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Although surgical resection is the first-line treatment for biliary tract cancer(BTC), elderly patients often have underlying diseases and decreased cardiopulmonary function that place them at a high risk of undergoing surgery. We examined the safety and efficacy of surgical resection in elderly BTC patients. Among the BTC cases that underwent surgical resection at Kobe University Hospital from 2009 to 2015, the safety and prognosis ofthose aged 75 years or older(Group 1)were compared to those younger than 75 years(Group 2)at the time ofsurgery. Fifty-two patients with perihilar cholangiocarcinoma( Bp), 29 patients with intrahepatic cholangiocarcinoma(ICC), and 40 patients with ampulla ofVater cancer(AV) were included. There was no significant difference between the 2 groups with respect to complications of Grade Ⅲor above, while surgery-related death was more common in Bp and ICC ofGroup 1. The median survival ofGroup 1 following hepatectomy for Bp and ICC(22 months)was significantly shorter than that of Group 2(40 months)(p=0.023). There was no significant difference in overall survival of Group 1 and Group 2 patients with AV(p=0.094). Surgical resection for BP and ICC for elderly patients has a higher risk of hepatectomy; therefore, precise assessment of oncologic and patient risk factors should be performed. As we can expect to achieve similar prognoses between non-elderly and elderly patients with AV, aggressive treatments should be considered for elderly patients with AV.

Although the first-line treatment for hepatocellular carcinoma(HCC)is hepatectomy, extreme elderly(80 years or older) patients often tend to have a variety of underlying diseases and decreased cardiopulmonary function, which means that surgery involves a high risk. In this case, we examined the safety and efficacy of hepatectomy performed in an extreme elderly patient with HCC. Of the patients with HCC that underwent initial hepatectomy at Kobe University Hospital(n=348)between 2009 and 2015, 23 patients aged 80 years or older at the time of surgery(Group 1, n=23)and those younger than 80 years at the time(Group 2, n=325)were compared, based on parameters related to safety and prognosis. We did not identify differences between the 2 groups with respect to blood loss and operating time. Intraoperative blood transfusion was more common in Group 1. There was no significant difference between the 2 groups with respect to complications of Grade Ⅲ or higher. The median survival of Group 2 patients following hepatectomy(42 months)was better than that of Group 1 patients(34 months), but there was no significant difference between the 2 groups(p=0.429). Furthermore, when the same parameters were compared after adjusting for and matching propensity scores, there were no significant differences in complications, hospitalization periods, and prognosis between the 2 groups. Through proper assessment of oncologic factors and patient risk factors, hepatectomy can be performed safely and effectively even for extreme elderly patients with HCC. If there is no other disease regulating the prognosis, we can expect to achieve similar prognosis in non-extreme elderly patients. Hence, treatments should not be limited solely based on a patient being extremely elderly; rather, proactive treatments should be considered.

A 71 year -old man underwent sigmoid colectomy for sigmoid colon cancer. A solitary liver metastasis found on examination 8 months after the initial surgery was resected. One year after the second surgery, 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) and computed tomography (CT) revealed multiple peritoneal and liver metastases, and laparotomy was performed. All metastatic lesions were resectable or controllable. Eight peritoneal and 3 hepatic lesions were removed surgically and 1 hepatic lesion was treated with radiofrequency ablation. Eight months after the third surgery FDGPET and CT examination again revealed recurrence of liver and peritoneal metastases. Chemotherapy was ineffective and metastases progressed and resulted in death 26 months after the third surgery (39 months after the initial recurrence). We suggest that aggressive resection for multiple peritoneal and liver metastases can be an effective therapy for selected patients with recurrent colon cancer.

The patient was a 50-year-old man diagnosed as having a large type 3 advanced gastric cancer with para-aortic lymph node metastasis and with positive peritoneal cytology. We administered a combined systemic and intraperitoneal chemotherapy involving docetaxel, cisplatin, and S-1 (DCS). After 2 courses of treatment, the primary tumor and lymph nodes were significantly reduced in size, suggesting that this therapy induced a partial response (PR). No cancer cells were observed in the peritoneal cytology, and therefore, we performed curative total gastrectomy with para-aortic lymph node dissection. Histological findings revealed that there were no cancer cells in either the primary tumor or the lymph nodes, and pathological grading indicated that the resected lesions were grade 3. Adjuvant chemotherapy with S-1 was administered after surgery. At 18 months after surgery, the patient is still alive and free of disease.

Complete resection of advanced bile duct cancer is difficult due to the anatomical location of the tumor and invasion into other organs. Even if a complete resection is achieved, the survival rates of patients with bile duct cancer after surgery are lower as compared to those associated with other gastrointestinal tumors. Certain cases with para-aortic lymph node metastasis have a poor prognosis. In the present report, we describe a case involving long-term survival following bile duct cancer that was treated by multidisciplinary therapy (particle radiotherapy, surgical resection, chemotherapy). In the present case, we detected lymph node (LN) metastasis only in LN#16, but not in LN#13 or LN#17. We believe that particle radiotherapy, consisting of proton and carbon-ion, can be used to control the lymphatic metastasis around the pancreas head and hepatoduodenal ligament. Our findings suggest that particle radiotherapy can be a standard neoadjuvant therapy for bile duct cancer.

A 53-year-old woman underwent sigmoid colectomy for sigmoid colon cancer with peritoneal metastasis. Liver and intrapelvic metastases were found upon examination 6 months after surgery during adjuvant chemotherapy with XELOX plus bevacizumab. After hepatic subsegmentectomy, the patient received S-1 treatment in combination with radiotherapy for the intrapelvic metastasis. One year after the second surgery, abdominoperineal rectal resection was performed as the intrapelvic tumor had increased in size. At 16 months after the third surgery, computed tomography( CT) revealed a small lung nodule that gradually increased in size. The patient underwent partial lung resection. The nodule was a recurrence of the sigmoid colon cancer. During this period, the patient was treated again with S-1 combined with radiotherapy because 2 intrapelvic metastases had been identified. At present, these metastases have been well controlled for 3 years after the initial recurrence. Thus, it is suggested that aggressive radiotherapy and resection are effective therapies for recurrence of chemotherapy-resistant colon cancer.

A 60-year-old woman was diagnosed as having duodenal cancer by upper gastrointestinal endoscopy and biopsy. Pylorus-preserving pancreatoduodenectomy was performed. Pathological findings suggested T4(CBD)N1M0 primary duodenal carcinoma. Adjuvant chemotherapy with S-1(80 mg/m² of S-1 administered for 2 weeks followed by a 1-week drug-free period)was administered after surgery. One year after the surgery, computed tomography(CT)scans showed swelling of the paraaortic lymph nodes. Recurrence of the duodenal carcinoma was diagnosed, and gemcitabine chemotherapy was initiated. Eight months later, CT scans revealed lung metastasis. The patient was then treated with oxaliplatin in combination with infusional 5-fluorouracil/Leucovorin(FOLFOX regimen). After completing 6 courses of the chemotherapy regimen, CT scans showed a partial response(PR). Currently, at 1 year, PR has been maintained. Therefore, we suggest that the FOLFOX regimen can be highly effective for the treatment of patients with duodenal carcinoma.

Pancreatic neoplasms during pregnancy are rare. We describe two cases of mucinous cystic neoplasm (MCN) associated with pregnancy. A 34-year-old woman in the 26th week of pregnancy was given a diagnosis of MCN measuring 19 cm in diameter. We decided to resect it post partum in consideration of the risk of abortion. She had a healthy infant in the 40th week of pregnancy and three months later, distal pancreatectomy was performed. Pathological analysis revealed a mucinous cystadenoma of the pancreas. The second case was a 36-year-old woman. She was given a diagnosis of MCN, measuring 16 cm in diameter, post partum and distal pancreatectomy was performed. Pathologically, the tumor was an invasive mucinous cystadenocarcinoma of the pancreas. In this report, we did an extensive literature review and discussed the management of MCN during pregnancy with special reference to the timing of the operation and the relationship between tumor growth and sex hormones.