Efficacy of pleural coverage with polyglycolic acid sheet after bullectomy for postoperative recurrence of spontaneous pneumothorax in young patients: a multi-institutional cohort study

OBJECTIVE

Various surgical procedures have been performed to decrease the recurrence of primary spontaneous pneumothorax after video-assisted thoracic surgery. This study aimed to examine the efficiency of pleural coverage for the prevention of postoperative recurrence in relatively young patients.

METHODS

Between January 2008 and December 2012, a total of 357 cases of 345 patients (age 15-29 years) with primary spontaneous pneumothorax who underwent bullectomy at 13 institutions were enrolled in this multi-institutional retrospective cohort study. A concurrent bilateral operation was counted as two cases. Polyglycolic acid sheets were used in 238 cases, and oxidized regenerated cellulose sheets were used in 37 cases to cover the visceral pleura, with no pleural coverage in 82 cases. The average observation period was 4.2 ± 2.0 years.

RESULTS

Postoperative recurrence was observed in 50 cases (14.0%) after video-assisted thoracic surgery. Twenty-six cases (10.9%) in the polyglycolic acid group, eight (21.6%) in the oxidized regenerated cellulose group, and sixteen (19.5%) in the non-coverage group experienced postoperative recurrence. Kaplan-Meier analysis revealed that the rate of freedom from postoperative recurrence in the polyglycolic acid group was significantly higher than that in the non-coverage group. Multivariate analysis showed that age ≥ 20 years and coverage with polyglycolic acid sheets were associated with reduced risk factors for postoperative recurrence.

CONCLUSION

Pleural coverage with a polyglycolic acid sheet is suggested to be effective in preventing postoperative recurrence of pneumothorax compared with non-coverage in relatively young patients.

Upfront surgery in patients with clinical skip N2 lung cancer based on results of modern radiological examinations

Background

Direct lymphatic drainage from a primary tumor to the right paratracheal or aortic window lymph nodes is often noted in pN2 disease. This multi-institutional retrospective study investigated the outcomes of upfront surgery in patients with clinical skip N2 disease (N2 disease without N1 disease) and a tumor in the right upper lobe or left upper segment based on results of modern radiological examinations, including positron emission tomography (PET).

Methods

We identified 143 patients with cN2 disease who underwent upfront surgery in 12 institutions under the Thoracic Surgery Study Group of Osaka University between January 2006 and December 2013. Among 143 patients, 94 who underwent PET were analyzed. We classified these patients into Group A (n=39; clinical skip N2 disease and a tumor in the right upper lobe or left upper segment) and Group B (n=55; other).

Results

The median follow-up was 56.5 months. Among the 94 patients, 50 (53.2%) had skip N2 disease and 65 (69.1%) had a tumor in the right upper lobe or left upper segment. The 5-year overall survival (OS) rates of the 94 patients with cN2 disease was 47.9%. The 5-year OS rates for the cN2pN0/1 (n=22) and cN2pN2 (n=70) groups were 74.9% and 41.2%, respectively (P=0.034). The univariate analysis of OS revealed no significant differences in age, sex, histology, carcinoembryonic antigen (CEA) level, tumor size, PET findings, and number of metastatic lymph nodes when these parameters were dichotomized. A significantly better 5-year OS rate was observed in Group A than in Group B (64.0% vs. 37.0%; P=0.039). The multivariate analysis of OS revealed that Group A was a significantly prognostic factor (P=0.030).

Conclusions

Patients with cN2 disease in Group A had a more favorable prognosis. Upfront surgery may be a treatment option for such selected patients with non-small lung cancer in the specific group.

Laparoscopic colectomy after self-expanding metallic stent placement through the ileocecal valve for right-sided malignant colonic obstruction: A case report

A 78-year-old man with a history of open sigmoidectomy for sigmoid cancer presented with abdominal pain and vomiting. Abdominal multi-detector CT revealed an obstructive ileocecal tumor with distended small bowel on the oral side. We performed emergency drainage using a transnasal decompression tube, and 2 days later, we conducted a colonoscopic examination, which lead to a provisional diagnosis of obstruction with a malignant tumor invading the ileocecal valve. We then placed a self-expanding metallic stent (SEMS) through the ileocecal valve. We confirmed patency of the ileocecal valve and removed the transnasal decompression tube 2 days after SEMS placement. We then performed elective laparoscopic colectomy 8 days after SEMS placement. To the best of our knowledge, there has been only one previous report of laparoscopic colectomy after decompression with SEMS placement through the ileocecal valve for right-sided malignant colonic obstruction.

Broad ligament hernia successfully repaired by single-incision laparoscopy: A case report

A 52-year-old woman with a history of two parturitions presented with lower abdominal pain. Multi-detector CT of the abdomen showed discontinuity of the sigmoid colon near the broad ligament on the left side. We assigned a provisional diagnosis of an internal hernia progressing through a defect in the broad ligament. SILS revealed a total broad ligament defect on the left side but no signs of ischemic, necrotic bowel. We successfully repaired the broad ligament defect with suturing. At the 2-month follow-up, the patient remained well with no signs of recurrence. This case appears to be the first report of a broad ligament hernia successfully diagnosed and repaired by SILS.

[A Case Report - A Case of a Rapidly Growing Anal Canal Origin Malignant Melanoma]

An 85-year-old woman presented to her local physician in early August 2015 with a new-onset "swelling" of the anal region and was referred to our department for evaluation and treatment at the beginning of September. At our initial evaluation, the rectal examination showed a black mass lesion, approximately 3.0×1.5 cm in size, in the anal canal by November, the mass had grown to approximately 7.0×3.5 cm in size. The lesion was diagnosed as malignant melanoma by colonoscopic biopsy. Abdominal cystography computed tomography showed an area of lymphadenopathy around the rectum, but no distant metastasis was detected. The patient underwent abdominoperineal resection of the rectum in December. Her postoperative course was good, and she was discharged on the 30th postoperative day. Arecurrent lesion was detected at a recent follow-up examination(approximately 5 months post-discharge), and the patient has been scheduled for immunotherapy. Malignant melanoma of the anal canal has a poor prognosis, and no standard therapy has been established. This report includes a brief review of current literature about the disease.

[A Case of Angioimmunoblastic T-Cell Lymphoma Merged with Colorectal Cancer That We Were Able to Resect after a Chemotherapy Response]

The patient was 77-year-old man. He visited our hospital with the chief complaint of an abdominal mass in March 2015. We diagnosed the patient with transverse colon cancer and he was suspected of having malignant lymphoma. In March 2016, we attempted to perform right hemicolectomy for the transverse colon cancer, but it was difficult because swollen lymph nodes had formed a large mass with the surrounding tissue, including vessels of the mesentery. We could only complete the surgery after mesenteric lymph node biopsy. On the basis of the results of this biopsy, we diagnosed angioimmunoblastic Tcell lymphoma. At first, we administered THP-COP therapy for malignant lymphoma. However, after 3 courses of this therapy, the patient suddenly developed ileus due to the aforementioned colon cancer. According to enhanced CT performed at the onset of intestinal obstruction, chemotherapy dramatically reduced the size of the intraperitoneal lymph nodes. We therefore concluded that it was able to treat the colon cancer. We performed right hemicolectomy in June 2015. Angioimmunoblastic T-cell lymphoma comprises only 2-3% of all malignant lymphoma cases. We experienced a rare case of complications from angioimmunoblastic T-cell lymphoma and colorectal cancer.

[Successful Treatment of Local Recurrence of Advanced Gastric Cancer Using Curative Gastrectomy via Distal Pancreatectomy after Chemoradiotherapy]

The patient was a 65-year-old woman. She was diagnosed with advanced gastric cancer with liver invasion. After receiving systemic chemotherapy(S-1 plus PTX)for 3 months, she underwent total gastrectomy and partial hepatectomy in May 2008. Because she developed celiac artery circumference lymph node recurrence in November 2010 during postoperative adjuvant chemotherapy consisting of S-1 plus PTX, we changed her chemotherapy regimen to CPT-11 plus CDDP. We observed an increase in the size of the lymph nodes in August 2013 and the response was poor even after switching to DOC. However, the lymph nodes continued to increase in size and we administered radiotherapy of 60.4 Gy/33 Fr that resulted in shrinkage of the nodes. We observed an increase in lymph node size and pancreas invasion in September 2015, including an expansion of the mid pancreatic duct. We performed distal pancreatectomy without identifying the recurrence observed in November 2015 assuming it was an exacerbation. Six months after the surgery, the recurrence was not apparent. We report an example of long-term survival that was achieved for Stage IV gastric cancer. The patient underwent combined modality therapy for 8 years, and local recurrence was controlled via a primary operation.

[Two Cases of Small Intestinal Metastasis of Lung Cancer]

Case 1: A 66-year-old man who had undergone upper right lobe resection for large cell lung carcinoma 2 months earlier presented with abdominal pain and vomiting. Computed tomography showed intussusception of the small intestine. Partial resection of the small intestine was performed. The tumor was pathologically diagnosed as lung cancer metastasis to the small intestine. The patient died 30 days after surgery. Case 2: A 57-year-old man was admitted to hospital due to appetite loss. Computed tomography showed a large intestinal tumor and a small lung tumor, as well as multiple liver metastases and lymph node metastases. We diagnosed perforation of the small intestine tumor, and partial resection of small intestine was performed. Pathological examination and immunohistochemical staining revealed that the tumor was a metastatic adenocarcinoma, and the patient was diagnosed with small intestine metastasis of lung cancer. He died 75 days after surgery. Although small intestine metastasis of lung cancer is rare, the incidence is increasing. The prognosis of lung cancer metastasis of the small intestine is poor, and therefore, we must urgently decide the appropriate treatment.

[Two Cases of Bowel Perforation during Chemotherapy with Bevacizumab to Metastatic Rectal Cancer]

Case 1: A male patient in his 60's who had rectal cancer and liver metastases underwent Hartmann's operation in January 2009. In April 2009, he received chemotherapy with modified FOLFOX6 plus bevacizumab as second-line treatment. Thirteen days later, he complained of abdominal pain and visited the emergency department. Computed tomography(CT)revealed gastrointestinal tract perforation. He underwent emergency surgery. However, dirty brownish ascites was observed, and the perforation point of the gastrointestinal tract could not be found. We suspected perforation of the colon and created an artificial anus in the terminal ileum. After the surgery, his condition improved. Case 2: A male patient in his 60's who had rectal cancer underwent Miles' operation in March 2005. In February 2010, CT revealed local recurrence in the presacral region. After radiotherapy, he received chemotherapy with CapeOX plus bevacizumab. During the course of the chemotherapy, he was admitted for upper abdominal pain and fever. He was diagnosed with a perforation of the transverse colon and underwent emergency surgery. After the surgery, drainage was needed for peritonitis, for about 1 month. At 93 days after the surgery, he was discharged. Gastrointestinal tract perforation is one of the most serious adverse events associated with bevacizumab. To avoid death caused by serious adverse events, medical staff and patient orientation or education on the possible serious adverse event is very important.

[A Case in Which a Patient Was Operated for Intra-Abdominal Desmoid Tumors after Total Colectomy in FAP]

The patient was a 22-year-old woman with FAP, who had undergone laparoscopic total colectomy 3 years previously. She presented to our hospital with a high fever and abdominal pain. Large hard tumors were palpated in the right lower abdomen and pelvis. Blood examination showed an inflammatory response. CT scan revealed 17 cm diameter solid tumors. At surgery, 2 tumors arising from the mesentery of the small intestine were found, neither of which invaded any organs. We performed tumor extirpation with partial resection of the duodenum, ileum, right fallopian tube and rectum. A jejunal stoma was formed, leaving a length of remnant intestine of about 120 cm. The histopathological diagnosis was given as desmoid tumor with infection. The patient was discharged from the hospital on the 9th postoperative day. Desmoid tumor is the second most common cause of death in FAP patients. Although desmoids can also occur in the extremities, most FAP patients develop intra-abdominal tumors. Despite being histologically benign, they are locally infiltrative and can cause death through invasion and destruction of adjacent vital structures and organs. Here, we report a case of desmoid tumors with FAP with reference to the literature.

[Intraluminal Type Gastrointestinal Stromal Tumor Resected by Single-Incision Percutaneous Endoscopic Intragastric Surgery--A Case Report]

We report a patient with gastric gastrointestinal stromal tumor (GIST) who underwent single-incision percutaneous endoscopic intragastric surgery. The patient was a 70-year-old man. Esophagogastroduodenoscopy and abdominal computed tomography revealed the presence of an intraluminal type gastric submucosal tumor, 4 cm in diameter, in the posterior wall of the gastric body. Laparoscopic partial gastrectomy was performed via a single incision made in the epigastric region. The postoperative course was uneventful. The pathological diagnosis was a low-risk GIST. This method is easy and safe to perform; therefore, we consider it to be an important option for the treatment of intraluminal type gastric GIST.

[Clinical evaluation of the risk factors for liver abscess after TACE or RFA]

Radiofrequency ablation(RFA)and transcatheter arterial chemoembolization (TACE) are widely enforced as a standard combined therapy for liver cancer. Liver abscess occurs occasionally as a complication. This clinical study was conducted to determine risk factors for liver abscess. We investigated the clinical background of 10 cases complicated by liver abscess in 957 cases of patients who underwent TACE or RFA for liver cancer at Minoh City Hospital between April 2002 and March 2012. Risk factors for liver abscess were analyzed statistically in comparison to a control group without liver abscess. Diabetes and a history of biliary tract organic disease were statistically significant independent risk factors determined by multivariate analysis. We consider patients with a history of biliary tract organic disease, or who have a potential biliary tract infection, and diabetes, to be susceptible to infection. A case presenting with diabetes and a history of biliary tract disease is in a high-risk group, so treatment with TACE or RFA for such cases should be considered carefully.

[Palliative care during chemotherapy for advanced colon cancers]

BACKGROUND

The median survival time following chemotherapy for unresectable metastatic colorectal cancer (mCRC) is approximately 2 years. Although palliative care during the chemotherapy period is very important, it has not been reported in detail.

PATIENTS AND METHODS

Information on the palliative care of 110 patients with Stage IV mCRC, who were treated from September 2007 to March 2011, was retrospectively examined.

RESULTS

Following an explanation of their recurrence or metastases of mCRC, all the patients received mental care from nurses or psychiatrists. They also needed care to prevent the side effects of chemotherapy. Some patients experienced pain associated with tumor growth. Thus, they required NSAIDs or opioids to reduce the cancer-related pain. After they could not be taken chemotherapy, 87.5% of these patients consulted medical social workers to discuss where they would live.

CONCLUSIONS

The patients required palliative care depending on the duration of chemotherapy for mCRC. Thus, we believe that palliative care is an important part of treatment for advanced cancer.

[A case of superior sulcus tumor treated with carbon ion radiotherapy]

Superior sulcus tumor( SST) is a rare type of lung cancer. Treatment usually consists of surgical resection after chemoradiotherapy. We report a case of a woman in her fifties who underwent carbon ion radiotherapy for SST. The patient complained of left shoulder pain, and imaging studies revealed a 5.2×3.5-cm local solid tumor at the apex of the left lung, invasion to the ribs, and no lymph node swelling. The level of tumor marker, carcinoembryonic antigen (CEA), was 5.7 ng/mL. Needle biopsy specimen revealed adenocarcinoma. The diagnosis was SST, T3N0M0, stage IIB. We did not detect Horner syndrome. Carbon ion radiotherapy at 66 Gy equivalent dose per 10 fractions was administered to the SST site. Subsequently, the tumor size decreased to 4.5×1.9-cm. The adverse effect was Grade 1 skin and pulmonary toxicity. Six months later, Grade 2 left shoulder connective tissue toxicity was observed; it was difficult to differentiate this from tumor recurrence. After 2.5 years from radiotherapy, the patient is free from recurrence. Carbon ion radiotherapy is effective and safe and can be considered as an important treatment option for SST.

[Recurrent gastric cancer treated with fourth-line chemotherapy consisting of capecitabine and cisplatin leading to partial response]

A 70-year-old man with advanced gastric cancer was treated with neoadjuvant chemotherapy consisting of S-1 plus cisplatin( CDDP). He exhibited symptoms of cerebral infarction during the second course of chemotherapy. Distal gastrectomy was performed and the histological diagnosis was pT3N3aM0, pStage IIIB. Adjuvant chemotherapy was administered; however, after the second course, gastric cancer recurred in the lymph nodes. Second-line chemotherapy with irinotecan (CPT-11) and CDDP was initiated. Thereafter, third-line chemotherapy with docetaxel was performed. However, the response to treatment was progressive disease (PD). Subsequently, fourth-line chemotherapy was performed with capecitabine and CDDP (XP chemotherapy). After the fourth course of XP chemotherapy, the response was partial response (PR). Moreover, PR was maintained after 20 courses of chemotherapy.

[Two cases of liver abscess caused by Clostridium perfringens after transcatheter arterial chemoembolization]

Case 1 involved a 74-year-old man. After transcatheter arterial chemoembolization( TACE) for hepatocellular carcinoma (HCC), abdominal computed tomography (CT) revealed a gas-containing lesion in the liver. The patient was diagnosed as having a gas-containing liver abscess, necessitating emergency drainage under laparotomy. Blood culture revealed Clostridium perfringens. He was discharged on day 63 after surgery. Case 2 involved a 70-year-old man who was admitted to our hospital for obstructive jaundice caused by HCC. He was treated with TACE after endoscopic retrograde biliary tract drainage (ERBD). On the second day, he was diagnosed as having a ruptured gas-containing liver abscess with massive hemolysis, necessitating emergency drainage under laparotomy. He died the next day after surgery. The clinical course of liver abscess caused by Clostridium perfringens can be fulminant and fatal with massive hemolysis.

[Chemotherapy-mediated tumor regression in a patient with stage IV stomach small cell cancer]

Gastrointestinal tract endoscopy revealed the presence of a 5-cm-diameter type 3 tumor in the cardiac portion of the stomach. The tumor was chromogranin positive, and stomach small cell cancer was diagnosed by immunostaining and biopsy pathology. S-1+CDDP therapy was administered as the first-line treatment. A switch to S-1 monotherapy was made after the patient experienced grade 4 hyponatremia. However, following 7 courses of therapy the disease had progressed. Second-line chemotherapy of CPT-11+CDDP was initiated and after 2 courses the disease stabilized.

[Fluoropyrimidines with oxaliplatin(L-OHP) as an adjuvant chemotherapy for Stage III colon cancer]

As an adjuvant treatment for Dukes B2 and C colon cancer, adding oxaliplatin (L-OHP) to a regimen of fluorouracil and Leucovorin improved disease-free survival in Western countries. In Japan, however, adjuvant chemotherapy with L-OHP is not commonly used to treat Stage III colon cancer. We report the present condition of adjuvant treatment for colon cancer in our hospital. Between September 2009 and December 2011, 66 patients with Stage III colon cancer were enrolled after curative surgery. The details of adjuvant therapy with fluoropyrimidines with and without L-OHP were explained to the patients. After the explanation, 33.3% of the patients(IIIa: 18.9%, IIIb: 55.5%) selected L-OHP chemotherapy. Regardless of the side effects, adjuvant chemotherapy including L-OHP is expected to protect against cancer recurrence in patients with Stage IIIb colon cancer.

[A case of advanced gastric cancer with Trousseau syndrome and pulmonary embolism]

A 60-year-old man showed symptoms associated with pulmonary embolism and anemia in June 2011, and was subsequently diagnosed with stage IV gastric cancer. Following frequent multiple cerebral infarctions and the development of symptoms, the patient was diagnosed with Trousseau syndrome. A total gastrectomy was performed to control bleeding. After the surgery, oral ingestion became possible. The patient was discharged and a hypodermic injection of heparin was given by the home doctor.

[A case of bilateral 3-lung lesion (metastatic and primary tumour, tumourlet) resected simultaneously]

A 70-year-old male patient underwent right nephrectomy for renal clear cell carcinoma. After 8 years an X-ray showed a nodule on the left lung, and CT scan detected it to be a 15 × 12 mm mass in S1+2 segment of the left lung. CT also detected another 15 × 7 mm mass in the right S3 segment. These lesions had a high FDG accumulation. Pre-operative diagnosis is bilateral pulmonary metastases from renal cell carcinoma, and bilateral lung segmentectomy was performed. Left S1+2 resected tumor was histologically clear cell carcinoma by intra-operative examination, then right S3 segmentectomy was done. And that time, small tumor was found in the middle lung lobe, and a wedge resection was performed. These specimens revealed a primary lung carcinoma of right S3, and tumourlet of middle lobe. It is very rare that three different histlogical types of lung tumor were found.

[A case of unresectable gastric cancer with pyloric stenosis which was resectable by chemotherapy after gastrojejunostomy]

A man in his fifties was referred to our hospital for anorexia and vomiting. Upper gastrointestinal endoscopy showed a gastric cancer (Borrmann Type 3) with pyloric stenosis. We performed gastrojejunostomy to allow oral intake for a tumor invading the pancreas head (cT4bN1H0P0CY1, Stage IV). After the operation, systemic chemotherapy with S-1 (120 mg/m²) was administered from July 2007, which caused grade 3 mucositis oral and drug rash after one week. Then, bi- weekly administration of CPT-11 (60 mg/m²) and CDDP (30 mg/m²) was started from August 2007 as second-line chemotherapy. The treatment was repeated for 14 courses till an allergic reaction happened. A weekly paclitaxel (PTX) therapy (80 mg/m²) was started from January 2009 as third-line. After 6 courses, CT showed that direct invasion to the pancreas was not clear any more, so a distal gastrectomy with D1 lymphadenectomy was performed on August 2009 (ypT3N- 1P0CY0, Stage IIB). The patient received 9 courses of weekly PTX therapy and after that the treatment has been discontinued. Recurrence was not observed for 48 months after an initial treatment.

[A case of advanced transvers colon cancer with inguinal lymph node metastasis]

An 80-year-old woman complaining of a right inguinal induration and pain was performed an inguinal lymph node resection. Histological examination with immnohistochemistry revealed that the lymph node was metastasis of colon carcinoma. With total colonoscopy, she was diagnosed as advanced transvers colon cancer with right inguinal lymph node metastasis. She was performed a right hemi-colectomy. She was dead with peritoneal metastasis of colon cancer 2 years and 1 month later. We report this case that was diagnosed having transverse colon cancer with inguinal lymph node metastasis.

[A case of pneumocystis pneumonia during chemotherapy for gastric cancer]

We report a death case of a man in his sixties with pneumocystis pneumonia during chemotherapy for gastric cancer. He was diagnosed with cStage IIIB (T4a, N2, H0, P0, M0). Because of bulky N2, systemic chemotherapy of S-1 and CDDP was performed from April 2009. But no reductions were noted after 2 courses. We next treated this patient with S-1 and CPT-11. He had also received corticosteroid treatment for nausea. Because of high fever and choke, he came to our hospital at day 12 in 3 courses, and a severe respiratory failure occurred. CT of the chest showed diffuse ground-glass bilateral opacities, and we immediately started a treatment with trimethoprim-sulfamethozazole and corticosteroid for the possibility of pneumocystis pneumonia. We finally deduced pneumocystis pneumonia from markedly elevated serum beta-D-glucan and PCR positive after hospitalization. In spite of early treatments, he died of bacterial pneumonia and gastric cancer. We should be careful of pneumocystis pneumonia during chemotherapy and corticosteroid treatment.

[A successful case with CPT-11 + CDDP chemotherapy for recurrent gastric cancer of the remnant stomach]

We report a successful case with irinotecan (CPT-11 60 mg/m2) + cisplatin (CDDP 30 mg/m2) chemotherapy (once in 2 weeks) for recurrent gastric cancer of the remnant stomach. A 77-year-old man was performed a distal gastrectomy for duodenal ulcer 42 years ago. He had a total gastrectomy for gastric cancer of remnant stomach when he was at 73 years old. After the surgery, we treated this patient with S-1 mono-therapy for five courses. However, we finished this treatment for lymph-node metastases. Next we treated him with CPT-11 + CDDP. An abdominal CT revealed a CR after 6 courses. We finished this treatment after 12 courses for anemia (grade 3). After the treatment, the metastatic lymph-nodes appeared in no change. So we considered that CR was continued for 3.5 years.

[Three-case reports--a program of strength training for home health care on frail elderly patients with protein rich supplement just after the training]

We have a program of strength training for home health care with protein rich supplement just after the training on frail elderly patients. Three cases (80-90 years old) received a new good taste protein rich supplement. They were also frail patients after acute clinical treatments, and were able to go home directly against their physical moving problems for daily life. We performed cardio-pulmonary and swallowing function, energy intake, parameters of muscle strength and the status for daily life before and after the training. Practical results were very different among the patients. But, the status for daily life of all was better than before. It was not clear that the new supplement was effective for the parameters of muscle strength, or not. But a trial for programs with thus foods should be an option for promoting to home health care after hospitalization in frail elderly.

[A case of a 14-month survival patient on advanced esophageal cancer with uncontrolled brain metastasis completely responding to nedaplatin, adriamycin, plus 5-FU (NAF) therapy]

This case was a male patient, about 50 years old. He received a curative operation for advanced esophageal carcinoma [poorly differentiated squamous cell carcinoma type, Lt, pT3 (pAd) pN3, pstage III] in March 2005. He also received adjuvant chemotherapy of 5-FU plus cisplatin (CDDP). Fourteen months later (May 2006) from surgery, metastases to the left lung and left subclavian lymph nodes were diagnosed, so he received first-line triplet combination chemotherapy (NAF regimen; nedaplatin 60 mg/m2: day 1, adriamycin 50 mg/m2: day 1, 5-FU 700 mg/m2: day 1-5). According to the 9 courses of treatment of this regimen, complete response for these metastases was observed and first-line chemotherapy was finished. However, a severe headache appeared 3 months later, and he had a diagnosis of solitary 5 cm brain metastasis by MRI. Excision of the metastasis was performed with sequential whole-brain radiation therapy (30 Gy). Five months later, diffuse and multiple brain metastases relapsed, and second-line chemotherapy did not respond well, and finally he was died 3 months after palliative care. But, completely controlled metastases (lung and lymph node) by first-line chemotherapy did not relapse again in all his clinical period. If an anticancer therapy goes in complete response in an advanced esophageal carcinoma patient, we should consider about a rare brain metastasis in order to find out as small and solitary state.

[A case of successful management of recurrent intrahepatic cholangiocarcinoma by repeated radiofrequency ablations]

A 67-year-old man with intrahepatic cholangiocarcinoma (ICC) underwent an extended right hepatectomy. Approximately, during the next 20 months after the operation, the patient underwent 6 times of radiofrequency ablation for solitary recurrence of ICC. He has survived for 26 months after hepatic resection with PS 0. Radiofrequency ablation for solitary recurrence of ICC may be effective for a good prognosis.

[A case of liver metastasis of rectal cancer demonstrating complete response for more than two years to mFOLFOX6]

A man in his fifties with rectal cancer underwent low anterior resection in another Hospital in January 2006. He was finally diagnosed with Stage III a (pA, pN1, H0, P0). The patient who had postoperative complication such as ruptured suture left the hospital in May 2006, when he was detected with multiple liver metastases and was referred to our hospital for systemic chemotherapy. Systemic chemotherapy with mFOLFOX6 was performed from May 2006. Grade 3 diarrhea and grade 2 peripheral neuropathy, nausea and vomiting were observed. After 6 courses of mFOLFOX6, MRI revealed metastasis had been disappeared and levels of CEA and CA19-9 were decreased below normal. The treatment has been discontinued. Recurrence was not observed for 30 months.

[A 14-month surviving patient on advanced esophageal cancer with big lymph node metastasis to cardia responding to S-1 plus cisplatin (CDDP) therapy at home]

This case was a 70s male patient. He was hospitalized with some dysphasia and a severe body weight loss since August 2004. The diagnosis was the esophageal cancer (type 2, 11 cm) with big lymph node metastasis on cardia (8 cm), and also pathologically poorly differentiated squamous cell carcinoma from two legions. He wanted a home chemotherapy for it. We administered a combination chemotherapy of S-1 plus cisplatin (CDDP) therapy. An eight-day admission within an each course to CDDP treatment and nutritional support were required for adverse events of anorexia (grade 3), but for other days home chemotherapy was done with good compliance of S-1 up to 6 courses. After 2 courses, endoscopic findings showed a pathological complete response of esophageal mass, and CT findings also showed a partial response of the lymph node. After 6 courses of S-1 + plus cisplatin in May 2005, a home S-1 single therapy which was not needed the admission started at will. But the lymph node mass of cardia progressed again in September 2005, and his therapy moved to the terminal care at home.

[Surgical resection of pulmonary metastases from colorectal carcinoma in our hospital]

Pulmonary metastases from colorectal carcinoma are not rare next to liver metastases. Lung resection has been widely accepted, but postoperatively local lung recurrence has been seen in the wedge resection procedures. In our hospital, specimen of the wedge resection was histologically reviewed and revealed floating cancer cell clusters around the main tumor. The cause of the recurrence was supposed to be floating clusters or a technical problem of surgical margin in the video-associated thoracic surgery. Since 2004, we used 3-dimensional CT and identified the pulmonary segmental area of peripheral metastatic tumor less than 2.0 cm in diameter. From 1986 to 2003, we performed 18 cases of lung resection and found that recurrent cases were 25 to 64%. On the other hand, we detected 0 to 16% recurrence cases in 12 patients during the period of 2004-2007. We recommend segmentectomy to metastatic tumor less than 2.0 cm in diameter from colorectal carcinoma.

[Third-line treatment of intermittent hepatic arterial infusion for unresectable liver metastases from colorectal cancer]

We report 6 cases of liver metastases from colorectal cancer with third-line treatment of intermittent hepatic arterial infusion and systemic chemotherapy for unresectable liver metastases with clinical signification of direct invasion to adjacent organs in Stage IV colorectal cancer. Subjects were 19 consecutive patients who underwent R0 surgery to the primary tumor for colorectal carcinoma, pT4, M1 in 1995-2003. We studied the relationship of pathological invasion to adjacent organs of tumor to other clinicopathological factors to prognosis. Of the 19 patients, 11 (57.8%) were R0 surgery to the tumor of metastases. Only 4 (36.7%) patients survived more than 3 years. The patient without excision did not survive for three years. The median survival time was only 8.5 months. Multivariate analysis indicated that only R0 surgery to the tumor of metastases was an independent prognostic factor. The optimum resection for adjacent organs may prolong a survival. But the extended resection is a possibility of shortening the survival time.

[A case of metastatic rectal cancer from serous adenocarcinoma of the ovary]

A 51-year-old woman was hospitalized with constipation and bloody feces. Under diagnosis of a primary rectal cancer with peritonitis, an ileostomy was scheduled. Since peritoneal dissemination was found, histologically she was diagnosed as metastatic rectal cancer from serous adenocarcinoma of the ovary. Chemotherapy with paclitaxel and carboplatin was performed, and complete disappearance on assessable examination was seen. Eight months after the first operation, she underwent total hysterectomy, oophorectomy and low anterior resection of rectum. No viable cancer tissue could be found. After the second operation, she has been doing well without any recurrence for 1 year and half.

[A clinical significance of peritoneal carcinomatosis to recurrent colorectal cancer with ileus]

We studied a clinical significance of peritoneal carcinomatosis to metastatic recurrent colorectal cancer with ileus. The subjects were 16 patients with ileus confirmed in 1995-2005. Of the 16 patients, 7 had surgical treatment and the other 9 had conservative treatment. The median survival time of the 16 patients was 98 days; the 7 patients of surgical treatment were 235 days; the 9 patients of conservative treatment were only 67 days. Only 4 patients survived more than 200 days. These 4 patients had surgical treatment, and were the cases where no peritoneal fluid was confirmed and the metastatic tumor was excised. However, only 2 patients improved in QOL. The 3 patients in the surgical treatment were aggravated. An optimum resection may prolong a survival time and patient's QOL could be improved. On the other hand, an extended resection may contribute to shorting a survival time.

[Three successful cases with CPT-11 + CDDP chemotherapy where S-1 failed to respond to recurrent gastric cancer]

We report three successful cases with irinotecan (CPT-11 60 mg/m2) + cisplatin (CDDP 30mg/m2) chemotherapy (once in 2 weeks) where S-1 failed to respond to recurrent gastric cancer. Case 1: A total gastrectomy and splenectomy were performed for a cardiac gastric cancer (T3, N2, H0, P0, CY0, por 1, Stage IIIB). An abdominal CT revealed paraortic lymph node metastases 4 months after the surgery. No reductions were noted after S-1 monotherapy. We next treated this patient with CPT-11 + CDDP. An abdominal CT revealed a CRin after 11 courses. Case 2: A total gastrectomy, splenectomy and cholecystectomy were performed for a cardiac gastric cancer (T3, N3, H0, P0, CY1, tub1, Stage IV). After the surgery, we treated this patient with S-1 mono-therapy. However, we finished this treatment for abdominal recurrence. We next treated this patient with CPT-11 + CDDP. An abdominal CT revealed a CR after 24 courses. Case 3: A distal gastrectomy and cholecystectomy were performed for a pyloric gastric cancer (T2, N1, H0, P0, CY0, tub 2, Stage II). An abdominal CT revealed paraortic lymph node metastases 10 months after the surgery. We treated this patient with S-1 + paclitaxel (PTX) chemotherapy. No reductions were noted after 2 courses. We next treated this patient with CPT-11 + CDDP. An abdominal CT revealed a CR after 8 courses.

[A case of ascending colon carcinoma metastasized to an inguinal hernia sac]

While inguinal hernia is one of the most common diseases, metastatic cancer of an inguinal hernia sac is rare. We report a case of ascending colon cancer metastasized to an inguinal hernia sac. A 60-year-old man, who was undergone a right hemicolectomy for an ascending colon cancer, was pointed out a palpable inguinal mass at one year and eight months after the operation. He was diagnosed as inguinal hernia, and herniorrhaphy was performed. In the operation, a tumor of the inguinal hernia sac, which invaded to spermatic cord, could be found and was removed with right testis. Bassini's method was performed after the resection of the inguinal tumor. Histological examination revealed that the tumor was metastasis of colon carcinoma. Examination of the entire body showed no other metastasis. As for the advanced colon cancer, we need to mention the possibility of metastatic saccular tumor.

Data Processing for Radioimmunoassay Standard Curve Using Microcomputer: A New Basic Program for Weighted Logit-Log Transformation

A new BASIC program of the weighted linear, quadratic and cubic logit-log regression methods for data processing of radioimmunoassay standard curve was developed using a microcomputer. Using this program, three regression analyses are calculated and the table for root mean square of residuals in each regression are shown for the selection of the regression method. The data of three radioimmunoassays of human pancreatic enzymes and pancreatic secretory trypsin inhibitor were examined by this program and compared with those processed by the four parameter logistic method. The weighted cubic logit-log regression showed better fit in radioimmunoassays of human pancreatic enzymes with larger molecular weights. The present program is useful and practicable for its simplicity and accuracy.

[A case of malignant fibrous histiocytoma of the buttocks]

A 67-year-old woman was admitted because of a tumor of the buttocks wall. The tumor was 13 x 10 x 8 cm in size, elastic hard, fixed to the gluteus maximum muscle. She was suspected of having a malignant tumor in the soft tissue, and the tumor was resected as completely as possible. After the first operation, she was diagnosed with recurrence of tumor in the local area a year later. After the second resection, she was found with recurrence of the tumor in the same area five years later. After the third operation, she has been doing well without any recurrences for five years. The prognoses of MFH are usually not so good, but this case could turn out to be a case of long metastasis free survival after local recurrences.

[A clinical significance of direct invasion to adjacent organs in stage IV colorectal cancer]

We studied a clinical significance of direct invasion to adjacent organs in Stage IV colorectal cancer. The subjects were 19 consecutive patients who underwent R0 surgery to the primary tumor for colorectal carcinoma, pT4, M1 1995-2003. We studied the relationship of pathologic invasion to adjacent organs of tumor among other clinicopathological factors to prognosis. Of the 19 patients, 11 (57.8%) had R0 surgery to the metastatic tumor. Only 4 (36.7%) patients survived more than 3 years. Of the 8 patients without the surgery, none of the patients survived more than 3 years. And the median survival time was only 8.5 months. Multivariate analysis indicated that RO surgery to the metastatic tumor was only an independent prognostic factor. The optimum resection for adjacent organs may prolong survival. But an extended resection is a possibility in shortening survival time.

[A long term survival case of advanced colon cancer with adjacent organ involvement and multiple liver metastases]

We report a long-term survival case of advanced colon cancer with adjacent organ involvement and multiple liver metastases. A 50-year-old man was admitted to our hospital because of occult bloody feces. An advanced colon cancer of the cecum was found with a colonoscopy. Histopathologically, it was a moderately differentiated adenocarcinoma with a biopsy examination. Abdominal CT showed advanced colon cancer with adjacent organ involvement and multiple liver metastases. He received right hemi-colon resection and right hepatic lobectomy. The patient was followed by 8 courses of adjuvant chemotherapy with 5-FU. He has been doing well without any recurrence for five years and six months after the operation. Usually the prognoses of Stage IV colorectal cancer patients are very unpleasant. Even thougn a few patients with Stage IV colorectal cancer can be a long-term survivor after multiple operations, we need to consider carefully the indication of the operation and QOL for a Stage IV colorectal cancer patient.

Intracystic papilloma in the breast of a male given long-term phenothiazine therapy: A case report

We experienced a very rare case of intracystic papilloma in a 57-year-old man who came to our hospital complaining of a left subareolar mass and nipple discharge. The patient had a history of chronic schizophrenia, necessitating long-term treatment with phenothiazines. His serum prolactin levels were elevated. Mammography demonstrated a well defined mass with microcalcifications. Ultrasonography revealed a cyst with an intracystic component. The inner lesion of the mass enhanced on contrast-enhanced computed tomography. The carcinoembryonic antigen concentration of the cyst fluid was 400 ng/mL and no malignant cells were found by aspiration biopsy cytology. Excisional biopsy was performed under local anesthesia. Pathological examination revealed the intracystic component to be intracystic papilloma. There are ten reports of male intracystic papilloma including ours. We report the second case of a patient given long-term phenothiazine therapy, which is known to increase serum prolactin levels.

[A case of rectal cancer with solitary adrenal metastasis]

This is the case of a 67-year-old woman with a sudden on-set of lower abdominal pain and pre-shock. A physical examination showed signs of pan-peritonitis. Emergency was operation performed 5 hours after the onset. She had undergone Hartmann's operation for rectal cancer. Six month after the operation, abdominal CT scan revealed the mass of puriform acites, about 20 mm in diameter, in the right suprarenal region. Right adrenalectomy was performed with a diagnosis of solitary adrenal metastasis from rectal cancer. Histologically, the metastatic adenocarcinoma was moderately differentiated to the adrenal medulla. The capsule was kept intact, and no swelled lymph nodes were found around the adrenal gland. There have been no signs of recurrence for 4 years after the operation.

[A case report of the 8 year survivor--unresectable liver metastases from advanced gastric cancer (Stage IV) were completely responsive, after 4 years from a total sequential gastrectomy, combining docetaxel treatment to regress the recurrence]

This case was a 69-year-old male who had advanced gastric cancer with unresectable multiple liver metastases (Stage IV). He received a combination therapy consisting of a continuous venous infusion (cisplatin: CDDP 10 mg/body, 5-FU 500 mg/body, day 1-28). As a result, metastatic tumors in the liver completely disappeared and a total gastrectomy was sequentially performed. Four years after the surgery, neck lymph node (LN) metastases and the right adrenal metastasis appeared, and chemotherapy (TS-1, and sequentially TS-1+CDDP) was performed. But, the chemotherapy to eradicate the metastases was hardly enough to be effective. Next, docetaxel (DOC 60 mg/m2 q3w) was started. After 9 courses, they were effective and marked regressions (70%). A total of 15 courses of docetaxel administration were possible until tumor progression recurred. This regimen was not severe in toxicity for the duration except for grade 3 poor appetite. Docetaxel will be a key drug for the gastric cancer. In case of responding well to the chemotherapy, we can hope for an extended long-term survival with a continuation of this regimen.

[A report of two cases--two patients of the extremely advanced hepatocellular carcinoma have responded completely for a long time after a combination therapy consisting of arterial chemotherapy and injection of interferon-alpha]

The prognosis of advanced hepatocellular carcinoma (HCC) is extremely poor. Patient 1 was a 43-year-old male with major portal tumor thrombi. He received combination therapy consisting of continuous arterial infusion (MTX 30 mg/m2, day 1, CDDP/5-FU 6 mg/m2: 250 mg/m2, day 1-14) and subcutaneous injection of IFN-alpha (500 x 10(4) U, 3 times a week, 4 weeks). Patient 2 was a 66-year-old male with major hepatic venous tumor thrombi. He received combination therapy consisting of continuous arterial infusion (5-FU 6 mg/m2: 250 mg/m2, day 1-14) and subcutaneous injection of IFN-alpha (500 x 10(4) U, 3 times a week, 4 weeks). Decrease in tumor was observed in both patients markers and marked regression of tumor was observed in both patients. They are still in complete response. This combination therapy is an effective strategy for advanced HCC.

Successful use of 111In-pentetrotide scintigraphy for localizing ectopic adrenocorticotropin-producing bronchial carcinoid tumor in a patient with Cushing's syndrome

A 34-year-old man was diagnosed with clinical Cushing's syndrome based on circadian fluctuation of plasma adrenocorticotropin and serum cortisol levels and Liddle's-method. The presence of ectopic adrenocorticotropin production was suspected. Urine 5-hydroxyindoleaceturic acid level was high. Chest computed-tomography scan revealed a mass in the right upper lung. 111In-pentetrotide scintigraphy demonstrated marked accumulation in the right upper lung. We suspected an adrenocorticotropin-producing bronchial carcinoid. Plasma adrenocorticotropin and serum cortisol levels decreased immediately following resection of the tumor. Adrenocorticotropin production by tumor cells was confirmed by immunohistochemistry. This case indicates 111In-pentetrotide scintigraphy could be successfully used to identify and localize ectopic adrenocorticotropin-producing bronchial carcinoid.

[TS-1 and lentinan combination immunochemotherapy for advanced or recurrent gastric cancer: a preliminary report]

The immunocompetence and nutritional state of patients with advanced or recurrent gastric cancer is low, making it important to conduct chemotherapy while at the same time improving or maintaining their immunocompetence and nutritional state. To reduce the side effects but not the antitumor effect of TS-1, a 2-week regime of TS-1, and 1-week drug-free interval, in combination with the immunotherapeutic agent lentinan (LNT) was started in 5 patients with advanced or recurrent gastric cancer. Toxicity, efficacy, immunocompetence and nutritional state were investigated preliminarily to examine whether or not usefulness of lentinan could be evaluated. The IAP tended to decrease. TS-1 and lentinan combination immunochemotherapy was able to be carried out safely in patients with advanced recurrent gastric cancer. In order to examine the usefulness of combined LNT, it is thought to be necessary to perform a randomized trial using toxicity and not only efficacy but QOL and immunological and nutritional parameters as indicators.

[Long-term survival after neck lymph node metastases from sigmoid colon cancer--a case report]

We report a 73-year-old female who had been operated on for sigmoid colon cancer and neck lymph node metastases. Tumor size was controlled by systemic chemotherapy for about 3 years. During the chemotherapy, toxicity over grade 2 was not observed and good QOL was maintained on an outpatient basis. It is suggested that low-dose systemic chemotherapy may be useful for patients with poor general status.

[A case of hepatic metastasis and local recurrence from rectal cancer responding to hepatic arterial infusion and systemic chemotherapy]

A 71-year-old man underwent low anterior resection for rectal cancer. Two years after the surgery, liver metastasis and local recurrence were found on the CT scan. The first-line treatment was systemic chemotherapy (CPT-11 and 5'-DFUR). Effect was satisfactory for local recurrence, but a new liver tumor was found on the CT scan. The second-line treatment was a hepatic arterial infusion (5-FU) and systemic chemotherapy (UFT). After 4 courses, the liver metastasis was reduced, but after 5 courses, the liver tumors had enlarged. The third-line treatment was a hepatic arterial infusion (5-FU + levofolinate) and systemic chemotherapy (UFT). After 5 courses, the liver tumor disappeared, and no other recurrence was found on the CT scan.

A new regimen for S-1 therapy aiming at adverse reaction mitigation and prolonged medication by introducing a 1-week drug-free interval after each 2-week dosing session: efficacy and feasibility in clinical practice

BACKGROUND

The response rate of advanced or recurrent gastric cancer to S-1 (TS-1) is 46.5%, which is higher than the response rate of this type of cancer to any other anticancer agent. However, the incidence of adverse reactions to this drug has also been reported to be as high as 83.2%. According to a postmarketing survey, adverse reactions to this drug begin to appear 2-3 weeks after the start of drug administration. With these findings in mind, we recently devised a new dosing regimen for the drug, by which the drug is administered for 2-week periods separated by 1-week drug-free intervals (the 2-week regimen). The aim of this retrospective study was to evaluate the efficacy and feasibility of the 2-week regimen in comparison with a 4-week dosing regimen with a 2-week interval between sessions (the 4-week regimen) as the historical control.

METHODS

The subjects were 27 patients with advanced or recurrent gastric cancer who received S-1 therapy at our center between September 1999 and November 2001. Of these patients, 14 who received the 4-week regimen before January 2001 served as historical controls, and the results in these patients were compared with those of the remaining 13 patients, who received the 2-week regimen after February 2001. Patient backgrounds, adverse reactions, compliance, and efficacy were investigated retrospectively.

RESULTS

The incidence of adverse reactions tended to be lower in the 2-week-regimen group (77%) than in the 4-week-regimen group (93%). The percentage of patients who received the drug for 6 months in complete compliance with the dosing schedule, as calculated by the Kaplan-Meier method, was 85% in the 2-week-regimen group and 40% in the 4-week-regimen group. The response rate to the drug was 23% in the 2-week-regimen group and 21% in the 4-week-regimen group.

CONCLUSION

These results suggest that this 2-week regimen may mitigate adverse reactions and prolong the medication period.