40 kg, was scheduled for laparoscopic right-hemicolectomy. Forty minutes after starting the laparoscopic procedure, PaCO2 increased to 64.3 mmHg. Massive subcutaneous emphysema from the anterior thorax to the abdomen was noted and we stopped the laparoscopic procedure. In the laparoscopic procedure for the treatment of colectomy, it is important to discover abnormalities such as snowball crepitation and arrhythmia, and to monitor ETCO2 continuously in order to avoid massive subcutaneous emphysema and hypercapnia. During a laparoscopic procedure, hypercapnia might cause acidosis, arrhythmia, hypotension, myocardial ischemia, and cardiac arrest.

[Two long-term survival cases of Stage IV colon cancer through multidisciplinary treatment]

We report the long-term survival in two cases of colon cancer through multidisciplinary treatment, including surgery. Case 1: A 67-year-old male patient underwent anterior rectal resection, partial hepatectomy(S4, S5, S5/8) and cholecystectomy for rectal cancer with liver metastasis in July 2006(pSS, pN0, sH1, sP0, sM0, Stage IV, Cur B). Liver metastasis, lung metastasis, and metastatic colon cancer occurred 5 times during the 59 months following the first operation. We performed surgery and adjuvant chemotherapy to treat each recurrence. Case 2: A 42-year-old male patient underwent sigmoidectomy for sigmoid colon cancer with multiple liver metastasis in May 2007 (pSS, pN0, sH2, sP0, sM0, Stage IV, Cur C). Recurrence occurred 7 times at the liver and lung during the 58 months after the first operation. We performed surgery and adjuvant chemotherapy to treat each recurrence.

[Three cases of sigmoid colon cancer accompanied by invagination]

Invagination in adults is rare compared to children. We experienced 3 sigmoid colon cancers in which symptoms of invagination were discovered. Because the tumors in 2 of the 3 cases could be reduced, operations were electively performed. The tumor in the remaining case could not be reduced and an urgent operation was required. Because all cases responded in the early stage, their postoperative progress was good. Invagination in adults is typically caused by an organic disease, particularly cancer. It is necessary to consider not only reduction of the invagination but also treatment of the primary disease causing invagination. It is important that the malignant symptoms be detected promptly in order to develop a suitable treatment strategy.

[A resected case of signet-ring cell carcinoma of the rectum]

Here, we present the case of a 76-year-old woman who consulted us in April 2010, following a positive fecal occult blood test, and was diagnosed with lower rectal cancer. Signet-ring cell carcinoma was diagnosed by histology. Because hydronephrosis of both sides was considered the cause of dissemination of the tumor, only chemotherapy was performed. After the eighth course of XELOX+bevacizumab treatment, hydronephrosis of both sides improved and the tumor marker level became normal. An abdominoperineal rectal resection was performed in February 2011. The results of pathological examination of the resected specimen showed complete response. After the operation, the tumor marker level was elevated, and recurrence in the pelvic cavity and multiple bone metastases were detected by positron emission tomography/ computed tomography. Chemotherapy has now been resumed. Signet-ring cell carcinoma is rare in colorectal cancer. The frequency of multiple organ metastases is high, and the growth rate of the tumor is also high. Poor prognosis compared to the usual colorectal cancer has been reported.

Preoperative insulin secretion ability and pancreatic parenchymal thickness as useful parameters for predicting postoperative insulin secretion in patients undergoing pancreaticoduodenectomy

Periampullary malignant neoplasms have been increasing in Japan, mainly in response to an increase in the incidences of pancreatic cancer, and glucose intolerance due to deterioration of insulin secretion is an important problem. We investigated preoperative parameters to predict postoperative insulin secretion and the need for insulin therapy in patients undergoing pancreaticoduodenectomy (PD). Thirty-six patients with malignant neoplasms of periampullary lesions were enrolled. Preoperative pancreatic parenchymal thickness was evaluated by computed tomography. Insulin secretion and glucose tolerance were evaluated by a 75-g oral glucose tolerance test and an intravenous glucagon loading test. The relationships between postoperative insulin secretion and preoperative parameters and the cut-off values for predicting the need for postoperative insulin therapy for glycemic control were investigated. Pancreatic parenchymal thickness and other preoperative parameters, including the increment of serum C-peptide (Δ C-peptide), fasting plasma C-peptide (F-CPR), insulinogenic index (I.I.) and fasting plasma glucose (FPG), were significantly associated with postoperative insulin secretion. Multiple regression analyses revealed that preoperative Δ C-peptide or F-CPR was the most significant determinant of postoperative insulin secretion, followed by pancreatic parenchymal thickness. In the receiver operating characteristic curve, the best preoperative cut-off values for predicting the need for postoperative insulin therapy were a Δ C-peptide of 0.65 ng/mL, a F-CPR of 0.85 ng/mL and a pancreatic parenchymal thickness of 6.0 mm. Both preoperative insulin secretion and pancreatic parenchymal thickness effectively predict postoperative insulin secretion and identify subjects who need postoperative insulin therapy for glycemic control.

CD13 is a therapeutic target in human liver cancer stem cells

Cancer stem cells (CSCs) are generally dormant or slowly cycling tumor cells that have the ability to reconstitute tumors. They are thought to be involved in tumor resistance to chemo/radiation therapy and tumor relapse and progression. However, neither their existence nor their identity within many cancers has been well defined. Here, we have demonstrated that CD13 is a marker for semiquiescent CSCs in human liver cancer cell lines and clinical samples and that targeting these cells might provide a way to treat this disease. CD13+ cells predominated in the G0 phase of the cell cycle and typically formed cellular clusters in cancer foci. Following treatment, these cells survived and were enriched along the fibrous capsule where liver cancers usually relapse. Mechanistically, CD13 reduced ROS-induced DNA damage after genotoxic chemo/radiation stress and protected cells from apoptosis. In mouse xenograft models, combination of a CD13 inhibitor and the genotoxic chemotherapeutic fluorouracil (5-FU) drastically reduced tumor volume compared with either agent alone. 5-FU inhibited CD90+ proliferating CSCs, some of which produce CD13+ semiquiescent CSCs, while CD13 inhibition suppressed the self-renewing and tumor-initiating ability of dormant CSCs. Therefore, combining a CD13 inhibitor with a ROS-inducing chemo/radiation therapy may improve the treatment of liver cancer.

[A case of long-term survival for advanced gallbladder cancer]

A 50-year-old woman with epigastric uncomfortable feeling was referred to our hospital. We have diagnosed her as an advanced gallbladder cancer with direct liver invasion and lymph node metastasis of hepatoduodenal ligament by the image analysis, including enhanced abdominal CT, MRI and FDG-PET. Subsequently, we performed operation with cholecystectomy, hepatic segmentectomy of S4a/5, bile duct resection and D2 lymph node dissection, resulted in the curative operation. We additionally performed adjuvant chemotherapy with 6 courses of 800 mg/m2 of gemcitabine (GEM) on days 1, 8 and 15 for every 35 days. No recurrent signs were observed for 33 months after curative operation.

Intraperitoneal administration of paclitaxel and oral S-1 for a patient with peritoneal dissemination and hydronephrosis due to advanced gastric cancer

We report a patient with type 3 gastric cancer with peritoneal dissemination and hydronephrosis who was successfully treated with intraperitoneal infusion of paclitaxel and oral administration of S-1. He was diagnosed with unresectable gastric cancer with severe peritoneal dissemination by staging laparoscopy. We selected combined chemotherapy with both paclitaxel and S-1. Paclitaxel at 60 mg/m(2) was administered intraperitoneally on days 1 and 8, and S-1 at 100 mg/body was administered orally for 14 days, followed by 7 days' rest, as one course. After five courses, primary tumor reduction was confirmed and no cancer cells were detected on pathocytological investigation at second-look laparoscopy. The patient underwent total gastrectomy with lymph node dissection. He died from liver metastasis 29 months after the initial treatment, but he had not suffered from peritoneal metastases and had kept a good quality of life (QOL) since that treatment. This chemotherapy can be applied as one of the promising candidates for the treatment of patients with peritoneal metastasis of gastric cancer.

Preoperative manometry is not a predictor of postoperative dysphagia in chagasic achalasia

We report a case of gastric cancer with peritoneal recurrence that responded to chemotherapy with paclitaxel and TS-1. A 62-year-old woman, who underwent total gastrectomy for advanced gastric cancer 2 years and 6 months ago, was admitted to our hospital with a chief complaint of abdominal distention and intestinal obstruction due to a large amount of ascites. Cytology of ascites revealed peritoneal dissemination, and chemotherapy with bi-weekly paclitaxel (90 mg/body) was begun. Clinical symptoms, including ascites and intestinal obstruction, were improved only after the second administration of paclitaxel. As she was able to take food orally, she was placed on combined chemotherapy consisting of tri-weekly paclitaxel (9 0 mg/body-120 mg/body: day 1) and TS-1 (80 mg/day: day 1-14) and 1 or 2 weeks rest. The patient had no signs or symptoms of peritoneal metastasis or toxicity except for general fatigue and watery eyes 1 year and 8 months after the diagnosis of peritoneal metastasis. Paclitaxel and TS-1 therapy was thought to be an effective chemotherapy against recurrent gastric cancer with peritoneal dissemination.

[Two cases of gastric cancer with peritoneal dissemination that responded to TS-1 without progression or recurrence for over 3 years]

for over 3 years. A 67-year-old woman underwent distal gastrectomy for advanced gastric cancer. Histological examination of several nodules in the posterior gastric wall led to suspicion of peritoneal dissemination. Low-dose FP treatment was performed for only 5 days after surgery. Peritoneal dissemination was diagnosed at the time of surgery for postoperative abdominal hernia 20 months after the gastrectomy. TS-1 was administered postoperatively, and recurrence or progression has not been detected for 3 years 4 months. Another patient, a 68-year-old woman,underwent distal gastrectomy for advanced gastric cancer with multiple lymph node metastasis and peritoneal dissemination. TS-1 was administered after surgery, and no recurrence or progression has been detected for 3 years and 7 months. These cases suggest that TS-1 is a promising treatment for gastric cancer with peritoneal dissemination.

[Two cases of successful local control with intermittent hepatic arterial infusion therapy using 5-FU and external radiation therapy for unresectable advanced gall bladder cancer]

Unresectable advanced gall bladder cancer has a very poor prognosis. No good chemotherapeutic regimen is available. We report two cases of unresectable advanced gall bladder cancer patients who received the combination of intermittent hepatic arterial infusion chemotherapy and external radiation therapy. A 45-year-old male was alive for 576 days, and a 69-year-old male was alive for 246 days after the first diagnosis. They have been able to maintain a good quality of life without any severe adverse effects.

[A case of gastric cancer with peritoneal dissemination which showed the intraperitoneal CR by administrating TS-1 orally and paclitaxel intraperitoneally]

A 66-year-old male was diagnosed with advanced gastric cancer with pylorus stenosis, and the first abdominal computed tomography (CT) revealed a large amount of ascites. A staging laparoscopy revealed peritoneal dissemination and positive cytology for numerous amounts of ascites (s-T3(SE), N0, M0, p(+), cy(+), H0, s-Stage IV). The patient received TS-1 orally and paclitaxel administered to the peritoneal cavity. After finishing the second course of the combined chemotherapy, second-look staging laparoscopy was performed, which showed the disappearance of peritoneal dissemination and negative cytology. Chemotherapy combined with oral TS-1 and paclitaxel administered to the peritoneal cavity might be an effective strategy against advanced gastric cancer with peritoneal dissemination.