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Laparoscopic proximal gastrectomy(LPG)for upper gastric cancer is still inadequate. We verified the validity of LPG by comparing the surgical outcomes of 15 cases who underwent LPG(PG group)and 14 cases who underwent laparoscopic total gastrectomy(TG group)in 29 cases who underwent laparoscopic surgery for upper gastric cancer at our hospital between January 2014 and December 2022. As a patient background, the PG group was significantly older(p=0.03)than the TG group and tended to have more high-risk cases(p=0.12). As a tumor factor, cancer progression tended to be earlier in the PG group(p=0.05). As a surgical(short-term)outcomes, although the range of lymph nodes dissection was narrow (p<0.01)and the amount of blood loss was significantly lower(p=0.01)in the PG group, there was no difference in operation time or postoperative complications between the 2 groups. Furthermore, there was no difference in the rate of weight loss, the rate of change in nutritional indicators in the medium-term(1 year after surgery), or the long-term prognosis.

We report a case of rectal cancer that was resected 1 year and 3 months after SEMS implantation. An 89-year-old man was previously diagnosed with sigmoid colon cancer at another hospital but did not undergo surgery. Three years and 7 months after the diagnosis, SEMS was implanted at another hospital. Four years and 10 months after the diagnosis, the patient was diagnosed with intestinal obstruction at our hospital. Since the SEMS was open on colonoscopy, the patient was also suspected of having flaccid constipation. The primary tumor was resected, and a colostomy was constructed in the descending colon. Bridge to surgery for obstructive colorectal cancer was performed within a few weeks after SEMS implantation. At our hospital, resection was performed after a long time. No complications, such as obstruction or perforation, were observed. In addition, although there were concerns regarding increased vascular invasion due to compression and drainage of the cancerous tissue, in our case, the vascular invasion was mild, and no distant metastasis or invasion of other organs was observed. SEMS can be used for long-term implantation and does not necessarily cause cancer progression.

Surgery for transverse colon cancer is very difficult because of small number of patients, variations in the vascular system, and complexity of the mobilize hepatic and splenic flexure of colon. We analyzed the clinical characteristics and surgical outcomes in 51 cases who underwent surgery for transverse colon cancer at our hospital between January 2014 and December 2021, and examined the optimal laparoscopic approach method. The surgical procedure was right hemicolectomy in 24 cases, transverse colectomy in 22 cases, and left hemicolectomy in 5 cases, of which 37 cases had laparoscopic surgery. In laparoscopic surgery, when comparing the cranial first approach group in 21 cases and the caudal approach group in 16 cases, the operative time was almost the same between the 2 groups. In the cranial first approach group the amount of bleeding tended to be small, the number of MCA lymph node dissections tended to be large and the hospital stay tended to be short, though there was no statistically significant difference. The results suggest that the cranial first approach tends to be safer and more accurate than the caudal approach.

We report a patient with inoperable hilar cholangiocarcinoma due to invasion at the umbilical portion who survived more than 4 years after right portal vein embolization and administration of S-1(50 mg/day). A 64-year-old male patient was immediately hospitalized for liver dysfunction and a high level of HbA1c. The disease was diagnosed as hilar cholangiocarcinoma mainly extending along the right hepatic duct. We made a request for operation to Nagoya University. He received right portal vein embolization in order to grow the residual liver but was deemed inoperable because of invasion at the umbilical portion. He refused chemotherapy but accepted administration of S-1(50 mg/day). Approximately 3 months after starting S-1, his ALP level normalized and about 9 months later stenting tube was lost. Subsequently, he returned to his job. Approximately 2 years and 2 months later, administration of S-1 was interrupted due to a harmful side effect. After approximately 13 months without S-1, the levels of CA19-9 and ALP again became elevated and administration of S-1 was restarted. He was temporarily hospitalized for abdominal pain and fever, but quickly recovered. Although CA19-9 and ALP levels re-normalized, he died after returning home. We emphasize the possibility of maintaining long-term health by minimal- dose S-1 therapy for inoperable hilar cholangiocarcinoma.

We report the y-shape+1 method, which is a retraction of the liver method, independent of the position of the costal arch. Additionally, we report changes in liver enzymes induced by different methods of liver retraction. Three Penrose No. 6 drains were cut into 6 cm pieces. Penrose 1 was fixed with a thread attached to the end and Penrose 2 in a y-shape. A knitting thread with needles was prepared, and a loop was made at the end of the thread. The needle thread was passed over the abdominal wall and through the Penrose 2. The needle thread was passed over the diaphragmatic leg and through the Penrose 3. The thread was pulled over the abdominal wall and diaphragmatic leg and fixed to the end of Penrose 1 out of the body, and the liver was drained. The rate of change in liver enzymes from the preoperative to postoperative stages was examined separately in the Penrose and Nathanson groups. In the y-shape+1 technique, retraction of the liver can be performed regardless of the position of the rib arch; however, intracorporeal suture ligation is necessary. This method is useful when the conventional Penrose method is inappropriate because of the position of the rib arch.

Non-ampullary duodenal tumors are relatively rare; however, in recent years, they have been encountered more frequently. We analyzed the surgical outcomes and clinicopathological findings in 20 patients who underwent surgery based on preoperative diagnoses of non-ampullary duodenal tumors at our hospital between January 2011 and April 2021. We performed surgery for 3 cases of GIST, 4 cases of adenoma, and 13 cases of adenocarcinoma. The average age of the patients was 64.3 years and the male-to-female ratio was 17:3. The location of the tumor was the blub in 5 cases, the superior duodenal angle in 2 cases, the descending portion in 9 cases, the horizontal portion in 3 cases, and the ascending portion in 1 case. The histological type of adenocarcinoma was tub1 in all cases of early cancer, whereas in advanced cancer, there were many cases with histological types other than tub1. Various surgical procedures from duodenal local resection to pancreatoduodenectomy can be performed for treating non-ampullary duodenal tumors depending on the tumor location and the necessity of lymph node dissection. It is important to establish a treatment policy that considers both curability and invasiveness.

The purpose of this study is to examine the maximum brightness of the monitor, which is suitable for radiological technologists' (hereinafter referred to as technicians) interpretation assistance and image inspection. The signal detection ability was evaluated by receiver operating characteristic (ROC) analysis using a chest X-ray image with a simulated nodule. In order to examine the ease of observation and the effect on the subjective evaluation by changing the maximum brightness, evaluation was performed by the normalized ranking method using chest X-ray images. ROC experiments were performed using images with and without simulated nodules in the chest phantom. There was no significant difference in detectability by changing the maximum brightness (p>0.05), but the average area under the curve (AUC) was higher at 350 cd/m 2 than at 100 cd/m 2 and 170 cd/m 2 . A normalized ranking method was performed focusing on simulated nodules on chest X-ray images. In the least significant difference (l.s.d.) method, there was a significant difference between the maximum luminance, and the higher the maximum luminance, the better the evaluation. From these results, the change in the maximum brightness did not significantly affect the signal detection ability of the technician's chest X-ray image, but the higher the maximum brightness, the easier it was to observe and the higher the subjective evaluation. It has been reported that the higher the maximum brightness, the shorter the signal recognition time, and a monitor with a high maximum brightness may lead to more efficient image inspection by a technician. From the results of this study, it is considered appropriate to use a medical liquid crystal display (LCD) monitor with a maximum brightness of 350 cd/m 2 for the technician's interpretation assistance and image inspection.

An 89-year-old woman with complete blindness presented with a right lower abdominal tumor and weight loss. The CT scan showed a huge mass approximately 9 cm in diameter in the ileocecum, invading the right urinary tract and right iliac artery and vein. Findings of the TCS biopsy led to the suspicion of ileocecal carcinoid. Another punch biopsy specimen acquired under general anesthesia indicated mucinous cell carcinoma. When she suffered from right leg pain approximately 3 months later, we provided radiation therapy(50 Gy)because of intolerance to UFT. Consequently, pain disappeared, and the tumor size decreased significantly. We administered TS-1 but discontinued it because of intolerance. Further, 2.8 years after the first medical examination, the tumor recurred, and she developed ileus. We performed ileocolectomy, and pathological findings indicated that the adenocarcinoma in the appendix had progressed from goblet cell carcinoid(sig, si[right ovary], ly1b, v1a, n0). Four years after the first medical examination, CEA had elevated rapidly, and lung metastases were found. She died approximately 4.2 years after the first medical examination. The last measured CEA level had been 596.7 ng/mL. Starting from the lowest level at the first examination, the CEA level had slowly elevated until before the operation and rapidly elevated postoperatively. Immunopathological findings showed that the operated specimen stained diffusely for CEA, without any mucinous component. We suspected that radiation therapy modified goblet cell carcinoid to adenocarcinoma.

We herein report a case of application of sugar to the edematous stoma for obstructive rectal cancer. A 70-year-old male patient was diagnosed with rectal cancer, bowel obstruction and multiple lung metastases. Colostomy was performed. Seven days after operation, severe edema and congestion of stoma continued. We started spraying of sugar to stoma, and a few days later, edema and congestion of stoma improved. Before discharge, stoma size markedly reduced. Steady state of stoma and achievement the ability to self-care their stoma is important for introduction of chemotherapy. Application of sugar to reduce edema of rectal prolapse and prolapsed stoma have reported. Although the number of reported cases is still small, effectiveness of sugar to reduce edema of stoma have reported. In our case, application of sugar to the stoma is effective in reduction of edema. Application of sugar might be effective in reduction edema of stoma.

Malignant esophageal stenosis adversely affects the quality of life(QOL)on account of poor oral intake. Endoscopic esophageal stenting is one of palliative therapy for improve QOL because of minimally invasive and simple procedure. We investigated the outcomes of esophageal stenting in our institution. Twenty patients with malignant esophageal stenosis who underwent esophageal stenting in our institution between April 2014 and December 2019 were included in this study. Six(30%)out of 20 patients showed fistula. Dysphagia score was improved significantly before and after stenting(3.3± 0.6 vs 1.8±0.9, p<0.01). Complications associated with stenting occurred in 6(30%)cases. Thirteen(65%)patients were able to be discharged from the hospital, but 7(35%)patients including 4 with fistula were outcomes of death in the hospital. Esophageal stenting for malignant esophageal stenosis improved food ingestion and QOL. The prognosis in the case of malignant esophageal stenosis with fistula is extremely poor.

The present case pertained to a 70-year-old woman. The fecal occult blood test was positive. Colonoscopyrevealed rectal cancer. She underwent the first operation of low anterior resection. Pathological diagnosis was carcinoid, se, ly2, v0, n1. Approximately2 months later, multiple liver metastases were found. Because of strong enhancement at angiography, transarterial chemoembolization(TACE)was selected. After 3 rounds of TACE, we operated the residual liver metastasis approximately1 year and 7 months after the first operation. However, approximately8 years and 9 months after the first operation, multiple liver metastases were found again. Hepatic arterial infusion(HAI)was chosen because tumors showed weak en- hancement on CT. First, we tried high-dose HAI(5-FU 1 g/dayat 1-3 and 5-7, amount: 6 g/week), and liver metastases was almost in CR. However, extrahepatic metastasis was found on PET-CT. Because of rapid growth, we operated the growing lymph node. Pathological diagnosis was diffuse large-cell type B-cell malignant lymphoma. Thus, we extended the interval of HAI(weekly, biweekly, and monthly)and simultaneously4 courses of R-THP-COP(R: rituximab, THP: pirarubicin, C: cyclophosphamide, O: vincristine, P: prednisolone)therapyfor malignant lymphoma was administered. She is now an outpatient. Liver metastases continue to be in CR at approximately1 year and the IL-2R value is almost within normal range.

The use of endoscopic submucosal dissection(ESD)for the treatment of duodenal tumors has increased recently. ESD is less invasive than surgical resection of duodenal tumors. However, a high rate of complication, including perforation and bleeding, has been reported to be associated with ESD. Here, we report the minimally invasive surgical procedure called "endoscopy guided single-incision laparoscopic partial duodenectomy" for the treatment of duodenal tumors, along with its and safety and treatment outcomes. Five patients were included in this study. We mounted the LAP PROTECTORTM and EZ access®in the umbilical incision. Single-incision laparoscopic surgery was performed using 3 trocars(5mm)that were placed into the EZ access®. First, we mobilized the duodenum and pancreatic head from the retroperitoneum using the laparoscopic "Kocher maneuver". Next, the peritumoral site was marked by an endoscopic procedure using a clip and electric needle knife. Using an endoscope, we performed laparoscopic full-thickness resection of the duodenal wall including the tumor. The defect in the duodenal wall was then closed by suturing.

We report a case of metastasis to the small intestine from squamous cell carcinoma of the lung with fistula formation in the adjacent small intestine as well as an analysis of reported cases in Japan of small intestinal metastasis from lung cancer invading other organs. A 63-year-old man was diagnosed with squamous cell carcinoma of the lung as a result of pneumonia. Chemoradiotherapy was administered and sequential chemotherapy was performed, but a single brain metastasis of right parietal lobe was detected 6 months later. Tumor resection was performed. Twelve months after the lung cancer diagnosis, metastasis of the small intestine was detected. Single-incision laparoscopic surgery with partial resection of the small intestine was performed. The tumor had invaded the abdominal wall and 2 parts of the small intestine and had formed a fistula with part of the small intestine. Subsequently, peritoneal dissemination recurred and the patient received the best supportive care. There are 10 reported cases in Japan of small intestinal metastasis from lung cancer invading other organs. Analysis of the reported cases indicates a poor prognosis for patients with fistula. Resection can improve prognosis in patients with primary lung cancer and without distant metastasis. Surgical resection should be considered even if metastasis in the small intestine from lung cancer has invaded other organs.

A case of a skin ulcer caused by bevacizumab(Bmab)is reported here, which recurred with re-administration of bevacizumab. A 69-year-old male patient was diagnosed with cecal cancer, multiple liver metastases, multiple lung metastases, and bone metastasis. Resection of the cecal cancer was performed, and the patient was post-operatively treated with XELOX and Bmabchemotherapy. After the second cycle of chemotherapy, a skin ulcer developed. The ulcer improved after cessation of chemotherapy, debridement, and treatment with antibiotic medication. In spite of re-administration of XELOX chemotherapy, the skin ulcer healed completely, however, the dermatopathy recurred after re-administration of Bmab. Bmab chemotherapy is associated with various risks, including dermatopathy and protracted wound healing, and some cases of skin ulcers caused by Bmab have been reported. Because the skin ulcer was suspected to be cutaneous actinomycosis, Bmab chemotherapy was reintroduced while the patient was treated using antibiotic agent feeding, but the skin ulcer reoccurred. Reported cases of skin ulcers caused by Bmab in Japan show that skin ulcers often recur after re-administration of Bmab. Therefore, if skin ulcers caused by Bmab develop, re-administration of Bmabshould be considered carefully.

Persistent descending mesocolon(PDM)is caused by absence of fusion of the descending colon to the retroperitoneum. We report a case of laparoscopy-assisted surgery for descending colon cancer in a patient with PDM. An 88-year-oldfemale patient complaining of abdominal pain was diagnosed with bowel obstruction, and referred to our hospital. A computed tomography(CT)scan showed bowel obstruction due to descending colon cancer. After decompression of the colon by insertion of a transanal drainage tube, she underwent laparoscopy-assistedleft hemicolectomy. Intraoperatively it was observed that the descending colon was not fixed to the retroperitoneum, and the patient was diagnosed with persistent descending mesocolon. The accessory middle colic artery and the inferior mesenteric vein branched radially. In patients with PDM, the inferior mesenteric artery often branches radially. However, the various morphologies of branching of the accessory middle colic artery and the inferior mesenteric vein have not been reported. It is not clear whether the radial branching of the accessory middle colic artery and the inferior mesenteric vein is characteristic of patients with PDM. We should however expect radial branching of the accessory middle colic artery and the inferior mesenteric vein in such cases.

Surgery for obstructive colon cancer was highly invasive due to poor nutritional status of patients, risk of emergency surgery, and unavoidable colostomy formerly. However, recently, we have been able to perform laparoscopic elective surgery safely without colostomy, by using self-expanding metallic stents(SEMS). Laparoscopic colectomy for transverse colon cancer is inherently very difficult because of variations in the vascular system, small number of patients, and absence of large, randomized trials. Laparoscopic complete mesocolic excision(CME)for colectomy has been shown to be technically feasible and effective. We report the treatment strategy for obstructive transverse colon cancer which involves laparoscopic transverse colectomy by cranialapproach preceding medialapproach after successfuldecompression by stenting, along with a review of relevant literature. We consider it a s minimally invasive treatment for obstructive transverse colon cancer.

We report an 86-year-old patient successfully treated by multimodality treatment for advanced pancreatic cancer with synchronous multiple liver metastases and liver dysfunction. Systemic chemotherapy(SC)(gemcitabine[GEM]1 g and 5-FU 1 g biweekly)was initiated. Two weeks after, the radiation therapy(55 Gy/25 days)was added. Three weeks after, the short period's high dose hepatic artery infusion(SPHDHAI)(5-FU[1 g]×3 days: 1 day rest: 5-FU[1 g]×3 days)was started. By these treatments, liver dysfunction was completely improved and abdominal pain was disappeared. After 2 times of weekly high dose hepatic artery infusion(WHDHAI)(5-FU 1,500mg), the mixed chemotherapy(MC)(GEM 800 mg[systemic] and 5-FU 1,500 mg hepatic artery infusion:[HAI]biweekly)were started. She could live without admission for about 1 year. About 13 months after lung metastases was appeared and she died about 19 months after first chemotherapy. Our multimodality treatment(systemic and HAI therapy and radiation)was effective for keeping patient quality of life and for improving the survival even if the patient was a very old age and showed liver dysfunction.

We treated 2 cases ofcolon metastasis ofgastric cancer considered to be caused by different pathway. Case 1 was a 55- year-old male with gastric cancer associated with metastases for lymph node, gallbladder, and liver. Curative surgical treatment of distal gastrectomy, partial hepatectomy, cholecystectomy and lymph node dissection was performed. The final find- ing was, L, Less, Type 3, pT4b(GB), tub2, pN3a(10/20), sP0, CY0, pH1, pM1, Stage IV , R0. Ten months after, ileocecal resection was performed, as a tumor was detected in the cecum. It was a submucosal tumor of well to moderately differentiated adenocarcinoma, and diagnosed as a metastasis ofgastric cancer. Case 2 was a 59-year-old male who received total gastrectomy. The final finding was UE, Less, Type 4, tub2-por2, pT4a, pN2(5/19), cM0, sP0, CY0, Stage III B, R1. One year and 10 months later, unevenness and redness in the mucosal membrane ofthe transverse colon occurred. Signet-ring cells were observed by the endoscopic biopsy, and colon metastasis ofstomach cancer was diagnosed. Consequently, transverse colectomy was performed. Diffused invasion of cancer cells was observed in all layers of the wall, which was considered as metastasis via gastrocolic ligament. Although colon metastasis ofstomach cancer is rare, its pathway varies, such as infiltration, direct invasion, hematogenous, and lymphogenous. Form oflesion also varies. For diagnosis ofcolon lesion occurring during follow-up after gastric cancer, these points should be noted.

We report a CR case of huge ovarian cancer with peritoneal and liver metastases who was operated bilateral ovaries, uterus and peritoneal metastases at first, followed by systemic chemotherapy and performed 4 times of radiofrequency ablation (RFA)and 2 times of liver resection(LR). The case was a 50-year-old woman. She suffered with bowel enlargement from over 1 year ago. Preoperative MRI finding was huge ovarian serous cyst with partial solid tumor inside. The major axis was about 30 cm. CA125 and CA19-9 levels were elevated. Tumor reduction surgery was performed with bilateral salpingooophorectomy and hysterectomy with resecting peritoneal metastatic lesions. Postoperative systemic chemotherapy(carbo- platin 550mg/day 1 plus paclitaxel 130mg/day 1, 8, 15)(CBDCA plus PTX)were performed amount 6 courses. Unfortu- nately liver metastases at S3, S4, S6, S7 and S8/5 appeared about 7months after operation.We restarted the CBDCA plus PTX therapy from 15 months after operation when the tumor maker elevated. After 18 courses of CBDCA plus PTX therapy liver metastases remained only at S3. But gradually tumors grew up and size of tumors increased in spite of 3 more courses of CBDCA plus PTX therapy. So we challenged 2 times of RFA at S8/5 metastases that grew most rapidly and the values of increasing tumor makers stopped elevating. Then we performed LR at S3 and S4 metastases and the values of tumor makers returned to the normal level. But next S6 and S7 metastases appeared, we chose the RFA at first. At last recurrence of S7 was resected and all of liver metastases were treated. We checked no peritoneal metastases twice at the time of operation. The values of tumor makers became the normal level. Now she is alive well without metastases over 6 years after first operation. RFA and LR were effective at liver metastases from ovarian cancer that became resistant to systemic chemotherapy.

A 76-year-old man with the chiefcomplaint ofmelena visited our hospital. A mass was palpable in the right lower abdomen. We diagnosed the illness as small intestinal malignant lymphoma in the terminal ileum and performed a single incision laparoscopic ileocecal resection "TANKO-ICR" with D3 lymph node dissection with the idea ofobtaining a wide visualization and surgical field. The Aesculap®internal organ retractor(B BRAUN)is very useful in such cases. We grasped the pedicle of the ileocecal artery using the retractor and pulled out the nylon line connected to the retractor by using ENDO CLOSETM (COVIDIEN)to extraabdomen for drawing the pedicle. Single incision laparoscopic surgery can be performed with only an umbilical wound; therefore, it is minimally invasive and has a superior aesthetic outcome. Small intestinal malignant lymphoma is a relatively rare malignant tumor ofthe digestive organs. We report this case demonstrating that single incision laparoscopic surgery was possible and provide a review ofthe relevant literature.

The patient was a 73-year-old woman who underwent distalpancreatectomy for pancreas tailcancer (T3, N0, M0, stage III ). Hepatic arterialinfusion(HAI)using high-dose 5-fluorouracil(5-FU)(6,000mg/week)was performed 35 days after curative resection to prevent liver metastases. Although chemotherapy with gemcitabine(GEM)was administered for 2 weeks, the patient was aware of a nodule(1 cm in diameter)on the right lower quadrant of the abdomen. Resection of the cutaneous mass was performed and histological findings revealed metastatic adenocarcinoma from the pancreas cancer. Six courses of chemotherapy with GEM were administered as adjuvant therapy. Two years after the treatment with GEM, neurological symptoms appeared, and computed tomography(CT)and magnetic resonance imaging(MRI)revealed a solitary metastatic thalamus tumor(2 cm in diameter). After stereotactic radiotherapy, the patient was transferred to a different hospitalfor physicaltherapy. Herein, we report on a case of 2 year recurrence free survivalafter the resection of a cutaneous metastasis from pancreatic cancer.

We reported a case of hilar cholangiocellularcarcinoma with complete obstruction of the portal vein. The patient, who was a 65-year-old woman, suffered from fever and general fatigue as a result of acute cholangitis after insertion of a tube stent into the right bile duct. The main tumor was present on the right side of S1 and spread to both sides of the bile duct. S1 lobe was swollen and diffuse intrahepatic invasion was noted in the right lobe and S1. The portal vein was completely obstructed at the porta hepatis with a coronary vein-left renal vein shunt. We immediately administered a high-dose hepatic arterialinfusion( 5-FU 1 g×3 days: one day off 1 g×3 days)(HDHAI)to the right hepatic artery using a transient catheter insertion method. After 2 courses of HDHAI, the intrahepatic invasion decreased. However, after 4 courses of HDHAI(2 on the right side and 2 on the left side), the invasion on the left side of the IVC had increased. We then chose radiation therapy. Subsequently, transient cystic changes were observed; however, 4 months after radiation, the invasion on the left side of the IVC had regrown into the cardia. The patient suffered from vomiting as a result of the narrowing of the esophagus. We chose HDHAI and dilation of the esophagus using a balloon. Finally, the invasion on the left side of the IVC and S1 swelling decreased, and she could eat again. Thirteen months later, she remains an outpatient. We recommend HDHAI and radiation therapy to hilar cholangiocellularcarcinoma even if the portal vein is completely obstructed.

Liver retraction is a necessary operative procedure for enabling greater visualization and a wider surgical field during laparoscopic surgery of the stomach. We have developed a new liver retraction method for laparoscopic surgery that uses penrose drains, is very easy to perform and in minimally invasive. We call this method the "V-Shape+1 method". We performed laparoscopic surgery using this method on 16 patients within 8.3(5.3-13.7)min(median). We analyzed the postoperative changes in the serum levels of AST, ALT, and T-Bil, which are indicators of liver function. The serum AST, ALT values were elevated at postoperative day 1. Thereafter, the values improved immediately. This early liver function failure is acceptable. We have not experienced any complication related to this method. Therefore, we believe this method is useful for obtaining wide visualization easily for not only laparoscopic gastrectomy but also for laparoscopic upper abdominal surgery.

We report a patient who experienced a weight loss, general fatigue, and appetite loss and had huge hepatic metastases of colon cancer after right lobectomy for hepatic stone. After 2 courses of treatment with high-dose hepatic arterial infusion of 5-FU (HDHAI; 5-FU 6 g/week), the appetite loss decreased, and low anterior resection was performed. Unfortunately, the other symptoms continued, and she received 5 additional courses of HDHAI during about 6 months. Finally, all of the symptoms disappeared, and she could receive systemic chemotherapy and HAI. Bone metastasis at vertebra TH 9 was observed about 9 months after radiotherapy, and local recurrence at the anastomosis site was observed at about 1 year 1 months after radiotherapy. Both the metastasis and local recurrence were well controlled. Although the lung metastases were growing slowly (number and size), the patient was well enough to go to the hospital on her own and her weight loss almost disappeared. If liver metastases were the most threatening factor of life, HDHAI may be effective for the improvement of symptoms.

The patient was an 83-year-old man who underwent distal gastrectomy for gastric cancer (T3, N1, M0, P0, M0, stage ⅡB) at a different hospital from ours. A metastatic lesion was detected in the liver 5 months after gastrectomy. Although chemotherapy with S-1 or bi-weekly CPT-11 was administered for 6 months, the liver tumor increased in size. The patient was referred to our hospital for treatment of the liver metastasis. Abdominal-computed tomography (CT) and magnetic resonance imaging (MRI) revealed a solitary metastatic liver tumor (9 cm in diameter: S7/S6/S8) with a hypervascular tumor stain. Transcatheter arterial chemoembolization (TACE) using degradable starch microspheres (DSM) plus mitomycin C, and hepatic arterial infusion (HAI) using high-dose 5-fluorouracil (5-FU) (6,000 mg/week), were performed 54 days before curative resection of the liver (S6+S7+S8+S5b/c). Histological findings revealed metastatic adenocarcinoma with a tumor thrombus in the posterior branch of the portal vein. The patient was treated with 2 courses of adjuvant chemotherapy with paclitaxel. No recurrence was observed 8 months after hepatectomy. This case suggests that combined treatment with TACE/HAI as a multimodal treatment might be effective in the management of hypervascular liver metastasis from gastric cancer.

An 87-year-old woman with the chief complaint of bloody stool was referred to our hospital from an institution for the aged. The abdomen was soft and flat, and a tumor was not palpable on digital rectal examination. Tumor markers were within normal ranges. Abdominal enhanced CT scan showed a multiple concentric ring sign at the rectum. Colonoscopic and barium examination led to a diagnosis of rectal intussusception due to rectal cancer. We first tried to reposition it preoperatively, but it was impossible. She fortunately had no symptoms of ileus; therefore, we chose to perform laparoscopic surgery. We achieved the reposition intraoperatively and performed Hartmann's operation with D2 lymph node dissection because she was a very elderly patient with high-risk comorbidities. The pathological diagnosis was as follows: RS, 40×40 mm, type 2, tub2, pT3 (SS), pN0, ly0, v0, pStageⅡ, R0, Cur A. Adult intussusception due to rectal cancer is extremely rare. We report that in this case that laparoscopic surgery was possible, along with a review of the relevant literature.

A 55-year-old man suffering from gastric cancer associated with metastases to the lymph node, gallbladder, and liver was administered chemotherapy with S-1 and cisplatin. Before initiation of therapy, the primary tumor, lymph node metastases, and liver metastases showed fluorodeoxyglucose (FDG) accumulation by positron emission tomography (PET). After 1 course of chemotherapy, the patient received curative surgical treatment including distal gastrectomy, partial hepatectomy, cholecystectomy, and lymph node dissection. The final pathological finding was moderately differentiated adenocarcinoma, T4b(SI), N3a(10/20), P0, CY0, pH1, pM1, Stage IV. Five months after surgery, the serum carcinoembryonic antigen (CEA) level was found to be increasing and PET examination identified an FDG-accumulating nodule in the ascending colon. Colonoscopy identified a submucosal tumor diagnosed as a metastasis from the gastric cancer. Right colectomy was performed 7 months after the first surgery resulting in a curative resection. In each surgery, PET examination indicated that no other distant metastases existed, and curative resection would be possible. Furthermore, although solitary metastatic colorectal lesions are rare, PET examination revealed them accurately. Thus, FDG-PET is very useful for identifying metastases in patients with gastric cancer.

A 58-year-old woman was suffering from abdominal pain due to large liver metastases(LM)and lung metastasis from sigmoid colon cancer. After laparoscopic sigmoidectomy, three 6 g/wk high dose hepatic arterial infusions(HDHAI)of5 - fluorouracil (5-FU) were administered and the tumor decreased in size. Unfortunately, the patient had an infectious pseudoaneurysm at the site of puncture. She was given a drainage and femoro-femoral(F-F)bypass. At last, a hepatectomy, radiofrequency ablation(RFA), and catheter insertion from gastroepiploic artery, were performed successfully. Subsequently, she received a half HDHAI and several systemic chemotherapy drugs. However, residual liver metastases developed thrice and we operated on all of them. Finally, when the hepatic arterial infusion(HAI)catheter became unavailable, we only continued the systemic therapy (Erbitux+FOLFIRI). However, inoperable residual liver metastases(maximum 13 cm in size)occurred. We chose to administer hepatic transarterial embolization(TAE)therapy 3 times. From the second time, we performed TAE from the right subphrenic artery and in the third time, we added 1-day HAI therapy. Finally, the tumor size decreased(maximum 9 cm). The patient is still an outpatient 5 years after the first HDHAI.

We report a case suffered from an abdominal pain with huge hepatic metastases from the colon cancer. After laparoscopic partial colectomy with a three-time treatment of high dose hepatic arterial infusion by 5-FU (HDHAI), the tumor was decreased in size. Unfortunately she had an infectious pseudoaneurysm at the site of puncture. She was given with a drainage and F-F bypass. She has at last successfully done hepatectomy, radiofrequency ablation (RFA), and insertion of catheter at the site of common hepatic artery from gastroepiploic artery. Then she received a half HDHAI and systemic chemotherapy of CPT-11. However, residual liver metastases happened twice, but we could have them operated all (9.3 months after and 20.5 months after from first operation). If the liver metastases were the most threatening factor of life, HDHAI and repeated hepatectomy maybe effective for prolongation of life.

Collagen VI-related muscle disorders include severe Ullrich's disease (Ullrich congenital muscular dystrophy:UCMD) and milder Bethlem myopathy. Mutations in the 3 collagen VI genes, namely, COL6A1, COL6A2, and COL6A3, cause both diseases. UCMD is inherited in an autosomal recessive manner, and de novo dominant mutations are also reported. Bethlem myopathy is usually inherited in an autosomal dominant manner, but a rare autosomal recessive inheritance has recently been reported. Patients with UCMD have generalized muscle weakness, multiple contractures of the proximal joints, and hyperextensibility of the distal joints. Bethlem myopathy is characterized by a combination of proximal muscle weakness and contractures of finger, elbow, and ankle joints. Because intermediate phenotypes occur, UCMD and Bethlem myopathy should be considered diseases in a continuous spectrum of collagen VI-related muscle disorders. Abnormalities of cell adhesion, regeneration, mitochondrial permeability transition pore, and autophagy have been reported in UCMD. Respiratory surveillance for nocturnal hypoventilation and proper respirator implementation are crinical management considerations in UCMD. Orthopedic assessment in necessary if surgery for Achilles tendon contractures is being considered in patient with Bethlem myopathy. We evaluated the role of nonsense-mediated mRNA decay (NMD) in UCMD associated with a premature termination codon in the COL6A2 gene, which caused the loss of collagen VI. A pharmacological block of NMD caused upregulation of the mutant collagen VI and partially functional extracellular matrix formation. Cyclosporin A has been reported to correct mitochondrial dysfunction and muscle apoptosis in patients with collagen VI myopathies, and a pilot trial of cyclosporin A was carried out.

We report a case of patient who recovered from liver failure with synchronous diffuse liver metastases of sigmoid colon cancer by a short-term high volume (6 g of 5-FU in a week) hepatic arterial infusion (STHV-HAI). After four times of STHV-HAI, she had sigmoidectomy and bilateral oohorectomy and continued a weekly hepatic arterial infusion therapy until now. The case was a 75-year-old lady. She admitted of general fatigue. Serum bilirubin was about 2 mg/dL, GOT about 200 U/L and CEA over 40 thousand ng/mL. She started STHV-HAI next day of her admission. After 4-course, her liver function became normal and the amount of CEA level became about 1,000 ng/mL. We had the operation of sigmoidectomy and bilateral oohorectomy. After that, she received the HAI every week as an outpatient. The lowest level of CEA became at the 90 ng/mL. The liver metastases were also almost CR. STHV-HAI will be safe and effective to a patient of liver metastases with ascites and jaundice.

A 31-year-old man was admitted to our hospital, complaining of muscular weakness and pain in the legs one month after a common cold. On admission, neurological examinations demonstrated moderate weakness in the arms and mild weakness in the legs with decreased or diminished deep tendon reflexes, and mild dysphagia. Weakness was gradually extended to the arm, throat and respiratory muscles, requiring artificial ventilation. Laboratory examinations demonstrated increased levels of CK (upto 24,380 IU/L) and positive anti-cytomegalovirus (CMV) -IgM antibodies in the serum, and myogloburinuria. CMV was not detected in either the blood cells or muscles by PCR. There were no antibodies against viruses including Ebstein-Barr virus and HIV, in the serum. There were no autoantibodies related to collagen diseases in the serum. Systemic PET scan did not show any evidence of malignancy. Bone marrow biopsy did not show any atypical cells. Muscle MRI demonstrated mild atrophy with high intensity signals in part. Muscle biopsy demonstrated scattered necrotic and regenerated muscle fibers without inflammatory cell infiltration. The patient was therefore diagnosed as having rhabdomyolysis associated with CMV infection. After three courses of intravenously administered high dose methylprednislone over three days, muscle weakness improved gradually, and the serum CK level was normalized in two months. The patient recovered and was removed from artificial ventilation three months after the therapy. There were no sign of renal failure. Steroid therapy should be considered for the treatment of rhabdomyolysis or myopathy associated with CMV infection in order to prevent renal failure or fatal progression of the disease.

Collagenopathies with collagen VI mutations include Ullrich congenital muscular dystrophy (Ullrich's disease) and Bethlem myopathy. Patients with Ullrich's disease have generalized muscle weakness, multiple contractures of the proximal joints and hyperextensibility of the distal joints. Bethlem myopathy is characterized by the combination of proximal muscle weakness and contractures of finger, elbow, and ankle joints. We found for the first time a deficiency of collagen VI in Ullrich's disease. Furthermore, we found an abnormality of cell adhesion and abnormal regeneration or maturation in Ullrich's disease. Mutations in the genes COL6A1, COL6A2, COL6A3 are associated with Ullrich's disease and Bethlem myopathy. Bethlem myopathy is inherited in an autosomal dominant manner and Ullrich's disease usually in an autosomal recessive manner. Recently, de novo dominant mutations are reported in Ullrich's disease. We evaluated the role of nonsense-mediated mRNA decay (NMD) in Ullrich's disease that has a frameshift mutation with a premature termination codon in the COL6A2 gene causing the loss of collagen VI. The pharmacological block of NMD caused upregulation of the mutant collagen VI and partially functional extracellular matrix formation. Our results suggest that NMD inhibitors can be used as a therapeutic tool to rescue some human genetic diseases exacerbated by NMD.

A 76-year-old male with local recurrence after abdominosacral resection of recurrent rectal cancer was admitted to our hospital. Computed tomography (CT) and magnetic resonance imaging (MRI) indicated a recurrent tumor at the back of the prostate and seminal vesicles up to the resected sacral (S3) stump. However, positron emission tomography (PET)/CT fusion images showed no 18F-2-fluoro-2-deoxy-D-glucose (FDG) uptake at the pre-sacral region, which suggested postoperative scarring of the tissue. Based on the PET/CT diagnosis, we performed abdominoperineal en bloc resection of the recurrent tumor with bladder, seminal vesicles, prostate, internal obturator muscle, ischial spine, and gluteal muscle without resection of the sacrum. Specimen revealed no circumferential resection margin involvement by tumor on pathologic examination. The patient was discharged from the hospital on postoperative day 23 without major complications.

Positron emission tomography (PET) has been developed to visualize biochemical and physiological phenomena in living humans. Blood flow, blood volume, glucose metabolism, amino acid metabolism, neural transmission system functions can be quantitatively estimated by means of PET with various radioactive tracers. A glucose analog, 18F-fluoro-deoxy-glucose, has been utilized to evaluate glucose metabolism. The whole body PET scanner enables imaging of brain; heart, and neoplasms within an hour. Screening for cancer and evaluation of remote metastasis, recurrence, and effects of radio-chemotherapy are now performed clinically. Further development of the tracers may enable a visualization of gene expression by means of radioactive anti-sense nucleic acids. In regeneration medicine, functional recovery can be estimated by means of PET.