Search

On 5 September 2018 the UICC-Asia Regional Office(UICC-ARO)convened the second Japan Public-Private Dialogue Forum at the House of Councilors Members' Building as a follow-up to the previous meeting held at United Nations University in Tokyo in April 2018. Senior representatives of government, academia and industry met to discuss the progress made since April, noting the significance of the Japanese government having included specific reference to cancer in its revised basic policy on the Asia Health and Wellbeing Initiative, which was adopted in July 2018. The meeting provided an opportunity for all stakeholders to discuss ways forward for improving access to cancer care, with the WHO Cancer Report and other global initiatives in mind.

A man aged 66 years presented with pneumaturia as a major complaint. Cancer of the sigmoid colon with infiltration to the urinary bladder was diagnosed and the patient underwent colectomy of the sigmoid colon and partial cystectomy of the bladder in May 2015. Histopathologic examinations revealed pT4b, Si(bladder), pN(-), cM0, fStage II . Because intestinal sub-obstruction and lymphatic invasion were present, CapeOX was administered as an adjunctive chemotherapy for the high-risk Stage II cancer. Because Grade 2 peripheral neuropathy appeared as a side effect, the dose was decreased to 80% from the 3 cycle. After the 7 cycle, cough and disturbed breathing appeared. The chest CT scans did not reveal drug-induced interstitial pneumonia, but indicated an elevated right diaphragm and zosteroid changes in the medial lobe of the right lung due to discoid atelectatic condition. The Grade 1 respiratory symptoms were mild, and the lung field was considered to exhibit no problems. Thus, the 8 cycle was administered. The symptoms disappeared after about 2 weeks following completion of oral administration of capecitabine. The diaphragm also recovered to its original height. In the attached document, the frequency is unknown and "dyspnea" is written for L-OHP and capecitabine, respectively. It is unknown whether phrenic nerve paralysis occurs. However, because other organic lesions were absent and the symptoms appeared during chemotherapy, the possibility is not deniable. At present, 2 years postoperatively, recurrent lesions in the mediastinum and recurrent respiratory difficulties are absent. Generally, although phrenic nerve paralysis is not considered to be a specific side effect, it was considered that for respiratory difficulties, CT reveals not only the affected condition in the lung fields, but is also useful for detection.

Preoperative simulation of vascular anatomy has been widely accepted in order to reduce surgical complications and improve postoperative outcomes. In esophagectomy, preservation of the bronchial artery (BA) was shown to reduce postoperative pulmonary complications. However, some anomalous BA branching patterns have been reported and these can make BA preservation difficult during surgery. Recently, the clinical utility of preoperative three-dimensional computed tomography angiography (3D-CTA) has been reported as a form of preoperative anatomical simulation. Consequently, the BA was safely preserved and efficient lymph node (LN) dissection was achieved. In surgery for gastric cancer, tracing the inner dissectable layer is necessary for LN dissection. Particularly in laparoscopic total gastrectomy with spleen preservation, there is considerable variation in the vascular anatomy of the splenic artery, splenic vein, and short gastric artery. Therefore, preoperative 3D-CTA could improve the safety of this procedure. Recently, the number of dissected LNs has been shown to be increased after introduction of 3D-CTA in laparoscopic surgery for both esophageal and gastric cancer, which showed that preoperative anatomical simulation could achieve more radical LN dissection. As a future perspective, intraoperative navigation systems could become more practical guides for endoscopic surgery for upper gastrointestinal cancer.

A 72-year-old man was admitted to our hospital department in September 2014 because of a positive fecal occult blood test.Colonoscopy showed a type 2 tumor in half of the AV 15 cm rectosigmoid colon.Histology of the biopsy indicated a moderately differentiated adenocarcinoma, and the RAS gene test found wild type.On CT examination, there were multiple liver lung metastases and a 30mm diameter tumor with pancreatic duct extension to the pancreatic body.A PET-CT examination had a high SUVmax at the same site.Because of the location of the tumor EUS-FNA was not used.However, the possibility of pancreatic body cancer could not be denied after the CT examination.Treatment by radical resection was impossible because of the spread of the cancer so we selected chemotherapy.Undeniable pancreatic metastasis of rectal cancer, pancreatic cancer was used as a prognostic factor as double cancer of rectal cancer and pancreatic cancer, from that UGT1A1 test side effects appearance was a low-risk decision, was selected FOLFIRINOX in the treatment regimen.After 25 cycles, the pancreatic body tumor and liver metastases and also the primary tumor were reduced, the multiple lung metastases disappeared, and disease control was good.Side effects were diarrhea on the day of administration of irinotecan, but this was controllable by administering oral loperamide when starting the infusion.Grade 3 or more peripheral neuropathy has not developed, and this regimen is continuing.Pancreatic cancer is a solid cancer with a poor prognosis; if you do not reach the tissue diagnosis of metastatic pancreatic cancer, was a case in which no choice but to select a regimen to carcinoma of the prognostic.

Purpose: To determine factors affecting physical activity in outpatients with gastrointestinal cancer., Methods: This observational study applied the International Physical Activity Questionnaire(IPAQ)to identify factors affecting physical activity in outpatients(male, n=51; female, n=24; mean age, 64.2±10.2 years)with gastrointestinal cancer undergoing chemotherapy. Relationships between the main outcome measures, total weekly physical activity score(TPA)and total weekly energy expenditure(TEE), and patient background factors were analyzed., Results: The median duration of induction chemotherapy in the 75 outpatients who completed the IPAQ was 242.5(range 7-2,294)days. The TPA and TEE tended to decrease in older patients and were lower in all patients compared with age-specific standard values for healthy persons. Both values tended to increase to a greater extent among patients who worked than among those who did not, and being employed was significantly associated with Eastern Cooperative Oncology Group performance status(ECOG-PS). The TEE tended to be lower among patients with adverse events(AE)such as pain., Conclusion: Progressive cachexia, changes in lifestyle, and AE affected physical activity among outpatients with gastrointestinal cancer undergoing chemotherapy. Comprehensive support by an oncology team would probably play an important role in encouraging elderly patients to participate in physical activity.

Transthoracic esophagectomy for patients with esophageal cancer is one of the most invasive of all gastrointestinal surgery. Postoperative management and surgical techniques are improved. However, many patients are more elderly or suffering from comorbid diseases or in malnutrition status. In order to prevent for postoperative complications after esophagectomy, especially for respiratory complication and swallowing dysfunction, adequate rehabilitation approaches are necessary depending on the various conditions.

A 51-year-old woman had previously received treatment for breast cancer at another hospital but had refused early and aggressive treatment. Therefore, she was treated with symptomatic therapy. As her disease progressed, the patient wished to receive palliative care, and was transferred to a palliative care hospital. However, based on her general condition, it was determined that aggressive treatment should not be abandoned, and she was referred to our hospital for treatment. During her initial visit, the patient was found to have left breast cancer with chest wall invasion, right breast metastasis, multiple liver and lung metastases, left pleural effusion accompanied by pleural dissemination, and left upper limb edema. There was no evidence of bone metastases. The patient's pain was managed with oral oxycodone sustained-release tablets (320 mg daily), using high-dose (80 mg) oral oxycodone hydrochloride hydrate as rescue medication. The results of immunohistochemical testing, confirmed by her previous hospital, were ER (-), PgR (-) and HER2/neu positive. First-line treatment was initiated with paclitaxel (PTX) plus trastuzumab (Tmab), and the response was rated as stable disease (SD). During the course of treatment, she developed drug-induced interstitial pneumonia, which was probably caused by the taxane. Therefore, the first-line treatment was discontinued and T-DM1 was initiated as second-line treatment. However, beginning with cycle 3 of the T-DM1 treatment, the patient began complaining of joint pain, mainly in the upper limbs. Therefore, the dose of oxycodone sustained-release tablets was increased to 600 mg per day. However, the patient's joint pain showed no improvement and it was considered unlikely that the pain was due to bone metastases. It was suspected that the pain was an adverse reaction to T-DM1, and the dose of T-DM1 was reduced by one step in cycle 7 of treatment. This resulted in a dramatic improvement of the patient's symptoms. Since oxycodone sustained-release tablets was being used at a high dose, sleepiness caused by the drug interfered with her activities of daily living. Consequently, as part of an opioid rotation scheme, topical fentanyl citrate was used concomitantly, and the initial daily oxycodone sustained-release tablets dose of 600 mg was reduced to 40 mg and administered in combination with fentanyl citrate (12mg). These findings suggest that uncontrollable joint pain can occur as an adverse reaction to T-DM1.

A 62-year-old woman was admitted with abdominal pain and distention in July 2013. Computed tomography (CT) revealed a small bowel obstruction caused by an ileocecal tumor, and colonoscopy revealed a type 3 cecal tumor. Because an ileus tube was not effective to relieve her symptoms, she was transferred to the Department of Surgery for an emergency operation. Open resection of the ileocecal tumor along with the right ureter and psoas was performed. Histological examination showed that cancer cells were present in the radial margin. The patient was treated with a post-operative course of chemotherapy (capecitabine and oxaliplatin), but the level of carcinoembryonic antigen was increasing; positron emission tomography (PET) revealed a local cancer recurrence. Although the right external iliac artery and reconstructed right ureter were encased by the tumor, there were no signs of lymph node metastasis or distant metastasis. Because the tumor was localized, we decided to perform a re-excision. Intraoperatively, the right external iliac vein was difficult to separate from the tumor. Therefore, we resected the right ureter, kidney, and right external iliac artery and vein en bloc. The right external iliac artery and vein were replaced with grafts. Histopathologically, the reconstructed right ureter was completely invaded by the tumor, and cancer cells had invaded the nearby adventitia of the artery, but the surgical margin was negative. Four months after the second operation, peritoneal dissemination was detected on PET. The patient was followed-up in an outpatient clinic without chemotherapy.

In June 2010, a 73-year old man diagnosed with sigmoid colon cancer underwent laparoscopic sigmoidectomy. The histopathological diagnosis was tub2, pSS, n (-), stageⅡ.Vascular invasion was present; however, at the patient's request, no adjuvant chemotherapy was administered.Computed tomography (CT) performed at the outpatient follow-up 4 years and 6 months after the surgery revealed a para-aortic lymph node metastasis in the caudal aspect of the left renal artery branch point. No other definite mass shadows were detected. Positron emission (PET)-CT revealed high tracer accumulation (SUVmax) not only in the CT-identified lymph node, but also near the site of the anastomosis in the bowel. Considering that no tracer accumulation was detected at any other sites and the patient's compliance with medication and scheduled visits was poor, surgical resection rather than chemotherapy was adopted as the treatment strategy. No metastases other than at the sites identified by the diagnostic imaging were found during the surgery. Since the findings on palpation did not rule out the possibility that the nodule near the anastomotic site was present inside the intestinal tract, lymph node dissection, resection of the intestinal tract including the anastomotic site, and re-anastomosis were performed. The most likely diagnosis based on the histopathological findings was dissemination for both the adenocarcinoma and the nodule near the anastomotic site. At present, the patient is being treated with adjuvant chemotherapy. In the Japanese Society for Cancer of the Colon and Rectum (JSCCR) Guidelines for the Treatment of Colorectal Cancer, the recommended therapeutic intervention is surgical resection of hematogenous metastases; however, no treatment is specified for lymph node metastases. In general, chemotherapy is administered for distant metastases. However, we have found no reports of cases in which a complete remission has been achieved. There are reports of improvement of survival by surgical resection in cases with solitary lymph node metastasis or isolated dissemination of colorectal cancer. These observations suggest that surgical therapy may have contributed to the improved prognosis in the present case.

A 72-year old woman visited our hospital complaining of an umbilical mass and a foul smell from the umbilical region. During the evaluation, a massive immobile tumor was palpated in the center of the lower abdomen in addition to an umbilical mass with necrosis. Computed tomography (CT) revealed a massive ovarian tumor accompanied by an umbilical tumor and cyst with peritoneal dissemination, metastases in the liver and spleen and a urachal tumor. There were no symptoms or imaging findings of gastrointestinal obstruction. While searching for the primary focus, it was determined that the ovarian tumor was not of ovarian origin. Under these circumstances, colonoscopy was the only remaining diagnostic modality. However, evaluation of the large intestine was impossible due to compression by the tumor, and diverticulosis of the sigmoid colon did not allow smooth insertion of the colonoscope. Therefore, an excisional biopsy of the umbilical tumor was performed. The most likely diagnoses based on the histopathological findings were colorectal cancer and urachal cancer. Therefore , mFOLFOX6 was selected for chemotherapy because it has been reported to be effective against both urachal and colorectal cancer. At the time of writing, good tumor control had been achieved in the lesions evaluated. Cases of Sister Mary Joseph's nodule have sporadically been reported. The most common primary foci for peritoneal metastases are the stomach, pancreas and ovary. However, in the present case, these sites were ruled out and the primary focus remained unidentified, making it difficult to select appropriate treatment. We present this case with a discussion of the literature.

A 79-year-old woman was admitted with cholangitis caused by a common bile duct stone (CBDS), and the CBDS was removed by endoscopic sphincterotomy (EST). The patient had undergone distal gastrectomy for gastric cancer located in the lower body of the stomach in 2006. A flat, elevated lesion of the cardiac region was noted in the preoperative examination; however, this lesion was not treated because there was no clear evidence of malignancy upon histopathological examination of the biopsy specimen. Following esophagogastroduodenoscopy in 2013, the macroscopic findings had changed to infiltrative cancer. The lesion was considered to be a submucosal(sm)cancer, and the patient underwent simultaneous cholecystectomy and remnant gastrectomy. The histopathological examination of the surgical specimens revealed a well differentiated tubular adenocarcinoma, type 0-IIb+0-IIa, tub1>tub2, pT1b1, ly0, v0, n0.

A 74-year-old man complained of blood in his urine over a 1-week period beginning in early October 2013, and was examined in the urology department of our hospital. A thorough examination revealed bladder cancer, and surgery was planned after two cycles of preoperative gemcitabine plus cisplatin chemotherapy. A chest computed tomography (CT) performed to evaluate the response to chemotherapy revealed a mass in the right breast. The patient had previously complained about the same site, and mammography and ultrasonography had suggested the possibility of a malignant mammary gland tumor. The results of aspiration cytology were Class V, and based on that finding, a diagnosis of cancer of the right breast was made. In February 2014, we performed a mastectomy, while preserving the pectoral muscles, along with sentinel node biopsy, total cystectomy, urethrectomy, pelvic lymph node dissection, and ureteroileal anastomosis. The histopathological diagnosis of the right breast tumor was invasive ductal carcinoma[scirrhous carcinoma, ly (+), v (-), g (+), f (+), s (+), nuclear grade 1=atypia 2+mitosis 1, EIC (-), ICT (-), NCAT (-)]. A micrometastatic tumor measuring approximately 1mm was observed in the sentinel lymph node. The breast disease was classified as pT1N1mi(sn)M0, Stage IIA, and the tumor was ER (+), PgR (+), HER2/neu (2+), and FISH (-). The bladder cancer was diagnosed as urothelial carcinoma, non-papillary, invasive G2>G3, pT2a; no pelvic lymph node metastases were detected, and it was classified as pT2aN0M0, Stage II. Synchronous male breast cancer and bladder cancer is a very rare condition, and we report the case with a review of the literature.

The patient was a 79-year-old male complaining of fever, loss of appetite, cough, and a feeling of obstruction when swallowing. He was diagnosed with pneumonia and admitted as an emergency case the same day. Because an esophagus space-occupying lesion was observed on chest computed tomography(CT), in addition to evidence of pneumonia, an upper gastrointestinal endoscopy was performed. A tumor, protruding into the lumen of the esophagus, was seen in the midesophagus, 25-30 cm from the incisors. Because of the narrow lumen, only a fine caliber fiber could be passed. Biopsy results indicated only necrotic tissue, and a repeat biopsy was performed, with similar histological findings. No esophagobronchial fistulas were observed during bronchoscopy. We therefore diagnosed the patient with aspiration pneumonia, secondary to esophageal narrowing by a tumor. A preoperative diagnosis of cancer could not be made, and no distant organ metastasis was detected, but surgery was indicated because of the narrowing of the esophagus, regardless of the possibility of cancer. After the pneumonia improved, total thoracic esophagectomy was performed through a right thoracolaparotomy, plus a 3- region cervico-thoraco-abdominal lymph node dissection. Pathological examination of the surgical specimen revealed autolysis of the superficial layer with progression to necrosis and associated inflammation. The majority of the tumor was composed of spindle-shaped atypical cells, but because a very small transitional area between squamous cell carcinoma and sarcoma was noted, a diagnosis of carcinosarcoma was made. Depth of invasion was sm3, and no regional lymph node metastasis was detected. The patient's disease was classified as pT1b(sm3)N0M0, StageI. No definite diagnosis was made preoperatively. Although carcinosarcoma of the esophagus is rare, the endoscopic findings are characteristic. We report this case with a review of the literature.

Although acute aortic occlusion (AAO) and acute mesenteric ischemia (AMI) are relatively rare condition, it is very important to know clinical features and managements for these because a delay in diagnosis and appropriate interventions results in high morbidity and mortality. AAO can result from aortic saddle embolus, acute thrombosis of an atherosclerotic aorta, and so on. Superior mesenteric artery embolism and thrombosis are main cause of AMI. The purpose of this article is to review the pathophysiology, clinical presentation, diagnosis, and management of these diseases. The latest information in this article may help readers to promptly make the diagnosis and effectively manage it in a timely manner.

Board-certifying systems play an important role as guideposts in postgraduate training courses to develop superior surgeons with both general and subspecialty surgery competence. The board-certified surgeon designation of the Japan Surgical Society (JSS) as the first guidepost has provided the foundations for board-certified surgeon systems of subspecialty surgical societies as the second guidepost. In April 2010, the National Clinical Database (NCD) was founded by the JSS and other societies. Data on surgery and treatment have been entered into the NCD from January 1, 2011, and more than 1 million cases were submitted to the NCD in that year. The NCD is an unprecedented, advanced activity. The data will be used for the authorization of board-certified surgeons of subspecialty surgical societies as well as that of the JSS. The data will be also used for benchmarking, and clinical research teams will cooperate with the NCD.

Purpose: Several technological advances have been made in laparoscopic surgery, and the use of reduced port surgery (RPS)has gradually become widespread. To assess the safety and usefulness of RPS, we compared the short -term outcomes of conventional laparoscopy-assisted total gastrectomy(LATG)and LATG with the RPS approach., Patients and Methods: From April 2009 to February 2012, 16 cases with gastric cancer underwent conventional LATG with 5 ports as well as minilaparotomy for anastomosis(Conventional group). From February 2012 to November 2012, 12 cases underwent RPS LATG(RPS group). In the RPS group, a multi-instrument port at the umbilicus was used during surgery. This port held 3 trocars and 2 5-mm trocars that were inserted under the right lumbocostal arch., Results: The mean operation time was 333 minutes in the Conventional group, and 370 minutes in the RPS group. The mean postoperative hospital stay was 23 days in the Conventional group, and 17 days in the RPS group. Postoperative mortality was 0% in both groups. Anastomotic leakage occurred in 2 cases in the Conventional group, whereas pancreatic fistula occurred in 2 cases in the RPS group. Due to postoperative bleeding, 1 case in the RPS group underwent redo laparoscopic operation. Anastomotic stenosis was noted in 4 cases in each group. The patients with stenosis required endoscopic balloon dilation several times and the symptom eventually resolved in all cases., Conclusion: By comparing the short-term outcomes for conventional LATG and RPS LATG, we noted that reduced port laparoscopy-assisted total gastrectomy is a feasible procedure.

Natural orifice translumenal endoscopic surgery (NOTES) is considered the ultimate minimally invasive intervention for visceral disease. The transvaginal route is now the only one that can be used for NOTES procedures in daily clinical practice. We performed hybrid NOTES appendectomy that was preevaluated and approved by the Japan NOTES and Institutional Review Board. A 5-mm trocar was inserted transumbilically and used for laparoscope access. An additional transumbilical 2.3-mm port was placed, through which the surgeon inserted a grasper. We created a transvaginal port with a long 12-mm trocar. Laparoscopic instruments such as a vessel sealing system, surgical staplers, and a retrieval bag were introduced, and the surgical technique consequently became safer, although the access route was limited. The appendix was removed transvaginally. The patient did not need epidural anesthesia or any pain medication. The cosmetic results were better than that of conventional single-port surgery. Triangulation is achieved in this procedure, which makes the surgery easier. To generalize NOTES to many types of surgery and enable it to be performed in men, the transgastric approach is essential. The development of flexible instruments designed for NOTES is also necessary.

A 78-year-old man was admitted to Ogikubo Hospital for pancreatic tumors detected by computed tomography (CT). The patient had undergone right nephrectomy for renal cell carcinoma (RCC) 27 years previously. Dynamic CT revealed a hypervascular mass in the pancreatic head and a cystic mass in the pancreatic body that were approximately 35 mm and 20 mm in size, respectively. Total pancreatectomy and splenectomy were performed. Histological examination of the resected specimens revealed metastatic tumors from RCC and they were diagnosed as clear cell type. Metastatic carcinoma of the pancreas is uncommon. Pancreatic metastasis from RCC is rare; however, it could occur many years after the initial diagnosis and treatment of the primary tumor. A long and careful follow-up that includes examination of the pancreas is mandatory after nephrectomy for RCC. In this paper, we discuss a case of RCC metastasis to the pancreas and report it in the literature.

A 60-year-old woman receiving treatment for diabetes underwent laparoscopic-assisted low anterior resection and was diagnosed as having rectosigmoid cancer in January 2010( pSS, n2[ +], sM0 fStage IIIb, mutant-type K-ras). She refused adjuvant chemotherapy. In July, after surgery, chest-abdominal-pelvic computed tomography( CT) scans showed bilateral lobe multiple liver metastases and right lobe lung metastases. We recommended oxaliplatin and capecitabine (CapeOX) plus bevacizumab( BV) chemotherapy or surgery. The CapeOX plus BV regimen was initiated at the patient's request. After 8 cycles of chemotherapy, a partial response was observed in the metastatic liver tumors and stable disease was observed in the lung metastases. As hypertension appeared after 16 cycles of chemotherapy, we switched the treatment to CapeOX. After 10 cycles of CapeOX, the chemotherapy was changed to capecitabine at the patient's request owing to the development of grade 2 chronic peripheral neuropathy. Chest-abdominal-pelvic CT scans after 32 cycles of this regimen revealed shrinkage of the multiple liver metastases. The patient has been receiving treatment as an outpatient. Surgical resection should be considered for patients with initially unresectable colon cancer with liver and/or lung metastases if systemic chemotherapy is effective.

A 71-year-old postmenopausal woman was undergoing treatment for depression. She visited the hospital with a chief complaint of fibrosclerosis of the entire left breast 8 years previously. She was diagnosed as having stage IV( T3N1M1b) left breast cancer (papillotubular>scirrhous carcinoma, g+, f+, estrogen receptor [ER]-negative, progesterone receptor [PgR]-negative, and human epidermal growth factor receptor 2[ HER2/neu]-positive[ 3+]). Synchronous bone metastases were detected in the left tenth rib, the eleventh dorsal vertebra, and in the area spanning the lower lumbar to sacral vertebrae. First-line treatment was systemic therapy with 4 cycles of Adriamycin and cyclophosphamide (AC) followed by 4 cycles of trastuzumab and paclitaxel. The breast mass initially observed on clinical imaging disappeared and only calcifications were observed. Bone metastases were detected only in the left tenth rib. As an additional therapy, 3-dimensional radiotherapy( 50 Gy/25 fractions), which irradiated the left mammary gland, axilla, and supraclavicular fossa, was administered. The tumor was well controlled for approximately 3 years. However, a gradual increase in the level of carcinoembryonic antigen( CEA) was accompanied by an increase in the left breast mass and enlargement of left axillary lymph nodes. Modified radical mastectomy (Bt+Ax [level I]) was performed for this condition 3 years ago. Papillotubular-type invasive ductal carcinoma (INF β, ly3, v0, g+, f+, s+, nuclear grade 3 [atypia 3+mitosis 3]) was diagnosed histopathologically. Lymph node metastases were also detected. As histopathological examination of the bone metastatic lesion showed no progression, administration of lapatinib and capecitabine was initiated. After 15 cycles of treatment, enlarged right axillary lymph nodes were observed and local excision was performed. Histopathological examination revealed recurrence of the breast cancer. The patient was diagnosed as having grade 3( atypia 3, mitosis 2) breast cancer( ER-negative, PgR-negative, HER2/neu positive[ 3+], and MIB-1 index 50%). The response to treatment with lapatinib and capecitabine was progressive disease( PD), and therefore, trastuzumab and gemcitabine therapy was selected. Currently, the patient has undergone 30 cycles of this regimen and the tumor is well controlled. This regimen was considered effective for the treatment of patients with HER2-positive metastatic breast cancer.

Hematoxylin and eosin (HE) and immunohistochemical (IHC) staining have been commonly used in combination with thin serial sectioning of frozen and paraffin-embedded specimens for the detection of micrometastatic disease in the lymph nodes of patients with esophageal cancer. The application of IHC has markedly improved the sensitivity of micrometastatic disease detection in the lymph nodes beyond the capability of routine HE staining alone. Increasing the sensitivity of occult tumor cell detection in the lymph nodes using molecular-based analysis should enable a more accurate understanding of the clinical significance of various patterns of micrometastatic nodal disease. Further studies will explore the clinical significance of micrometastases or isolated tumor cells in the lymph nodes in patients with esophageal cancer. Individualized selective and modified lymphadenectomy targeting sentinel nodes for clinically NO early esophageal cancer may become feasible and clinically useful as a less invasive surgical procedure.

In the US and Europe, chemoradiotherapy has become a standard treatment not only for head and neck cancer, esophageal cancer, pancreatic cancer, and rectal cancer, but also for gastric cancer. In particular, chemoradiotherapy has been established as an adjuvant therapy. In Japan, it has not been established as a standard treatment. Its indications are limited, and it is often performed as palliative care. Disadvantages of radiation therapy for gastric cancer include the difficulty of establishing the area to irradiate due to peristaltic movement, risk of perforation and ulceration from high-dose radiation, and ineffectiveness against adenocarcinoma with low radiosensitivity. In recent years, technological advancement of radiation therapy has enabled pinpoint accuracy in the treatment of primary gastric lesions and regional lymph nodes. There has been much anticipation that chemoradiotherapy will become a part of multidisciplinary treatment for advanced cancer. This report describes the current state of chemoradiotherapy for gastric cancer in Japan and overseas, and outlines our approach to locally advanced gastric cancer.

New methods to facilitate recovery from end-stage organ failure are needed since only limited treatment options are available in this context, including replacement therapy such as hemodialysis or organ transplantation. Recent progress in the field of tissue engineering has opened attractive approaches for clinical applications of regenerative medicine which could be an option in this regard. Of these, tissue decellularization technology, which retains all the necessary cues for cell maintenance and homeostasis, such as the three-dimensional structure of the organ and its extracellular matrix components, has recently been applied to whole organs. It has demonstrated efficacy in generating an engineered graft that is transplantable by vascular anastomosis. Several different therapeutic targets have been explored and applied clinically. However, the use of this technology in the context of the digestive organs is still under investigation, which is more difficult because of their complicated three-dimensional structure and complex functioning. We applied this technology to the liver and demonstrated its efficacy in recellularized hepatocyte function and three-dimensional structure that was anatomically feasible for transplantation. Recent progress in stem cell technology will facilitate this new method as a novel platform for functional organ grafting in patients with organ failure.

As pharmacokinetics in patients undergoing haemodialysis is different from patients with normal renal function, it remains unclear whether chemotherapy can be performed safely for patients with haemodialysis as well as those who have normal renal function. Here, we report a case with recurrence of rectal cancer who received FOLFIRI with bevacizumab chemotherapy under haemodialysis, and obtained good tumor control. A 47-year-old woman had undergone haemodialysis for 10 years due to chronic renal failure. At 45 years of age, she received abdominoperineal resection due to rectal cancer (pStage II). Four months after the surgery, liver metastasis was found, for which partial resection of the liver and adjuvant chemotherapy [UFT (400 mg/body)/UZEL (75 mg/body)] were performed. Eighteen months after the liver resection, multiple lung metastases were found. Therefore, intensive chemotherapy using FOLFIRI (CPT-11: 90 mg/m2) with bevacizumab (2.5 mg/m2) was performed. Severe neutropenia (grade 3, 4), but not non-hematologic adverse events such as diarrhea and bevacizumab-specific adverse events, was observed. As she did not recover easily from neutropenia in spite of treatment with G-CSF, a dose reduction of the FOLFIRI regimen was gradually performed. Although chemotherapy was conducted approximately monthly, the tumor response reflected a stable disease 8 months after 8 courses of chemotherapy. We suggest that it is important to investigate the pharmacokinetics of toxic agents such as CPT-11, (SN38) for dose modification, and for the safe and continuous chemotherapy of patients receiving haemodialysis.

A 55-year-old female was admitted to Ogikubo Hospital for severe anemia and prolapse of a tumor from the anus, which had developed over 2 years. Rectal examination revealed a giant soft tumor. Endoscopic study revealed a lobulated giant tumor with a granular surface. Gastrografin-enema study showed a giant tumor, which was full of the rectum. Pathological examination showed a well differentiated carcinoma. No other prominent metastatic lesions were demonstrated. The transanal diagnostic resection of rectal cancer was performed in October 2010. This correct diagnosis showed both well differentiated adenocarcinoma and intramucosal carcinoma. We therefore recommend that a tumor of the lower rectum should undergo a diagnostic excision by means of either a local excision, ESD or TEM.

Objectives: The prevention of metabolic syndrome (MetS) is one of the main targets of health promotion activities in the workplace. The present study aimed to clarify the incidence of MetS and associated lifestyle factors in a worksite male population., Methods: The study subjects consisted of 948 working men (mean age: 44 yr old) who did not meet the Japanese criteria for MetS during the annual health examination at a precision instrument development plant in Kanagawa, Japan, 2005. New-onset MetS was followed using the health examination data from 2006 to 2009. The incidence of MetS according to the combination of the presence of abdominal obesity and the number of other components of MetS (elevated blood pressure, dyslipidemia, and elevated fasting glucose) at baseline were calculated. The incidence of MetS was also compared among the groups with regard to differences in lifestyles (dietary habits, smoking status, sleep duration, exercise habits, and alcohol intake). A Cox proportional hazard model was used to identify independent factors contributing to an increased risk of MetS., Results: New-onset MetS was observed in 76 subjects during a mean follow-up period of 3.7 yr. The incidence of MetS was 2.2/100 person-years and the 4-year incidence of MetS according to Kaplan-Meier analysis was 8.5%. The highest 4-year incidence of MetS was found in the group without abdominal obesity but with two or more components of MetS (37.9%) and the second highest incidence was found in the group with abdominal obesity and one other component of MetS (24.6%). The presence of abdominal obesity and each increase in the number of other components of MetS had an increased age-adjusted hazard ratio for an increased risk of MetS (5.23 and 4.79, respectively, both p<0.001). Similarly, sleep duration 5 h or less, current smoking, and ethanol intake 300 g/wk or more had an increased age-adjusted hazard ratio for an increased risk of MetS., Conclusions: The present study showed a high incidence of MetS in not only the group with abdominal obesity, but also the group without abdominal obesity but with two or more components of MetS. Sleep deprivation, current smoking, and excess alcohol intake were found to be factors contributing to an increased risk of MetS among several lifestyle factors examined. The usefulness of health promotion activities that preferentially target subjects who have such medical conditions and/or lifestyles are therefore expected to reduce the incidence of MetS in the workplace, from a high-risk strategy viewpoint.

A 62-year-old female was diagnosed with type 2 advanced gastric cancer in May 2003. Pathological examination showed a poorly differentiated carcinoma. Computed tomography (CT) revealed paraaortic lymph node metastasis, duodenal metastasis and ascites due to peritoneal dissemination. Chemotherapy with CDDP+S-1 was started and continued. After the chemotherapy, there were progressive diseases. Therefore, paclitaxel (PTX) was administered at a dose of 80 mg/m2/day for 3 weeks followed by a week rest. Clinical symptoms were relieved, and CT scan revealed metastatic lymph nodes were reduced after 4 cycles. After 13 cycles, MRI revealed a solitary brain mass was detected. She was resected for a right temporal-occipital brain metastatic tumor, and local cerebral irradiation was performed. After this operation, she was diagnosed with brain metastasis from advanced gastric cancer. The procedure was interrupted for about 6 months. After rehabilitation, PTX treatment was restarted as 14th cycle. She has survived without recurrence more than 30 cycles after the resection. A weekly administration of PTX may be a promising regimen as second-line chemotherapy for S-1 resistant recurrent gastric cancer.

Legal standard of medicine is not equal across the all kinds of medical institutions. Each medical institution is required its respective standard of medicine in which its doctors are expected to have studied medical informations, which have been spread among medical institutions with similar characteristics. Therefore, in principle, clinical guidelines for the treatment of a disease formed by public committees do not directly become the medical standards of respective disease treatment. However, doctors would be legally required to practice medicine with reference to the clinical guidelines because medical informations, mediated by internet or many kinds of media, have been spread very fast to all medical institutions these days. Moreover, doctors would be required to inform their patients of non-standardized new treatments, even if such treatments are not listed in clinical guidelines in case patients have special concern about new treat-

Active clinical researches for breast cancer advance the therapeutic strategies remarkably, however, it seems to be more difficult to choose the appropriate treatment based on the evidence for each patient due to its diversification. Moreover, the striking achievements of various molecular targeting drugs established by basic researches make it complex, since the biological feature of tumor cell must be considered carefully for drug selection. To make it straight, the latest strategies for breast cancer treatment based on both basic and clinical evidences are summarized, especially about surgical and medical treatments of primary therapy for breast cancer.

A 58-year-old female was admitted to Ogikubo Hospital for advanced hepatocellular carcinoma in April 2007. Pathological examination showed moderately differentiated hepatocellular carcinoma. Tumor marker increased the PIVKA-II level became 129 mAU/mL after the operation. FDG-PET was showed a solitary pelvic tumor sized about 2.5 cm in diameter. No other prominent metastatic lesions were demonstrated, so that a resection of intrapelvic tumor was performed in May 2008. The report which exhibited an asynchronism recurrence of peritoneal dissemination after hepatectomy is very rare. She has survived without a recurrence more than 13 months after the resection.