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Esophageal gastrointestinal stromal tumors (GISTs) are relatively less symptomatic and may have a significantly large tumor diameter at diagnosis. Large esophageal tumors are difficult to resect because it is tough to maintain the surgical field in the narrow mediastinal region. In addition, because GIST has a risk of dissemination if the tumor collapses during surgery, it must be resected with as little force as possible. We herein report a middle and lower thoracic esophageal GIST with a maximum lateral diameter of 12 cm that could be safely resected by a bilateral thoracoscopic approach in the prone position. The case was that of a 70-year-old man. Since his tumor diameter was large and the surrounding organs were severely compressed, it was deemed to be borderline resectable, and preoperative chemotherapy with imatinib was decided. However, administration of imatinib did not result in tumor shrinkage, and interstitial pneumonia occurred. Thus, the final decision was to resect it. It was difficult to remove the left side of the tumor by normal thoracoscopic operation from the right side as the tumor was large. There was also the risk of the tumor collapsing due to unreasonable traction. Therefore, we selected a surgical procedure in which the left and right sides of the tumor were detached by bilateral thoracoscopic operation in the prone position and then the tumor was removed from the abdominal cavity by a transesophageal hiatal operation under laparotomy. Followed by gastric tube reconstruction by the posterior sternal route. The postoperative course was uneventful. In this case, taking advantage of the thoracoscopic approach from both sides, the tumor could be safely resected without unreasonable traction. Furthermore, the prone position has the advantage that bilateral thoracoscopic operation is possible without changing the position. This technique could also be applied for the excision of esophageal cancer involving the left side.

Many patients with esophageal cancer have problems with preoperative physiological functions related to smoking, drinking, and malnutrition. Therefore, a certain frequency of patients die from other diseases after radical resection of esophageal cancer. In this study, we examined non-cancer-related death cases after esophageal cancer surgery to clarify the clinical significance and to consider its improvements. Methods In this retrospective cohort study, we examined 52 patients with esophageal cancer treated surgically from 2011 to 2016. Of the 52 patients analyzed, 7 died of other diseases during postoperative follow-up. Seven of the 52 patients were women, but all 7 died of other diseases were men. The median age of the 7 patients was 72 (65–76) years, slightly older than the median age of 66 (50–76) years in all cases. Results The postoperative survival of the 7 patients who died from other diseases was 9.4 months, including four patients who died early within one year without recurrent lesions. Their death was due to aspiration pneumonia in 5, 1 asphyxiation, and 1 unknown. The median preoperative BMI of the 7 patients who died of other diseases was 19.5, lower than 21.4 in all cases. The median preoperative one second forced expiratory volume was 2.36 L for the 7 patients, which was lower than 2.54 L in all cases. Conclusion Other deaths after esophagectomy were more common in men, the elderly, thinner, and patients with reduced respiratory function. Because there are some cases of death from other diseases early after esophagectomy, early rehabilitation intervention and nutrition management are required after surgery.

Cervical anastomotic stricture after esophagectomy is a serious complication that adversely affects postoperative recovery, nutritional status and quality of life. Cervical anastomosis by a circular stapler (CS) has been widely accepted as a simple and convenient method, but anastomotic strictures are likely to occur. The aim of this study was to investigate an association between CS size and the incidence of anastomotic stricture after cervical esophagogastric anastomosis performed by a CS. Between April 2011 and March 2016, 236 consecutive patients underwent cervical esophagogastric anastomosis by a CS via a retrosternal route after esophagectomy for esophageal cancer. These patients were divided into according to CS size for the procedure as follows: small-sized (25 mm) CS group (SG, n = 116) and large-sized (28 or 29 mm) CS group (LG, n = 120). The clinical data of patients were analyzed retrospectively to compare the two groups. Overall, anastomotic strictures were observed in 90 patients (38%). The incidence of anastomotic stricture was significantly lower in the LG than the SG (23% vs. 53%, p

We clarified the effects of perioperative enteral supplementation with glutamine, fiber, and oligosaccharide (GFO) after an esophagectomy on preventing surgical stress. Of 326 patients with esophageal cancer, 189 received GFO administration (GFO group) and 137 did not (control group). The propensity score matching method was used to identify 89 well-balanced pairs of patients to compare postoperative laboratory parameters and clinical and postoperative outcomes. The duration of the systemic inflammatory response syndrome (SIRS) was significantly shorter in the GFO group compared to the control group (p = 0.002). Moreover, the lymphocyte/neutrophil ratio (L/N ratio) had significantly recovered in the GFO group on postoperative day-3, and the CRP value was significantly lower in the GFO group than that in the control group on postoperative day-2. Perioperative use of enteral supplementation with glutamine, fiber, and oligosaccharide likely contributes to a reduction in early surgical stress after an esophagectomy. These beneficial effects can bring about early recovery from postoperative immunosuppressive conditions after radical esophagectomy.

Background and study aims We report a case of amelanotic malignant melanoma of the esophagus (AMME), an exceedingly rare disease. A 77-year-old Japanese woman presented to our hospital with features suggestive of a middle esophageal submucosal tumor, which was diagnosed pathologically as AMME. The patient underwent thoracoscopic resection of the esophagus and laparoscopic gastric tube reconstruction. Three years after surgery, computed tomography showed no recurrence. Generally, the prognosis of malignant melanoma of the esophagus is very poor. However, our patient had no recurrence, and is alive 3 years after surgery and 5 years after the tumor was first detected.

Jejunostomy, which requires the fixation of the jejunum to the abdominal wall, is commonly used as an enteral feeding access after esophagectomy. However, this procedure sometimes causes severe complications, such as mechanical bowel obstruction. In 2009, we developed a modified approach to insert an enteral feeding tube through the reconstructed gastric tube using the round ligament of the liver. The aim of this study is to investigate the usefulness of this approach as compared to the approach through jejunostomy. Between January 2005 and March 2015, 420 patients with thoracic esophageal cancer underwent esophagectomy via thoracotomy and laparotomy. Of these, 214 underwent feeding jejunostomy (FJ group) and 206 patients underwent feeding via gastric tube with round ligament of the liver (FG group). Catheter-related complications, other postoperative complications, and mortality were compared between the two groups. The incidence of catheter site infection during catheterization in the FG group was significantly lower (n = 1/206, 0.5%) compared to the FJ group (n = 11/214, 5.1%) (P < 0.01). The postoperative bowel obstruction did not occur in the FG group, while it occurred in eight patients (3.7%) in the FJ group (P < 0.01). The incidences of other catheter-related and postoperative complications were similar between the two groups. Feeding catheter gastrostomy with the round ligament of the liver can be a useful enteral feeding access after esophagectomy, because the incidence rate of severe catheter-related complications, such as surgical site infection and mechanical obstruction tend to be lower with this technique compare to jejunostomy.

Background: Intrathoracic herniation of gastric tube (IHGT) pull-up via the retrosternal route is a rare complication following esophagectomy, which is caused due to an injury in the parietal pleura during a blunt dissection of the retrosternal space. However, little is known regarding the clinical impact of IHGT pull-up via the retrosternal route. Patients and Methods: Clinical data of 231 patients receiving gastric tube reconstruction via the retrosternal route following esophagectomy were collected from medical charts. Results: Of the 231 patients, 19 (8%) developed IHGT. Vocal cord palsy, particularly with delayed onset, developed at a significantly high frequency in the group of patients with IHGT. There were no significant differences in the frequency of other surgical complications. Conclusion: This is the first report to examine the clinical impact of IHGT pull-up via the retrosternal route. Vocal cord palsy, particularly with delayed onset, developed in the group of patients with IHGT. Therefore, when reconstruction is performed via the retrosternal route, it is very important that blunt and blind dissection of the retrosternal space be performed with extreme care to prevent pleural injury.

Herein, we describe the operative procedure for combined resection of re-recurrent lateral lymph nodes and the external iliac vein. There is no consensus on the clinical implications of resection of locally re-recurrent colorectal tumors, as the operative procedure is extremely difficult. We present the case of a 52-year-old woman who underwent abdominoperineal resection. About one year later, we excised a recurrent lymph node in the left lateral obturator area through an extraperitoneal approach. About 18 months later, lymph node re-recurrence in the left external iliac area was observed. Re-recurrent lymph nodes directly invade the left external iliac vein. We removed the re-recurrent lymph node with combined, radical segmental resection of the left external iliac vein, left obturator artery and vein, and left obturator nerve. J. Med. Invest. 65:136-138, February, 2018.

To stratify stage IIB (pT4a PN0) colorectal cancer in terms of histopathologic findings. We reviewed the medical records of 80 patients who underwent surgery for stage IIB colorectal cancer. The disease-free survival (DFS) and overall survival (OS) rates were evaluated and correlated with the presence or absence of “Tumor Necrosis”, “Crohn’s-like lymphoid reaction”, and “Perineural Invasion”. Patients with “Tumor Necrosis” had significantly lower DFS rates (p

A germ cell tumor is the most common form of malignancy in early male life, and can be classified as either seminomatous or nonseminomatous. Choriocarcinoma, comprised of nonseminomatous germ cells, is the most aggressive type of germ cell tumor and characteristically metastasizes to the retroperitoneal lymph nodes and less frequently to the lungs, liver, bone or brain [Shibuya et al., 2009;48: 551–554]. A 56-year-old man was admitted to another hospital complaining of abdominal distension. Symptoms included anorexia, vomiting, and diarrhea. The patient was diagnosed with an extragonadal germ cell tumor and referred to our hospital to receive chemotherapy. The day after admission, the patient’s abdominal distension gradually worsened. An emergency operation revealed venous hemorrhage from the surface of a metastatic extragonadal germ cell tumor between the ligament of Treitz and the inferior mesenteric vein in a horizontal position. Hemostatic treatment was performed with 4-0 proline thread attached to a medicated cotton sponge, rather than using a simple proline thread, and the closure area was manually compressed. Chemotherapy was initiated on postoperative day 10. A metastatic extragonadal germ cell tumor that causes massive hemorrhage and gastrointestinal hemorrhage is very rare, and represents a life-threatening emergency. If the patient’s condition carries a substantial risk of bleeding to death, it may be worthwhile to attempt abdominal operations.

A 69-year-old man who had undergone an esophagectomy was diagnosed with chylous leakage on postoperative day 2, and his pleural effusion output gradually increased daily. On postoperative day 6, intranodal lymphangiography using lipiodol demonstrated chylous leakage from branches of an incomplete duplicated left-sided thoracic duct; it also indicated successful ligation of the right-sided thoracic duct at initial operation. After lymphangiography, the chylous leakage did not heal and remained uncontrollable. Based on the preoperative lymphangiographic findings, we ligated the left-sided thoracic duct with left-sided video-assisted thoracoscopic surgery, with the patient in the prone position, on postoperative day 9. The patient experienced no other postoperative complications. The use of the prone position with pneumothorax treatment was helpful in providing a wide operative field in the posterior mediastinum, thus allowing for a better chance for a successful postoperative outcome.

A 77-year-old Japanese female underwent laparoscopic ileocecal resection and lymph node dissection for cecal cancer by a previous doctor. Two years and 9 months after previous operation, contrast-enhanced computed tomography and magnetic resonance imaging with gadolinium ethoxybenzyl-L-diethylenetriamine pentaacetic acid revealed an intraperitoneal tumor at the right subphrenic fossa. 18F-fluorodeoxyglucose position emission tomography showed fluorodeoxyglucose accumulation in the tumor, and we suspected the tumor to be solitary distant peritoneal metastasis of the previous cecal cancer to the right diaphragm. We performed partial diaphragmectomy and direct closure, and pathological examination revealed moderately differentiated tubular adenocarcinoma resembling the previous cecal cancer, which seemed to be disseminated metastasis in the pathological features. Based on the intraoperative findings, we assumed the tumor to be solitary distant peritoneal metastasis caused by procedures during the previous laparoscopic operation. The present report suggests the importance of paying close attention to procedures during laparoscopic colorectal resection to prevent peritoneal seeding. J. Med. Invest. 64: 288-290, August, 2017.

We report the case of a 72-year-old female who underwent laparoscopic total gastrectomy for gastric cancer. The pathological diagnosis was pT3, N1, M0, pStage II B. She received adjuvant chemotherapy with the TS-1®combination OD tablet, beginning 48 days after gastrectomy. The first course was stopped at day 7 because of neutropenia. The dose was decreased, a second course was started, and the patient completed her second course without neutropenia. After completion of the second course, we discovered that she had taken generic drugs(NKS-1®combination OD tablet)during the second course. She was enrolled in a clinical trial in which the administration of generic drugs was not permitted, as per the protocol. Beginning with the third course, we once again treated her with TS-1, and we observed a return of neutropenia in every subsequent course. We decreased the dose of TS-1 and changed the administration schedule each time. She exhibited no neutropenia only when using the generic S-1 formulation. It is possible that the anti-tumor effect of the generic S-1 formulation, and its associated adverse events, are not identical to the innovator formulation.

Esophageal schwannomas are extremely rare esophageal submucosal tumors. Herein, we report a case of simultaneous resection of left lung cancer and an esophageal schwannoma with video-assisted thoracoscopic surgery. An asymptomatic 74-year-old woman received a diagnosis of an esophageal submucosal tumor during the preoperative assessment of a left lung cancer. The esophageal submucosal tumor arose in the left wall of the lower esophagus, and the patient was diagnosed as having a schwannoma by endoscopic ultrasound-guided fine needle aspiration. She underwent video-assisted thoracoscopic surgery for the simultaneous removal of both tumors. Her postoperative course was uneventful. Thoracoscopic surgery is less invasive than thoracotomy, and this allowed the patient to undergo simultaneous operations for two tumors.

Background Spontaneous esophageal rupture, also known as Boerhaave syndrome, is a very serious life-threatening benign disease of the gastrointestinal tract. It is typically caused by vomiting after heavy eating and drinking. However, in our patient, because of a combination of hypopharyngeal cancer with stenosis and chemoradiotherapy (CRT), which caused chemotherapy-induced vomiting, radiotherapy-induced edema, relaxation failure, and delayed reflexes; resistance to the release of increased pressure due to vomiting was exacerbated, thus leading to Boerhaave syndrome. To the best of our knowledge, this is the first report of a patient with esophageal rupture occurring during CRT for hypopharyngeal cancer with stenosis. Case presentation A 66-year-old man with a sore throat was referred to our hospital. He was found to have stage IVA hypopharyngeal cancer, cT2N2bM0, and underwent radical concurrent CRT consisting of weekly cisplatin (30 mg/m2) and radiation (70 Gy/35fr), for larynx preservation. On day 27 of treatment, he vomited, which was followed by severe left chest pain radiating to the back and the upper abdomen. Enhanced computed tomography (CT) revealed extensive mediastinal emphysema and a small amount of left pleural effusion. Esophagography revealed extravasation into the left thoracic cavity, and the patient was diagnosed with an intrathoracic rupture type of Boerhaave syndrome. He underwent emergency left thoracotomy 21 h after the onset. The ruptured esophageal wall was primarily repaired by closure with two-layer suturing and covered by a pedicled omentum. A jejunostomy tube was placed for postoperative enteral nutrition. On postoperative day (POD) 16, the patient was transferred to head and neck surgery to finish CRT and was discharged on POD 56. He has survived without relapse for 11 months after surgery. Conclusion Patients with head and neck cancer are at risk for developing Boerhaave syndrome during CRT. In addition, since such patients often are in poor overall condition because of immunosuppression and protracted wound healing, Boerhaave syndrome can rapidly lead to severe life-threatening infections such as empyema and mediastinitis. Therefore, awareness of this condition is important so that appropriate treatment can rapidly be implemented to increase the likelihood of a good outcome.

Conservative treatments are usually attempted for the management of post-esophagectomy chylous leakage. However, surgical intervention may be needed when the chylous leakage cannot be stopped using conservative treatments. For the therapeutic management of refractory chylous leakage, it is important to identify the leakage sites when deciding if surgical intervention is required. Nine patients underwent lymphangiography for the treatment of refractory post-esophagectomy chylous leakage. Radiological findings, the daily outputs of pleural effusion after lymphangiography, and the clinical outcomes after lymphangiography were analyzed in our cases and in a retrospective collection of 24 cases from 1983 to 2015 recorded with precise detail. In the 9 cases directly studied in our center, the median postoperative day of lymphangiography was 15 days. The detection rate of leakage sites after lymphangiography was 89 %. After lymphangiography, daily outputs of pleural effusion less than 500 ml were observed in 5 patients (56 %), all of whom healed conservatively. Daily outputs of more than 500 ml were seen in 4 patients (44 %). Of these patients, 1 patient had leakage from the main trunk and underwent clipping of the thoracic duct. In the remaining 3 patients, the leakages were instead observed in branches or were not observed; the 2 patients who had no anatomical variants were healed by chemical pleurodesis, and the 1 patient who had anatomical variants required surgical intervention. In the analysis of 33 previously reported cases (which included our 9 cases), the therapeutic policy was determined after lymphangiography, and all patients were successfully healed. Early lymphangiography is recommended for patients with refractory post-esophagectomy chylous leakage. Lymphangiography may contribute valuable information in deciding whether surgical intervention is required.

We report the case of a 60-year-old male who was diagnosed with gastric cancer. Upper gastrointestinal endoscopy indicated advanced cancer in the posterior wall of the gastric body. Biopsy revealed poorly differentiated adenocarcinoma. Abdominal computed tomography demonstrated thickening of the gastric wall and enlargement of the regional lymph nodes and of the para-aortic lymph nodes (PAN). The involvement of the PAN extended from the celiac axis to the caudal area of the inferior mesenteric artery [cT3N3aH0P0M1(LYM), stage IV]. Systemic chemotherapy was initiated. After 3 courses of S-1 plus cisplatin combination chemotherapy, the primary lesion and the enlarged lymph nodes revealed marked regression except for a minute residual lesion in the lymph nodes. Upon obtaining informed consent, open distal gastrectomy, D2 lymphadenectomy with PAN dissection, and Roux-en-Y reconstruction were performed. The patient was discharged from the hospital 35 days after the operation. Histopathological examination of the resected samples revealed malignant cells only in the PAN, not in the stomach or in the regional lymph nodes [ypT0N0M1(LYM), stage IV]. Currently, the patient is undergoing postoperative adjuvant chemotherapy with S-1 and has remained well without any recurrence after 6 months following surgery.

To investigate the influence of addition of docetaxel to neoadjuvant chemotherapy (NAC) with cisplatin plus 5-fluorouracil (CF) in patients with clinical stage III or T3 esophageal squamous cell carcinoma. Information about 209 esophageal cancer patients with stage III or T3 disease, who underwent NAC consisting of CF with or without docetaxel, was reviewed. The survival outcomes were analyzed using the Kaplan–Meier method and propensity score-adjusted Cox proportional hazards models. The relevant variables were included in the propensity score model. NAC was administered to 149 patients in the CF group and 60 patients in the docetaxel plus CF (DCF) group. Overall, 129 patients treated with CF and 58 patients treated with DCF underwent surgery after NAC. The overall response rate was significantly higher in the DCF group compared with the CF group (61.0 vs. 43.2 %, p = 0.021). After matching, recurrence-free survival did not differ statistically between the CF and DCF groups [hazard ratio (HR) 0.83, 95 % confidence interval (CI) 0.50–1.37, p = 0.46]. After matching, the improvement in overall survival in the DCF group reached statistical significance (HR 0.49, 95 % CI 0.24–0.999, p = 0.050). No significant differences in rate of locoregional or distant recurrences were observed between the CF and DCF groups (53.0 vs. 48.3 %, p = 0.54). NAC with DCF is superior to CF in patients with clinical stage III or T3 esophageal squamous cell carcinoma.

We review the current status of proteomics for esophageal cancer (EC) from a clinician's viewpoint. The ultimate goal of cancer proteomics is the improvement of clinical outcome. The proteome as a functional translation of the genome is a straightforward representation of genomic mechanisms that trigger carcinogenesis. Cancer proteomics has identified the mechanisms of carcinogenesis and tumor progression, detected biomarker candidates for early diagnosis, and provided novel therapeutic targets for personalized treatments. Our review focuses on three major topics in EC proteomics: diagnostics, treatment, and molecular mechanisms. We discuss the major histological differences between EC types, i.e., esophageal squamous cell carcinoma and adenocarcinoma, and evaluate the clinical significance of published proteomics studies, including promising diagnostic biomarkers and novel therapeutic targets, which should be further validated prior to launching clinical trials. Multi-disciplinary collaborations between basic scientists, clinicians, and pathologists should be established for inter-institutional validation. In conclusion, EC proteomics has provided significant results, which after thorough validation, should lead to the development of novel clinical tools and improvement of the clinical outcome for esophageal cancer patients. This article is part of a Special Issue entitled: Medical Proteomics.

We retrospectively compared the effects of immediate extubation (IE) in the operating room with those of overnight mechanical ventilation (MV) after radical transthoracic esophagectomy with 3-field lymphadenectomy in patients with thoracic esophageal cancer. A total of 96 patients were evaluated. 48 patients were extubated in the operating room after surgery (IE group). The other 48 patients were extubated on the following morning (MV group). The propensity score-matching method was used to assemble a well-balanced cohort. Clinical and postoperative outcomes were investigated in each group. We also compared postoperative laboratory parameters between groups. The rate of ambulation on postoperative day (POD) 1 was significantly higher in the IE group compared with that in the MV group (50 vs 19%, respectively, p = 0.003). Moreover, the rate of catecholamine use in the ICU was significantly lower in the IE group compared with that in the MV group (15 vs 65%, respectively, p

Tracheal diverticulum, a benign entity characterized by single or multiple invaginations of the tracheal wall, is commonly asymptomatic and detected incidentally. We report the case of a 76-year-old man with a tracheal diverticulum who underwent thoracoscopic esophagectomy with a three-field lymphadenectomy for middle thoracic esophageal cancer. The tracheal diverticulum was located at the right posterolateral region of the trachea, which overlapped the region of dissection of the right recurrent laryngeal nerve lymph nodes. Paratracheal lymph node dissection is an important surgical procedure for thoracic esophageal cancer. In such cases, there is a risk of misidentifying a tracheal diverticulum as an enlarged lymph node and injuring it. Injury of a tracheal diverticulum causes serious complications such as mediastinal emphysema, mediastinitis, and pulmonary fistula. It is important to recognize its existence preoperatively and perform accurate lymph node dissection by taking full advantage of the magnified visual effect provided by thoracoscopic surgery.

Herein, we report coincident recurrences at the port site and functional end-to-end anastomosis after laparoscopic right hemicolectomy for cancer of the ascending colon. The patient was an 83-year-old man who had undergone the aforementioned procedure (Stage IIA) in the referral hospital. At the 10-month follow-up, computed tomography showed two tumours around 3 cm in diameter: one on the right-flank abdominal wall - the surgical port-site - and the other at the functional end-to-end anastomosis. Likewise, a positron emission tomography scan was positive for two tumours. Endoscopic examination showed an ulcerated tumour with a clear margin, and a biopsy confirmed moderately differentiated tubular adenocarcinoma. The patient was diagnosed with coincident recurrences at the port site and functional end-to-end anastomosis after laparoscopic right hemicolectomy for cancer of the ascending colon. We re-operated in March 2016. The tumours at the functional end-to-end anastomosisand functional end-to-end anastomosiswere resected. After 7 months, no recurrence was detected. J. Med. Invest. 64: 177-180, February, 2017.

This study aimed to assess the pathogenic causes, clinical conditions, surgical procedures, in-hospital mortality, and operative death associated with emergency operations at a high-volume cancer center. Although many reports have described the contents, operative procedures, and prognosis of elective surgeries in high-volume cancer centers, emergency operations have not been studied in sufficient detail. We retrospectively enrolled 28 consecutive patients who underwent emergency surgery. Cases involving operative complications were excluded. The following surgical procedures were performed during emergency operations: closure in 3 cases (10.7%), diversion in 22 cases (78.6%), ileus treatment in 2 cases (7.1%), and hemostasis in 1 case (3.6%). Closure alone was performed only once for peritonitis. Diversion was performed in 17 cases (77.3%) of peritonitis, 4 cases (18.2%) of stenosis of the gastrointestinal tract, and 1 case (4.5%) of bleeding. There was a significant overall difference (P = 0.001). The frequency of emergency operations was very low at a high-volume cancer center. However, the recent shift in treatment approaches toward nonoperative techniques may enhance the status of emergency surgical procedures. The results presented in this study will help prepare for emergency situations and resolve them as quickly and efficiently as possible.

We retrospectively evaluated rectal cancer surgery cases in which resection had been performed for invasion of other organs in terms of pathologic findings from the viewpoint of sex differences. We enrolled 61 consecutive patients with rectal cancer who had undergone curative surgery with resection of invaded adjacent organs. We investigated invasion of adjacent organs in terms of pathologic findings according to sex differences. Among males, 4 cases (13.8%) had received combined radical resections of more than 2 organs, while the number of such female cases was 15 (46.9%). The difference between males and females was statistically significant (P = 0.006). Among male cases, histopathologic invasion was present in 4 (13.8%), while 9 female cases (28.1%) showed this feature. Nevertheless, there was not a statistically significant difference between males and females (P = 0.08); the rate in females was roughly twice that in males. No significant difference was recognized in the overall survival rates between males and females, but more females than males experienced local recurrence. In cases with rectal cancer invading neighboring organs, the effect of the invasion must be carefully determined, and the most appropriate operative approach selected accordingly.

We report a long-term survivor of colorectal cancer who underwent aggressive, frequent resection for peritoneal recurrences. A 58-year-old woman was diagnosed with descending colon cancer. Resection of the descending colon along with lymph node dissection was performed in September 2006. The pathological findings revealed Stage IIA colorectal cancer. The following peritoneal recurrences were removed: two in July 2007, two in the omental fat and two in the pouch of Douglas in June 2008 resected by low anterior resection of the rectum, one in the uterus and right ovarian recurrence resected via bilateral adnexectomy and Hartmann’s procedure in May 2011, and one in the ascending colon by partial resection of the colon wall in December 2011. Postoperative adjuvant chemotherapy (uracil and tegafur/leucovorin, fluorouracil/levofolinate/oxaliplatin/bevacizumab, 5-fluorouracil/leucovorin/bevacizumab, irinotecan/bevacizumab, and irinotecan/panitumumab) was administered. The patient did not desire postoperative adjuvant chemotherapy after the fourth operation. The long-term survival was 6 years and 7 months.

Esophageal cancer (EC) is one of the most common causes of cancer-related death worldwide. Identifying suitable biomarkers for early diagnosis as well as predicting lymph node metastasis, prognosis and the therapeutic response of EC is essential for the effective and efficient management for EC. There is an urgent need to develop effective, novel approaches for patients who do not respond to conventional treatment. Areas covered: EC is characterized by the presence of two main histological types such as squamous cell carcinoma and adenocarcinoma, which differ in their response to treatments and prognosis. Thus, this review describes the latest research into biomarkers and novel treatment targets generated by cancer proteomics for the two main histological types. Finally, the main difficulties facing the translation of biomarkers and novel treatment targets into the clinical settings are discussed. Expert commentary: EC proteomics have provided useful results and, after their validation, novel clinical tools should be developed to improve the clinical outcomes for EC patients.

症例は57歳の男性で，17歳時に特発性血小板減少性紫斑病で脾臓摘出の既往がある．自覚症状はなく，健診で膵尾部腫瘤を指摘された．血液検査上，血小板数・腫瘍マーカー・ホルモン値の異常は認めなかった．腹部造影CTにて，膵尾部に早期から造影効果を伴う直径約2.5cmの球状の腫瘤を認めた．MRIでは，T1強調画像・T2強調画像・拡散強調画像のいずれにおいても腫瘤は低信号を示した．腫瘍内部に変性を伴う非機能性膵内分泌腫瘍と術前診断し膵尾部切除を施行した．切除標本の病理組織学的検査にて，腫瘤は膵尾部に接する脾症と診断した．組織内にヘモジデリンが豊富に沈着しており，これによりMRIのT2強調画像で著明な低信号，拡散強調画像にて低信号を呈したと考えられた．

The occurrence of intra-abdominal sterile abscesses due to remnant clips after laparoscopic sigmoidectomy is rare. Here, we report one such case in a 74-year-old woman. Two years after laparoscopic sigmoidectomy, abdominal CT indicated an area of fluid accumulation approximately 5 cm in diameter and located in the middle of the abdominal cavity that contained a cluster of clips. Fine-needle aspiration of the fluid was performed through the wall of the sigmoid colon. The luminal fluid was found not to contain cancer cells on histological examination. After 1 year, abdominal surgery was performed. The abscess was located in the mesorectum at the anastomosis site; it was incised and a significant quantity of ivory-white viscous solution containing a cluster of clips was extracted. This case emphasizes the importance of reducing the number of clips used in laparoscopic surgery.

Background Patients with surgical T4b (sT4b) thoracic esophageal cancer undergo exploratory thoracotomy or non-curative resection. However, in some cases, it is difficult to decide whether to perform exploratory thoracotomy without resection, or perform non-curative resection to the extent possible. The purpose of this retrospective study was to analyze surgical outcomes of sT4b thoracic esophageal cancer to clarify the optimal treatment strategy. Methods A total of 12 patients with sT4b thoracic esophageal cancer underwent exploratory thoracotomy (n = 7) or non-curative resection (n = 5) between January 2011 and December 2015. Of the seven patients who underwent exploratory thoracotomy, two underwent bypass surgery. In the five patients who underwent non-curative resection, gastric reconstruction was performed. Clinical data from these 12 patients were analyzed retrospectively. Results Compared to the seven patients who underwent exploratory thoracotomy (Ex group), the five patients who underwent non-curative resection (NC group) had a significantly longer period until the start of post-treatment (median, 23/57 (Ex/NC) days; P = 0.0027). No significant difference was observed in the postoperative survival period between the two groups (Median survival time (MST), 9/12 (Ex/NC) months; P = 0.55). In the prognostic factor analysis, patients with progressive disease (PD) responsiveness to preoperative treatment had a significantly poorer prognosis (MST, 13.5/5.5 (partial response-stable disease/PD) months; P = 0.01). On the other hand, patients with cStage 3 disease and who received postoperative chemoradiotherapy had a relatively good prognosis (cStage 3/4; MST 12.5/5.5 month, P = 0.09, postoperative chemoradiotherapy received/not received; MST 13/5 month, P = 0.11). The period until the start of post-treatment was not a prognostic factor. Conclusion Responsiveness to preoperative treatment was found to be a prognostic factor in patients with sT4b thoracic esophageal cancer. Thus, if patients show a poor response to preoperative treatment, R0 resection should be performed without exploratory thoracotomy. On the contrary, for patients with a good response to preoperative treatment, administration of post-operative chemoradiotherapy should be considered, while maintaining performance status without causing serious secondary injury. Disclosure All authors have declared no conflicts of interest.

Our intent was to compare survival following neoadjuvant chemotherapy followed by surgery versus chemoradiotherapy (CRT) among patients with potentially resectable esophageal squamous cell carcinoma. Information about 406 consecutive esophageal cancer patients with resectable disease who underwent surgery with neoadjuvant chemotherapy consisting of cisplatin plus 5-fluorouracil or who underwent definitive CRT was reviewed. The survival outcomes were analyzed using the Kaplan–Meier method and propensity score-adjusted Cox proportional hazards models. Relevant variables were included in the propensity score model. Overall, 206 patients planned to undergo surgery (S group) and 200 patients planned to undergo CRT (CRT group). In the unadjusted situation, progression-free survival and overall survival did not differ statistically between the groups. After matching, both survival outcomes were better in the S group compared to the CRT group. Subanalysis showed both survival outcomes were better in the S group for patients with only stage III disease. However, survival outcomes for stages I, II, and IV were not significantly different between treatment groups. Among patients with resectable disease, survival outcomes in the S group were favored over those of the CRT group. These results indicate that different therapeutic strategies should be used for stage III esophageal cancer than for other stages.

A sufficient surgical margin is critical for preventing re-recurrence and achieving R0 status after resection of a local recurrence of rectal cancer (LRRC).Re-recurrence-free survival was analyzed in 110 cases of LRRC according to histological type of primary lesion. The circumferential resection margin (CRM) was classified as 'R1' (x=0 μm), 'R0 shortness' (0 μmx2,000 μm), or 'R0 longness' (x≥2,000 μm). The histological change from the primary lesion to the recurrent lesion was classified as 'No change pattern', from well- to moderately-differentiated (W/M) to an expanding lesion; as 'Change pattern', from W/M to an infiltrating lesion.Re-recurrence-free survival was better in 'R0 longness' than 'R0 shortness' groups and showed that 'No change pattern' cases had considerably better prognosis than 'Change pattern' cases.Ensuring a CRM2,000 μm during resection of LRRC is more likely to prevent re-recurrence. Cases with poorly differentiated carcinoma from the primary lesion to the recurrent lesion tend to have poor prognoses.

Rectourethral fistula is one of the complications that can occur after prostatectomy in the urologic discipline. However, a delayed-onset rectourethral fistula after intersphincteric resection (ISR) for low rectal cancer is extremely rare. Here, we report one such case in a 57-year-old man. After ISR for low rectal cancer with a diverting stoma (DS), the DS was closed. After approximately 1 year, frequent pneumaturia and right orchitis were observed. Results of contrast enemas and abdominal computed tomography examinations revealed a rectourethral fistula from an anastomosis to the urethra. The colonoscopic appearance revealed a pinhole fistula on the anastomotic line, with thick pus. We performed a transverse colostomy, and the pneumaturia and right orchitis were no longer observed. Two months later, colonoscopy, contrast enemas, and cystoscopy revealed no rectourethral fistula. To the best of our knowledge, our case is the first report of a delayed-onset rectourethral fistula after ISR.

The purpose of this study was to determine the adequate circumferential resection margin (CRM) for abdomino-peranal (intersphincteric) resection (ISR) that would prevent the relapse of rectal cancers.The records of 41 cases that underwent curative ISR for rectal cancer were retrospectively reviewed. The relapse-free survival rates and overall survival rates were evaluated and correlated with the maximum depth of the inner muscularis layer reached during ISR (i.e., the radial margin [RM] and distal margin [DM]). Cases were divided into three groups based on the sizes of the RM and DM: (1) group A (RM2 mm and DM1.5 cm), (2) group B (RM2 mm or DM1.5 cm but not both), and (3) group C (RM2 mm and DM1.5 cm).The relapse-free survival rates of the cases in group C were lower than those in the cases of group A or group B (p = 0.002 and 0.037, respectively). The resection margins required to prevent rectal cancer relapse were2 mm for the RM and1.5 cm for the DM. For these margins, the intersphincteric space had to be entered (i.e., between the internal and external anal sphincters).It is critical to enter the intersphincteric space to ensure an adequate CRM (RM2 mm and DM1.5 cm) for preventing rectal cancer recurrence after ISR.

Neoadjuvant therapy has been proven to be extremely valuable and is widely used for advanced esophageal cancer. However, a significant proportion of treated patients (60%-70%) does not respond well to neoadjuvant treatments and develop severe adverse effects. Therefore, predictive markers for individualization of multimodality treatments are urgently needed in esophageal cancer. Recently, molecular biomarkers that predict the response to neoadjuvant therapy have been explored in multimodal approaches in esophageal cancer and successful examples of biomarker identification have been reported. In this review, promising candidates for predictive molecular biomarkers developed by using multiple molecular approaches are reviewed. Moreover, treatment strategies based on the status of predicted biomarkers are discussed, while considering the international differences in the clinical background. However, in the absence of adequate treatment options related to the results of the biomarker test, the usefulness of these diagnostic tools is limited and new effective therapies for biomarker-identified nonresponders to cancer treatment should be concurrent with the progress of predictive technologies. Further improvement in the prognosis of esophageal cancer patients can be achieved through the introduction of novel therapeutic approaches in clinical practice.

Thoracic esophageal cancer with a double aortic arch is extremely rare. We herein report the case of a 63-year-old man with a double aortic arch who underwent an esophagectomy with a three-field lymphadenectomy for cancer in the lower thoracic esophagus. In such cases, it is important to recognize the relationship between the right and left aortic arches and the bilateral recurrent laryngeal nerves (RLNs). We were able to accurately understand the anatomical position of the RLNs using a precedent cervical procedure with partial resection of the manubrium to remove the nodes along the bilateral RLNs.

To examine the usefulness of the histopathological finding of tumor necrosis for stratifying TNM stage IV colorectal cancer in R0 status.We enrolled 98 patients with stage IV colorectal cancer, without residual disease after resection. The extent of necrosis was assessed using published thresholds, the extent was graded as "absent", "moderate" (30% of tumor area), or "severe" (≥30%) in each section.In multivariate analysis, the only significant difference in the disease-free survival rate was related to tumor necrosis (p=0.01) and the significant differences in the overall survival rates were related to the maximum tumor size and the degree of tumor necrosis (p=0.02 and p=0.001, respectively).Tumor necrosis is associated with a poor prognosis in colorectal cancer and may allow the stratification of TNM stage IV patients without residual disease after surgery.