[A Case of Long-Term Survival with Tumor Resection and DOX plus DTIC Therapy for Desmoid Tumor after FAP Surgery].

The patient is a 22-year-old, female. She had a family history of familial adenomatous polyposis(FAP)and a prophylactic total colorectal resection was performed for FAP at age of 18. She presented with fever and abdominal distention and palpated a mass with tenderness in the right lower abdomen. Contrast-enhanced CT scan of the abdomen showed a heterogeneous contrast effect around the tumor margins. With the diagnosis of intra-abdominal desmoid tumor, a partial duodenal resection, small bowel mass resection, and right fallopian tube resection were performed along with the tumor, and an artificial anus was created with the jejunum. Contrast-enhanced CT scan of the abdomen 16 months after resection of desmoid tumor showed a 6.5 cm long desmoid tumor recurrence in the mesentery. She received 5 courses of doxorubicin (DOX)plus dacarbazine(DTIC)therapy followed by continued NSAIDs. Seven years after the operation, she has been able to maintain the shrinkage of the recurrent tumor and is still on medication. Long-term surveillance is necessary because of the possibility of the appearance of other associated lesions in the future.

[A Case of Right Hemicolectomy for Inflammatory Myofibroblastic Tumor Arising in the Right Transverse Colon].

The patient was a 21-year-old male. He presented with right lower abdominal pain and showed tenderness in the same area. An abdominal contrast-enhanced CT examination revealed a 45 mm tumor that continuously stained in the right transverse colon. The patient presented with tenderness and rebound tenderness. Due to a suspected submucosal tumor, laparotomy was performed and an elastic hard tumor of 5 cm in size was found on the serous membrane side of the right transverse colon. As malignancy could not be ruled out, a right hemicolectomy with lymph node dissection was performed. The pathological diagnosis was an inflammatory myofibroblastic tumor(IMT), characterized by the proliferation of spindle- shaped spindle-shaped fibroblast-like cells with inflammatory cell infiltration. As of 9 years post-surgery, there has been no recurrence. However, long-term surveillance is necessary.

[A Case of Surgery for Skin Metastasis of Papillary Thyroid Carcinoma in a Very Elderly Patient to Improve the Quality of Life].

The patient was a 100-year-old woman who underwent right lobe thyroidectomy for papillary thyroid cancer in another hospital around 1990. She developed local recurrence in 2010 and underwent anterior tracheal local recurrence resection in May 2017. Subsequently, metastases were confirmed in the lateral cervical lymph nodes, but the patient only received TSH suppression because of her advanced age. Multiple pulmonary metastases developed in November 2020 and supraclavicular lymph node metastases in July 2021, but the patient was under the care of a visiting physician on best supportive care. The patient was referred to our hospital in January 2022 due to the appearance of a cutaneous mass in the sternal incision area, which gradually increased in size. A well-mobile, well-defined, spherical mass was found in the sternotomy area. The maximum diameter was 19 mm. The cytological findings were consistent with cutaneous metastasis of papillary thyroid carcinoma. As the patient was elderly and had multiple pulmonary metastases, she was temporarily observed. However, by June 2022, the mass had increased from 19 mm to 33 mm with cutaneous discoloration. There was no tendency for multiple pulmonary metastases to grow during this period. The decision was made to operate in order to prevent a decline in quality of life due to self-destruction of the cutaneous metastasis. The tumor was removed under general anesthesia, including the cutaneous discoloration, and reconstructed with a rhomboid skin flap. Post-operatively, there was no local recurrence or significant increase in pulmonary metastases. It is suggested that resection of cutaneous metastasis of malignant tumors may be effective in preserving quality of life even in a 100-year-old elderly patient like the present case and should be considered as an indication.

[Long-Term Survival of a Patient with Advanced Antral Gastric Cancer Successfully Treated with Multidisciplinary Therapy].

We report the case of long-term survival of a patient with advanced antral gastric cancer with multiple paraaortic lymph nodes metastasis who was successfully treated with multidisciplinary therapy. A 70-year-old female was admitted to our hospital complaining of vomiting. Upper gastrointestinal endoscopy revealed a Type 3 tumor in the gastric antrum. Computed tomography(CT)showed a marked decrease in the size of the primary gastric tumor and lymph nodes after 9 courses of mFOLFOX6 therapy. Subsequently, 7 courses of paclitaxel plus ramucirumab(PTX plus Rmab)therapy and 10 courses of nivolumab therapy were administered. After nivolumab therapy, marked shrinkage of the lymph nodes was observed on CT. Distal gastrectomy with D2(+ #16a2+b1)lymph node dissection was performed. The pathological finding was ypT0N1M0 with a Grade 3 effect of the chemotherapy. After 6 months of adjuvant chemotherapy with S-1, CT revealed supraclavicular lymph node metastases. After 4 courses of nivolumab therapy, CT showed a marked increase in the size of the lymph node. Consequently, the regimen was changed to irinotecan. After 16 courses of irinotecan therapy, CT showed a marked shrinkage in the size of the lymph node. The patient is currently alive with no signs of recurrence for 5 years, ie, since the initiation of the multidisciplinary therapy.

[An Experience of Multidisciplinary Treatment for Advanced Esophageal Cancer with Tumor Perforation during Preoperative Chemotherapy].

Perforation of esophageal cancer is one of the fatal oncologic emergencies, and a prompt and accurate treatment strategy is required. Here, we report a case of advanced esophageal cancer that had perforated during preoperative chemotherapy and was successfully resected with multidisciplinary treatment. The prognosis of perforated esophageal cancer can be expected to improve by multidisciplinary treatment appropriately combining initial treatment for infection control and subsequent cancer treatment.

[A Case of Malignant Rectal B Cell Lymphoma That Was Difficult to Differentiate from Rectal Neuroendocrine Tumor].

A 74-year-old woman with a chief complaint of hematochezia was admitted to our hospital. Colonoscopy revealed a 2 cm submucosal tumor with an erosion in the Rb of the rectum. Biopsy showed various inflammatory cell clusters, but no malignant findings. Thoracoabdominal CT and abdominal MRI showed no abnormal findings other than that of rectal wall thickening. Somatostatin receptor scintigraphy performed on suspected rectal NET showed no abnormal accumulation. A total of 3 biopsies were performed, but a definitive diagnosis was not confirmed, and transanal rectal mucosal resection was performed for diagnostic purposes. Immunohistochemistry showed CD20(+)and bcl-2(+), and the lesion was diagnosed as malignant rectal B cell lymphoma. For 1 year postoperatively, the patient showed no recurrence. For this case, biopsy often failed to confirm a definitive diagnosis on rectal submucosal tumors. If the tumor is >1 cm in diameter in a rectal NET, a rectal resection with lymph node dissection is required, and anal function may be impaired. Local tumor excision for diagnosis and treatment may be worthwhile in rectal submucosal tumors if pre-resection diagnosis with biopsy is difficult.

[A Case of Nivolumab Responding to Multiple Lymph Node Metastases during Multidisciplinary Treatment for Esophageal Cancer].

In nivolumab therapy for unresectable advanced esophageal cancer, there are a few cases that show a complete response, and long-term survival can be expected in such cases. Here, we report a case in which nivolumab had a complete response to multiple lymph node metastases during multidisciplinary treatment for esophageal cancer and survived for a relatively long period despite being elderly. Examination of complete response cases provides us with significant insights in considering the unexplained biomarkers of immune checkpoint inhibitors and treatment discontinuation during complete response.

Vein-first Lobectomy for Lung Cancer Assessed According to the Status of Clustered Circulating Tumour Cells.

Background/Aim: Vein-first lobectomy (VFL) in lung cancer might reduce shedding of circulating tumour cells (CTCs). This study assessed the clinical significance of VFL. Patients and Methods: Lung cancer patients undergoing lobectomy and CTC testing were evaluated. The primary evaluation item was postoperative clustered CTC detection, and the secondary outcome measures were the 2-year overall survival and recurrence-free survival rates according to the status of VFL and postoperative clustered CTC. Results: Eighty-six patients with similar backgrounds, except for lobe resection and pulmonary vein dissection time, showed postoperative clustered CTC identification rates of 43.8% and 37.9% in the VFL group (n=57) and no-VFL group (n=29), respectively. However, prognosis was not significantly different, although the presence of clustered CTC after surgery was a predictor of recurrence. Conclusion: The status of postoperative clustered CTC was similar regardless of VFL or not, although the detection of clustered CTC was a predictor of recurrence.

Clustered Circulating Tumor Cells in Lung Adenocarcinoma: Implications of Test Results of Continuous Variables.

BACKGROUND/AIM: We investigated the relationship between solid component size (SS), carcinoembryonic antigen (CEA), and standardized uptake value (SUVmax) as continuous variables and postoperative clustered circulating tumor cell (C-CTC) detection in patients with pulmonary adenocarcinoma who underwent surgery. PATIENTS AND METHODS: C-CTC detection was the main evaluation item, which was analyzed using the receiver operating characteristic curve to calculate areas under the curves (AUCs) for the variables. Additionally, the two-year recurrence-free survival rates (2Y-RFSRs) were analyzed. RESULTS: Among the 84 patients examined, SS, CEA, and SUVmax had AUCs>0.7, and were independent. Their thresholds were 2.1 cm, 7.5 ng/ml, and 2.9, respectively. The 2Y-RFSR were significantly better in the non-C-CTC group (n=58) and in the group of patients without high levels of these predictors (n=32). CONCLUSION: SS, CEA level, and SUVmax predicted postoperative CTC detection in pulmonary adenocarcinoma patients.

[A Case of Successful Treatment of Metachronous Liver Metastasis from Gastric Cancer with Hepatectomy].

A 77-year-old man was found to have advanced gastric cancer and underwent total gastrectomy (pT4aN2H0P0M0, Stage ⅢB). Two years after gastrectomy, we found an elevated tumor marker level, and a liver metastasis appeared in segment 5 (20 mm in diameter). He was treated with S-1/CDDP combination chemotherapy. After 2 courses of chemotherapy, the tumor marker level kept rising and a CT scan detected a progressive tumor. S-1/irinotecan combination chemotherapy was administered as second-line chemotherapy. After 6 courses of chemotherapy, the size of the liver metastasis was reduced and the tumor marker level normalized. Because lymph node metastasis or peritoneal recurrence was observed, a partial resection of the liver (S5) was performed. After the operation, he was treated with S-1 chemotherapy again for 1 year and has had no recurrence.

[A case of sigmoid colon cancer liver metastasis accompanied by multiple liver abscesses].

We describe the case of a patient with sigmoid colon cancer liver metastasis accompanied by multiple liver abscesses. The 59-year-old female patient presented with a fever at a body temperature of 39.0°C. On abdominal computed tomography (CT), multiple liver abscesses were detected, and percutaneous transhepatic abscess drainage (PTAD) was performed. The day after the PTAD, the patient's fever subsided and her inflammatory response abated. A lower gastrointestinal examination, performed to identify the origin of her symptoms, revealed a type 1 tumor in the sigmoid colon. A biopsy indicated a moderately differentiated adenocarcinoma. Prior to surgery, a second abdominal CT scan was performed, and a single liver metastasis was detected. Laparoscopic sigmoidectomy and partial liver resection were simultaneously performed. The histopathological diagnosis of the colon cancer was tub2, pN1, pH1, P0, ly1, v1, stage IV. To date, the patient remains free from hepatic abscess and colon cancer recurrence. Gastrointestinal examinations should be performed as early as possible to identify the cause of hepatic abscesses. Moreover, therapeutic decisions should only be made after imaging and examinations have been performed, which will be sufficient to identify the presence of liver metastases.

[Advanced lung cancer with recurrence of liver and tracheal metastases responsive to multimodality therapy - a case report].

We report a case of advanced lung cancer with recurrence of liver and tracheal metastases that were responsive to multimodality therapy. The patient was a 77-year-old man who suffered from advanced lung cancer with chronic obstructive pulmonary disease (COPD) and alcohol-induced liver cirrhosis. The primary lung cancer was surgically resected. Eight months after resection of the primary lung cancer, a solitary liver tumor appeared and hepatic resection was performed. Histological findings showed that both the primary lung tumor and the solitary liver tumor were squamous cell carcinoma (SCC). Subsequently, he developed a recurrence in his trachea 8 months after hepatic resection. Radiotherapy, endobronchial argon plasma coagulation (APC), and systemic chemotherapy were administered. The tracheal tumor remained stable without any liver metastasis for 25 months.

[A case of surgery for stenosis of the colon from recurrent gastric cancer].

In June 2010, a 67-year-old man presented with advanced gastric cancer. He underwent 2 courses of combination chemo- therapy with S-1/CDDP. After chemotherapy, total gastrectomy was performed (pT4aN3aM0, Stage IIIC). Although he underwent S-1 chemotherapy, colon tumors recurred 22 months after the operation. Colonoscopy revealed the presence of type 2 advanced cancer in the ascending colon, and type IIa early cancer in the transverse colon, which were diagnosed as either primary colon cancers or recurrent gastric cancers upon pathological examination. In October 2012, resection of the right side of the colon was performed in order to prevent malignant bowel obstruction. Pathological examination of the resected specimen identified recurrent gastric cancers. After the surgery, he is currently undergoing S-1 chemotherapy and has no sign of recurrent tumors.

[A case of locoregional recurrence after gastric cancer surgery, which was treated with XPT regimen chemotherapy].

Based on the results of the trastuzumab for gastric cancer (ToGA) trial, the regimen of Xeloda/5-FU+CDDP+trastuzu- mab (XPT/FPT) has become the standard of care for treatment of HER2-positive unresectable or recurrent gastric cancers. In our hospital, the percentage of HER2-positive gastric cancer patients is 16.7%; we present a case of recurrence 26 months after gastric cancer surgery. A 67-year-old man presented with locoregional lymph node recurrence, with swelling in a paraaortic lymph node. ¹8F-fluorodeoxy glucose positron emission tomography (FDG-PET) examination revealed abnormal accumulation in these lymph nodes. He was treated with a regimen of XPT chemotherapy because of the HER2-positive status of his gastric cancer. After 8 courses, the lymph nodes had shrunk and FDG-PET examination revealed no abnormal accumulation. Imaging revealed the presence of interstitial pneumonia, and the adverse events of venous thromboembolism, and grade 3 hand-foot syndrome were detected; as a result, chemotherapy was suspended. The XPT regimen may be an effective treatment for HER2-positive unresectable or recurrent gastric cancers. HER2 status should be the key determinant in the strategy for the treatment of unresectable and recurrent gastric cancers in the future.

[A case of gastric cancer with portal vein tumor thrombosis].

We present a case of gastric cancer with portal vein tumor thrombosis. A 77-year-old man visited our hospital because of epigastric pain. Esophagogastroduodenoscopy and computed tomography (CT) revealed advanced gastric cancer. Total gastrectomy was performed. During surgery, peritoneal dissemination was found. Histopathological diagnosis was Stage IV gastric cancer (por2, T4aN3M1) with massive vascular invasion. He was treated with a chemotherapy regimen of S-1 plus docetaxel for approximately 2 years after which the regimen was changed to S-1 monotherapy. Six months later, CT revealed portal vein tumor thrombosis (PVTT) without progression of peritoneal dissemination. The metastatic route of PVTT was believed to be hematogenous because neither liver nor lymph node metastasis was detected. The regimen was shifted to CPT- 11 plus cisplatin therapy since the effects of the treatment was evaluated as progressive. The patient was alive with stable disease after 5 courses of chemotherapy. PVTT should be taken into consideration as a possible type of recurrence when the tumor is associated with massive vascular invasion, although gastric cancer with PVTT is rare.

[Safety and efficacy of duodenal stenting for malignant gastric outlet obstruction].

Malignant gastric outlet obstruction( GOO) compromises the ability to eat and drink. Surgical gastrojejunostomy has long been the standard palliative procedure for patients with GOO. However, it might not be applicable for patients with a poor general condition. In Japan, duodenal stenting for malignant GOO has been covered by health insurance since April 2010. In our hospital, 5 patients with malignant GOO underwent duodenal stenting using a WallFlexTM stent( Boston Scientific Corporation). Subsequently, we evaluated the safety and efficacy of duodenal stenting for malignant GOO. Most of the patients in this study were elderly, had systemic inflammation, and were malnourished. We achieved 100% technical and clinical success rates. Four patients were discharged from the hospital. No major complications such as perforation were noted. The median survival time after stenting was 86 days. In conclusion, endoscopic duodenal stenting for malignant GOO is safe and effective, and it could be an option for palliative therapy.

[A case of para-aortic lymph node metastasis from gastric cancer treated with chemoradiotherapy].

A 64-year-old man was diagnosed as having advanced gastric cancer with peritoneal and para-aortic lymph node metastases. He received 2 courses of chemotherapy with S-1 and cisplatin( CDDP) and 5 courses of combination chemotherapy with capecitabine, CDDP, and trastuzumab. The peritoneal and para-aortic lymph node metastases disappeared after chemotherapy, and subsequently, total gastrectomy was performed (pT2N3aM0, stage IIIA). Although the patient received combination chemotherapy with capecitabine and trastuzumab, para-aortic lymph node recurrence was noted 6 months after the operation. Radiation therapy at a total dose of 50 Gy targeted at the para-aortic lymph node metastasis along with S-1 and trastuzumab chemotherapy was administered. No serious adverse effects were observed during chemoradiotherapy. Following chemoradiation therapy, tumor recurrence was not observed. Therefore, chemoradiotherapy is considered an effective treatment for lymph node metastasis from gastric cancer.

Preoperative assessment of the pulmonary artery by three-dimensional computed tomography before video-assisted thoracic surgery lobectomy.

OBJECTIVE: Our aim was to evaluate the efficacy of 3D imaging using multidetector row helical computed tomography (MDCT) in the preoperative assessment of the branching pattern of pulmonary artery (PA) before complete video-assisted thoracoscopic lobectomy (complete VATS lobectomy) for lung cancer. METHODS: Forty-nine consecutive patients with clinical stage I lung cancer scheduled for complete VATS lobectomy were evaluated about branching pattern of PA on 16-channel MDCT. Intraoperative finding of the PA branching pattern were compared with the 3D-CT angiography images obtained using MDCT. RESULTS: According to the intraoperative findings, 95.2% (139 of 146) of PA branches were precisely identified on preoperative 3D-CT angiography. All of the seven undetected branches were within 2mm in diameter. There was not a case that needed conversion to open thoracotomy because of intraoperative bleeding. CONCLUSION: A 3D-CT angiography using MDCT clearly revealed individual anatomies of pulmonary artery and could play an important role in safely facilitating complete VATS lobectomy procedure. However, we were unable to detect several thin branches with this technique. So, more care should be taken to avoid bleeding from these small vessels.

Pulmonary suture abscess with false-positive 18F-fluorodeoxyglucose positron emission scan mimicking lung cancer recurrence.

We present the case of a 57-year-old woman with pulmonary suture abscess. She had undergone right S3 segmentectomy for early lung adenocarcinoma 7 years before and right breast-conserving surgery for invasive ductal carcinoma 5 months previously, followed by irradiation plus endocrine therapy. Chest radiography and computed tomography revealed an irregular mass (3.5 cm in diameter) between the residual S1 segment and the middle lobe, neighboring the staple line of the segmentectomy. 18F-fluorodeoxyglucose uptake into the mass increased, seen by positron emission scans. Therefore, we could not rule out the possibility of local recurrence of lung cancer and resected it. Pathologically and microbiologically, the mass was a suture abscess arising around the nylon suture of the previous segmentectomy. This lesion was the result of a foreign-body reaction, as confirmed by polarized microscopy. Moreover, titanium staples at the segmentectomy and breast-conserving surgery may also have contributed to this condition.

Application of HVJ-liposome mediated gene transfer in lung transplantation-distribution and transfection efficiency in the lung.

OBJECTIVE: A novel hemagglutinating virus of Japan (HVJ)-liposome-mediated gene transfer system has been shown to have benefits of a high efficiency of transfection and low immunogenicity. The aims of this study were to determine the effect of re-transfection of the HVJ-liposome system via the airway, and to quantify the distribution of gene expression between transtracheal and transplantation approaches. METHODS: Beta-galactosidase (beta-gal) plasmid DNA was introduced into lung tissues using the HVJ-liposome method. Two groups of Sprague-Dawley (SD) rats received intratracheal instillation of 10 microg of the beta-gal gene, once on Day 0 in 1 group (Group Tb-1, n=4) and 3 times on Days 0-2 in another (Group Tb-3, n=4). In a third group of SD rats (Group Tx, n=5), an orthotopic left lung transplantation was performed after the donor lung was flushed with an HVJ-liposome complex solution and preserved for 1h. Gene expression and distribution in lung tissue was then quantified by counting the X-gal stained cells. RESULTS: Both the transtracheal and transplantation approaches resulted in low levels of transfection in the vascular endothelial cells (0.2+/-0.1 and 4.0+/-1.8%), respectively, but a moderate degree of transfection to the airway (11.0+/-7.1 and 28.0+/-20.7%) and alveolar cells (3.0+/-1.8 and 6.0+/-3.6%). Three repetitive injections via the airway increased gene expression in airway epithelial cells of 41.0+/-12.0% compared with the single administration of 11.0+/-4.3%. CONCLUSIONS: Our results suggest that the repeated transtracheal gene transfection using HVJ-liposome may have benefits for treatment of problems after lung transplantation. In addition, gene transfer using a flushing solution during harvest may provide an opportunity for gene manipulation in the setting of lung transplantation.