[A Case of Stage â £ Pancreatic Head Cancer with Aortic Lymph Node Metastasis Treated with 40 Courses of mFOLFIRINOX Therapy after Surgery and Maintaining PR].

The patient was a male in his 60s who presented with obstructive jaundice and was diagnosed with pancreatic head cancer. He was referred to the Department of Surgery 2 months later due to prolonged jaundice and immediately underwent pylorus-preserving pancreatoduodenectomy with the diagnosis of resectable pancreatic cancer. Pathology showed pN1b (14/37), but 16b1 interaorticocaval was 0/1. The patient was then diagnosed with Stage ⅡB, R0. After completion of adjuvant chemotherapy with S-1, 1 year after surgery, CA19-9 was reelevated and PET/CT-positive enlarged lateroaortic lymph nodes and multiple nodules in both lungs were observed. The lymph nodes were also seen on preoperative CT, and the preoperative diagnosis was Stage Ⅳ. After insertion of an implantable central venous port, mFOLFIRINOX therapy was initiated. The patient had an anaphylactic reaction after 7 courses of L-OHP, and the treatment was continued without L-OHP. After 40 courses of mFOLFIRINOX therapy, the aortic lymph nodes reduced in size, PET results were negative, and the pulmonary nodules partially resolved. We report a case of a patient with Stage Ⅳ pancreatic head cancer who maintained PR for more than 1 year and 7 months after the initiation of mFOLFIRINOX therapy and survived for more than 2 years and 10 months since the initial diagnosis.

[An Analysis of Surgery for Colorectal Cancer Lung Metastasis].

OBJECTIVES: Resection of lung metastasis in colorectal cancer leads to a good prognosis; therefore, surgical treatment for resectable metastases is recommended by the Japanese Society for Cancer of the Colon and Rectum Guidelines for the treatment of colorectal cancer. In this study, we investigated the factors that affect the prognosis of resection of such lung cancers. RESULTS: Outcomes of 23 cases of lung resection performed from 2000 to 2019 were investigated. The 5-year overall survival rate after lung resection was 55.5%, and the 5-year relapse-free survival rate after liver resection was 27.0%. Univariate analysis identified sex(p=0.024), tumor size(p=0.0129)and complications(p=0.0129)as prognostic factors, while multivariate analysis revealed sex(p=0.0278, relative risk=5.38)to be a prognostic factor. CONCLUSION: In this study, sex was identified as a poor prognostic factor. Further evidence from cases is needed to ascertain the effects of other factors.

[Laparoscopic Partial Hepatectomy for the Liver Metastasis of Gastric Cancer after Nab-Paclitaxel plus Ramucirumab Combination Therapy-A Case Report].

We report a case of laparoscopic partial hepatectomy after nab-paclitaxel plus ramucirumab(nab-PTX plus RAM)combination therapy for postoperative liver recurrence of gastric cancer. The patient was a 50's man who underwent laparoscopic distal gastrectomy, D2 lymph node dissection, and Billroth-I reconstruction for gastric cancer. The pathological findings were L, Gre, Post, Type 3, por>tub2, pT3N3a, M1(CY1), fStage Ⅳ. Postoperative chemotherapy with S-1 was performed. The CT examination 6 months after the operation revealed a total of 3 tumors(maximum diameter of 5×4 cm)in liver segments S6, 7, and 8. We started nab-PTX plus RAM combination therapy for liver metastases and performed laparoscopic partial hepatectomy when 12 courses of the treatment were completed. The postoperative course was uneventful, and the patient was discharged on postoperative day 7. Pathological results suggested that the tumor was exposed on the cut surface, and 6 courses of nab-PTX plus RAM combination therapy were administered postoperatively. The patient has been recurrence-free 12 months after the operation.

[A Case of Sigmoid Colon Cancer with Complete Visceral Inversion].

Complete visceral inversion occurs in 1/5,000 individuals. In 64%of cases, complete visceral inversion is complicated by the malformation of other organs. Careful attention is required when performing surgeries. In recent years, with the development of laparoscopic surgery, some cases of laparoscopic surgery with complete visceral inversion have been reported. Herein, we report a case of safely performed laparoscopic surgery for sigmoid colon cancer with complete visceral inversion along with a relevant discussion.

[A Case of Recurrent Gastric Cancer with Clinical Complete Response after Ramucirumab plus Paclitaxel Therapy].

We report a case of a 61-year-old man who underwent open total gastrectomy and D2 lymph node dissection for gastric cancer. The pathological findings were suggestive of pT2N3M0, fStage ⅢA. S -1 was administered for 1 year post-surgery. One year and 9 months after the operation, an epigastralgia was found, and the PET-CT showed an increase of SUVmax 3.80 around the celiac artery. S -1 plus CDDP therapy was initiated. However, due to the occurrence of neutropenia, the therapy was changed to ramucirumab plus paclitaxel. After 20 courses of the same regimen, no PET-CT uptake was observed. We thus considered it cCR and discontinued further chemotherapy. The patient has been alive for 15 months without recurrence. By performing effective chemotherapy at an early stage, cCR could be observed after a secondary treatment. Therefore, longterm survival could be expected for post-operative recurrence of gastric cancer.

[Chemoradiotherapy with S-1 for Recurrence Cases of Colorectal Cancer].

INTRODUCTION: Although chemotherapy is the main treatment for recurrent colorectal cancer, the utility of radiotherapy as a local treatment has been widely reported. We performed chemoradiotherapy with S-1 for cases with recurrence after surgery, and the outcomes are reported herein. MATERIALS AND METHODS: Chemoradiotherapy with S-1 was performed in 4 cases. S-1 was administered for 2 weeks during the irradiation period, and the off period provided was 1 week. RESULTS: X-ray irradiation was performed in 2 cases and proton beam irradiation in the other 2. The progression free periods of the 2 cases receiving proton beam irradiation were 31 months and 36 months. In contrast, the progression free periods of the 2 cases given X-ray irradiation were 24 months and 21 months. DISCUSSION: It is known that S-1 not only achieves a high anticancer effect via dihydropyrimidine dehydrogenase(DPD)inhibition, which is a major metabolic pathway of 5-FU, but also increases the radiation susceptibility of malignancies. S-1 is regarded as an ideal anticancer agent when used in combination with radiation therapy. Since the local control achieved in our 4 cases was good, chemoradiotherapy with S-1 was considered to be a useful treatment.

[Examination of Cases of Hepatectomy for Metastatic Colorectal Cancer].

OBJECTIVES: Resection of liver metastasis from colorectal cancer is known to improve prognosis; therefore, surgical treatment is recommended for resectable metastases in the Japanese Society for Cancer of the Colon and Rectum Guidelines for the Treatment of Colorectal Cancer. In this study, we investigated factors that affect the prognosis of resection of such metastatic liver tumors. RESULTS: Thirty-three cases of liver resection performed during the period from 1998 to 2017 were investigated. The 5-year overall survival rate after liver resection was 47.3%, and the 5-year recurrence-free survival rate after liver resection was 29.9%. Univariate analysis identified CA19-9(p=0.02)and operative procedure(p=0.0046)as prognostic factors, while multivariate analysis revealed operative procedure(p=0.03)to be a prognostic factor. When prognosis was examined in terms of operative procedure(ie, lobectomy, segmental resection, or partial resection), the prognosis of patients undergoing lobectomy was significantly poorer compared to those undergoing segmental resection(p=0.0092, RR=28.94)and partial resection(p=0.0092, RR=25.37). CONCLUSION: In this study, operative procedure was identified as a poor prognostic factor. The prognosis of liver metastasis requiring lobectomy is considered to be poor. Further accumulation of cases is needed to investigate the effects of other factors in the choice of operative procedure.

Two-staged treatment strategy in patients with severe carotid or cerebrovascular diseases undergoing coronary artery bypass grafting.

PURPOSE: There is no clear consensus on how to treat patients undergoing coronary artery bypass grafting (CABG) who have severe concomitant carotidcerebral artery stenosis. The aim of this study was to evaluate our surgical results in patients with severe carotid and/or cerebrovascular disease undergoing CABG. METHODS: Between October 2003 and April 2009, a total of 47 such patients were treated at our institution with the following strategies: (1) protective carotid artery stenting for severe carotid stenosis performed either before (n = 20) or after (n = 5) CABG or (2) a superficial temporal artery-middle cerebral artery anastomosis procedure followed by CABG if indicated (n = 4). Off-pump CABG was performed in 75% of the patients. RESULTS: There were no major perioperative strokes or in-hospital deaths; however, three patients had transient ischemic attacks and two had minor strokes during the early post-CABG period. All of the patients with postoperative cerebrovascular events had had unilateral carotid artery occlusion. There were no late deaths during the follow-up period (up to 6 years, with a mean of 27 months). However, major adverse cardiocerebrovascular events (MACCE) occurred in seven patients (14.9%). The rates of freedom from MACCE at 1 and 3 years were 92% and 74%, respectively. CONCLUSION: It appears that our two-staged approach is safe and may reduce the risk of postoperative cerebrovascular events.

Treatment of prosthetic valve endocarditis complicated by destruction of the aortic annulus.

PURPOSE: It has been reported that surgical treatment for prosthetic valve endocarditis complicated by destruction of the aortic annulus is associated with high mortality and morbidity. The aim of this study was to evaluate the efficacy of our surgical strategy for this situation. METHODS: Between October 2003 and April 2009, eight patients (mean age 68.6 years) with prosthetic valve endocarditis complicated by destruction of the aortic annulus were surgically treated at our hospital. We use a relatively simple procedure consisting of a patch plasty of the abscess cavity in addition to complete removal of the infected tissue of the abscess cavity followed by standard aortic valve replacement. All patients had active endocarditis and were in New York Heart Association functional class III or IV. Preoperative echocardiography revealed that four patients had moderate or severe aortic regurgitation, and two had mitral valve endocarditis as well. RESULTS: There were no operative deaths (≤30 days). Cardiac complications included paroxysmal atrial fibrillation in three patients and transient atrioventricular block in one. One patient died of multiple organ failure 66 days after the surgery. The overall in-hospital mortality was 12.5%. Patients were followed-up for 6-49 months (mean 31 months). There was no recurrent prosthetic valve endocarditis. One patient required reoperation (mitral annuloplasty and redo aortic valve replacement). There were two late deaths: lung cancer in one and multiple organ failure related to pneumonia after the aforementioned redo operation in the other. CONCLUSION: Our simple procedure for complicated prosthetic valve endocarditis yielded excellent early and midterm outcomes.