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The efficacy of lenvatinib was evaluated in 7 patients with advanced hepatocellular carcinoma(HCC), between March 2018 and February 2019. Their mean age was 74.3 years, and 6 of them were men. All patients had an Eastern Cooperative Oncology Group(ECOG)performance status(PS)of 0. The median number of treatment days was 185. The relative dose intensity was 87.5%. The major Grade was 3, and the overall toxicity events were AST elevation(14.3%)and hypertension (14.3%). The 6-month progression-free and overall survival rates were 71.4% and 100%, respectively. The overall response rate was 57.1%, and the disease control rate was 71.4%. Lenvatinib can be used as a standard treatment for patients with advanced HCC.

A 67-year-old man without a history of surgery presented with bloody stool and anal pain. Colonoscopy and abdominal CT revealed locally advanced rectal cancer with right lateral lymph node metastasis. We administered 6courses of neoadjuvant therapy with capecitabine, oxaliplatin, and irinotecan(XELOXIRI)to the patient. After neoadjuvant chemotherapy, remarkable tumor shrinkage was observed. The patient underwent safety intrasphincteric resection(ISR)and lateral lymph node dissection with anal preservation. The postoperative course was uneventful, and he was discharged 17 days postoperatively. Pathologically, no residual cancer cells were observed in the rectum and lymph nodes(pathological CR). This case of locally advanced rectal cancer was successfully treated with laparoscopic ISR after XELOXIRI chemotherapy, and showed pathological CR. ISR after neoadjuvant XELOXIRI chemotherapy was safely performed and might be a good option for locally advanced rectal cancer.

Aflibercept beta and FOLFIRI combination therapy were approved for metastatic colorectal cancer as secondline treatment in 2017. Aflibercept beta is a recombinant fusion protein that traps vascular endothelial growth factor(VEGF)- A, VEGF-B, and placental growth factor(PlGF).We retrospectively evaluated the efficacy and safety of aflibercept beta and FOLFIRI in metastatic colorectal cancer patients(pts)between June 2017 and April 2018 at our institution. Afliber- cept beta(4mg/kg)was administered with FOLFIRI every 2weeks.Twenty pts received aflibercept beta and FOLFIRI. There were 11 males and 9 females, with a median age of 69.5(53-81)years. Performance status(PS)was 0 in 12 pts and 1 in the remaining 8 pts. Aflibercept beta and FOLFIRI were prescribed as second-line treatment in 8 pts and the others in 12 pts. The median number of aflibercept beta and FOLFIRI cycles was 5(1-11)cycles. Progression -free survival and overall survival have not yet been estimated. In terms of adverse events, serious adverse events of Grade 3 or higher, including Grade 5 neutropenia, were seen among all pts.Aflibercept beta and FOLFIRI demonstrated acceptable toxicity in heavily pretreated metastatic colorectal cancer patients.

Introduction In intraperitoneal-onlay-mesh repair with hernia defect closure (IPOM-plus), the abdominal cavity can be reliably approached through the hernial orifice. Adhesions can then be detached, and the hernial orifice can be closed by direct visual manipulation. Presentation of cases IPOM-plus via the hernial orifice approach was performed in 49 patients. First, an incision is made just above the hernial orifice to reach the abdominal cavity. Under direct visualization, the adhesions are dissected, and the mesh is inserted after laparoscopic manipulation. After closing the hernial orifice under direct visual manipulation, the mesh is fixed again under laparoscopic guidance. Conclusions This technique has the advantages of an easy intra-abdominal approach and direct visual manipulation. No mesh infections were observed in this study, suggesting that it may be useful as a hybrid procedure.

Respiratory syncytial virus (RSV) induces not only infantile recurrent wheezing but also potentially atopic asthma.To test the effect of RSV infection on development of subsequent atopic asthma, we evaluated whether palivizumab, an anti-RSV monoclonal antibody, by preventing severe RSV disease in the first year of life, could impact subsequent recurrent wheezing and atopic asthma at 6 years of age.During the 2007 to 2008 RSV season, the decision to administer palivizumab was made based on standard medical practice and an observational prospective multicenter (n = 52) case-control study in preterm infants with a gestational age between 33 and 35 weeks followed from 0 to 3 years (preceding Committee on Recurrent Wheezing study). The 52 investigators at hospitals then followed these subjects until 6 years of age, reported here (Effects of Preventive Treatment for Respiratory Syncytial [RS] Virus Infection During Infancy on Later Atopic Asthma in Preterm Infants; Scientific Committee for Elucidation of Infantile Asthma). Parents of study subjects reported the infants' physicians' assessment of recurrent wheezing, using a report card and a novel mobile phone-based reporting system using the Internet. The primary endpoint was the incidence of atopic asthma.Of 444 preterm infants enrolled, 349 received palivizumab during the first year of life. At 6 years, atopic asthma was not different in the groups: 15.3 and 18.2% of infants in the treated and untreated groups, respectively (P = 0.57). On the other hand, physician-diagnosed recurrent wheezing was observed in 15.3 and 31.6% in the treated and untreated groups, respectively (P = 0.003).Palivizumab prophylaxis administered to preterm infants did not suppress the onset of atopic asthma but resulted in a significantly lower incidence of recurrent wheezing during the first 6 years. Clinical trial registered with www.clinicaltrials.gov (NCT 01545245).

Background: Objective assessment of upper limb physiological features may allow for early detection and proper intervention for lymphedema after breast surgery. However, the development of diagnost...

Background Rectal metastasis from pulmonary adenocarcinoma is rare, and it has been regarded as an end-stage phenomenon. Recently, however, advances in lung cancer treatment have improved the chance of long-term survival of patients with unresectable distant metastases. We describe the occurrence and management of metastatic spread of a pulmonary carcinoma to the rectum. Case presentation The patient was a 79-year-old woman who had undergone thoracoscopic left lobectomy for pulmonary adenocarcinoma and then, over the next 11 years, various drugs (carboplatin + paclitaxel (as adjuvant therapy), gefitinib, gemcitabine + vinorelbine, S1 (an oral 5-fluorouracil-based drug), carboplatin + pemetrexed + bevacizumab, erlotinib, nivolumab, afatinib, and carboplatin+ S1) were administered, especially for hilar and mediastinal lymph node recurrences. During the eleventh postoperative year, left and right iliac bone metastases were detected, and radiation therapy was undertaken for local control of these lesions. When 18F-fluorodeoxyglucose positron emission tomography was performed for evaluation of the disease, tracer accumulation in the upper rectum was seen. Colonoscopic examination of the rectum revealed an intramural mass with central ulceration, and the mass was diagnosed histologically as an adenocarcinoma. The bone metastases appeared to be controlled, and the patient’s performance status was good, but she had suffered constipation for about a year and desired treatment. Thus, laparoscopic low anterior resection was performed. Histopathologic analysis revealed a moderately differentiated adenocarcinoma existing mainly between the submucosa and serosa, and immunohistochemical analysis showed the tumor to be positive for cytokeratin (CK) 7, negative for CK20, positive for thyroid transcription factor-1, and negative for special AT-rich sequence-binding protein 2 and caudal type homeobox 2, confirming the diagnosis of rectal metastasis from the primary pulmonary adenocarcinoma. The patient recovered well without any change in her functional status. Systemic chemotherapy was resumed, and she continues to do well, now 6 months after surgery. Conclusions Surgery may be a good option for the management of an isolated rectal metastasis from pulmonary cancer in patients whose functional status is good.

Leiomyosarcoma of the mesocolon is a very rare disease. Previously, there was no recommendation for chemotherapy or radiotherapy for leiomyosarcoma of the mesocolon, and only surgical resection reportedly offers a chance for cure. However, the reported cases of leiomyosarcoma of the mesocolon were not distinguished from those of gastrointestinal stromal tumor (GIST), which is the same mesenchymal tumor; thus, there is a possibility that they include cases that should be diagnosed as GIST. We report a case of leiomyosarcoma of the sigmoidal mesocolon.

Pancreatic ductal carcinoma is one of the leading causes of cancer deaths in Japan. However, with remarkable progress in chemotherapy, studies have reported successful resection of initially unresectable pancreatic adenocarcinoma after chemotherapy. We report a case of curative surgery of pancreatic ductal adenocarcinoma with liver metastasis after chemotherapy. A 66-year-old man presenting with jaundice and weight loss was admitted to our hospital for an evaluation of pancreatic lesions. Computed tomography revealed a hypoattenuating mass in the head of the pancreas. We diagnosed this cancer as cT4(SMA1/2)N1M0, cStage Ⅲand performed chemoradiotherapy for this locally advanced pancreatic cancer. Because of the appearance of liver metastasis, we treated this patient with GEM plus nab-PTX chemotherapy. There were no serious adverse events. After 3 therapy courses, the existing liver metastasis disappeared, and no new metastases were noted. Therefore, radical subtotal stomach-preserving pancreatoduodenectomy was performed. The tumor was diagnosed as moderately differentiated adenocarcinoma, ypT1a ypN0 ypM0, ypStage ⅠA, R0.

The patient was a 67-year-old female without a history of surgery. She presented with an abdominal pain and vomiting, and was rushed to our hospital. The abdominal pain was severe, but no peritoneal irritation sign was observed. Abdominal CT scan revealed a strangulating intestinal obstruction and accumulation of ascitic fluid. Emergency surgery was performed for diagnosis and treatment. The intraoperative finding showed serous ascitic fluid and strangulating intestinal obstruction caused by appendiceal tumor coiling around the terminal ileum, which had become ischemic with thinning of its wall. Ileocecal resection with removal of lymph nodes(D3)was performed. The postoperative course was uneventful, and the patient was discharged 13 days after the surgery. Pathological examination of the appendiceal tumor revealed a low-grade appendiceal mucinous neoplasm(LAMN)with no metastasis to the lymph nodes. We had a rare case of strangulating intestinal obstruction caused by coiling of LAMN to the terminal ileum.

A 70s man was admitted to another hospital with a complaint of abdominal pain, and was diagnosed with a gastrointestinal perforation based on the presence of free air in the abdominal cavity on computed tomography. The patient was transferred to our hospital in shock and underwent emergency surgery. Operative findings showed a perforation of the rectosigmoid colon and rectal cancer at the anal side of the perforation site. As his general condition was unstable due to septic shock, only the segments of the colon including the perforation site and rectal cancer were resected for source control. The abdominal wall was kept open, and intraperitoneal contamination was managed with an open management method using negative pressure wound therapy. Systemictreatments for septicshoc k were performed in the intensive care unit with a vasopressor and polymyxin-B hemoperfusion. The general condition became stable with intensive care by postoperative day 3. We performed additional lymph node dissection and one-step rectal sigmoidoscopic anastomosis on postoperative day 4. The pathological results confirmed pT4aN1M0, pStage Ⅲa disease. Although the course was complicated by postoperative pneumonia, the patient was discharged on postoperative day 28. We experienced a case in which curative resection with radical lymph node dissection and one-step anastomosis were performed after infection and source control with open abdomen management.

Sorafenib is an oral multi-targeted tyrosine kinase inhibitor used in cases of unresectable advanced HCC that significantly improves progression-free and overall survival. Complete response(CR)is uncommon; however, if major or complete radiological response are obtained, the issue of the discontinuation of sorafenib remains unresolved. The present study reported a case of a 75-year-old man with non-hepatitis B and C virus-related cirrhosis and multiple recurrent HCCs followingresection. In December 2010, a CT scan revealed multiple intrahepatic recurrence after TACE. Laboratory testingshowed Child-Pugh class A cirrhosis and an alpha-fetoprotein level of over 20,000 ng/mL. Sorafenib(800mg/day)was started in December 2010. The subsequent dynamic CT performed at the 6th month of therapy showed a partial response accordingto RECIST criteria and a complete response accordingto mRECIST. The AFP had decreased to within normal levels. In May 2012, the sorafenib dose was reduced(200 mgtwice daily)due to side effects(skin reaction). In December 2013, treatment was stopped after confirmation of a CR associated with shrinkage of the HCC. The patient maintained this remission until June 2018, more than 54 months after the discontinuation of sorafenib therapy. The adverse events of sorafenib were reversible. Further reportingof similar cases should help in the design of treatment strategies after CR to sorafenib therapy.

A 51-year-old man with a gallstone was found to have a tumor in the tail of the pancreas during preoperative examination. We performed EUS-FNA and a pancreatic neuroendocrine tumor was suspected.Therefore, laparoscopic distal pancreatectomy and cholecystectomy were performed.Pathological examination and immunohistochemistry showed that the pancreatic endocrine cells were uniformly increased and were composed of normal Langerhans islets.Therefore, the patient was diagnosed with pancreatic endocrine cell hyperplasia.Typical pancreatic endocrine cell hyperplasia does not form a tumor and is asymptomatic.However, some cases are symptomatic; therefore, when hypoglycemia or pancreatic hormone elevation are found without a clear cause, it should be distinguished.Because pancreatic tumors are difficult to diagnose definitely by imaging inspection alone, needle biopsy is necessary.However, neuroendocrine tumor and neuroendocrine cell hyperplasia are difficult to differentiate by biopsy.

A 54-year-old woman with unresectable multiple liver-limited metastases of rectal cancer was treated with cisplatin-based transcatheter arterial chemoembolization(TACE). Before initiating TACE, we performed abdominoperineal resection for advanced rectal cancer, resection of the bilateral ovaries for metastasis, liver resection for metastasis, and oxaliplatin/irinote- can/anti-EGFR chemotherapy for the unresectable liver metastases. For the liver-limited metastases that did not respond to systemic chemotherapy, we successfully controlled the disease in 26 months with TACE every 4 or 5months. A combination of 50mg cisplatin and 4 mL lipiodol was injected into the liver through the left or middle hepatic artery with a microcatheter via the femoral artery. The hepatic arteries were mildly embolized with Embosphere. Immediately after TACE, non-contrastenhanced CT was performed to confirm the distribution of the cisplatin powder and embolization. Tumor response was assessed by enhanced CT 3 months after the treatment. We report a case of liver metastasis of colorectal cancer successfully controlled with cisplatin-based TACE over 2 years.

Gemcitabine and cisplatin combination therapy(GC therapy)is now considered a highly effective regimen for patients with unresectable and metastatic biliary tract cancer. We performed GC therapy for 18 patients between January 2014 and April 2018. The median age of the patients was 67.5 years, and 13 patients were men. Fifteen patients had a performance status (PS)score of 0, and 3 patients had a PS score of 1. Nine patients had distal cholangiocarcinoma, 3 had intrahepatic cholangiocarcinoma, 3 had duodenum papilla cancer, and 3 had gallbladder cancer. Fourteen patients showed recurrence after the radical resection, and 9 had liver metastasis. Sixteen patients had over Grade 3 hematological or non-hematological toxicities. The most-common adverse event was neutropenia. None of the patients had Grade 5 adverse events. The response rate was 11.1%, and the disease-control ratio was 66.7%. GC therapy was effective for patients with unresectable and recurrent biliary tract cancer. However, it is necessary to examine the eligibility of patients before treatment.

An 82-year-old man was diagnosed with advanced gastric cancer(tub2, HER2-positive), and the clinical findings were T3N3M1(LYM), Stage Ⅳ. We started chemotherapy with capecitabine, cisplatin, and trastuzumab. After the first course, the dose of capecitabine was reduced and cisplatin was discontinued due to Grade 3 neutropenia. After 4 courses, the remarkable shrinking of the primary tumor and metastatic lymph nodes enabled us to assess the possibility of radical resection, but the patient and his family declined it because of his advanced age. Thereafter, we continued the chemotherapy with capecitabine and trastuzumab for 75 courses. Until multiple lung, liver, and lymph node metastasis occurred after 77 courses, he was adequately managed and maintained good performance status(PS)over a long period of about 53 months.

Schwannomas are rarely observed in the gastrointestinal tract. A 63-year-old man was referred to our hospital with gastric submucosal tumor with central ulceration by upper gastrointestinal endoscopy. Biopsy was performed, but pathological diagnosis was not obtained. A contrast-enhanced computed tomography scan of the abdomen revealed a round mass in the lower part of the stomach and regional lymphadenopathies. A distal gastrectomy with dissection of the regional lymph nodes (D2)was performed. The submucosal tumor measuring 67×49mm was resected. Histopathological examination revealed spindle-shaped cells arranged in palisades. The specimen was positive for S-100 protein, but negative for desmin, SMA, c-kit, and CD34. No tumor cells were found in the resected enlarged lymph nodes, indicating reactive lymphadenopathies. Based on these findings, the tumor was identified as a benign gastric schwannoma. Our patient shows no recurrence at 6 month follow-up.

Airway invasion due to inoperable advanced esophageal cancers can sometimes cause serious complications includingairway stenosis and fistula, and compromise patients' QOL. We retrospectively evaluated the effect of tracheobronchial airway stentingfor airway stenosis due to inoperable advanced esophageal cancers.Between 2010 and 2017, 9 patients with airway stenosis due to inoperable advanced esophageal cancers were treated by placement of a tracheo- bronchial airway stent.Eight patients were treated with self-expandable metallic stents and only 1 patient was treated with a Dumon Y stent. In all cases, tracheo-bronchial airway stents were successfully placed without major complications. Four patients received post-stentingtreatment and 5 patients could be discharged from the hospital. The median survival time after stent placement was 2.8 months.Tracheo-bronchial airway stentingwas a safe and effective treatment for improvingpatients ' QOL.

A 78-year-old man complained of dysphagia. Gastrointestinal endoscopy showed a Type 2 tumor in the lower esophagus and a Type 0-Ⅱa lesion in the posterior wall of the upper gastric body. An enhanced CT scan showed several swollen abdominal and cervical lymph nodes as well as bilateral lung multiple nodules, suggesting distant metastasis. We diagnosed the patient with double cancers consisting of an unresectable advanced esophageal squamous cell carcinoma with multiple lymph nodes and lung metastases(Lt, cT3N4M1, cStage Ⅳb)and early gastric cancer(U, post, cType 0-Ⅱa, cT1N0M0, cStageⅠ). On day 4 of the first course of chemotherapy(docetaxel plus cisplatin plus 5-FU: DCF), a high fever was observed. A chest CT scan revealed suspected mediastinitis and right pyothorax due to perforation by the esophageal cancer. Thoracoscopic mediastinal drainage was immediately performed. CT-guided abscess drainage was added for a residual abscess in the right thoracic cavity on day 10 after drainage surgery. The patient's general condition improved, and he was discharged on 24th postoperative day. The patient was able to reinstitute and continue DCF therapy until disease progression.

We reported the outcome of colorectal peritoneal dissemination resection. Eleven patients who underwent R0 resection for colorectal peritoneal dissemination from January 2009 to December 2017 were examined in our hospital. The median observation period was 23 months, the 3-year overall survival rate was 72.8%, and the 3-year relapse free survival rate was 22.7%. Thus, surgical resection might be useful for peritoneal dissemination.

We report 2 cases of resected appendiceal carcinomas. Case 1: A 67-year-old woman. At surgery, multiple mucoid foci were observed in the peritoneal cavity. Laparoscopic right hemicolectomy(R2)was performed. The pathologic findings were a mixture of well-differentiated adenocarcinoma and well-differentiated mucinous carcinoma, grade 1, pStage ⅣA (pT2N0M1bG1). Six months after surgery, she is undergoing adjuvant chemotherapy at an outpatient clinic. Case 2: A 48- year-old woman. At surgery, invasion into the terminal ileum was observed. A laparoscopic right hemicolectomy resection (R0)was performed. The pathological diagnosis was Stage Ⅱ(pT4bN0M0). She has been followed-upat an outpatient clinic. Discussion: Case 1 had a relatively good prognosis if only well-differentiated mucinous carcinoma was seeded; however, because of the co-existence of well-differentiated adenocarcinoma, postoperative chemotherapy was performed. Case 2 was diagnosed with invasive mucinous carcinoma(grade 2), but because there was no dissemination or lymph node metastasis, follow-upfor Stage Ⅱ disease without adjuvant therapy was considered appropriate. Staging based on TNM classification appendiceal carcinoma cases is desirable for the prediction of prognosis and determination of the appropriate treatment strategy.

A 69-year-old man was admitted for the growing anal tumor and referred to our hospital. The tumor was about 40mm in size, and by biopsy, he was diagnosed the adenocarcinoma. Based on this diagnosis, abdominoperinealresection and edge resection were performed. Histopathologicalfindings showed mucinous carcinoma originating from analgl and with pagetoid spread. Postoperative chemotherapy was not performed, but 1 year 6 months after the surgery, inguinall ymph node recurrence was found, and lymph node dissection was performed. One year after the operation, recurrence was not found.

Appendiceal mucinous adenocarcinoma accompanied by cysts ruptures by surgical operation and leakage of mucus into the peritoneal cavity results in deterioration of prognosis.We report a case where the appendix mucinous adenocarcinoma was safely excised by laparoscopically preceding vascular treatment, lymph node dissection and intestinal dissection.The case was a woman in her forty-age suffering from the right lower quadrant and fever; no improvement was observed even when antibiotics were administered.A cystic lesion with a maximum diameter of 75mm was found on the right side of the pelvis with CT, and numerous lymph adenopathy was observed along the iliac artery.Preoperative diagnosis was diagnosed as appendiceal mucinous adenocarcinoma suspected and laparoscopic resection of the cecum was performed with the above procedure without breaking the cyst.Pathological diagnosis was findings of appendicular mucinous adenocarcinoma.She was discharged on the 7th postoperative day after surgery, 6 months after surgery without relapse survival.In order to resect a cystic tumor by laparoscopic surgery, it is considered to be useful to take care to prevent the forceps from touching the tumor, and perform a procedure that precedes vascular dissection and intestinal dissection.

A 66-year-old man reporting chest stenosis was examined. Upper gastrointestinal endoscopy showed type 2 esophageal cancer. An enhanced CT scan showed several swollen lymph nodes in the lesser curvature of the esophagus. We diagnosed the patient as having advanced esophageal cancer with multiple lymph node metastases(cT3N2M0, Stage III ). After 2 courses of chemotherapy(DCF), a significant reduction was observed in the esophageal tumor; however, the tumor at the lesser curvature was almost unchanged. MIBG scintigraphy showed high uptake in the left adrenal gland. In addition, urinary adrenaline was elevated. Therefore, we diagnosed the patient with pheochromocytoma. Metachronous surgery was performed. First, left adrenalectomy was performed. After we confirmed stability of blood pressure, esophagectomy was performed. The patient is alive without recurrence for 7 months after these operations.

The aim of this study was to evaluate the rate of surgical site infection(SSI)after hepatectomy in elderly patients with hepatocellular carcinoma(HCC). From June 2010 through December 2016, 276 cases of hepatectomy for HCC were performed in our hospital, and 39 cases included patients aged80 years. The rate of SSI in the elderly group compared to the non-elderly group was 15.38%(6/39 cases)vs 7.73%(p=0.0855). The Child-Pugh classification(A/B/C)in the SSI group (n=6)vs in the non-SSI group(n=33)was 6/0/0 vs 32/1/0(p=0.5605), the liver damage classification(A/B/C)was 4/ 2/0 vs 25/8/0(p=0.6467), BMI was 23.3 kg/m / 2 vs 22.8 kg/m2(p=0.6544), PNI was 43.1 vs 46.2(p=0.3804), the operation time was 348.5 minutes vs 315.1 minutes(p=0.4478), blood loss was a small amount vs 401.5mL(p=0.0143), and the hospital stay after the operation was 27.5 days vs 10.0 days(p=0.0401), respectively. Hepatectomy for elderly patients was safe and feasible, and the only significant risk factor for SSI in elderly HCC patients was intraoperative blood loss.

We report a case of a woman who was suffering from post-radiochemotherapy perineum abscess concurrent with the recurrence of vaginal cancer for which total pelvic exenteration was performed. A 66-year-oldwoman presentedat our hospital with irregular genital bleeding in November 2014. A series of examinations showedthat she was suffering from vaginal cancer(cT2N0M0, cStage II ). A radiochemotherapy regimen(external irradiation 45 Gy/25 Fr, CDDP 40mg/m2, 5 course)was commencedin January 2015. In the meantime, MRI revealedsome therapeutic effect, but in October 2015, MRI indicated the enlargement of the primary tumor(PD). The chemotherapy regimen was alteredanda regimen of paclitaxel plus nedaplatin was commenced in November 2015 andw as continueduntil April 2016. MRI was performedin March 2016 to distinguish the therapeutic response between PR and CR. In May 2016, the patient complainedof an increasedfrequency of melena. Colonoscopy was performedto reveal Grade 3 radiation enteritis, andargon plasma coagulation was requiredto stop bleeding. In June 2016, MRI was performedandrevealedCR. In July 2016, however, the radiation enteritis led to rectovaginal fistula, for which we performed transverse colostomy. Thereafter, the necrotic tissue gradually expanded into the perineum area to involve the urethra. Recurrence of the cancer was suspected; therefore, we decided to perform total pelvic exenteration in December 2016. Pathological examination of the surgical specimen indicated the recurrence of the vaginal cancer. We report this rare case andd iscuss the usefulness of total pelvic exenteration for the recurrence of vaginal cancer.

A 60-year-oldman was diagnosedwith ascending colon cancer with multiple bilobar metastases. He then received7 courses of tegafur-gimeracil-oteracil andoxaliplatin (SOX)plus panitumumab as downstaging chemotherapy. This treatment significantly reducedthe size of the metastatic tumor, andwe subsequently triedto perform a curative resection. A twostage hepatectomy was plannedto avoidthe risk of hepatic failure from small future liver remnant. First, the anterior segmentectomy andthe left portal vein ligation were performed. Then, a curative resection consisting of a left lobectomy andextend - edright hemicolectomy were performed2 0 days after the first surgery. No recurrence was observed1 5 months after the operation. Two-stage hepatectomy as well as a combination of induction chemotherapy and portal vein ligation may have contributedto the improvedprognosis of the initially unresectable multiple bilobar liver metastases.

The patient was a 59-year-old woman with progressive sigmoid colon cancer with multiple metastasis(T3N2M1b[P2, H3, PUL2]Stage IV ). As the RAS gene in the patient was wild-type, we administered cetuximab monotherapy every week. One month after chemotherapy initiation, the tumor marker levels declined and the tumor size reduced. Patient's general condition was improved and mFOLFOX6 therapy was then continued in addition to cetuximab. As a side effect, acne-like rash is only grade 1 to 2, and there are no other serious side effects. Cetuximab monotherapy may contribute to the treatment of poor PS patients.

Pancreatic neuroendocrine tumor(P-NET)is relatively rare and often has less aggressive biological behavior. P-NET was re-designated by the WHO in 2010 and 2017. Laparoscopic surgery is minimally invasive but has technical difficulties such as limitation of movement and laparoscopic view. The purpose of this study is to evaluate the efficacy of laparoscopic pancreatectomy(LPT)for P-NET.Between January 2012 and June 2017, 6 patients underwent LPT for P-NET at Kansai Rosai Hospital. Five patients who received open pancreatectomy(OPT)for P-NET and 41 patients who received laparoscopic distal pancreatectomy(LDP)for cystic tumor(CyT)or invasive ductal carcinoma(IDC)were included for comparison.All patients who underwent LPT for P-NET were NET G1 in WHO Classification 2017 and Stage I in UICC TNM 2016. No significant differences were noted between LPT and OPT groups with respect to patient age or gender. Operation time was 421.5 versus 423.5 minutes(ns), blood loss was 121.7 versus 1,918.3mL(ns), hospital stay was 20.5 versus 58.0 days(ns)for LPT and OPT respectively. In LDP, there were no significant differences between PNEN, CyT, and IDC groups with respect to patient age, gender, operation time, blood loss and hospital stay. All patients who underwent LPT for P-NET alive without recurrence. The average observation period was 58.4 months.Laparoscopic pancreatectomy is safe and effective approach to the management of pancreatic neuroendocrine neoplasm.

Celiac artery compression syndrome(CACS)is a rare disorder characterized by postprandial intestinal angina caused by insufficient blood supply to the gastrointestinal organs. In this syndrome, the root of the celiac artery is compressed and narrowed by the median arcuate ligament of the diaphragm during expiration, sometimes causing difficulties in trans-arterial intervention. We report here a case that trans-hepatic arterial intervention was able to performed by splenic bypass. A 74- year-old man with multiple hepatocellular carcinoma(HCC)was performed the angiography, and diagnosed as CACS due to celiac artery root obstruction. The median arcuate ligament was incised in order to introduce trans-arterial intervention, but sufficient resumption of blood flow in the root of celiac artery could not be obtained, so bypass surgery was added from left common iliac artery to splenic artery with grafted right saphenous vein. One month later, trans hepatic arterial intervention is performed via graft, and treatment of HCC is ongoing. Splenic artery left common iliac artery bypass surgery was also considered to be an option for cases in which the resurgence of the blood flow in the root of the celiac artery was not obtained even in the median arcuate ligament dissection for CACS.

A 76-year-old woman had undergone a laparoscopic low anterior resection for rectal cancer. After 12 months, CT showed 2 tumors measuring 25mm in diameter in the pelvis and hydronephrosis. The patient was treated with CapeOX plus bevacizumab( Bmab). After 3 courses of chemotherapy, the size of the tumors was remarkably reduced. After 6 courses, the chemotherapy was withdrawn because of cystitis. Anaphylactic shock occurred after the 7th course after resumption of treatment. After 42 days, the chemotherapy(Cape plus Bmab)was resumed. The patient is recurrence free 13 months after achieving a complete response(CR).

A 30-year-old woman was admittedto the hospital because of fecal occult bloodpositivity . Endoscopic colonoscopy indicated pressure on the right side of the rectum from the wall. Abdominal contrast CT and pelvic MRI revealed a cystic lesion with a maximum diameter of 5 cm on the pre-coccyx andthe right side of rectum. There was no continuity between the tumor andthe uterus/ovary. We diagnoseda pararectal tumor andremovedit via a sacral approach. The cyst was diagnosed as an epidermoid cyst. She was discharged on the 5th postoperative day. We could resect the tumor completely, because we chose an appropriate approach, considering the position, developmental direction, and size of the tumor.

A 80s-year-old man with hemophilia B underwent operation for rectal cancer.Metastasis of the lymph nodes was revealed, so he was treated with adjuvant chemotherapy involving capecitabine and oxaliplatin(CapeOX).For safety, we measured tissue factor IX before every course of chemotherapy, and he completed 8 courses safely.

FOLFIRINOX is now considered to be a highly effective regimen for patients with metastatic pancreatic cancer. We administered FOLFIRINOX therapy in 18 patients between October 2014 and April 2017 as follows: 2-hour infusion of L-OHP at a dose of 85mg/m2, 2-hour infusion of LV at a dose of 200 mg/m2, infusion of CPT-11 for over 90 minutes at a dose of 150 mg/m2, followed by continuous infusion of 5-FU over 46 hours at a dose of 2,400mg/m2. The median age of the patients was 66.5 years. There were 15 patients with performance status(PS)0, and 3 with PS 1. Two patients were Stage III and 16 patients were Stage IV . More than half of the patients had over Grade 3 hematological or non-hematological toxicities. The most common adverse event was neutropenia. Two patients had Grade 5 adverse events: severe cholangitis occurred in the patient with a biliary stent and overwhelmingpost -splenectomy infection occurred in the patient who underwent distal pancreatectomy. The response rate was 11.1%, and the disease control rate was 77.8%. FOLFIRINOX was effective in the patients with unresectable and recurrent pancreatic cancer. However, it is necessary to examine the eligibility of the patients.

Lynch syndrome is an inherited syndrome with the development of the colorectal and various other cancers. Lynch syndrome is caused by mutations in the mismatch repair genes. A 33 year-old male underwent XELOX adjuvant chemotherapy for ascending colon cancer with Lynch syndrome. Although efficacy of 5-FU is not demonstrated in Lynch syndrome, MOSAIC trial had suggested a benefit from FOLFOX compared with 5-FU in patients who have colorectal cancer with Lynch syndrome. Oxaliplatin-based adjuvant chemotherapy can be a therapeutic option for colorectal cancer in lynch syndrome patients.

The patient was a 58-year-oldpostmenopausal woman. Vacuum assistedbiopsy of the left breast tumor revealedinvasive ductal carcinoma. Immunohistochemical examination was negative for estrogen receptor(ER), negative for progesterone receptor(PgR), andshowedan HER2 score of 3+. FDG-PET/CT revealedmultiple metastases to the left supracravicular and axillary lymph nodes and lungs. She was diagnosed with HER2-positive T3N3M1, Stage IV breast cancer. A 2-year regimen of chemotherapy with trastuzumab andvinorelbine achieveda complete response with regardto the metastatic sites; however, the size of the primary tumor increasedd espite the chemotherapy, andsurgical resection of the left breast with axillary lymph node dissection was performed for local control. Pathological examination of the surgical specimen revealed metaplastic carcinoma with sarcoma component surrounded by non-invasive ductal carcinoma. No component of invasive ductal carcinoma was found. Immunohistochemically, metaplastic carcinoma was negative for ER, negative for PgR, andrevealedan HER2 score of 0. There was discordance of HER2 status between pre- andpost -chemotherapy. The patient receivedno further chemotherapy following surgery andhas been without disease progression for 6 years. We suggest there is heterogeneity, that is, the metastatic sites andthe partial primary tumor were HER2-positive invasive ductal carcinoma and the remainder of the primary tumor was triple negative metaplastic carcinoma. As a result, the patient was able to discontinue chemotherapy with higher quality of life.

A 63-year-old man with multiple endocrine neoplasia type 2(MEN2)was admitted to the hospital because of positive fecal occult blood tests. Colonoscopy revealed a 50mm type 2 tumor at the rectum, which was diagnosed as an adenocarcinoma based on histology. Since there was no apparent distant metastasis, laparoscopy-assisted low anterior resection with regional lymph node dissection was performed. The final diagnosis was pT3, pN0, pM0, pStage II . Almost all patients with MEN2 have RET mutations, and they are resistant to EGFR inhibitors. Those who have thyroid cancer with RET mutations are often given a RET kinase inhibitor. In this case, if the patient develops recurrent rectal cancer, it warrants checking for RET mutations and using a multi-kinase inhibitor.

Proteus syndrome (PS) is characterized by the progressive, segmental, or patchy overgrowth of the skin, and other tissues. This is the first case report of recurrent severe insulin-independent hypoglycemia in an infant with PS. Somatic p.E17K of AKT1 mutation was confirmed. The patient also had a giant umbilical cord, which has not yet been reported in PS.

Amikacin (AMK) is used as empiric therapy for severe infections such as sepsis in low birth weight (LBW) infants. AMK administered once daily (OD) in adults is reported to be therapeutically effective and prevent side effects, however, evidence on AMK administration in LBW infants is limited, with no clear indications of effectiveness. We performed therapeutic drug monitoring analysis of 20 infants treated with AMK OD for severe infections such as bacteremia. Treatment effectiveness was admitted by the patients’ medical records, and side effects of renal dysfunction and ototoxicity were investigated. The mean gestational age was 30.4 ± 5 weeks and mean body weight (Bw) was 1280.2 ± 809.8 g. The mean AMK dose was 14.1 ± 2.6 mg/kg and mean administration period was 10.1 ± 4.1 days. Blood concentration was measured 6.3 ± 2.3 days after AMK administration; mean peak and trough concentrations were 29.1 ± 7.5 μg/mL and 7.6 ± 6.9 μg/mL, respectively. Additionally, therapeutic effect was observed in all patients, and no significant change in serum creatinine (CRE) concentration (a marker of renal dysfunction) was observed, suggesting no renal dysfunction. Ototoxicity was observed in 4 patients, 3 of whom had trough concentrations ≥10 μg/mL. When we categorized patients into two groups using a trough cut-off value of 10 μg/mL, no difference in AMK dose was observed. However, there were significant differences in peak concentration, Bw, volume of distribution and CRE. Our findings suggest AMK trough concentration ≥10 μg/mL significantly affects ototoxicity in neonates.

A 75-year-old man was admitted with abdominal pain and taken to our hospital. CT and MRI showed a tumor measuring 60mm in diameter in the pelvic cavity. Based on the imaging findings, we suspected a schwannoma and decided to perform surgery. As the tumor was found to be benign in intraoperative frozen section diagnosis, the tumor was enucleated. Histopathological findings showed no nuclear atypia, and the patient was diagnosed with a schwannoma. He complained of paresthesia in his right leg after surgery, and underwent walking training. Six months after surgery, no recurrence was found.

A 64-year-old man reporting dysphagia was examined. Upper gastrointestinal endoscopy showed a type 3 cancer at the esophagogastric junction. Enhanced CT scan showed several swollen mediastinal and abdominal lymph nodes. We diagnosed the patient with advanced adenocarcinoma of the esophagogastric junction with multiple lymph node metastases(Siewert type II , cT3N2M1[LYM], Stage IV ). After 5 courses of chemotherapy(S-1 plus cisplatin), a significant reduction was observed in the size of the tumor and lymph nodes. Therefore, we performed conversion surgery. The patient underwent esophagectomy and mediastinal lymph node dissection using a right thoracotomy approach. He has survived without recurrence in the 10 months since this radical surgery.

A 60-year-old woman was diagnosed with a rectal neuroendocrine tumor(NET)with SM invasion.We performed laparoscopic low anterior resection with D3 lymph node dissection.Pathological findings were rectal NET, G1, pSM(9,000 mm), ly0, v0, pN0, PM0, DM0, pR0, pStage I .Four years and 6 months later, contrast enhanced abdominal computed tomography (CECT)and contrast enhanced magnetic resonance imaging revealed multiple liver metastases.The tumors were unresectable because they were bilobar; therefore, we performed transcatheter arterial chemoembolizaion(TACE).One month later, CECT showed the lesions had shrunk.The metastases were well controlled via repeated TACE.For unresectable liver metastases from rectal NET, TACE can be an effective treatment.