[A Case of Advanced Gastric Cancer with Synchronous Liver Metastases Treated with Combination Therapy].

A 66-year-old woman was admitted to our hospital because of epigastralgia, and she was diagnosed with a type 2 tumor at the antrum of the stomach. Pathological examination suggested a moderately differentiated adenocarcinoma with negative staining for HER2 on immunohistochemistry. Abdominal CT showed gastric wall thickening and enlarged lymph nodes. Although the clinical finding was Stage ⅢB(T4aN2M0), a liver metastasis (S2) was found during the operation. We performed distal gastrectomy with D2 lymph node dissection and partial hepatic resection in December 2010. A post-operative pathological diagnosis of gastric cancer, pT4aN2M1, pStage Ⅳ, was made. Although adjuvant chemotherapy of S-1 was administered, CT revealed a liver metastasis in S3 5 months after the operation, and the patient underwent transcatheter arterial chemoembolization (TACE) followed by a regimen of S-1 plus CPT-11. After 3 courses of this regimen, grade 2 anorexia was observed, and the treatment schedule was changed to a regimen of capecitabine plus cisplatin (XP). After 7 courses of this regimen, CT revealed multiple liver metastases in S2, S3, and S8, and the treatment schedule was changed to several other chemotherapy regimens. However, liver metastases continued to grow, and the patient died 51 months after surgery. Although the prognosis of gastric cancer with synchronous liver metastases is very poor, it is possible to prolong survival with multimodal therapy.

[Laparoscopic Surgery for T4b Colorectal Cancer].

BACKGROUND: It is considered difficult to perform laparoscopic surgery for colorectal cancer with T4b that is directly invades to adjacent organs. This retrospective study evaluated pT4b colorectal cancer in terms of the efficacy of laparoscopic surgery. METHODS AND RESULTS: Forty-six cases with pT4b colorectal cancer that occurred between 2006 and 2014 were investigated. Laparoscopic surgery (LAC) was performed in 20 cases, of which 5 were conversions, and open surgery (OC) was performed in 26 cases. Pathologically-proven invaded organs resected by LAC were the abdominal wall (n=6), greater omentum (n=5), small intestine or colon (n=3), bladder, appendix, or ovary (n=1). Organs resected by OC were the abdominal wall (n=8), bladder (n=5), colon, greater omentum, or small intestine (n=3), stomach, ovary, spermatic duct (concurrent with bladder), prostate, or sacrum (n=1). Operation time (median) was 275 min for LAC and 260 min for OC. Blood loss (median) was 100 mL for LAC and 410 mL for OC. The duration of hospital stay (median) was 15 days after LAC and 18 days after OC. There were 2 cases with morbidities greater than Grade 3 after LAC and 1 case after OC. There was 1 hospital death in the OC group. CONCLUSION: Laparoscopic surgery for T4b colorectal cancer can be feasible in select cases.

[A Case of RFA for Liver Metastasis after Resection for Rectal Cancer in a 102-Year-Old Man].

A 100-year-old man was admitted to our hospital because of bloody stool. Colonoscopy revealed a type-2 tumor in the rectum, which was diagnosed as moderately differentiated adenocarcinoma. There was no distant metastasis on CT. After meticulous preoperative evaluation of surgical risks considering his age, laparoscopic high anterior resection was performed. During surgery, the edge of the descending colon showed ischemia; therefore, we performed conversion to open surgery and transverse colon resection. However, the edge of the transverse colon showed ischemia; therefore, ascending colon resection and ascending colon-rectum anastomosis were performed. On day 5 after surgery, the patient developed aspiration pneumonia, for which respirator management was conducted. As his condition improved, he was discharged on postoperative day 32. The pathology results were tub2, pT3, ly0, v2, PM0, DM0, RM0, pN1, Stage Ⅲa. One year 6 months after the surgery, when the patient was 102 years old, CT revealed liver metastasis. RFA was performed for the liver lesion. In people aged 100 years or older, few reports are available on colectomy, and there is no report of treatment for metastasis.

[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.

Preoperative T staging of gastric cancer by multi-detector row computed tomography.

BACKGROUND AND PURPOSE: Preoperative T staging demands high accuracy, because it greatly influences subsequent therapies in advanced gastric cancer. PATIENTS AND METHODS: 616 patients with gastric cancer underwent multi-detector row computed tomography (MDCT) before operation. The results were compared with operative and pathologic findings. Especially, we evaluated the correlations among the diagnostic accuracy of T staging and various clinicopathologic parameters by focusing on 276 patients who had detectable lesions by MDCT. RESULTS: The overall diagnostic accuracy of preoperative T staging by MDCT was 90.9% (560/616). For each pathologic T stage, the accuracy was 95% for pT1, 76% for pT2-3, 92% for pT4a, and 75% for pT4b, respectively. Among the 276 patients, 239 (87%) were correctly staged by MDCT whereas 29 (11%) and 8 (3%) were over- or under-staged, respectively. Antral tumors (P = .045), and Borrmann type 1 tumors (P = .0001) were incorrectly T staged by MDCT, whereas differentiated type tumors tended to be over-staged. All patients with positive cytology (n = 12 cases) and peritoneal metastasis (n = 7 cases) diagnosed at laparotomy had been diagnosed as T4a or deeper by MDCT. The 5-year overall survival rates classified by preoperative T staging by MDCT (T1/T2-3/T4a/T4b) were 100%, 89%, 59%, and 31%, respectively, whereas those for each pT stage were 100%, 84%, 59%, and 19%. CONCLUSION: Preoperative T staging of gastric cancer by MDCT is highly accurate and could contribute to treatment strategies, particularly in advanced disease.