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An 80-year-old woman presented with epigastric discomfort and dysphagia, underwent upper gastrointestinal endoscopy, and was diagnosed with type 2 advanced lower esophageal adenocarcinoma. Computed tomography data revealed that there was the lower esophageal tumor is T3, but a large carina lymph node invading the left bronchus. We diagnosed this patient unresectable cT4bN1M0, cStage ⅣA advanced esophageal adenocarcinoma, and we administered nivolumab plus S-1 plus oxaliplatin(SOX)therapy. After 3 courses of the therapy, imaging showed marked reduction in the size of primary tumor and carina lymph node. We diagnosed partial response(PR)and attempted conversion surgery. Video-assisted thoracoscopic esophagectomy with 2 fields lymphadenectomy was performed. The pathological examination demonstrated no residual tumors and no lymph node metastases, and the histological response of primary tumor was determined to be Grade 3, with a pathological complete response(pCR). Currently, the patient is alive without recurrence for 1 year after surgery.

A 75-year-old man was transferred to our hospital with a diagnosis of acute cholecystitis. On next day, a laparoscopic cholecystectomy was performed. Histologic examination confirmed an adenocarcinoma arising from duct of Luschka. Patient underwent additional resection of the liver bed. No residual adenocarcinoma was seen in the surgical specimen. Adenocarcinoma of duct of Luschka is rare, but it is important during cholecystectomy to consider the presence of duct of Luschka, possibility of malignant disease and careful dissection of the gallbladder from its fossa staying close to the gallbladder wall.

A 71-year-old woman who have been taking Sanshishi for 50 years until the age of 70 for dermatitis underwent colonoscopy( CS)to reveal the reason of abdominal pain. CS showed ascending colon tumor(AT)with major axis 3 cm and suspicious of the mesenteric phlebosclerosis. Although endoscopic submucosal dissection(ESD)was performed for AT, colon perforation due to colonic wall fibrosis was occurred and ESD was suspended. Therefore, surgical resection was planned. Intraoperative observations by laparoscopy showed that the color of colon serosa from the cecum to the splenic flexure was grayish white and colonic wall thickening with lead tubular change was observed. From the descending colon to the sigmoid colon, wall thickening was mild, and Haustra was confirmed. Although the tumor location was in the ascending colon, laparoscopic subtotal colectomy and functional end-to-end anastomosis of ileum and sigmoid colon was performed for safe intestinal anastomosis. For treat of colon cancer complicated mesenteric phlebosclerosis(MP), endoscopic resection is considered difficult due to fibrosis and extended resection of the colon may be required to reduce the risk of anastomotic leakage. Herein, we report our case and details of past reported literatures.

We report the case of a patient with recurrent gastric cancer that showed a complete response(CR)after short-term nivolumab administration. A 76-year-old woman was diagnosed with unresectable advanced gastric cancer(T4b, N+, M0, cStage ⅣA). The patient was administered 7 courses of SOX. Since the primary lesion was reduced significantly after the chemotherapy, radical gastrectomy was performed. Although postoperative adjuvant chemotherapy with weekly nab-PTX was performed, cancer recurrence occurred in the abdominal cavity, and another surgery was performed. However, complete resection was difficult to achieve. Postoperatively, chemotherapy was continued; however, CEA levels increased, and thus RAM+PTX was administered as second-line treatment. Stable disease was maintained for a while; however, disease progression occurred eventually. Thus, RAM+PTX was discontinued after 8 courses, and nivolumab was administered as the third-line treatment. However, due to the rapid deterioration of renal function, nivolumab could not be continued after 3 courses. After nivolumab discontinuation, CEA levels normalized and the image showed CR. Approximately 1.5 years have passed since then, with no report of recurrence without any treatment. Although nivolumab has been shown to be useful as a third-line treatment for unresectable advanced/recurrent gastric cancer, there are few reports demonstrating CR and none showing maintenance of CR after short-term nivolumab administration. Moreover, the rationale of continuing nivolumab is unclear once clinical CR is achieved. Our experience shows the feasibility of discontinuation of short-term nivolumab if CR is achieved.

We have introduced neoadjuvant chemotherapy(NAC)for locally advanced lower rectal cancer(LARC)since 2014. We report 2 LARC cases in which a pathological complete response(pCR)was obtained by using cetuximab(Cmab)plus oxaliplatin plus S-1(SOX)for NAC. Case 1: A 68-year-old woman underwent 4 courses of Cmab plus SOX for Rb rectal cancer (well-differentiated adenocarcinoma, cStage Ⅲc: cT4b[vagina]N3M0). Lap posterior pelvic exenteration was performed. The pathological findings of the resected specimen revealed no carcinoma and we diagnosed it as pCR. As of 31 months after the operation, she is alive without recurrence. Case 2: A 72-year-old man underwent 4 courses of Cmab plus SOX for middle and lower rectal cancer(Rab, moderately differentiated tubular adenocarcinoma, cStage Ⅲc: cT3N3M0). After NAC, with the diagnosis of ycT3N0M0, laparoscopic-assisted(Lap)super-low anterior resection with bilateral lateral pelvic node dissection was performed. The pathological findings of the resected specimen revealed no carcinoma and we diagnosed it as pCR. As of 37 months after the operation, he is alive without recurrence. NAC with Cmab plus SOX may be an effective treatment for LARC.

Application of laparoscopic surgery(Lap)for colorectal cancer has expanded, and laparoscopic total pelvic exenteration (TPE)of locally advanced rectal cancer(LARC)invading the urogenital organs has been introduced in some institutions. In our institute, we have performed Lap TPE and posterior-TPE(PPE)in a total of 6 LARC patients so far. Here, we report the surgical technique of Lap TPE, and the associated surgical and short-term outcomes. We performed Lap TPE and Lap PPE in 3 patients each. Operation time was approximately 562 min, and the blood loss was 310 mL on an average. No patient developed postoperative complications above Clavien-Dindo Grade Ⅲ. One patient exhibited recurrence in the liver and another in peritoneum in the Lap PPE group. No recurrence was observed in the Lap TPE group(median follow-up period: 24.5 months). Although Lap TPE and PPE are difficult to perform and time consuming, it is suggested that these procedures may help reduce the intraoperative bleeding volume and shorten the length of postoperative hospital stay compared to open TPE and PPE.

A 75-year-old woman was treated with TC plus Bev for cancer of unknown primary. During treatment, she presented to the clinic with chief complaints of general malaise and anorexia. On presentation, abdominal distention and upper abdominal tenderness were noted, and sepsis was suspected. A thoracoabdominal CT scan revealed prominent intramural emphysema and mesenteric gas in the ascending colon. An emergency laparotomy was performed for suspected pneumatosis intestinalis non-obstructive intestinal ischemia. However, no intra-abdominal contamination or ischemic changes were observed intraoperatively. Histological examination revealed a small adenocarcinoma on the serous surface of the ascending colon, and immunochemical staining confirmed the diagnosis of serous adenocarcinoma as the patient's primary cancer. This report describes a case in which the patient achieved long-term survival after diagnosis. It also emphasizes the importance of identifying the subset of patients with cancer of unknown primary who have a good prognosis in order to provide appropriate treatment.

A 46-year-old woman with metastatic breast cancer developed dyspnea that progressed relatively rapidly during chemotherapy. Chest-abdominal CT revealed wedge-shaped infiltration shadow, and cardiac catheterization revealed elevated pulmonary artery pressure. Aspiration cytology of pulmonary arterial blood was performed and malignant cells were confirmed. Chemotherapy was difficult to continue because of deterioration in general condition, and she died 7 days after diagnosis. This time, we report a case of PTTM for which pulmonary arterial blood cytology was useful for diagnosis.

We present the case of an 88-year-old woman who had undergone breast conserving surgery for left breast cancer 8 years ago.She received postoperative radiotherapy(total dose of 60 G/30 Fr)to the residual breast together with endocrine therapy.She underwent skin biopsy after having had a red skin tumor in the left breast.Angiosarcoma was diagnosed and chemotherapy and radiotherapy were initiated.The patient is alive without recurrence 8 months after chemotherapy.

The demand for breast reconstruction is expected to increase with the currently observed increase in the number of breast cancer patients. Among the 70 patients included in the study, 59 received tissue expanders, 1 received implant, and 10 received deep inferior epigastric perforator flaps. Complications were noted in is 11 patients who received tissue expanders. In this study, age>50 years and smoking were associated with higher rates of complication. Choosing an appropriate method for breast reconstruction is important. In addition with plastic surgery, an approach to reduce complications will be necessary in future.

A 74-year-old man was admitted to a clinic because of epigastralgia in June 2018. He was referred to our hospital for further examination of right hydronephrosis. He was diagnosed as having type 2 gastric cancer in the middle gastric body and lesser curvature, with an upper gastric fiber, swollen para-aortic lymph node, and right hydronephrosis by using abdominal computed tomography. PET-CT revealed no hot spot in the para-aortic lymph node but revealed a hot spot in the lower small bowel. He was admitted to our hospital because of severe abdominal pain and appetite loss and underwent a reduction and palliative surgery for the unresectable gastric cancer. The omental cavity was perforated and penetrated into the retroperitoneum. He underwent esophageal jejunal bypass and intestinal fistula tube insertion in the stomach. He had a central vein port and was discharged from our hospital. He was able to eat during his short overnight stay at our hospital after the operation but died on postoperative day 30.

We reported a case of a 30s woman who underwent Hartmann's surgery for sigmoid cancer. Her pathological stage was Stage Ⅳ(pT4b, N1b, M1b[liver and lung]). Postoperatively, 10 courses of systemic chemotherapy with FOLFOX plus cetuximab( Cmab)or bevacizumab(Bmab)were administered. After the chemotherapy, partial liver dissection and radiofrequency ablation(RFA)for multiple liver metastasis were performed. After 2 years of systemic chemotherapy with FOLFIRI plus ramucirumab(RAM), no liver or lung metastasis was observed; however, left supraclavicular lymph node and para-aortic lymph node metastases existed and gradually increased. For the purpose of local control, the para-aortic lymph node metastasis was treated with cervical dissection and carbon ion radiotherapy. Therefore, carbon ion radiotherapy was a useful treatment for local control.

The incidence of perineal wound complications after extended pelvic surgeries for locally advanced or locally recurrent cancer is high. The management of these refractory complications is usually difficult. Extended pelvic surgeries are commonly associated with severe infectious complications owing to pre-operative chemoradiation therapy, the tissue damage during surgery, and the dead space after radical resections. Negative pressure wound therapy(NPWT)is widely used for the management ofseveral wounds. Recently, the utility ofNPWT has been reported on the management ofinf ectious wound complications post-surgery. Some authors reported the drainage effect of NPWT on pelvic abscess after surgery. However, so far, only a few reports have been published on the usefulness of NPWT in the management of perineal wound disruption or pelvic abscess. We performed NPWT on patients with perineal wound disruption or intractable lymphorrhoea. In these cases, NPWP was effective in early successful treatment. In summary, NPWT is an effective treatment option for perineal disruption and pelvic abscess after surgery for locally advanced or locally recurrent cancers.

No large clinical trials have been conducted to prove the efficacy of peritoneal dissemination resection for colorectal cancer, and no evidence has shown the usefulness of resection for metachronous peritoneal dissemination. An elderly woman in her 70s underwent a laparoscopic transverse colectomy for transverse colon cancer in 2014, which was performed by another physician. The pathological diagnosis was tub2-por>muc, pT3, ly2, v0, pN2, and pStage Ⅲb. The patient was followed up with capecitabine plus oxaliplatin(CapeOX)therapy as an adjuvant chemotherapy for 6 months. Three years postoperatively, the CEA level increased to 10 ng/mL, and CT showed a nodular shadow in front of the left prerenal fascia. After the diagnosis of peritoneal dissemination recurrence and 8 courses of capecitabine plus bevacizumab therapy, other metastases were not observed. She was referred to our hospital for surgery and underwent laparoscopic peritoneal dissection at 3 years and 6 months after the first operation. Only one apparent disseminated recurrent lesion, which was resectable, was observed. However, at 4 years and 9 months after the initial operation, CT showed a recurrence of Douglas pouch peritoneal dissemination without any other obvious metastasis. Laparoscopic low anterior resection of the rectum and hysterectomy were performed. Here, we encountered a case that could be radically resected for peritoneal dissemination twice after the colon cancer surgery.

The patient was a 55-year-old man who had undergone extended right lobectomy of the liver with a diagnosis of primary hepatic carcinoid tumor. Nine years after the operation, enhanced abdominalCT revealed a tumor measuring 2.2 cm in the remnant liver. He was diagnosed with recurrence of primary hepatic neuroendocrine carcinoma and underwent partial hepatectomy. Pathologically, the tumor cells had round nuclei and formed trabecular patterns. Immunohistologically, the cells were positive for CD56, synaptophysin, and chromogranin A. The Ki-67 index was 6%, which was equivalent to Grade 2 in the WHO classification revised in 2010. Since there were no other lesions suspected to be the primary site other than in the liver, it was diagnosed as recurrence of the primary hepatic neuroendocrine carcinoma. Two years after the operation, he was diagnosed with recurrence of primary hepatic neuroendocrine carcinoma and underwent partialhepatectomy again.

A 69-year-woman was admitted to the clinic in August 2018 because of general fatigue and low appetite.She had occult blood-positive and was referred to our hospital for further investigations.There was LST in the rectum for which colonoscopy and ESD were performed.She had abdominal pain and slight fever on postoperative day 1.Abdominal CT showed an intussusception in the ileum.We could not achieve endoscopic de-torsion and carried out laparotomy.The intussusception was found to be strangulated due to inflammatory polyp and mesenteric adhesion.The affected portion was resected.Although treatment for low hypoalbuminemia and neurogenic cystitis was required, she was discharged on postoperative day 28.

The patient, a woman in her 70s, was diagnosed with occlusive ileus caused by sigmoid colon cancer.She underwent transanal stent placement to release the occlusion.Subsequent detailed testing revealed a 70×60mm mass on the dorsal side of the pancreas and PET-CT indicated an SUVmax 18.2 FDG uptake. EUS-FNA was performed twice.However, the mass was unable to be definitively diagnosed.The patient was then referred to our hospital.She underwent laparoscopic sigmoid colectomy and laparoscopic biopsy of the mass for sigmoid colon cancer.The patient progressed well postoperatively and was discharged home on postoperative day 9.The postoperative diagnosis was colon cancer(S, Type 2, 58×50 mm, tub2, pT4a [SE], pN1, Stage Ⅲa)and the biopsied mass was found to be a nodal marginal zone B-cell lymphoma according to histopathological testing.After undergoing chemotherapy at our hematology department, she has experienced no recurrence.

We report a case of recurrent pancreatic cancer in the remnant pancreas after pancreatoduodenectomy(PD)that was successfully treated by surgical resection. A woman in her 70s who was treated for multiple lung metastases of breast cancer was referred to our hospital because of obstructive jaundice. A low-density area in the pancreas head(19mm in diameter) and dilatation of the main pancreatic duct were observed on abdominal CT. She was diagnosed with pancreatic head cancer and underwent PD. Twenty months after PD, abdominal CT revealed a tumor in the pancreas tail, and she started receiving chemotherapy containing gemcitabine(GEM)for the diagnosis of recurrent pancreatic cancer in the remnant pancreas. Twelve months after the induction of chemotherapy, we performed surgical resection of the tumor(total pancreatectomy). The pathological diagnosis was moderately differentiated adenocarcinoma, which was similar to the primary lesion, and the tumor was confirmed as recurrence of pancreatic cancer. Although she died of multiple lung metastases of breast cancer 62 months after the total pancreatectomy, the recurrence of pancreatic cancer was not observed without adjuvant therapy during that time.

A man in his 70s was diagnosed with gastric cancer and underwent total gastrectomy with D2 lymphadenectomy. The final diagnosis was T3(SS)N2M0, Stage ⅢA. After surgery, S-1 was administered for 1 year. One year and 6 months after surgery, abdominal computed tomography showed a single liver tumor(S4: 30mm). Based on overexpression of the human epidermal growth factor receptor 2(HER2)protein in the primary tumor, we selected capecitabine plus cisplatin plus trastuzumab as the combination chemotherapy. After the second course, the therapeutic response was stable. S4 partial liver resection was performed. The liver tumor was histologically evaluated as Grade Ⅰb metastatic gastric adenocarcinoma. After surgery, capecitabine plus trastuzumab was administered for 1 year. One year after resection of liver metastasis, the patient is alive without any relapse.

An 82-year-old man receiving oral administration of warfarin for atrial fibrillation underwent distal gastrectomy for advanced gastric cancer. The postoperative diagnosis was pT3(SS)N2M1H1P0CY0, pStage Ⅳ,(HER2, score 3+)gastric cancer. He received chemotherapy for the treatment of multiple liver metastases, following which, he developed lymph node metastases. Grade 3 anemia was observed at 46 months after initiation of chemotherapy when he was treated with third-line irinotecan plus cisplatin. Abdominal CT showed that CR for liver metastases and SD for lymph node metastases were maintained. Esophagogastroduodenoscopy and colonoscopy showed no intraluminal bleeding. As the anemia progressed, blood transfusion was required repeatedly instead of withdrawal of chemotherapy and replacement therapy of iron and vitamin B12. Double- balloon endoscopy revealed hemorrhagic tumor at duodenal stump. We diagnosed tumor bleeding from metastatic lymph node around pancreatic head invading to duodenum. Palliative radiotherapy(40 Gy/20 Fr)for hemostasis was performed. Finally, hemostasis and tumor shrinkage were achieved.

Here, we report a long-term survival case treated with docetaxel and S-1 combination therapy(DS therapy)for peritoneal dissemination of gastric cancer. A 58-year-old man was diagnosed with gastric cancer in 2006. Distal gastrectomy, D2 dissec- tion, and RY reconstruction were performed. The pathological diagnosis was gastric cancer, por2, pT3(SS), pN3a(8/27), pStage ⅢB. S -1 monotherapy was administered as an adjuvant chemotherapy for 1 year from 3 months after surgery. Five years after surgery, peritoneal dissemination and bladder recurrence caused rectal stenosis and hydronephrosis. We performed ileostomy and left nephrostomy. DS therapy was started 5 years and 2 months after the initial surgery. A complete clinical remission was observed 2 years and 10 months after starting DS therapy(23 courses). Multiple lymph node metastasis and bone metastasis were confirmed at 5 years and 5 months(57 courses). Even though irinotecan monotherapy was performed for five courses, the bone and lymph node metastasis increased at 5 years and 9 months after starting DS therapy, and the patient died at 69 years of age. DS therapy may be a useful option for peritoneal metastasis of gastric cancer.

We report a case of peritoneal metastasis of bile duct cancer that was successfully treated by surgical resection. A 70s man underwent pancreatoduodenectomy(PD)for bile duct cancer, and abdominal CT revealed a tumor in the peritoneum along the right kidney at 55 months after PD. As FDG uptake was seen at the lesion on PET-CT, he was diagnosed as recurrence of bile duct cancer or primary malignant tumor in the retroperitoneum. Because the tumor was solitary on CT and PET-CT, we conducted surgical resection of the tumor. Pathological diagnosis was well differentiated adenocarcinoma that was similar to the primary lesion, and the tumor was confirmed as recurrence of bile duct cancer. He remains alive without 2nd recurrence for 60 months since tumor resection(117 months since PD).

A 74-year-old man visited our hospital with an awareness of anal mass and bleeding. He was diagnosed as adenocarcino- ma of anal canal with wide spreading skin invasion. After neoadjuvant chemoradiotherapy(radiationtotal 45 Gy/25 Fr; cape- citabine 825mg/m2)was performed to reduce the mass volume, laparoscopic abdominoperineal resection with large perineum skin resection and lateral lymph node dissection was carried out. The perineal defect was repaired with a rectus abdominis musculocutaneous flap. Six days after surgery, the rectus abdominis musculocutaneous flap necrotized, and second perineum reconstruction by the bilateral gracilis musculocutaneous flaps was performed after debridement of necrotic tissue. We reported a case of radical resection of local advanced anal canal cancer with skin invasion by performing combined modality therapy and perineum reconstruction.

Here we report a case of a hemorrhagic gastric cancer patient with severe coronary artery disease, in whom the cancer was successfully resected with the support of intra-aortic balloon pumping(IABP). An 80-year-old man was referred to our hospital for further examination of his anemia and tumor around the pancreatic head. He was diagnosed with type 3 gastric cancer with multiple bulky lymph node metastases invadingto the pancreas(cT4b[LN-Panc], N3a, M1[LYM No.16a2int], cStage IV ). Tarry stools continued and blood transfusion was repeatedly required. To control tumor bleeding, we considered that gastrectomy should be performed prior to chemotherapy. Since he had a history of acute myocardial infarction, coronary angiography was performed, which showed severe coronary stenosis in 3 vessels. Preoperative percutaneous coronary intervention or coronary artery bypass grafting were inappropriate because of tumor bleeding. We performed palliative distal gastrectomy under the support of IABP. The postoperative course was uneventful and he could initiate subsequent chemotherapy smoothly. IABP may be a useful option for hemorrhagic gastric cancer patients with severe coronary stenosis.

The patient is a 65-year-old woman with anemia. The multiple liver tumors detected by ultrasonography, it was diagnosed as neuroendocrine tumor(NET), G2 by biopsy. There was an ulcer at the bulb of the duodenum, so we diagnosed liver metastasis of duodenum NET. Because the liver tumors spreaded to both right and left lobes, we carrying out a transcatheter arterial embolization(TAE)twice to liver metastasis, and chemotherapy by octreotide was performed. 20 months after the beginning of treatment, a 4 cm tumor was remained in the left lobe but others were not detected by computed tomography, so we performed cytoreductive surgery. Duodenum bulb resection and left hepatectomy was performed and the specimens were NET, G2 in the pathological findings. We detected a lot of tumors less than 1 cm in the right lobe during the operation, so TAE was carried out for the right lobe after surgery. The disease showed no progression for 28 months after the first admission(post operation5 months).

The most frequent relapse site of gastrointestinal stromal tumors(GIST)is the liver. We encountered a patient with longterm survival treated with multidisciplinary treatment, including4 hepatectomies for liver metastases. The patient was a woman aged 69 years at the time of the first medical treatment. She underwent total gastrectomy and S6 segmental hepatec- tomy for a stomach GIST with a hepatic metastasis. The tumor diameter was 24 cm and the mitotic figure was 65/50 HPF. According to the guidelines, it was diagnosed as a high risk GIST based on strong positive immunostaining for CD34 and c-kit. The tumor had metastasized to the liver and greater omentum. She took imatinib in the year following surgery. Because the GIST had spread to the lung1 8 months after the operation, she took imatinib again. Two years after the operation the pulmonary metastasis showed a clinical complete response(cCR)and the CR lasted for 4 years. Six years after the surgery she had a hepatic recurrence in S5, and she underwent an S5/4 partial hepatic resection. Seven years after the first operation, a liver S7 metastasis developed and she underwent S7 partial hepatectomy. Ten years after the first surgery, the GIST relapsed in liver S6 with right adrenal gland permeation. She underwent partial S6/7 liver resection and a right adrenal gland resection. She resumed takingimatinib after this surgical resection. Now, 11 years after the first operation, she is alive with an S1 hepatic recurrence taking sunitinib. Therefore, multidisciplinary treatment with surgical resection prolongs the survival of patients with resectable liver metastases of GIST.

We report a case of recurrent esophagogastric junction cancer successfully treated with chemotherapy including trastuzumab. A 66-year-old man reporting black stool was examined, and through upper gastrointestinal endoscopy was found to have a tumor at the esophagogastric junction. Video-assisted thoracoscopic surgery of the esophagus with 3-field lymph node dissection was performed. The final diagnosis was adenocarcinoma(tub1-pap-muc), pT3N3M0, pStage III C. The tumor was at the squamo-columnar junction and classified as Siewert type II . Following surgery, 6 months of adjuvant therapy with S-1 was administered. Computed tomography(CT)confirmed metastases in the lung, liver, and recurrence in the reconstructed stomach. In spite of chemoradiotherapy(FP plus RT)and weekly PTX, these metastases had grown. Pathological examinationshowed overexpressionof humanepidermal growth factor receptor 2(HER2), and treatment with CPT- 11 plus trastuzumab was initiated at postoperative 15 months. A partial response was achieved 3 months later. The lesions in the lung, liver, and reconstructed stomach were controlled with this therapy, but he died from meningeal seeding at postoperative 20 months. These findings suggest that inclusion of trastuzumab in chemotherapy regimens is effective for recurrent HER2-positive esophagogastric junction cancers.

Familial adenomatous polyposis has an autosomal dominant pattern of inheritance. Colon cancer occurs frequently as a result of colorectal adenoma. The standard treatment is total proctocolectomy. However, it is reported that duodenal papilla cancer and desmoid tumors can also occur alongside colon cancer. We report a patient with duodenal papilla cancer who underwent total proctocolectomy 22 years previously. The patient was a 47-year-old man who had undergone a total proctocolectomy at the age of 25 years for familial adenomatous polyposis. On abdominal CT, duodenal papilla cancer that was suspected to be malignant was found. Using single-balloon enteroscopy, duodenal papilla cancer was diagnosed and pancreatoduodenectomy was performed. Seventeen months after surgery, liver and lung metastases were diagnosed. We began to provide palliative treatment, but the patient died 7 years 10 months after surgery.

A 68-year-old man presented with type 3 advanced gastric cancer(Circ, tub2>por, HER2 score 3)in the antrum, with skip lesions in the duodenum. The tumor was cT4aN2M1(DUO)CY0, cStage IV . An XP plus trastuzumab regimen(1,000mg/m2 capecitabine[Xeloda®]twice a day on days 1-14, 80mg/m2 CDDP on day 1, 8 mg/m2 trastuzumab on day 1[second course- 6mg/m2])was administered every 3 weeks and repeated for 6 courses without severe adverse events. After 6 courses, the primary tumor and metastatic lymph nodes shrank by 31.7%(a PR according to the RECISTcriteria ), and open distal gastrectomy, D3 lymphadenectomy, and Roux-en-Y reconstruction(ante colic)were performed as conversion surgery(R0). During the administration of adjuvant chemotherapy with S-1, para-aortic, mediastinum, left supraclavicular fossa, and cervical lymph node recurrence developed. Four courses of weekly PTX plus trastuzumab as first-line chemotherapy and 11 courses of biweekly CPT-11 plus CDDP as second-line chemotherapy were administered. Because of prolonged adverse events such as Grade 3 diarrhea, the patient refused continuation of chemotherapy. The patient died 24 months after the start of preoperative chemotherapy.

We report a case of lymph node metastasis of intrahepatic bile duct cancer that was successfully treated using chemotherapy and radiation therapy.A man in his 70s underwent hepatic resection for intrahepatic bile duct cancer, and abdominal CT 1 year 8 months after surgery revealed lymph node swelling(25mm in diameter)along the common hepatic artery.He was diagnosed with lymph node metastasis and began to receive chemotherapy.We administered gemcitabine(GEM), cisplatin, and S-1 for 6 months, and GEM and S-1 for 1 year 4 further months as combination therapy.One year 10 months after the start of chemotherapy, the size of the lymph node decreased to 13 mm.However, as FDG uptake was seen on FDG-PET, radiation targeted to the lymph node was applied(50 Gy/25 Fr).After completion of radiation therapy, the lymph node has not regrown even in the absence of treatment, and the patient survives 6 years after the primary operation(4 years 4 months since the start of chemotherapy for recurrence).This case suggested that multidisciplinary therapy might be useful for lymph node metastasis of intrahepatic bile duct cancer.

We report a long-surviving patient with unresectable gastric cancer treated with multiple rounds of chemotherapy after gastrojejunostomy and ileocolonostomy. The patient was a 79-year-old man. Endoscopic examination revealed a type 3 gastric cancer in the antrum and showed pyloric stenosis. We observed that the gastric tumor had invaded the transverse colon, pancreas, and duodenum, and was associated with peritoneal metastasis on the surface of the hepatoduodenal ligament and the posterior leaf of the transverse mesocolon. We performed gastrojejunostomy and ileocolonostomy to allow oral intake and to prevent ileus. The final diagnosis was fT4b(SI), N2, H0, P1, M0, CY0, Stage IV . The patient's oral intake was not sufficient following the operation, and therefore, he was treated with 8 courses of 5-FU plus PTX intravenously until disease progression was observed. Bi-weekly administration of CPT-11 and CDDP was chosen as the second-line chemotherapy. Grade 2 renal dysfunction was observed after 13 courses of this therapy, and therefore, we changed the regimen to CPT-11 monotherapy, repeating 18 courses until disease progression was observed. The patient was treated with 18 courses of S-1 monotherapy as the fourth-line chemotherapy, and then 2 courses of S-1 plus DTX. The patient died of progressive disease 4 years and 5 months after surgery. During chemotherapy, he maintained a good performance status and could be treated as an outpatient.

Neoadjuvant chemotherapy(NAC)followed by surgery and palliative chemotherapy for unresectable advanced gastric cancer followed by conversion surgery are currently under investigation in clinical trials and are attractive therapeutic alternatives. We examined the relationship between ypStage and prognosis among patients with gastric cancer who underwent surgery following preoperative chemotherapy and evaluated the necessity of adjuvant chemotherapy in patients with pCR or ypStage I gastric cancer. Sixty-one patients received chemotherapy followed by surgery from 2006 to 2014 in Osaka National Hospital. For preoperative chemotherapy, 41 patients received NAC, and 20 patients received palliative chemotherapy. Five (8.2%)patients with pCR, ypStage I A, and Stage I B disease(n=2, 1, and 2, respectively), 3 of whom received adjuvant chemotherapy and 2 of whom did not, were all alive without recurrence after a median follow-up of 3 years and 6 months. The overall survival for patients from each ypStage in the preoperative chemotherapy group was comparable with that for each ypStage in the surgery without preoperative chemotherapy group during the same period. Discontinuation of adjuvant chemotherapy and intense follow-up is a treatment option after R0 resection for patients with gastric cancer who achieve pCR or downstaging to ypStage I .

We report a case of a 23-year-old womanwho developed pulmonary embolism(PE)during chemotherapy for advanced gastric cancer following total gastrectomy(R1). She presented with type 4 gastric cancer with peritoneal dissemination and positive washing cytology. Palliative total gastrectomy was performed(R1)and first-line chemotherapy with S-1(80mg/m2, days 1 to 21) plus CDDP(60mg/m2, day 8)(SP; every 35 days)was administered. PE occurred on day 15 of the 3rd courses of SP. Computed tomography(CT)revealed massive PE in both the pulmonary arteries, and ultrasonography indicated an increase in right-sided pressure. Thrombolysis using urokinase and heparin was performed immediately, and she recovered after 10 days in intensive care. Dehydration caused by the adverse event, as well as nausea and the anticancer drug itself, are risk factors for DVT and PE. Risk stratification, prevention, and early treatment are very important for PE.

We report a case of recurrent breast cancer with involvement of the right adrenal grand, which was resected using laparoscopic surgery. The patient was a 41-year-old woman who underwent duct-lobular segmentectomy for ductal carcinoma in situ. Histopathology showed microinvasion, and tested positive for ER and PR, but negative for HER2, so we applied radiation to the remaining breast and administered tamoxifen. After 9 months, local recurrence was detected and quadrantectomy with axillary lymph node dissection was performed. One year and 10 months later, local recurrence was again detected and a tumorectomy was performed. The adjuvant therapy was changed to an LH-RH analog plus anastrozole and it was administered effectively for 5 years. Left ileal metastasis appeared in the 2nd month after completion of the adjuvant chemotherapy, so radiation was applied and an LH-RH analog plus exemestane administration was started. Three years passed without recurrence, but a right adrenal tumor appeared on computed tomography. The tumor grew over 6 months, so laparoscopic right adrenalectomy was performed. Histopathologically, the tumor tested positive for ER and PR, and negative for HER2 so we diagnosed metastasis of breast cancer, and administered an LH-RH analog plus exemestane. The patient's disease has not progressed in the 3 months since surgery.

We report a long-term survival case of hepatocellular carcinoma with lymph node metastasis that was successfully treated with multidisciplinary therapy. The patient was a 52-year-old man. He underwent right lobe liver resection with lymph node sampling at the hepatic portal section for hepatocellular carcinoma. Histopathological examination revealed hepatocellular carcinoma with lymph node metastasis. Residual liver recurrences were treated by transcatheter arterial chemoembolization and percutaneous ethanol injection therapy, and lymph node recurrences were treated by radiation therapy and lymph node dissection combined with systemic chemotherapy. The patient has been in good health without recurrence for 10 years and 9 months after the first surgery.

We report a case of rectal metastasis of gastric cancer associated with dermatomyositis showing paraneoplastic syndrome. The patient was a 70-year-old man who had undergone curative total gastrectomy for Stage III Agastric cancer in March 2005. He was diagnosed with dermatomyositis and treated with prednisolone after gastrectomy. In April 2006, erythema of his face relapsed, and his serum CPK level was abnormally elevated. He experienced muscle weakness and dysphagia, and was treated with increased doses of prednisolone and gamma-globulin. At this time, endoscopic examination and computed tomography(CT)revealed a rectal tumor with hepatic metastasis. We performed Hartmann's operation in July 2006. The rectal tumor was predominantly submucosal, was 7 cm in diameter, involved #251 lymph node, and had positive peritoneal lavage cytology. The histopathological findings of the rectal tumor were comparable with those of gastric cancer, and we therefore diagnosed metastatic adenocarcinoma of gastric cancer. After surgery, we could control the patient's dermatomyositis with prednisolone at a reduced dose. However, chemotherapy with S-1 was ineffective and the patient died 8 months postoperatively.

A 50-year-old woman with a chief complaint of bloody stools was diagnosed with rectal cancer via colonoscopy. Laparoscopic rectal anterior resection with D3 lymph node dissection was performed in June 2014. The pathological diagnosis was pStage III a(Ra, pT3, N1)cancer, and the patient received 8 courses of XELOX as postoperative adjuvant chemotherapy. During follow-up at 12 months after surgery, chest computed tomography revealed a mass in the left lingular segment measuring 25mm in diameter and multiple small nodules in both the lungs, indicating lung metastases. We found several subcutaneous nodules with a maximum diameter of 10mm in her abdomen and the back of head. We removed 3 subcutaneous nodules for the purpose of diagnosis and treatment in June of 2015. The pathological findings were consistent with cutaneous metastases of rectal cancer. The patient received a 1 course of IRIS and 5 courses of IRIS plus bevacizumab. Subsequently, the lung metastases disappeared and no new skin lesions were detected. We suggest that this case could be a good reference in determining the appropriate treatment for rectal cancer having lung or cutaneous metastases.

A 68-year-old woman who underwent distal pancreatectomy combined with resection of the celiac axis had an abdominal wall recurrence and resection 2 years after the first surgery. She was treated with S-1 at an outpatient clinic following the surgery. She returned to the clinic with a high fever after the S-1 administration and was diagnosed with febrile neutropenia. However, treatment for febrile neutropenia including antibiotics and G-CSF did not improve her symptoms. Her history of chronic severe neck pain and painful enlargement of her thyroid gland suggested thyroiditis. After blood tests and thyroid scintigraphy, she was diagnosed with subacute thyroiditis and was treated with prednisolone. Her symptoms improved within a week. Although patients with neutropenia and a high fever during chemotherapy are likely to have febrile neutropenia, the possibility of another cause of neutropenia with fever should be considered if treatments for febrile neutropenia are not effective.

We report a long surviving case of gastric cancer with a synchronous adrenal metastasis in a patient who underwent curative resection. The patient was a 74-year-old man. Endoscopic examination revealed a type 3 gastric cancer in the proximal stomach. Abdominal computed tomography (CT) revealed a soft tissue density mass in the right adrenal gland and a high-density mass suspected as hemangioma in the left adrenal gland. The CT scan indicated no other distant metastasis. The patient had no endocrine abnormalities according to blood test results. Total gastrectomy with D2 lymphadenectomy and right adrenalectomy were performed in August 2003. On histopathological examination, the gastric tumor was diagnosed as a poorly differentiated adenocarcinoma. The histopathological findings of the right adrenal tumor were compatible with those of gastric cancer. The final diagnosis was por1, 105×65 mm, pT2 (SS), pN1 (#1: 2/8, #3: 1/11), P0, H0, CY0, pM1 (ADR), pStage Ⅳ. Two months after the surgery, the patient was treated with adjuvant TS-1 monotherapy (80 mg/m2 day 1-28/q6w) for 1 year 9 months. The patient had been in good health without a recurrence for more than 9 years 3 months after the operation.

The ACTS-GC trial showed the efficacy of adjuvant treatment with S-1 in patients who had undergone D2 gastrectomy for Stage Ⅱ or Ⅲ(excluding pT1) gastric cancer, classified according to the 13th Japanese Classification of Gastric Carcinoma. We retrospectively analyzed the treatment outcomes of pT1 gastric cancer patients who underwent gastrectomy at our institute to determine the optimal target population for adjuvant treatment among these particular patients. Patients with pT1 gastric cancer who underwent gastrectomy for primary gastric cancer at our institute between 2000 and 2008 without perioperative chemotherapy and mortality were included in the current analysis (n=461). The incidence of lymph node metastasis in M and SM patients were 1.7% (4/240) and 16.7% (37/221), respectively. The 5-year relapse-free survival in M and SM patients was 100% and 96.2%, respectively. On multivariate analysis, the most important risk factor for recurrence in SM patients was 3 or more involved nodes (HR: 6.53, [95%CI: 1.10-31.29], p=0.040). The 5-year relapse-free survival in SM patients with involvement of 3 or more nodes was 66.7% and was comparable with that in stage Ⅱ surgery-only patients in the ACTS-GC trial. Hence, SM patients with 3 or more involved nodes are candidates for effective adjuvant treatment after curative gastrectomy.

We report a case of recurrent gastric cancer with left cervical and para-aortic lymph node close to the hilum of the right kidney that was successfully treated with TS-1 monotherapy and surgical resection. The patient was a 55-year-old woman. She underwent total gastrectomy with D2 lymphadenectomy for gastric cancer in June 2002. Histopathological examination revealed type 4, por1, pT3 (SE), pN1 (#4d: 1/5), H0, P0, M0, CY0, pStageⅢA. She refused to receive adjuvant chemotherapy. At 1 year 7 months after gastrectomy, she noticed cervical lymph node swelling. Computed tomography (CT) revealed a 2.5 cm diameter lymph node. Histopathological examination of an aspiration needle biopsy specimen from the left cervical lymph node confirmed that the tumors had metastasized from gastric cancer. Treatment with TS-1 (120 mg/day) was initiated in January 2004 and continued for 2 years 5 months. A complete response was achieved 5 months after treatment initiation and continued until the present. Abdominal CT revealed a para-aortic lymph node that tended to increase in size. Positron emission tomography revealed accumulation with a standardized uptake value in the lymph node. Because it was a solitary tumor, we performed tumor resection in October 2009, histopathologically confirming the lymph node metastasis. Subsequently, the patient was again treated with TS-1 monotherapy again until the present. She is currently alive 5 years 9 months after the surgery, without any signs of disease recurrence.

A 62-year-old woman had undergone laparoscopic abdominoperineal resection for rectal cancer in February 2008. The pathological diagnosis was pT2, pN0, M0, pStageⅠ. At her request, she took UFT for 5 years as adjuvant chemotherapy. A CT examination revealed lateral lymph node swelling in January 2014. She was referred to our hospital after a diagnosis of lateral lymph node recurrence. She was administered 6 courses of FOLFIRI plus Cmab as neoadjuvant chemotherapy, after which the tumor size reduced by 62%. The treatment effect was rated as a PR. Laparoscopic right intrapelvic lymph node dissection was performed in July 2014, and the pathological diagnosis was recurrence of rectal cancer in the lateral lymph nodes. We report a case of dissection of lymph node recurrence 5 years after curative surgery for rectal cancer, along with a literature review.

The aim of this study was to evaluate the outcome of surgical treatment for recurrence after curative pancreatectomy for pancreatic ductal cancer. Ten cases were enrolled, and the time from initial pancreatectomy to recurrence, location of recurrence, and outcome after surgical treatment for recurrence was evaluated. The time to recurrence was more than 1 year in 4 cases, and the locations of recurrence in these cases were the remnant pancreas and lung in 3 and 1 patients, respectively. Among these 4 cases, a second recurrence was observed in only 1 case, and survival after surgical treatment of the first recurrent site was more than 3 years in the other 3 cases. For the remaining 6 cases, the time to recurrence was less than 1 year and the recurrences were located in the abdomen but not in the remnant pancreas. A second recurrence was observed in all cases, and the survival time was less than 2 years in 4 out of 6 cases. Based on the results of this study, recurrence in the remnant pancreas and lung after curative resection for pancreatic ductal cancer could be a potential indication for surgical treatment.

In the present report, we describe a man with type 2 progressive squamous cell carcinoma (cT3N1M0, cStage Ⅲ) that was detected in the esophago-gastric junction during follow-up after ESD for early gastric cancer. We performed a middle inferior part esophagectomy, a 2-region dissection, and a posterior mediastinum gastric tube reconstruction after preoperative chemotherapy (docetaxel plus cisplatin plus 5-FU). The patient only received 1 course of preoperative chemotherapy because of neutropenia. The pathology results were pT3N2M0, pStage Ⅲ. Six months later, we started chemotherapy (nedaplatin plus adriamycin plus 5-FU) owing to an abdominal lymph node recurrence. We administered 3 courses, but then switched to radiotherapy because of AEs. After receiving a radiation dose of 50.4 Gy, the patient experienced a para-aortic lymph node recurrence and was administered 50.4 Gy for the new lesion, resulting in a CR. Six months later, we identified lymph node recurrences under the left superficialis neck muscle and performed left cervical lymph node resection. All 3 of the enlarged lymph nodes that we resected were found to contain a metastasis of esophageal cancer. Currently (after 6 months), there are no signs of recurrence.

A 70-year-old woman underwent subtotal esophagectomy with two-field lymph node dissection for squamous cell carcinoma of the middle thoracic esophagus (type 0- /Ⅱa+Ⅱc, pT1bN1 [2/25] M0, pStage Ⅱ). Approximately 1 year and 2 months after surgery, abdominal CT showed a swollen paraaorticlymph node. PET-CT also indicated lymph node metastasis. The lymph node was diagnosed to have metastasis from the esophageal cancer, and the patient began treatment with chemotherapy. However, the treatment plan was changed to lymphadenectomy because of neutropenia. She underwent paraaortic lymph node dissection and right partial adrenalectomy. The lymph node was confirmed to have metastasis from the esophageal cancer. The neutropenia persisted after surgery, so she did not receive adjuvant chemotherapy. The patient remained alive for more than 5 years after surgery without any evidence of recurrence. Isolated paraaortic lymph node metastasis after esophagectomy is rare, and there have been only 2 cases, including our own, of long-term survival after paraaortic lymph node dissection. Lymphadenectomy for isolated lymph node metastasis can improve long-term prognosis but it cannot sufficiently predicate it. Therefore, accumulation of more cases is required.

We report a case of cholangiocarcinoma with intestinal malrotation that was treated with pancreaticoduodenectomy. The patient was a 74-year-old man, who underwent laboratory screening and was subsequently found to have elevated γglutamyl transpeptidase levels. Preoperative ultrasonography revealed intrahepatic bile duct dilatation. Endoscopic retrograde cholangiopancreatography demonstrated a filling defect in the common bile duct and cytology of the bile demonstrated the presence of an adenocarcinoma. On preoperative computed tomography (CT), the SMV was located on the left side of the SMA, which showed the SMV rotation sign. Additionally, the small intestine and the colon were deviated to the right and left side of abdominal cavity, respectively. We diagnosed the patient with cholangiocarcinoma with intestinal malrotation and preduodenal portal vein involvement using the CT scan, and performed pancreaticoduodenectomy. Since the ligament of Treitz was absent during surgery, we diagnosed this as a case of the nonrotation type of malrotation. The postoperative course was uneventful and the patient was discharged from the hospital 42 days after the surgery. Anomalies of the portal venous system are so rare that recognition of its variation is important in order to avoid accidental injuries during the operation.

We report of a 74-year-old man with advanced rectal cancer invading the small intestine and bladder. Initially, 3 courses of neoadjuvant chemotherapy with FOLFIRI and cetuximab were administered. At the beginning of the 4 course, the patient experienced fever and dyspnea. Chest radiography and computed tomography showed ground-grass opacities in both lungs. He was diagnosed with interstitial pneumonia induced by irinotecan or cetuximab. Steroid pulse therapy consisting of methyl-prednisolone (1,000 mg/day; 3 days) with respiratory assist resulted in significant improvement, and prednisolone was continued while reducing the dose gradually. He stopped the medicine on the 106th day from the first treatment, and underwent the R0 operation on the 113th day. We report for the first time a case of interstitial pneumonia occurring after neoadjuvant chemotherapy for advanced rectal cancer that was successfully resected after treatment.

We report the case of a patient with a postoperative recurrence of colon cancer who received XELOX plus bevacizumab chemotherapy whilst undergoing hemodialysis. A 73-year-old man had been receiving maintenance hemodialysis for 9 years due to chronic renal failure. At 64 years old, a Hartmann's operation and a posterior segment and segment 3 partial liver resection were performed for sigmoid colon cancer and metastatic liver cancer. Three years 1 months after surgery, local recurrence at the liver invading into the right lung was detected. XELOX plus bevacizumab chemotherapy was administered. After 16 courses of treatment, tumor control was achieved. Chemotherapy with molecular target drugs is currently recommended for advanced/metastatic colorectal cancer; however, a standardized strategy for hemodialysis patients is not established. As the number of hemodialysis patients receiving chemotherapy for some cancers is likely to increase in the future, it will be necessary to consider chemotherapy strategies for hemodialysis patients.

We report a case of a patient with resection margin involvement gastric carcinoma that recurred 5.5 years after additional resection. A 64-year-old man underwent distal gastrectomy for advanced gastric carcinoma (sig+por2, pSE, pN0, pStage IIB) in January 2008. A total gastrectomy was performed 2 months after the initial gastrectomy because of proximal resection line involvement, and curative resection was obtained. Adjuvant chemotherapy with S-1 was completed, and follow-up surveillance was finished 5 years after the additional surgery. In November 2013, the patient experienced bouts of vomiting, and a computed tomography (CT) scan showed an abdominal abscess that had spread to the liver and communicated with the intestine. Despite abscess drainage and antibiotic therapy, infection control was difficult and the patient died 20 days after hospitalization. An autopsy showed the recurrence lesions had diffusely spread to the peritoneum and was also disseminated around the Roux-Y jejunum. These findings suggest that peritoneal recurrence might lead to penetration of the intestine and abscess formation.

A 62-year-old man presented with type 3 gastric cancer (tub1, HER2 positive) in the cardia, with 10-cm direct invasion into the lower esophagus, and extensive lymph node metastasis (Virchow and paraaortic nodes). Trastuzumab (Her), in the XP regimen (capecitabine and cisplatin [CDDP] plus Her; Xeloda®: 2,000 mg/m² on day 1-14, CDDP: 80 mg/m² on day 1, Her: 8(6) mg/kg on day 1), was administered every 3 weeks and repeated for 6 courses. After administering 6 courses of the XP plus Her regimen, without severe adverse events in the patient, computed tomography (CT) revealed shrinkage of both the main tumor and the metastatic sites, by 51%. Esophagectomy and proximal gastrectomy with 3-field lymphadenectomy and gastric tube reconstruction was performed via right thoracotomy and laparotomy (R0). However, Grade 3 pneumonia occurred postoperatively, and the patient was discharged on day 67 after surgery. After treatment, the tumor was histologically evaluated as Grade 1b gastric cancer, and remnant cancer cells also expressed HER2. The patient was too frail to receive adjuvant chemotherapy, and he died of pneumonia 11 months after surgery, without obvious relapse. Perioperative chemotherapy with a regimen containing Her has a possible role in treating advanced HER2-positive gastric cancer. Multiple invasive conversion surgeries might decrease the feasibility of adjuvant chemotherapy and worsen the prognosis.