[A Case of Completion Gastrectomy for Metachronous Gastric Cancer in the Remnant Stomach after Successful Treatment with ESD].

A 73-year-old man underwent distal gastrectomy, D2 lymphadenectomy, and Billroth Ⅰ reconstruction for Type 3 advanced cancer in the lower corpus lesser curvature in 20XX. After postoperative adjuvant chemotherapy, he self-detected a mass in the left breast. It was diagnosed as breast cancer. He underwent mastectomy and axillary lymphadenectomy 16 months after gastric cancer surgery. After postoperative adjuvant chemotherapy, gastric or breast cancer did not recur. However, periodic upper gastrointestinal endoscopy revealed an 8-mm 0-Ⅱa lesion in the anterior wall of the remnant middle stomach(Group 5)80 months after gastric cancer surgery. Endoscopic submucosal dissection(ESD)was performed, and radical resection was achieved. Periodic upper gastrointestinal endoscopy was performed thereafter; an ectopic 0-Ⅱa lesion was detected in the greater curvature of the remnant middle stomach(Group 5)21 months after ESD. Since this lesion suggested massive submucosal invasion, total resection of the remnant stomach and Roux-en-Y reconstruction were performed. The postoperative course has been favorable, and the patient has been alive without recurrence for 6 months postoperatively. A long period passes before intestinal juice reflux induces progression of a chronic inflammatory gastric mucosal lesion to cancer in the remnant stomach. Thus, long-term endoscopic follow-up may be necessary.

[A Case of Laparoscopic Surgery for Advanced Rectal Cancer with Lateral Lymph Node Metastasis Resected after Neoadjuvant Chemotherapy].

A 62-year-old man with diarrhea and metastases was found to harbor 2 rectal cancers. Both lateral lymph nodes were suspected based on CT and PET-CT(cT3N3M0, cStage Ⅲb). We planned to administer neoadjuvant chemotherapy(NAC) (CapeOX plus Bmab). After 4 courses of NAC, the sizes of both the primary tumor and lymph nodes decreased(partial response: PR). We performed laparoscopic abdominoperineal resection of the rectum(APR)with dissection of both lateral lymph nodes. The therapeutic effect was PR(few residual cancer cells)(Grade 2). After 4 courses of adjuvant chemotherapy (CapeOX), there have been no signs of recurrence for 8 months. This case suggests that laparoscopic APR after NAC with CapeOX plus Bmab for locally advanced rectal cancer is a potentially effective procedure.

[A Case of Ascending Colon Cancer with Intestinal Malformation Treated via Laparoscopic Surgery].

A 66-year-old man attended a health check-up after a positive fecal occult blood test. Colonoscopy revealed a 2 cm type 2 lesion near the ascending colon and the upper lip ofBauhin 's valve. Contrast-enhanced computed tomography ofthe abdominal region revealed aplasia ofthe ligament ofTreitz, with the duodenum running through the center. Three-dimensional vascular construction revealed intestinal malrotation, in which the superior mesenteric artery was present on the right side of the superior mesenteric vein. A diagnosis ofascending colon cancer(T2N0M0, cStage I )was made, and a laparoscopic ileocecal resection was performed. The ascending colon was not fixed to the abdominal wall, and the colon was widely depressed within the pelvis. Because no adhesion was noted, vascular processing was performed after converting to extracorporeal manipulation via a small incision in the umbilical region. The controlling vessel was the ileocolic artery, and D2 dissection was performed. The patient suffered no postoperative complications and was discharged on hospital day 13. Most reports ofintestinal malrotation concern pediatric patients, and reports ofadult cases are relatively rare. The intestinal malrotation was confirmed intraoperatively, and the procedure was performed safely. This suggests that if intestinal malrotation can be confirmed, laparoscopic surgery can be safely performed.

A case of gastric cancer with heterogeneous components of EB virus (+)/TP53 (+) and EB virus (-)/TP53 (-).

Epstein-Barr virus (EBV)-associated gastric adenocarcinoma is a histological subtype of gastric adenocarcinoma, in which all of the carcinoma cells are basically positive for EBV-encoded small RNA (EBER) by in situ hybridization. Although its typical histology has some overlap with gastric carcinoma with lymphoid stroma, absence of massive lymphoid infiltrate is sometimes observed either in whole or in part. EBV-associated adenocarcinoma is one of the four representative molecular pathological subtypes recently identified by comprehensive genomic analysis of gastric adenocarcinomas. According to the analysis, typical EBV-associated gastric adenocarcinoma constitutes an independent molecular pathological subgroup, which is mutually exclusive to TP53-mutated adenocarcinoma with chromosomal instability, another molecular pathological subtype in gastric adenocarcinomas. Here, we report a rare case of gastric cancer heterogeneously composed of EBER (+)/TP53 (+) and EBER (-)/TP53 (-) portions. The EBER (+)/TP53 (+) component with massive lymphoid infiltrate surrounded the EBER (-)/TP53 (-) component showing well to moderately differentiated tubular adenocarcinoma. Although collision of two independent gastric cancers could be the simplest and most possible explanation for this situation, we discussed another possibility. In the case of gastric collision tumors, concurrent development of EBER (+) gastric adenocarcinomas and EBER (-) gastric adenocarcinomas in a single stomach is a rare incident. Since presence of the EBER (+)/TP53 (+) tumor component is atypical in itself, we also discussed the mechanism of development of the clone.

[A case of metastatic gastric cancer originating from transverse colon cancer].

Metastatic gastric cancer is uncommon, and metastasis of colorectal cancer to the stomach is extremely rare. We report a case of metastatic gastric cancer that originated from transverse colon cancer. A 52-year-old woman underwent a left hemicolectomy and D3 lymph node dissection based on a diagnosis of transverse colon cancer. The pathology results were as follows: mucinous adenocarcinoma, type 2, 6 × 11 cm, ss, ly1 v1, pm (-), dm (-), n1 (+), P0, H0, M0, Stage IIIa. The patient received XELOX as postoperative adjuvant therapy for 6 months. One year and 3 months after the left hemicolectomy, gastroscopy revealed a submucosal tumor in the lower body of the stomach and an incipient cancer in the cardia of the stomach, and a colonoscopy revealed an incipient cancer in the transverse colon. An endoscopic ultrasonography fine needle aspiration biopsy of the submucosal tumor in the lower body of the stomach was performed. Histology showed that this tumor was a mucinous adenocarcinoma similar to the primary transverse colon cancer, which led to a diagnosis of metastatic gastric cancer originating from transverse colon cancer. Distant metastasis was not detected. Endoscopic submucosal dissection of the incipient gastric cancer was performed, as were distal gastrectomy and partial colectomy. Peritoneal dissemination and para-aortic lymph node recurrence were detected 7 months after the second surgery.

[A case of primary carcinoma associated with anal fistula].

A 47-year-old man with no history of anal fistula was admitted to our hospital with a complaint of perianal pain. Computed tomography (CT) imaging revealed perianal abscess. Incision and drainage were performed under spinal anesthesia. Ten months after drainage, magnetic resonance imaging revealed anal fistula on the left side of the anus. Subsequently, core-out and seton procedures were performed for ischiorectalis type III anal fistula. Pathological examination of the resected specimen of anal fistula revealed a moderately differentiated adenocarcinoma, leading to the diagnosis of carcinoma associated with anal fistula. No distant metastases or enlarged lymph nodes were observed on positron emission tomography (PET)/CT. We performed abdominoperineal resection with wide resection of ischiorectalis fat tissue. The pathology results were tub2, A, ly0, v0, n0, PM0, DM0, RM0, H0, P0, M0, Stage II. Negative pressure wound therapy was performed for perineum deficiency, after which rapid wound healing was observed. Left inguinal lymph node recurrence was detected 8 months after surgery, for which radiotherapy was administered. Distant metastasis was detected 11 months after surgery. The patient died 21 months after surgery.

[A case of hemobilia developing after radiofrequency ablation (RFA) for hepatocellular carcinoma].

We report a case of hemobilia developing after RFA for hepatocellular carcinoma. A 75-year-old woman with hepatitis C was diagnosed as hepatocellular carcinoma (d=15 mm) located in subsegment 7. Laboratory data on admission are AFP 37.3 ng/mL, PIVKA-II 20 mAU/mL, GOT/GPT 84/52 IU/L, T-Bil 1.1 mg/dL, Alb 3.8 g/dL, Plt 8.9x104/microL, and PT 11.8 seconds (INR 1.28) "Child classification A". Under general anesthesia, percutaneous RFA (Cool-tip radionics 10 minutes) was performed. Tumor appeared to be well treated, but on day 5 after the procedure, the patient had sudden upper abdominal pain, followed by the elevation of total bilirubin conc. (3.3 mg/dL) and decrease of Hb. Abdominal ultrasonography showed a debris-like shadow in the gall bladder. Hemobilia was confirmed because endoscopic examination revealed blood contaminated bile from the papilla Vater. Since spontaneous thrombolysis is known to occur in the bile, the patient was only followed by MRI. Symptoms were subsided in a week without any treatment. Obstructive jaundice due to hemobilia is a rare complication of RFA, and may be followed without any treatment.

[Repeated resections of asynchronous liver metastases after pancreatomy for pancreatic cancer--a case report].

The prognosis of pancreatic cancer is most dismal in all gastrointestinal cancers, because the patients with pancreatic cancer are vulnerable for recurrence such as local relapse and liver metastasis even after a complete surgical resection. We herein report a case of pancreatic cancer, which underwent resection of local relapse and multiresections of liver metastases, resulting in a relatively longer survival. A 71-year-old woman was referred to our hospital for a local recurrence in the tail of the pancreas in October 2006, 17 months after the first distal pancreatectomy. A second distal pancreatectomy was curatively performed on this patient. After the second surgery, sequent solitary liver metastases appeared, and we then performed partial hepatectomies repeatedly in August 2007, December 2007 and December 2008. The histopathological findings of each specimen from the resected liver showed tubular adenocarcinoma, same as the original pancreatic tumor obtained from the first surgery. Although chemotherapy was not permitted due to gemcitabine-induced interstitial pneumonitis, the patient is still alive over 4 years after the first operation under palliative care. This study discusses a controversial issue about the resection of the liver metastases from pancreatic cancer, along with the necessity for careful selection of the patients before attempting the operation.

[Advanced lung cancer with mediastinal lymph node metastasis and recurrence of brain metastasis completely responsive to combination chemotherapy and gamma knife radiosurgery--a case report].

We report a case in which advanced lung cancer with mediastinal lymph node metastasis and recurrence of brain metastasis was completely responsive to combination chemotherapy and gamma knife radiosurgery. The patient was a 61-year-old woman, who suffered from advanced lung cancer (SCC) with bilateral mediastinal lymph node metastasis and contralateral lung nodule. She was treated with CBDCA combined with PTX. Bilateral lung nodules were surgically resected. Seven months after resection, solitary brain metastasis appeared, and gamma knife radiosurgery was performed. Histological efficacy of both primary lung tumor (SCC) and metastatic brain tumor was evaluated as Ef 3 (pCR). She has had no recurrence for 3 years after radiosurgery.

[A case of nonfunctioning islet cell tumor with extensive calcification].

A 52-year-old man was admitted for detailed examination of a mass with extensive calcification in the tail of the pancreas by fluoro-deoxy glucose-positron emission tomography/computed tomography (FDG-PET/CT). Abdominal CT and magnetic resonance imaging (MRI) findings showed a calcified tumor 5 cm in diameter with a smooth surface. The tumor mainly showed calcification at it center and a partially solid element around it margin which was enhanced in the early phase. With no definiture preoperative diagnossi, we performed distal pancreatectomy and splenectomy. Pathological and immunohistochemical studies revealed a nonfunctioning islet cell tumor with calcification. A nonfunctioning islet cell tumor with central calcification formation as it grew to a maximum diameter of 7 cm is rare. When diagnosing pancreatic tumors it must be kept in mind that some nonfunctioning islet cell tumors of the pancreas can show nontypical features such as calcification formation.

[A case of metastases of umbilicus (Sister Mary Joseph's nodule)].

We report a case of advanced unresectable pancreatic cancer (cT4N1M0/stage IVa). The patient was a 68-year-old man. Chemo-radiation therapy (CRT) with GEM (1,000 mg/body) was administered once a week on days 1, 8 and 15 for 3 weeks. The radiotherapy dose was 45 Gy (1.5 Gy x 2/day, 15 days). After CRT, the patient was treated with a GEM+ UFT-E combination chemotherapy. When that was done, CT scan revealed metastases of umbilicus (Sister Mary Joseph's nodule) and the liver. Microwave Coagulation Therapy for the liver metastasis and tumorectomy for metastasis of umbilicus were performed. But he died after 4 months from the therapies.

[A case of gemcitabine-based chemo-radiation therapy for unresectable pancreatic cancer with liver metastases].

We report a case of advanced unresectable pancreatic cancer with multiple liver metastases (cT4N x M1, stage IVb). The patient is a 68-year-old man. Serum DUPAN-2 was 15,800 U/mL. Abdominal CT scan revealed the body and tail of pancreatic cancer and multiple liver metastases. Chemo-radiation therapy (CRT) with GEM 1000 mg/body was given once a week on days 1, 8 and 15 for 3 weeks. The radiotherapy dose was 45 Gy (1.5 Gy x 2/day, 15 days). Hematological side effect such as anemia (grade 3) and thrombopenia (grade 2) appeared, but could be well controlled. Abdominal CT scan revealed no change in size, but serum DUPAN-2 decreased up to 4590 U/mL. After CRT, the patient was treated thereafter by the combination chemotherapy with GEM and S-1. After 7 months, CT scan revealed no change in tumor size.

[A phase I study of combination chemotherapy using TS-1 and weekly paclitaxel for advanced gastric cancer].

The safety of chemotherapy combining TS-1 and weekly paclitaxel for the treatment of unresectable and recurrent gastric cancer was evaluated in this study. Paclitaxel was administered by intravenous drip infusion at a starting dose (level 1) of 50 mg/m2 on days 1, 8, and 15. TS-1 was administered orally at a dose of 40 mg/m2twice a day for 2 weeks (days 1-14) followed by 2 weeks rest. A total of 9 patients were enrolled in this study. Two out of 6 patients treated with level 1 suffered from leukocytopenia and neutropenia, which were determined as dose-limiting toxicity (DLT). Three patients were treated with level 2, in which the dose of paclitaxel was increased up to 60 mg/m2. One of 3 patients suffered from grade 3 diarrhea and one patient from grade 4 leukocytopenia, eutrocytopenia, anemia, and stomatitis, which were determined as DLT. According to these results,level 1 of this regimen was recommended as a safe treatment for gastric cancer patients. A phase II study will be performed to evaluate the efficacy of the combination chemotherapy.