[A Case of Advanced Cardia Gastric Cancer with Pernicious Anemia].

A 70s male was referred to our hospital with anemia that was detected during a medical checkup. Upper gastrointestinal endoscopy showed advanced cardia gastric cancer. A diagnosis of pernicious anemia was made due to the macrocytic hyperchromic anemia and detection of intrinsic factor antibody. A CT scan showed fundic wall thickening and regional lymph node metastasis. After anemia improved following vitamin B12 injection, total gastrectomy with lymphadenectomy was performed. The histopathological findings showed adenocarcinoma(tub1>tub2), Type2 , pT3(SS), pN1(2/24), Stage ⅡB, INF b, ly1, v2, PM0, DM0, EW(+), pR1. He was administered systematic chemotherapy using S-1 for one year after surgery and has been followed up without recurrence for 5 years.

[A Case of Hepatocellular Carcinoma with Portal Vein Tumor Thrombus Successfully Treated by Three-Dimensional Conformal Radiotherapy].

A man in his 50s was referred to our hospital with a liver tumor detected by ultrasonography during a medical checkup. Enhanced CT scan and MRI showed hepatocellular carcinoma(HCC)in S8 of the liver. Laparoscopic partial hepatectomy was performed. The histopathological findings showed well differentiated HCC. Two years later, his serum PIVKA-Ⅱ levels were slightly elevated. A new lesion was detected by US, CT, and MRI at S5 of the liver. A second laparoscopic partial hepatectomy was performed. The histopathological findings showed moderately differentiated HCC. After 1 year, MRI detected 2 new HCCs(S4, S8). The tumor at S8 had invaded the right branch of the portal vein. There was no indication for right hepatectomy because of liver dysfunction. Lipiodol-TACE followed by DEB-TACE was not effective on the tumor. The HCC at S8 had enlarged and formed a portal vein tumor thrombus. PIVKA- / Ⅱ levels increased to 3,596 mAU/mL. The patient was adminis- tered Three-dimensional conformal radiotherapy(45 Gy/15 Fr)and his PIVKA-Ⅱ levels decreased to the normal range. He has been followed-up without recurrences for 2 years and 9 months.

[Jejunal Interposition after Totally Laparoscopic Proximal Gastrectomy Using Overlap Method].

There are several reconstruction methods in laparoscopic proximal gastrectomy(LPG)for earlygastric cancer at the upper part of the stomach. To prevent the esophageal reflux after gastrectomy, we chose jejunal interposition(JI)via the retrocolic route for LPG. We performed totallyLPG with JI using overlap method. METHODS: Five ports were placed. After the lymph nodes dissection bythe standard procedure, the esophagus and the proximal side of the stomach were transected byliner staplers. The jejunum was moved to the upper abdomen through the small hole of the mesocolon. The interposing jejunum was made, and the esophagojejunostomyand jejunogastrostomywere done byusing overlap method. At the end, the jujunum was pulled under the mosocolon escluding the interposing jejunum. The JI reconstruction via a retrocolic route after LPG was completed. DISCUSSION: Following LPG, the JI reconstruction is not so popular because the surgical procedure is complicated. In our technique, the JI reconstruction accomplished easier byoverlap method. CONCLUSION: Our procedure is a considerable operation of reconstruction following LPG.

[Two Cases of Stage IV Pancreatic Cancer Has Gained Relatively Long Free Survival in Multimodality Therapy].

We experienced 2 cases in which Stage IV pancreatic cancer(General rules for the study of pancreatic cancer, The 6th edition, Japanese Pancreas Society)underwent chemotherapy and radiotherapy after surgical operation and had relatively long term relapse-free survival. Local control by adding radiation therapy to surgical resection and suppressing the distant metastases in adjuvant chemotherapy may improve the prognosis.

[A Case of Long-Term Survival of Breast Cancer with Lymph Node and Liver Metastases Treated with Sequential Anti-HER2 Drugs, Chemotherapy, and Endocrine Therapy].

A 50s-year-old woman underwent left partial mastectomy with axillary lymphadenectomy for breast cancer. Histological examination indicated invasive ductal carcinoma, pT1c, pN0, Stage I , ly(+), ER(+), PgR(+). She received adjuvant therapy with tamoxifen and 50 Gy of irradiation to the residual breast. Four years after mastectomy, she was found to have left Rotter lymph node metastasis; then, anastrozole was administered instead of tamoxifen. Nine months later, she was found to have liver metastasis. Immunohistostaining revealed that the breast cancer was HER2-positive; she received AC followed by paclitaxel(PTX)with trastuzumab(T), and achieved complete response(CR). Subsequently, abdominal, cervical lymph node, and liver metastases appeared. Letrozole followed by lapatinib with capecitabine, FEC100, PTX with T, eribulin, S-1, docetaxel with pertuzumab and T, everolimus with exemestane, bevacizumab, and PTX were then administered, resulting in long-term disease control. Sixteen years after mastectomy, she receives outpatient chemotherapy in performance status 1 state.

[A Case of Squamous Cell Carcinoma of the Breast].

A 67-year-old woman presented with a 3 cm palpable mass in the lower lateral quadrant of her right breast. Mammography and ultrasonography showed a mass with an irregular border. Using fine needle aspiration biopsy and cytology, we detected malignant cells with keratosis, and made a diagnosis of squamous cell carcinoma(SCC). We performed total mastectomy with axillary lymph node dissection. Histologically, the tumor was identified as SCC with keratinization and a component of scirrhous adenocarcinoma; estrogen and progesterone receptor expression were not elevated. The tumor tested negative for HER2. The patient did not receive any adjuvant chemotherapy and is alive with no recurrence 13 years after surgery.

[A Case of Recurrent Inflammatory Breast Cancer Treated Using Multidisciplinary Therapy].

The patient was a 65-year-old woman who underwent segmental mastectomy for left breast cancer 5 years ago. The pathological diagnosis ofthe tumor was noninvasive ductal carcinoma, TisN0M0 and Stage 0. Postoperative radiation therapy was performed, but chemotherapy and hormone therapy were not administered. The patient presented with redness of the residual left breast. Skin biopsy showed lymphatic invasion of adenocarcinoma, and the patient was diagnosed with inflammatory carcinoma ofthe breast. After 4 cycles ofAC followed by 4 cycles ofdocetaxel, the mass was diminished and the redness disappeared. Total mastectomy with wide skin resection and axillary lymph node dissection was performed. The pathological diagnosis revealed scirrhous carcinoma ofthe left residual breast(T3N0, Stage II B, s, f, g, margin[-], ly0, v0, ER[+], PgR[+], HER2[1+]). She received treatment with an aromatase inhibitor, and 2 years after the operation is alive with no recurrence.

Recombinant soluble thrombomodulin for postoperative disseminated intravascular coagulation.

BACKGROUND: Thrombomodulin is a thrombin receptor on the endothelial cell surface that plays an important role in the regulation of intravascular coagulation. The purpose of this study was to evaluate the efficacy and safety of treatment with recombinant human soluble thrombomodulin (rhTM) for patients with septic-disseminated intravascular coagulation (DIC) associated with gastroenterological surgery. MATERIALS AND METHODS: From April 2011-September 2013, 201 patients with DIC associated with gastroenterological surgery were treated in 16 institutions in Kumamoto, Japan. The patients were diagnosed according to the Japanese Association for Acute Medicine DIC scoring system. The clinical course, mortality rate at 28 d, and adverse events were evaluated retrospectively. RESULTS: Forty-five patients were excluded because they did not meet the Japanese Association for Acute Medicine DIC criteria or had an insufficient duration of drug administration. Thus, 156 patients were analyzed. Of these patients, 107 received rhTM at the discretion of the attending surgeon and 49 did not. The most common reason for surgery in both groups was peritonitis due to perforation of the colon. Within 7 d, the platelet count, prothrombin time-international normalized ratio, DIC score, neutrophil count, and C-reactive protein level significantly improved in the rhTM group compared with those in the control. Treatment with rhTM was significantly associated with reduced inhospital mortality at 28 d. The incidence of adverse events did not differ between the two groups. CONCLUSIONS: Therapy with rhTM may be associated with reduced inhospital mortality in patients with septic DIC associated with gastroenterological surgery without increasing adverse events.

[A Case of Laparoscopic Gastrectomy for Gastric GIST after Neoadjuvant Chemotherapy with Imatinib Mesylate].

We report the case of a 68-year-old woman who underwent laparoscopic gastrectomy for a gastric gastrointestinal stromal tumor (GIST) after neoadjuvant chemotherapy with imatinib mesylate. After conducting gastroscopy because of weight loss and anemia, we identified a submucosal tumor in the cardia. A GIST of 8 cm in diameter invaded the pancreatic tail and excluded the splenic vein. We administered imatinib 400 mg/day as neoadjuvant chemotherapy. We performed laparoscopic partial gastrectomy 5 months after the initiation of chemotherapy. According to the histopathological diagnosis, the surgical margin was positive. As an additional excision, we performed laparoscopic proximal gastrectomy. Without postoperative complications, it passes smoothly as of 5 months after surgery.

[Lymphadenectomy performed along the left recurrent laryngeal nerve after anterior detachment of the esophagus via thoracoscopic esophagectomy in the prone position under artificial pneumothorax].

Thoracoscopic esophagectomy was performed in the prone position under artificial pneumothorax and did not affect the surgical area during lung ventilation; tracheal mobility was also improved. Lymphadenectomy around the left recurrent laryngeal nerve was performed by separating the left main bronchus and trachea between the esophagus and pericardium before detaching the dorsal side of the esophagus.

[A case of rectal cancer treated with aggressive surgery for liver and anal metastases].

A 64-year-old man underwent laparoscopic surgery for rectal cancer and lateral lymph node dissection. The histopathological findings indicated adenocarcinoma (moderate>well), pA, pN3(4/25No 263 1/1), pM0, Stage IIIb. After the surgery, he received 12 courses of adjuvant chemotherapy with modified 5-fluorouracil Leucovorin oxaliplatin (mFOLFOX6). Liver metastasis( S8)was present, and open hepatectomy was performed 1 year after the first surgery. Three months after the second surgery, the carcinoembryonic antigen (CEA) level increased and chemotherapy TS-1 was started. However, the CEA level continued to increase, and positron emission tomography-computed tomography revealed peritoneal dissemination, and multiple lymph node, bone, and local metastases(in the liver and rectum). Accordingly, 11 courses of chemotherapy with 5- fluorouracil Leucovorin irinotecan (FOLFIRI) and bevacizumab was administered. The patient recently experienced anal bleeding during each bowel evacuation, which developed owing to the recurrence of the cancer in the anus. To improve his quality of life, the anal tumor was excised 2 years 6 months after the first surgery. Chemotherapy with FOLFIRI and bevacizumab was restarted. The CEA level stopped increasing. We think that the anal surgery did not affect our patient's prognosis but helped improve his quality of life.

[A case report of scirrhous gastric cancer with peritoneal dissemination treated effectively with various chemotherapy regimens after laparoscopic distal subtotal gastrectomy].

We report a 44-year-old male patient who was diagnosed with scirrhous gastric cancer with peritoneal dissemination using laparoscopy. The patient underwent a non-curative resection with laparoscopic distal subtotal gastrectomy. In addition, we placed a port into the patient's abdomen for intraperitoneal chemotherapy administration. Postoperatively, we administered capecitabine (per os)+ paclitaxel (intraperitoneally) and, after 2 cycles, the oral anticancer agent 5-FU was given. The patient died of peritonitis carcinomatosa 25 months after the operation. The combined therapies contributed to improve the quality of life, specifically oral ingestion, for 2 years.