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With the emergence of immune checkpoint inhibitors(ICIs)in recent years, the treatment outcomes for unresectable recurrent esophageal cancer have improved markedly. In 5-FU+cisplatin(FP)first-line therapy, 5-FU administration takes 5 days and generally requires hospitalization. However, frequent hospitalization for treatment is a crucial issue that must be resolved in terms of time investment and optimal use of hospital resources. Here, we evaluated the safety and potential adverse effects of the administration of FP therapy in an outpatient setting. After central venous ports were placed in 5 patients, cisplatin was administered using a short hydration method and 5-FU was infused for 120 hours using an infusion pump. No crucial adverse events or major pump-related problems occurred, suggesting the feasibility of this treatment in an outpatient setting. However, the duration of 5-FU administration via the pump varied more than the expected deviation (10%, 12 hours), indicating that the issues require further consideration.

A 79-year-old woman was diagnosed with cT2N0M0, cStage Ⅰ sigmoid colon cancer. Preoperative staging computed tomography(CT)incidentally revealed severe stenosis of the celiac and superior mesenteric arteries. A collateral blood channel communicating between the inferior mesenteric artery and the celiac artery region was well developed. Therefore, a sigmoidectomy with D1 lymph node dissection was performed to preserve this collateral blood channel as a surgery for sigmoid colon cancer. There are few reports on surgical procedures for patients with simultaneous stenosis of multiple major abdominal arteries. In addition, there are no consensus about the optimal surgical procedure and extent of lymph node dissection for colorectal cancer with well-developed collateral vessels that should be preserved. Preoperative three-dimensional CT angiography(3D-CTA)and intraoperative blood-flow assessment using Indocyanine Green help risk management of multi- organ ischemia due to misidentification and injury of collateral arteries. It is important to keep oncological validity as well as risk management. We report a case of sigmoid colon cancer with asymptomatic stenosis of the celiac and superior mesenteric arteries.

A 71-year-old woman was referred to our hospital because of an esophageal submucosal tumor. Esophagogastroduodenoscopy revealed a submucosal tumor of 40×25 mm with ulceration in the lower thoracic esophagus and endoscopic ultrasonographic fine needle aspiration histology showed KIT(+), CD34(+), DOG-1(+), desmin(-), S-100 protein(-). We diagnosed esophageal GIST and performed mediastinoscope-assisted transhiatal esophagectomy with gastric tube reconstruction. Histopathological findings showed c-kit(+), Ki-67 index of 8%, and middle-risk GIST by the modified- Fletcher classification. Mediastinoscope-assisted transhiatal esophagectomy is useful in terms of shortening total operative time and preventing respiratory complications because it does not require thoracic operation, one-lung ventilation, or repositioning. Subtotal esophagectomy under a mediastinal approach could secure a margin for resection, which may reduce the risk of recurrence, and could be one of the surgical procedures for esophageal GIST.

A 66-year-old man presenting with melena was diagnosed with rectosigmoid cancer and underwent laparoscopic high anterior resection. Intraoperative findings showed that the descending colon did not adhere to the retroperitoneum and was largely displaced inward, and the descending and sigmoid colon extensively and strongly adhered to the small intestinal mesentery, as predicted prior to surgery. The patient was diagnosed with persistent descending mesocolon(PDM). The first sigmoid artery diverged from the left colonic artery; however, ligation of supplying arteries under laparoscopy was perceived as a risk for marginal artery injury due to the shortening of the mesentery by PDM. Therefore, the sigmoid artery and inferior mesenteric vein were ligated directly from the umbilical wound. No postoperative complications were observed, and the patient was discharged 9 days after the surgery. Although PDM has not been defined, it has been reported that preoperative prediction is possible depending on the positional relationship between the descending colon and the left kidney. In this case, we performed the surgery after taking into consideration the anatomical features assessed preoperatively, leading to a safe operation.

We report the case of a 36‒year‒old man who was treated with S‒1 plus oxaliplatin(SOX)therapy for gastric cancer with disseminated intravascular coagulation(DIC). The patient visited our hospital for the treatment of an unresectable type 4 advanced gastric cancer. He had respiratory distress at the first visit. A chest CT scan revealed ground‒glass shadows as well as interstitial and septal thickening diffusely located in both the lungs, which suggested cancerous lymphangiopathy. Moreover, based on blood test results, DIC was diagnosed. After the administration of SOX in combination with recombinant human soluble thrombomodulin, the patient recovered from DIC, and the values of the tumor markers(CEA and CA19‒9) were normalized. After more than 14 months post treatment, the patient has survived without relapse. There are several reports that chemotherapy for gastric cancer is effective for DIC; however, there are no reports on regimens using oxaliplatin. Regimens using this drug may improve the prognosis of gastric cancer complicated by disseminated myelocarcinomatosis and DIC.

Background: This study examined the treatment outcomes of gastrectomy in patients aged<85 years who had gastric cancer(GC)., Methods: The postoperative short- and long-term outcomes of 27 patients aged<85 years who underwent gastrectomy for GC at our institute were retrospectively investigated., Results: The median age was 87 years(range: 85-94 years), and 17 patients(63%)had comorbidities. Total, distal, and proximal gastrectomies were performed for 12, 14, and 1 patient, respectively. Only 13 patients(48%)underwent standard lymph lymphadenectomy(LND), while R0, R1, and R2 were performed for 23, 2, and 2 patients, respectively. The overall, surgical, and non-surgical complication rates were 59%, 26%, and 44%, respectively, even though the incidence of GradeBⅢa complications was only 4%, and there was no mortality. The 1-, 2-, and 3-year overall survival rates(OSR)were 91.7%, 79.4%, and 63.2%, respectively. The 3-year OSRs of the patients who underwent R0, R1, and R2 were 76.2%, 35.4%, and 0%, respectively. The 3-year OSR was significantly higher in the patients who underwent the standard LND(100%)than in those who underwent limited LND(36.6%)., Conclusion: The standard LND and R0 might also be useful for patients aged<85 years who had GC, although care should be taken for the high incidence of complications.

Background: This study examined the significance of preoperative neutrophil-lymphocyte ratio(NLR)as a predictor of postoperative outcomes of gastric cancer(GC)., Methods: NLR was calculated in 447 patients with GC undergoing curative gastrectomy, and its associations with postoperative short- and long-term outcomes were retrospectively examined., Results: Patients were divided into high-(n=313)or low-(n=134)NLR groups using an optimal cut-off NLR value of 1.6 according to the ROC curve analysis. A high-NLR was significantly associated with other clinical factors such as undifferentiated histology, advanced cT, and cN+. There was no difference in the incidence of postoperative complications between the 2 groups. Meanwhile, a high NLR was associated with a poor 5-year overall survival. Multivariate analysis identified preoperative NLR to be an independent prognostic factor(hazard ratio: 2.77, 95% confidence interval: 1.39-6.33, p=0.003)along with performance status, tumor location, and cT., Conclusion: Preoperative NLR could be one of the useful predictors of postoperative long-term outcomes of GC.

Background: This study investigated the prognostic value of preoperative serum C-reactive protein(CRP)level in patients with gastric cancer(GC)., Methods: This retrospective study examined 446GC patients undergoing curative gastrectomy. The associations between preoperative CRP level and postoperative long-term outcomes were examined by univariate and multivariate analyses., Results: The patients were divided into high(n=147)or low(n=299)CRP groups based on an optimal cut- off CRP value of 0.13mg/dL according to the ROC curve analysis. High CRP levels were significantly associated with other clinical factors such as older age(B65 years), high BMI(B25 kg/m2), poor performance status(PS), and advanced cT and cN+. In the survival analyses using only the clinical factors, high CRP levels were significantly associated with worse 5-year overall and cancer-specific survivals. The multivariate analysis for 5-year overall survival identified preoperative CRP to be an independent factor(HR: 1.95, 95%CI: 1.15-3.36, p=0.0129), as well as PS, tumor location, and cT., Conclusion: Preoperative CRP level could be a useful prognostic indicator in patients with GC undergoing curative gastrectomy.

The patient was a 69-year-old woman.Upper gastrointestinal endoscopy showed a protruding tumor in the mid-thoracic esophagus, and biopsy revealed small cell carcinoma in November 2012. Four courses of neoadjuvant chemotherapy comprising CDDP and CPT-11 were administered, and radical resection was performed in March 2013.I n March 2014, chest computed tomography revealed the recurrence of mediastinal lymph nodes; thus, we administered chemoradiotherapy comprising 5- FU and CDDP, and the size of the recurrent tumors decreased.However, in February 2015, positron emission tomographycomputed tomography revealed liver metastases.Therefore, we switched to a new chemotherapy regimen containing CDDP and VP-16.Although the treatment was very effective and the liver metastases significantly decreased in size, it was discontinued after 9 courses owing to neurotoxicity.Next, 7 courses of chemotherapy comprising amrubicin, which is administered for treating small cell lung carcinoma, were administered, which suppressed tumor growth for approximately 8 months.However, the tumor then re-grew.Chemotherapy comprising S-1 was administered; however, the tumor gradually progressed.The patient died 51 months after the initial treatment.

A 42-year-old woman with complaints of fever and abdominal pain, was diagnosed to have perforative appendicitis, for which emergency surgery was performed. Marked thickening and edema around the cecum, ileum, and the mesentery was observed. Ileocecal resection was performed, as malignant disease could not be excluded. Histopathological examination revealed abscess formation in the lining membrane of the intestine, inflammatory granulation and proliferation of the spindleshaped cells in the serosal membrane extensively, and an inflammatory pseudotumor(IPT)was diagnosed. It is generally difficult to clearly distinguish IPT from a malignant tumor before surgery. We thus report this case, along with a review of literature.

It has been reported that docetaxel, cisplatin, and 5-FU combination chemotherapy(DCF)is effective for advanced esophageal cancer. However, we often encounter severe hematotoxicity during DCF therapy. Here, we retrospectively analyzed the data of patients with advanced esophageal cancer treated with DCF at our department, and assessed the efficacy of pegfilgrastim and the issues associated with its use. According to the results, pegfilgrastim may reduce the severe hematotoxicity associated with DCF therapy and may contribute to the maintenance of the intensity of DCF. However, neutropenia had already occurred before pegfilgrastim administration on day 7 in most patients. Therefore, the appropriate timing of pegfilgrastim administration in DCF must be determined in a future prospective study.

A 67-year-old man was admitted to our hospital because of a type 2 tumor on the posterior wall of the cardia, and a biopsy resulted in a diagnosis of moderately differentiated tubular adenocarcinoma. Abdominal CT revealed swelling of the No. 1, 3, 11p(bulky N), and No.16a2lat lymph nodes. He was diagnosed with gastric cancer, T4aN2M1(LYM), cStage ⅣB, and was administered chemotherapy. After 2 courses of chemotherapy containing capecitabine plus cisplatin(XP), both the primary tumor and lymph nodes markedly decreased in size; then, total gastrectomy with D2+No.16a2lat was performed. Pathological examinations showed no residual cancer cells both in the primary lesion and lymph nodes; thus, the treatment effect of chemotherapy was Grade 3. Some gastric cancer patients may undergo curative resection even with extensive lymph node metastases when effective chemotherapy has been administered. Further discussions are needed about optimal chemotherapeutic regimens and surgical procedures.

Case 1 was that of a 65-year-old woman. Radical esophagectomy was performed after neoadjuvant chemotherapy(NAC) for lower thoracic esophageal cancer. Nineteen months after surgery, local recurrence was indicated on the dorsal side of the descending aorta. After chemoradiotherapy(CRT)and chemotherapy, residual cancer with aortic invasion was diagnosed. Case 2 was that of a 64-year-old man. Radical esophagectomy was performed after NAC for middle thoracic esophageal cancer. Five months after surgery, local recurrence was indicated between the descending aorta and left inferior pulmonary vein. After CRT and chemotherapy, residual cancer with invasion of the aorta and left lung was diagnosed. In both cases, we inserted an aortic stent and safely performed residual cancer resection including the aortic adventitia. In summary, aortic stent insertion enables safe resection of local recurrent tumors in the aorta after radical esophagectomy.

Anal canal adenocarcinoma with pagetoid spread has different a treatment strategy and prognosis from extramammary perianal Paget disease. We report two cases of anal canal adenocarcinoma with pagetoid spread along with a literature review. Case 1: A 69-year-old woman complained of perianal pain, redness, and erosion. Biopsy revealed adenocarcinoma with pagetoid spread. Laparoscopic abdominoperineal resection was performed, which resulted in 12 months' survival without postoperative recurrence. Case 2: A 62-year-old man complained of fecal occult blood and hemorrhoid. Under the diagnosis of anal canal cancer, transanal tumor resection was performed. Five years after surgery, he underwent endoscopic submucosal dissection for anal canal cancer. Ten years after surgery, he complained of anal tumor and perianal redness. Biopsy revealed adenocarcinoma with pagetoid spread. Laparoscopic abdominoperineal resection was performed, which resulted in 10 months' survival without postoperative recurrence.

The patient was a 67-year-old man. A Type 0-Ⅱa+Ⅱc tumor, 20mm in size was observed in the 1st portion of the duodenum under magnifying endoscopy. Mucosal cancer was suspected and endoscopic resection was performed, with pathological findings as follows: Type 0-Ⅱa+Ⅱc, 19×12 mm, tub1, pT1b(SM2: 700 mm), pUL0, Ly0, V0, pHM0, pVM0. He refused subtotal stomach-preserving pancreaticoduodenectomy(SSPPD)because of the high morbidity and mortality rates. Instead, he underwent only laparoscopic sampling of No. 5, 6, 12b, and 13a lymph nodes, and metastasis in a No. 6 node was pathologically confirmed. He eventually underwent SSPPD with D2, but no metastases were found in other lymph nodes. Pancreaticoduodenectomy is currently considered the best treatment option for complete removal of regional lymph nodes in duodenal cancer despite high morbidity and mortality rates. Further studies are needed to determine the pattern and incidence of lymph node metastasis by location and depth of the primary tumor, to establish optimal treatment guidelines for duodenal cancer.

The case is a 73-year-old man who underwent esophagectomy and retrosternal gastric conduit reconstruction for esophageal cancer. Reoperation was performed because the oral side of the gastric tube developed necrosis on the 31st postoperative day. The necrotic parts of the gastric tube were resected, and a cervical esophageal stoma was created. The remaining gastric tube was pulled up at the anterosternal subcutaneous location in preparation for the two-stage reconstructive operation. The reconstructive operation with a free jejunum graft through the anterosternal subcutaneous route was performed 35 days after the reoperation. Vascular anastomosis was performed with the right internal thoracic artery and vein by microsurgery. The postoperative course was satisfactory. Necrosis of the gastric tube is a rare and severe complication of esophagectomy. Reconstructive surgery for gastric tube necrosis is generally necessary but difficult to perform because of the severe surgical stress it confers on the patient. In this paper, we showed a new approach for two-stage reconstruction with a free jejunum graft through the anterosternal subcutaneous route. This operative procedure causes relatively less surgical stress than other procedures; hence, it is considered to be a beneficial reconstructive approach for patients with gastric tube necrosis.

A 68-year-old man was diagnosed with esophagogastric junction adenocarcinoma, cT4a(SE)N3aM0, cStage Ⅲ. Because "bulky N" was present, he was administered 2 courses of preoperative chemotherapy containing S-1 plus oxaliplatin(SOX). Both the primary tumor and enlarged lymph nodes had greatly decreased in size following chemotherapy, and total gastrectomy and lower esophagectomy with D2 lymphadenectomy were then performed. Histopathological examinations showed no residual cancer cell both in the primary lesion and dissected lymph nodes; thus, the efficacy of the chemotherapy was Grade 3. Preoperative chemotherapy containing SOX could be one of the useful treatment options for gastric cancer patients with extensive lymph node metastases including "bulky N".

Curative resection is necessary to survival in pancreatic cancer, however after surgery, pathologic examination sometimes diagnoses the remains of cancer at the resected stump. Therefore, it is necessary to evaluate the stump by intraoperative rapid pathological examination. 5-aminolevulinic acid(5-ALA)is an endogenous natural amino acid and precursor of the heme pathway. 5-ALA is metabolized and accumulated as protoporphyrin IX(Pp IX)that is photosensitive substance. 5-ALA mediated photodynamic diagnosis(PDD)(ALA-PDD)has high diagnostic ability. Andwe previously reportedusefulness of ALA-PDD for lymph node metastasis and peritoneal dissemination in gastric cancer and colorectal cancer patients. A case was 73-year-oldman who hadpancreatic headcancer. Since pancreatic cancer invasion to the inferior vena cava(IVC)was suspected during the operation, fluorescence observation was undergone. Pp IX fluorescence signal observedin the tissue around IVC by fluorescence observation. And, the tissue diagnosed adenocarcinoma by pathological findings. Therefore, it was judged that curative resection was difficult and the operation was completed. In conclusion, it was suggested that ALAPDD may be one of the methods of intraoperatively diagnosing the residual lesion of pancreatic cancer.

A 65-year-old woman with a history of pylorus-preserving gastrectomy(PPG)for early gastric cancer visited our hospital because of vomiting. Gastrointestinal endoscopy revealed a large bezoar in the anastomotic site of the stomach. Because the bezoar was too large to be collected orally, the dissolution therapy with taking Coca-Cola®was continued. On the 3rd day after hospitalization, she felt acute abdominal pain with vomiting. Computed tomography revealed intestinal obstruction by a mass with air bubbles inside in the ileum. Emergency operation was performed under a diagnosis of intestinal obstruction due to the bezoar. The black brown bezoar sized 80×35×30mm was extracted through an ileotomy. The delayed gastric empty is considered to involve in the bezoar formation. Therefore, the appropriate education of diet and periodic endoscopic screening are necessary for patients with large amounts of gastric residues especially after PPG. In the dissolution therapy, physicians need to be careful of intestinal obstruction by a bezoar.

Neoadjuvant chemotherapy(NAC)has been proven to have survival benefit for patients with resectable advanced esophageal squamous cell carcinoma(ESCC). Among a total of 208 patients with ESCC who underwent radical surgery following NAC between March 2000 and January 2017, 6 patients achieved histologically complete response. Before NAC, the average major axis length of the tumor was 57 mm, and the clinical stages were Stage II (2 patients)and Stage III (4 patients). FP therapy(cisplatin and 5-fluorouracil)was administered to 4 patients, and DCF therapy(docetaxel, cisplatin, and 5-fluorouracil) to 2 patients. Five patients showed partial response(PR)and 1 showed stable disease(SD). The average number of days between NAC and surgery was 26.2(16-44). Postoperative complications were observed in 2 patients(anastomotic leakage and recurrent nerve paralysis). There was no treatment-related mortality. All patients are surviving without relapse. The present study indicated that DCF therapy for patients with resectable advanced ESCC prior to surgery could further improve prognosis.

Differentiating primary Paget's disease from secondary Paget's disease, which is also known as Pagetoid growth of other cancers, in the perianal region is difficult. Given that the treatment strategies of both disease are significantly different, diagnosis of such conditions should be performed with caution. We report a case of secondary Paget's disease. A 76-year-old man previously visited a hospital because of erythematous plaque around the anus. It was diagnosed as extramammary Paget's disease based on skin biopsy results; consequently, perianal skin resection was performed. Pathological examination of the resected specimen indicated Pagetoid growth of mucinous carcinoma, and it was positive for stump. Consequently, laparoscopic abdominoperineal resection was performed. Finally, the plaque was diagnosed as anal canal adenocarcinoma with Pagetoid growth, and all the previous results were deemed as initial diagnosis., Conclusion: Discriminating between primary and secondary Paget's disease, even with immunohistological techniques, is difficult. Novel methodology that might facilitatemoreaccuratediagnosis preoperatively for erythematous plaquearound theanus and morecurativethe rapeutic strategy are needed.

A 49-year-old man was referred to our hospital for close examination of a submucosal tumor with ulceration located in the upper gastric body. PET-CT showed FDG uptake both in the gastric tumor and an enlarged lymph node. Although routine biopsies and EUS-FNA of this tumor did not demonstrate any malignant findings, he underwent excisional biopsy of the enlarged lymph nodes to rule out malignant lymphoma. Histopathological examination revealed that the excised specimens were metastatic nodes of poorly differentiated carcinoma probably from the known gastric tumor. Subsequently, he underwent total gastrectomy with D2, and histopathological findings confirmed the final diagnosis of gastric carcinoma with lymphoid stroma(GCLS). We report a case of GCLS that was difficult to diagnose.

This study aimed to examine the clinicopathological factors and prognoses of 5 patients with Stage IV gastric cancer(GC) who underwent chemotherapy followed by R0 resection at our institute from 2004 to 2013. Two patients had non-regional lymph node metastases, another 2 patients had peritoneal disseminations, and 1 patient had peritoneal dissemination and non-regional lymph node and left adrenal metastases. All patients underwent R0 resections following 2-6 courses of chemotherapy using multiple anticancer drugs. The disappearance of GC cells in non-regional lymph nodes and peritoneal nodules was confirmed. Clavien-Dindo II or less postoperative complications were found in 3 patients, but no perioperative mortality was observed. The histological response of the primary tumor to preoperative chemotherapy was determined as grade 1b or higher in every case. Although GC recurrence was found in 3 patients, 2 patients are alive without any recurrence. The median survival time of 5 patients was 28(range: 14-61)months. Some patients with Stage IV GC could achieve long-term survival due to chemotherapy followed by R0 resection.

A 39-year-old woman visited our hospital because of epigastric pain. Gastrointestinal endoscopy revealed a gastric submucosal tumor, 30mm in size, with ulcer locating near to the esophagogastric junction, and it was diagnosed with GIST by the endoscopic ultrasonography-guided fine needle aspiration. Then, she underwent laparoscopic surgery for the removal of gastric GIST. After peeling around the upper stomach, the local resection of the stomach was performed with linear staplers in the minor axis direction under the vision of the endoscope and laparoscope. Histopathological examinations confirmed that the tumor was GIST with an intermediate risk, and all surgical margins were free of GIST cells. Local resection with the laparoscopy endoscopy cooperative surgery(LECS)technique is a very useful way of the removal of gastric GISTs locating near to the esophagogastric junction in terms of the remnant gastric functions. Meanwhile, because the standard LECS requires the opening of the gastric lumen, there remains concerns about the intraperitoneal tumor dissemination for the gastric GIST with ulcer. We herein reported a case of laparoscopic local resection for a gastric GIST with ulcer locating near to the esophagogastric junction without gastric opening.

The patient was a 66-year-old man who was diagnosed with a type 3 lesion in the esophago-gastric junction and a type 1 lesion in the upper esophagus. Both the lesions were diagnosed as adenocarcinoma. Chest and abdominal computed tomography examinations pointed out No. 106recL lymph node metastasis. He was diagnosed with Stage III esophago-gastric cancer( T2N3M0)and treated by a laparoscopic subtotal esophagectomy with 2-field lymph node dissection. The histological diagnosis was type 3 adenocarcinoma in the esophago-gastric junction with intramural metastasis and massive lymph node metastasis(No. 1, No. 2, No. 101L, No. 106recL). A vertical connection of venous invasion in the submucosal layer was also observed from the primary lesion to the cervical esophagus via intramural invasion. Treatment based on esophageal cancer is necessary in advanced esophago-gastric cancers with intramural metastasis or massive venous invasion.

Since the national insurance to use oxaliplatin(L-OHP)for gastric cancer was approved in Japan, patients with advanced or recurrent gastric cancer have been treated by CapeOX therapy as one of the standard regimens. Here, we report a case of long-term complete response of peritoneal recurrence from advanced gastric cancer using CapeOx therapy following radical gastrectomy. The patient underwent total gastrectomy with curative intent for advanced gastric cancer with cytology positive, and received S-1 based adjuvant chemotherapy for 13 months. However, tumor marker elevation and peritoneal recurrence were detected by following examinations. The patient received capecitabine, which is a 5-FU prodrug, plus L-OHP therapy. Complete disappearance of peritoneal recurrence was confirmed under laparotomy after the 8th course. L-OHP-induced upregulationof thymidine phosphorylase(TP)was reported to enhance the effectiveness of capecitabine in vivo. CapeOX therapy was also an effective treatment strategy for recurrence following S-1 based chemotherapy.

The patient was a 57-year-old man. Upper gastrointestinal endoscopy revealed a 0- II c lesion at the anterior wall of the greater curvature in the lower third of the stomach, and the biopsy of this tumor gave the diagnosis of tubular adenocarcinoma. Abdominal contrast-enhanced computed tomography revealed many enlarged regional and non-regional lymph nodes. Because there was no definite evidence of lymph node metastasis, distal gastrectomy with D2 was performed. Histopathological examinations found the sarcoid reaction(SR)in lymph nodes, but could not demonstrate any cancer cells. SR is the epithelioid cell granuloma in lymph nodes found in patients without systemic sarcoidosis but with cancer. Early gastric cancer with SR is rare, with only 22 reported cases in Japan. SR is considered as one of the differential diagnoses when we find many enlarged lymph nodes in patients with early gastric cancer.

A 65-year-old man was diagnosed with leptomeningeal carcinomatosis based on the findings of cerebrospinal fluid cytology and magnetic resonance imaging(MRI).Treatment with erlotinib and bevacizumab was initiated, and partial improvement in consciousness and MRI findings were obtained.However, it was difficult to continue the treatment because of elevation in levels of liver enzymes and melena.We switched the treatment to afatinib monotherapy, and his consciousness improved immediately.Progression -free survival and overall survival from the initiation of the treatment with afatinib were 7 and 9.4 months, respectively. This clinical course suggests activity of afatinib for central nervous system lesions of EGFRmutated lung cancer.

Background and Objectives: Little is known about sex-based differences in morbidity and prognosis after gastrectomy for gastric cancer. This study was designed to detect risk factors for severe postoperative complications and define prognosis according to sex after gastrectomy for gastric cancer., Methods: Consecutive patients comprising 878 male and 421 female patients, who underwent R0 gastrectomy for Stage I - III gastric cancer, were retrospectively analyzed. We defined patients with severe postoperative complications as those with anastomotic leakage, a pancreatic fistula, and/or an intra-abdominal abscess of grade> II according to the Clavien-Dindo classification., Results: There was a significant association between sex and severe postoperative complications after gastrectomy for gastric cancer. In the male patients, poor nutrition, open surgery, and disease progression were independent risk factors for severe postoperative complications. In female patients, disease progression was the only independent risk factor. Regarding prognosis, poor nutrition was the only independent poor prognostic factor in male patients., Conclusions: Risk factors for severe postoperative complications were different between the male and female patients. Particularly in male patients, careful nutritional support may be required to prevent severe complications and improve the prognosis.

Endoscopic retrograde cholangiopancreatography(ERCP)is widely accepted as the standard therapy before surgery for hilar cholangiocarcinoma. The patient is a 68-year-old man who presented with liver dysfunction. Computed tomography (CT)revealed abnormal lesions in his liver. He was referred to our hospital for therapy. We present a rare case of expansion of left lobectomy for Bismuth III b hilar cholangiocarcinoma after grade 2 severe pancreatitis caused by ERCP. He received arterial infusion therapy and endoscopic necrosectomy 6 times and percutaneous transhepatic biliary drainage(PTBD). The surgical procedure could be performed after the severe pancreatitis resolved. His postoperative course was uneventful.

A 37-year-old man visited a previous hospital because of left abdominal pain. A contrast-enhanced CT scan revealed a 7 cm solid tumor in the pancreas body, and the patient was referred to our hospital. EUS-FNA showed that the tumor cells were positive for b-catenin in the nuclei, as well as for CD10 and CD56. On the other hand, the cells were negative for chromogranin A and synaptophysin. This is the typical immunohistochemical pattern of a solid pseudopapillary neoplasm(SPN). Therefore, we diagnosed this case as SPN before surgery. As the tumor progressed rapidly in 2 months, we performed distal pancreatectomy, total gastrectomy, and partial liver resection of the left lateral segment because of suspicious invasion of the pancreatic tumor to the stomach and the liver. On histological examination of the resected specimen, tumor invasion to the stomach was apparent, but the tumor did not invade the liver. Immunohistochemical staining showed the same SPN pattern as the EUS-FNA results. We identified small and uniform tumor cells, although no pseudopapillary pattern was observed with HE staining. Finally, we diagnosed this case as an undifferentiated carcinoma. We need to consider the possibility of malignant transformation or undifferentiated carcinoma even when a tumor is diagnosed as SPN on EUS-FNA.

The survival of patients with recurrent ovarian cancer who have completed secondary debulking surgery (SDS) has been shown to increase. However, whether tertiary debulking surgery (TDS) aimed at complete surgery is useful in patients with a second recurrence is unclear. Eight patients who had undergone SDS were treated after a second recurrence in our hospital. Their medical records were retrospectively reviewed. Consequently, TDS was performed in 4 of the patients (TDSgr). All 4 patients underwent complete debulking surgery, 2 patients received blood transfusions, and none had serious postoperative complications. The median treatment free interval (TFI) from recurrence surgery to the second recurrence was 16 months (range, 9-23 months), and the median TFI after the second recurrence was 30.5 months (range, 15-69 months). Meanwhile, the median TFI after the second recurrence was 7.5 months (range, 1-31 months) in the 4 patients who did not undergo TDS (non-TDSgr). The median survival times after the second recurrence in TDSgr and non-TDSgr were 53 months (range, 41-69 months) and 12 months (range, 2-30 months), respectively. When complete surgery is indicated in patients with a second recurrent ovarian cancer after SDS, in case of good physical condition with single or multiple recurrent lesions, TDS may increase survival and TFI.

Nanoparticle albumin-bound paclitaxel(nab-PTX)was approved for the treatment of gastric cancer without a large-scale clinical trial in Japan. Its safety and efficacy should be validated in clinical practice. We retrospectively investigated prognostic factors related to time to treatment failure(TTF)in 11 patients with unresectable or recurrent gastric cancer treated with nab- PTX in our hospital. In univariate analysis, Onodera's prognostic nutritional index(PNI)and the time from the start of first-line chemotherapy to the start of nab-PTX were related to TTF. In multivariate analysis, Onodera's PNI was identified as an independent predictive factor for TTF (hazard ratio 0.056, p=0.022). PNI could contribute to adequate patient selection and the improvement of nab-PTX therapy efficacy ingastric cancer.

We report a rare case of retroperitoneal lymphangioma that was difficult to differentiate from pancreatic tumor. The patient was a 38-year-old woman. In June 2011, CT detected a pancreatic tail tumor. She was expected to undergo radical surgery and was referred to our hospital. The tumor was 55×43×40 mm in size and was described as a multilocular cystic lesion with a partition on CT. MRI demonstrated the tumor as a high-intensity area on T2-weighted images. Sonazoid-enhanced US showed a contrast effect of the partition wall. Therefore, the lesion was diagnosed as a mucinous cystic neoplasm, and the patient underwent surgery. Intraoperatively, the tumor was a white multilocular cystic lesion with a capsule. The cystic lesion was exfoliated from the pancreatic parenchyma. Histologically, the tumor was diagnosed as a cavernous lymphangioma without malignancy. The surgery achieved good progress and the patient was discharged 12 days postoperatively. She is attending our clinic without any recurrence.

Vascular anomalies, as described by the Adachi classification, are an inevitable issue for gastric cancer surgery. Here, we report a safe technique for laparoscopic lymph node dissection in a patient with Adachi typeⅥ vascular anomaly. The patient is a 72-year-old woman, who presented with a submucosal gastric cancer located on the lesser curvature of the stomach. Preoperative MDCT revealed Adachi type Ⅵ vascular anomaly. At laparoscopic surgery, we first identified the portal vein. Then, dissection of the hepatoduodenal and No. 8a lymph nodes was performed from the location near the portal vein at the superior portion of the hepatoduodenal ligament to that near the splenic vein superior to the pancreas. This avoids the disorientation that may result from anomalous vessels and prevents error that can lead to vascular complications. Subsequently, she underwent D1 plus gastrectomy. Her postoperative course was uneventful. Our surgical technique offers a safe approach for laparoscopic gastrectomy in the patient with Adachi type Ⅵ vascular anomaly.

We report 2 cases of curative resection of pancreatic cancer after neoadjuvant chemotherapy. A 60-year-old woman was diagnosed as having borderline resectable pancreatic ductal adenocarcinoma with invasion of the nerve plexus covering the superior mesenteric artery. The preoperative chemotherapy, 4 courses of gemcitabine and S-1, reduced the volume of tumor; pancreaticoduodenectomy with portal vein resection after chemotherapy resulted in R0 resection. Pathological examination of the resected specimen showed fibroid tissue with myxoid degeneration and mucinous lake surrounded by differentiated adenocarcinoma. A 40-year-old woman was diagnosed as having borderline resectable pancreatic ductal adenocarcinoma with invasion of the common hepatic artery and splenic artery. The preoperative chemotherapy, 4 courses of gemcitabine and S-1, reduced the tumor volume; distal pancreatectomy with portal vein resection after chemotherapy obtained R0 resection. Pathological examination of the resected specimen revealed that the majority of the tumor was fibrotic and necrotic tissue, and few cancer cells remained viable. Neoadjuvant chemotherapy has a potential to increase the rate of R0 resection. Furthermore, preoperative chemotherapy can help avoid unnecessary surgery by allowing time for potential metastasis to become obvious.

Background: Thrombocytosis in patients with cancer is reportedly associated with an increased expression of angiogenic factors and a poor prognosis in some cancer types. The aim of this study was to analyze the clinicopathological significance and prognostic value of platelet counts in patients with gastric cancer., Methods: Preoperative platelet counts were measured in 306 patients with gastric cancer who underwent surgery between 2001 and 2010.We used the cut-off level of 250.9×10(3) mL (mean) to define thrombocytosis and then analyzed the correlation between platelet count and clinicopathological factors. The multivariate prognostic value was determined using the Cox proportional hazards model., Results: Platelet counts were significantly elevated in patients with lymph node metastasis (p=0.0349) and pStage Ⅲdisease (p=0.0326). Adjusting for venous invasion and pStage, multivariate analysis indicated that thrombocytosis as defined in this study was an independent prognostic factor (hazard ratio=1.50, 95%CI: 1.07-2.36, p=0.0402)., Conclusion: A high platelet count is associated with tumor progression and poor survival in patients with gastric cancer.

Wernicke's encephalopathy is usually related to alcoholism, malnutrition, or hyperemesis gravidarum. We report a case of Wernicke's encephalopathy after distal gastrectomy for gastric cancer. A 58-year-old man underwent distal gastrectomy with Billroth Ⅰreconstruction for early gastric cancer. Nine months later, he developed anorexia and vomiting for a few days. Brain MRI showed no significant findings, and he resumed ingestion 5 days after admission. On the 8th day of hospitalization, dysphagia suddenly developed and brain MRI indicated Wernicke's encephalopathy. Vitamin B1 was immediately injected, and neurological symptoms gradually improved. However, dysphagia did not adequately improve, leading to severe aspiration pneumonitis. Laparoscopic gastrostomy was performed for aspiration of the stomach contents and initiation of enteral nutrition. After gastrostomy, the patient made good progress and was transferred to a rehabilitation hospital. We should recognize that gastrectomy can cause Wernicke's encephalopathy.

A 67-year-old man was admitted to our hospital for treatment for multiple superficial esophageal cancers. Screening upper gastrointestinal endoscopy examination revealed a superficial squamous cell carcinoma (SCC) at the middle thoracic esophagus and Barrett's epithelium and a superficial adenocarcinoma at the abdominal esophagus. We performed a subtotal esophagectomy with gastric tube reconstruction via the retrosternal route. Pathological examination revealed a Barrett's adenocarcinoma at the abdominal esophagus. Esophageal cancer is thought to be a multicentric disease, and we sometimes find multiple esophageal cancers. In Japan, most cases of multiple esophageal cancers are composed of SCCs, and the occurrence of multiple esophageal cancers composed of SCC and Barrett's adenocarcinoma is rare. In contrast, the number of the patients with Barrett's esophagus is increasing, and the number of the patients with Barrett's adenocarcinoma also seems to be on the rise. Therefore, it is important be aware of the possibility of multiple esophageal cancers composed of SCC and Barrett's adenocarcinoma while making diagnoses.

Objective: Although the efficacy of adjuvant chemotherapy with oxaliplatin for colorectal cancer patients has been established, the tolerability of this regimen is rarely reported in Japan. The aim of this study was to clarify the tolerability of adjuvant oxaliplatin-based regimen for Japanese patients with colorectal cancer., Methods: This study included 158 advanced colorectal cancer patients who consecutively underwent a surgical procedure at our hospital and received adjuvant chemotherapy. Completion rate and adverse events were monitored in this study., Results: Among the 158 patients, 44 received oxaliplatin-based chemotherapy and the remaining received chemotherapy without oxaliplatin. The use of oxaliplatin was significantly correlated with more cases of adverse events such as myelosuppression (p<0.001) and peripheral neurotoxicity (p=0.005), which lead to dose reduction (p<0.001) or drug withdrawal (p<0.001). However, the completion rate did not significantly differ between the 2 groups. The median relative dose intensity (RDI) was 85.7%, which means that the oxaliplatin-based regimen is feasible. As for recurrence-free survival, no significant differences were observed between the 2 groups., Conclusion: This study demonstrates that adjuvant chemotherapy with oxaliplatin is tolerable by colorectal cancer patients in Japan.

Background: According to the 14th Japanese Classification of Gastric Carcinoma(JCGC), station No. 1 lymphadenectomy for distal gastrectomy was included in the D1 level, though the 13th JCGC classified station No. 1 lymphadenectomy to the D2 level in patients with primary lower-third gastric cancer (LGC). This study was designed to re-evaluate the therapeutic value of lymphadenectomy, and to clarify the possible risk factors for station No. 1 lymph node metastasis (LNM) in LGC., Methods: Between 1997 and 2014, 1,875 consecutive patients with gastric cancer underwent curative gastrectomy with radical lymphadenectomy. Of these, 344 patients who had a tumor located in the lower (L) or lower-duodenum (LD) area were analyzed retrospectively., Results: 1) The therapeutic value of lymphadenectomy of stations No. 6, No. 3, No. 8a, No. 5, No. 4d, and No. 1 lymph nodes was proved to be higher than that of lymphadenectomy of other station lymph nodes. Patients with station No. 1 LNM had a significantly higher incidence of undifferentiated type, lymphatic invasion, venous invasion, and pT2-4 tumor. 2) Regarding factors to predict station No. 1 LNM in LGC, there was no station No. 1 LNM in patients with both early and differentiated type LGC. Distance from the pylorus to the tumor center (DPT) significantly correlated with station No. 1 LNM. Particularly, there was no station No. 1 LNM in patients with early LGC and DPT<50 mm., Conclusions: In patients with early and differentiated type LGC and DPT<50 mm, limited surgery to omit station No. 1 lymphadenectomy might be possible.

Background and Aims: The epidemiology of gastric cancer is changing with an increasing proportion of tumors in the upper stomach. This study was designed to identify risk factors and clinical problems related to the difference between clinical and pathological diagnosis of tumor depth in cases of upper third gastric cancer., Patients and Methods: A total of 119 consecutive patients with upper third gastric cancer, who underwent curative gastrectomy between 2008 and 2012, were retrospectively analyzed., Results: The patients were divided into 2 groups based on the pattern of the difference between the clinical (c) and pathological (p) diagnosis of the T factor. Thirty patients (25%) were included in the underestimated diagnosis group (UE group, cTpT or cT=pT). The number of cases showing undifferentiated type (TMN) and lymphatic invasion was significantly higher in the UE group compared to the OC group. Multivariate analysis revealed that the undifferentiated type (TMN) was an independent risk factor for underestimation (p<0.05)., Conclusion: The presence of undifferentiated components in upper third gastric cancer was associated with a high incidence of underestimated diagnosis. Care should be taken in decision-making for surgical treatments based on the clinical diagnosis.

Background: We studied cases with single lymph node metastasis from thoracic esophageal squamous cell carcinoma., Methods: We reviewed the site of nodal metastasis in 73 cases with a single metastatic site., Results: The lymph node metastases of the upper thoracic cases were located in the cervical, superior mediastinal, middle mediastinal, lower mediastinal, and abdominal lymph nodes in 5, 10, 3, 0, and 0 cases, respectively. The lymph node metastases of the middle thoracic cases were located in the cervical, superior mediastinal, middle mediastinal, lower mediastinal, and abdominal lymph nodes in 1, 18, 6, 0, and 11 cases, respectively. The depth of tumor in the middle thoracic case that had metastasis in a cervical lymph node was T1b, and the location of the metastatic lymph node was number 104 L. The lymph node metastases of the lower thoracic cases were located in the cervical, superior mediastinal, middle mediastinal, lower mediastinal, and abdominal lymph nodes in 0, 2, 2, 4, and 11 cases, respectively. The depth of tumor in the lower thoracic cases with metastasis in a superior mediastinal lymph node was T1b and T4., Conclusion: Even in superficial thoracic esophageal squamous cell carcinoma cases, distant metastasis was observed at an early stage. Therefore, the range of lymph node dissection should be decided carefully in these cases.

A 48-year-old woman was found to have an esophageal cancer, and after preoperative chemotherapy with cisplatin (CDDP)/5-fluorouracil (5-FU), radical subtotal esophagectomy was performed. On the fifth day after surgery, her respiratory condition suddenly worsened and a chest radiograph showed low permeability in both lung fields, leading to a diagnosis of acute respiratory distress syndrome (ARDS) and intubation for mechanical ventilation. Since clinical examination did not detect signs of infection on the seventh day, we began administering hydrocortisone at a dose of 300 mg. Her inflammatory response and respiratory condition improved by the next day and the dose of hydrocortisone was gradually reduced. The patient was extubated on the 13th day, administration of steroids was halted on the 22nd day, and she was discharged from the hospital on the 26th day. ARDS remains a refractory disease and no drug has proven to be effective in randomized controlled trials. The use of steroids for ARDS management remains controversial. Our present case suggests that low-dose steroids from an early stage in uninfected ARDS patients may improve prognosis.

In advanced gastric cancer patients, preoperative multi detector row computed tomography (MDCT) often reveals abnormal ascites, which can indicate the possibility of peritoneal metastasis. The aim of this study was to clarify the clinical significance of preoperative ascites revealed by MDCT in gastric cancer patients. The study included a total of 183 advanced gastric cancer patients who underwent consecutive surgical procedures from February 2008 to November 2011. The results indicate that the presence of ascites on MDCT is significantly correlated with peritoneal metastasis (p<.005), pathological T4 (p< 0.005), R1-R2 (p<.01), and a positive diagnosis of peritoneal washing cytology(p<.05). Multivariate analysis indicated that the presence of ascites on MDCT was an independent prognostic factor (hazard ratio[HR]2.6). In conclusion, the presence of ascites on preoperative MDCT is strongly associated with peritoneal metastasis, and might indicate the need for diagnostic laparoscopy to evaluate Stage IV factors and select the best treatment strategy.

5-aminolevulinic acid (5-ALA) is widely used in clinical practice because it shows tumor-selective accumulation of protoporphyrin IX, a fluorescent substance and a metabolite of 5-ALA. In addition, some studies have reported that 5-ALA increases the radiation sensitivity of glioma and melanoma. In this study, we investigated the radiosensitization effect of 5-ALA on colon cancer. Mice implanted with the human colon cancer cell line HT29 were administered 5-ALA and subsequently X-ray irradiated. These mice were compared with those not administered 5-ALA. Following multiple irradiations, the tumor volume of the 5-ALA group was significantly lower than that of the non-5-ALA group (day 5: p value=0.0489, day 8: p value= 0.0318, day 12: p value=0.0394). Tumor growth was inhibited by multiple irradiations in the 5-ALA group compared with the non-5-ALA group. These results suggest that 5-ALA also exhibits a radiosensitization effect on colon cancer.

Background and Aims: Recent advances in anti-cancer drug treatments enable us to improve prognosis in Stage IV gastric cancer. In particular, in recent reports patients with only cytology positive (CY1) non-curative factors have comparatively better prognosis than others. This study was designed to evaluate our outcomes, to allow identification of CY1 gastric cancer patients and to investigate new treatment strategies., Patients and Methods: Between 2000 and 2008, 336 patients underwent peritoneal washing cytology for gastric cancer intra-operatively. Of these, 35 patients (10.4%) were diagnosed with CY1 gastric cancer., Results: 1 ) In all CY1 gastric cancers, 1-year, 3-year, and 5-year survival rates were 49%, 11%, and 5.7%, respectively. Clinical factors such as number of non-curative factors (p=0.008) and gastrectomy (p=0.001)were significantly related to poor prognosis. 2 ) The number of CY1 patients with only CY1 non-curative factors (Group C) and multiple non-curative factors (Group CM)were 14 and 21, respectively. The number of CY1 patients with gastrectomy and without gastrectomy were 30 (MST 366 days, Group C: 14 Group CM: 16) and 5 (MST: 88 days, Group CM: 5), respectively. 3 ) In CY1 patients with gastrectomy, patients treated with S-1 based chemotherapy had better prognosis in both Group C and Group CM. 4 ) 8 CY1 patients with neoadjuvant chemotherapy (NAC) followed by gastrectomy (MST 501 days, 1-year survival rate 62.5%) tended to have better prognosis than those without NAC (MST 132 days, 1-year survival rate 25.0% (p= 0.055)., Conclusions: Gastrectomy, number of non-curative factor, S-1 based chemotherapy and NAC were keys to improving prognosis by subgroup analyses in CY1 gastric cancer.

No ideal or generally accepted treatment strategy has been established for severe duodenum-related complications of gastrectomy for gastric cancer. Between 1997 and 2012, we successfully treated 5 patients with such complications using the retrograde intraduodenal drainage tube. Of the patients, 3 had anastomotic leakage of the duodenal stump, 1 had an intestinal injury, and 1 had the afferent loop syndrome. None of the patients experienced any further adverse events related to the procedure. This retrograde intraduodenal drainage technique was safe and effective, and may be considered as an optimal treatment strategy for severe duodenum-related complications of gastrectomy for gastric cancer.

Herein, we report 9 patients who underwent esophagectomy after endoscopic submucosal dissection (ESD) between April 2003 and December 2013. All patients were men, with a mean age of 65 years. En bloc ESD was performed, and no complications arose in any patient. The mean surgical time of esophagectomy was 323 minutes, and mean blood loss was 295 mL. Postoperative complications were present in 5 patients(anastomotic leakage in 3, pulmonary complications in 2, and recurrent laryngeal nerve palsy in 1). In a patient diagnosed with pT1b-SM1 disease after ESD, a residual tumor(pT1a-MM, N0) was detected after esophagectomy. In another patient diagnosed with pT1b-SM2 disease, lymph node metastasis was detected after esophagectomy. In all patients, curative resection was performed, and no recurrences have been observed to date. This highlights the importance of additional esophagectomy after ESD for patients with pT1b disease. Esophagectomy after ESD can be considered a valid treatment because it provides high curative rates with acceptable safety.

The present study investigated generational changes in the clinicopathological characteristics of younger patients with gastric carcinoma (GC). The medical records of 1,420 patients who had undergone gastrectomy for GC between 1997 and 2012 were reviewed retrospectively. The patients were divided into 2 groups based on age, with 49 patients below the age of 40 and 1,371 patients above the age of 40. Moreover, the clincopathological features of the 49 patients below the age of 40 were compared with age-matched GC patients who had undergone gastrectomy from 1985 to 1996. Younger GC patients group had a higher number of women and a higher incidence of undifferentiated GC, although there was no prognostic significance between the 2 groups. Comparison of three-generational younger GC patient groups (1985-1996, 1997-2002, and 2003-2012) demonstrated no difference in survival curve between the 3 groups, although a higher incidence of undifferentiated GC was observed with time. Furthermore, in younger patients with undifferentiated GC, the last generational group (2003-2012) had a tendency towards an improved prognosis in the early postoperative period. This study demonstrated that there was no prognostic significance between GC patients below the age of 40 and over the age of 40. Chemotherapy might contribute to improved prognosis in younger GC patients.