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Unresectable advanced gastric cancer is associated with poor prognosis. In a few studies, long-term survival was achieved with conversion surgery in patients who responded to chemotherapy. Here, we have reported a case of unresectable advanced gastric cancer in which curative resection was achieved with conversion surgery. A 70-year-old man who was diagnosed with advanced gastric cancer with multiple liver metastases received S-1/cisplatin therapy(S-1 120 mg/kg of bodyweight[bw]plus cisplatin 90 mg/kg of bw)as primary therapy. Because of the adverse reactions, secondary treatment with irinotecan therapy(CPT-11 200 mg/kg of bw)was initiated, which led to clinical complete response. A local recurrence was observed 44 months later; hence, irinotecan therapy was reinitiated. Although the disease was stable for 30 months, disseminated nodules appeared; thus, immunotherapy(nivolumab 150 mg/kg of bw)was initiated as tertiary treatment for the progressive disease. Although the number of disseminated nodules decreased, frequent blood infusions were necessary for anemia. Distal gastrectomy was planned as palliative surgery. Since no noncurative factors were detected intraoperatively, we considered that curative resection could be achieved with pancreaticoduodenectomy and changed the procedure. The operative time was 6 hours 35 minutes, and there was a blood loss of 312 g. The pathological diagnosis was ypT2- N1M0P0M0, ypStage ⅡA. At 13 months postoperatively, the patient was alive without recurrence.

Metastases to the subcutaneous scrotum are extremely rare. Here, we report a 78-year-old man who presented with pain to the scrotum and inguinal area. Two years ago, he underwent total gastrectomy for gastric cancer. The pain was attributed to increased scrotal wall thickness. Incisional biopsy of the thickened scrotal wall revealed diffused infiltration of the subcutaneous tissue by islands of scirrhous type malignant cells. Moreover, immunohistochemical studies showed that the tumor cells were positive for CK7, CK20, and CDX-2. These features suggested a metastatic adenocarcinoma of upper gastrointestinal origin. Although there were no visceral metastases, the tumor cells were too widely spread to be dissected curatively. Palliative chemotherapy with tegafur, gimeracil, and oteracil (S-1) was restarted, and local pain was subsequently ameliorated. Since scrotal metastasis is unlikely to occur it is difficult to diagnose. Therefore, in patients with groin discomfort or swelling and a history of gastric cancer, metastatic adenocarcinoma should be included in the differential diagnosis for early detection of a tumor.

A 52-year-old man underwent upper gastrointestinal endoscopy screening that identified a submucosal tumor in the gastric fornix, and a solid tumor with a maximum diameter of 35mm was suspected based on abdominal computed tomography. An endoscopic ultrasound-guided fine needle aspiration biopsy showed spindle-shaped cells with KIT, CD34, desmin, and S-100 all testing negative. Based on the diagnosis of a gastrointestinal stromal tumor, subtotal gastrectomy was performed laparoscopically. Postsurgical histopathological testing led to a diagnosis of a primary gastric inflammatory myofibroblastic tumor. The present case has been defined as one involving a tumor part way along the spectrum between benign and malignant, with local recurrence and distal metastasis. Reports indicate that recurrence occurs frequently in cases wherein sufficient margins are not obtained or wherein there is enucleation, and complete surgical resection is recommended. With laparoscopic surgery, because an enlarged field of view can be obtained, and depending on the lesion site, good exposure of the operative field is possible, the authors believe that this approach would be beneficial in terms of local control. Moreover, it has been reported that anaplastic lymphoma kinase(ALK), which is a tyrosine kinase receptor protein, tests positive in approximately 60% of cases. Reports have also indicated that distal metastasis occurs frequently in cases in which ALK tests negative, and watchful waiting of these cases at regular intervals should be carried out to the same extent as of cases involving malignant tumors.

A 72-year-old man with a history of distal gastrectomy was diagnosed with esophageal cancer (EC). A subtotal esophagectomy and the residual total gastrectomy were performed via a right-sided thoracotomy and laparotomy with D2 lymph node dissection followed by reconstruction with a retrosternal right colonic interposition. The pathological diagnosis was Mt, 65 mm, moderately differentiated squamous cell carcinoma, pT2, ly0, v2, pN0, sM0, pStage II. The patient suddenly developed neurological symptoms 10 days after the operation, and brain magnetic resonance imaging detected a single solid left cerebellar tumor. This tumor was completely excised, and pathological diagnosis confirmed the tumor as an EC metastasis. He received adjuvant chemotherapy with cisplatin + 5-fluorouracil. Seven months later, he developed multiple brain metastases; however, no evidence of local recurrence or other metastatic sites was found. He died 8 months after the surgery. Solitary cerebellar metastasis from EC in which the primary tumor is T2N0 is rare, and the mechanism of this metastatic pattern is of particular interest. Our case study suggests that even if the primary tumor is in the limited stage and other metastatic sites are not identified at presentation, it seems reasonable to perform preoperative imaging of the brain for all patients with EC.

A 71-year-old man was diagnosed with a gastric tumor approximately 50mm in diameter on computed tomography (CT). In January 2000, he underwent a proximal gastrectomy. Pathological examination showed 5 mitoses per 50 high-power fields, while immunohistochemical analysis showed positive staining for KIT. Accordingly, the tumor was diagnosed as an intermediate- risk malignant gastrointestinal stromal tumor (GIST) for which the patient was followed. In January 2002, an abdominal CT scan revealed multiple hepatic tumors and a lower abdominal tumor, and the patient was diagnosed with liver metastases and peritoneal disseminations from GIST. After informed consent was provided, chemotherapy with 400 mg/day imatinib was initiated. The patient demonstrated a partial response 2 months after treatment. At 12 years 8 months after the diagnosis of liver metastasis and peritoneal disseminations, the patient shows no sign of recurrence.

A 74-year-old woman underwent distal gastrectomy and D1+ α dissection for the treatment of gastric cancer (pT2a, pN2, H0, P0, M0, Stage IIIA) in February 2008. She was treated with adjuvant postoperative chemotherapy consisting of TS-1. However, 32 months after the operation, paraaortic lymph node recurrence was confirmed by computed tomography (CT). She was treated with combined TS-1 and cisplatin chemotherapy. After 14 courses, CT revealed that the paraaortic lymph node metastasis had disappeared, and a complete response was attained. The patient is currently disease-free, 6 years after the operation.