[A Case Report of Clinical Complete Response with Chemotherapy for Descending Colon Cancer Complicated with Severe Pulmonary Dysfunction].

A 76-year-old male patient was diagnosed with progressive descending colon cancer. Since the patient had severe respiratoryfunction impairment after right pneumonectomy, the anesthesiologydepartment of our hospital determined that general anesthesia induction was too difficult. He was thus started on capecitabine plus oxaliplatin(XELOX)therapy. Three months after starting this treatment, colonoscopyshowed that the site had become scarred, and tissue examination revealed no indication of malignancy. Accordingly, the patient achieved clinical complete response. The patient had no findings of recurrence 1 year and 11 months after the start of chemotherapy. Chemotherapy for unresectable progressive recurrent colorectal cancer is based on the 5-FU anticancer agent, which exerts its antitumor effect byinhibiting DNA synthesis. The antitumor effect is reportedly high when the expression of thymidylate synthase(TS), a target agent, is low. In this patient, TS expression was low based on tissue examination. TS expression maybe an effective useful predictive factor for the efficacyof chemotherapyadministered to patients with unresectable progressive recurrent colorectal cancer.

[A Case of Multiple Liver Metastases and Peritoneal Dissemination after Resection of a Gastrointestinal Stromal Tumor of the Stomach Successfully Treated with Imatinib Mesylate].

A 71-year-old man was diagnosed with a gastric tumor approximately 50mm in diameter on computed tomography (CT). In January 2000, he underwent a proximal gastrectomy. Pathological examination showed 5 mitoses per 50 high-power fields, while immunohistochemical analysis showed positive staining for KIT. Accordingly, the tumor was diagnosed as an intermediate- risk malignant gastrointestinal stromal tumor (GIST) for which the patient was followed. In January 2002, an abdominal CT scan revealed multiple hepatic tumors and a lower abdominal tumor, and the patient was diagnosed with liver metastases and peritoneal disseminations from GIST. After informed consent was provided, chemotherapy with 400 mg/day imatinib was initiated. The patient demonstrated a partial response 2 months after treatment. At 12 years 8 months after the diagnosis of liver metastasis and peritoneal disseminations, the patient shows no sign of recurrence.

[A Case of Idiopathic Thrombocytopenic Purpura during Adjuvant Chemotherapy for Colon Cancer].

A 76-year-old man underwent surgery for sigmoid colon cancer. The pathological finding was stage Ⅱ with a high-risk of recurrence (SI [bladder], l y0, v2, pN0, H0, P0, M0). He was treated with TS-1 as adjuvant chemotherapy. After the 1 course of chemotherapy, his platelet count was 4,000/mL. The high index of platelet associated IgG (PA-IgG) and bone marrow examination suggested that thrombocytopenia was caused by idiopathic thrombocytopenic purpura. The platelet count improved by prednisolone administration and Helicobacter pylori eradication treatment. After 6 months with no administration of adjuvant chemotherapy, the colon cancer recurred locally, and we performed a Hartmann's operation.

[A successful case with TS-1+CDDP chemotherapy for recurrent gastric cancer].

A 64-year-old woman underwent cholecystectomy for treatment of cholecystolithiasis in January 2005. Pathological examination rendered a diagnosis of gallbladder carcinoma. Wedge resection of the liver and dissection of the lymph nodes was performed. No tumor cells in either the liver nodule or lymph nodes were found during pathological examination. At 4 years after surgery, paraaortic lymph node recurrence was confirmed by computed tomography (CT). Gemcitabine was administered once weekly for the first 3 weeks in a monthly cycle, but the tumor continued to increase in size. Gemcitabine was then switched to TS-1, after which it was changed to cisplatin because of continued tumor growth. After 35 courses of chemotherapy, CT showed the disappearance of the paraaortic lymph node, and the patient achieved a complete response. She is currently free of disease at 9 years after surgery.

[A case of recurrent gastric cancer successfully treated with TS-1+CDDP chemotherapy].

A 74-year-old woman underwent distal gastrectomy and D1+ α dissection for the treatment of gastric cancer (pT2a, pN2, H0, P0, M0, Stage IIIA) in February 2008. She was treated with adjuvant postoperative chemotherapy consisting of TS-1. However, 32 months after the operation, paraaortic lymph node recurrence was confirmed by computed tomography (CT). She was treated with combined TS-1 and cisplatin chemotherapy. After 14 courses, CT revealed that the paraaortic lymph node metastasis had disappeared, and a complete response was attained. The patient is currently disease-free, 6 years after the operation.

[A case of long-term survival after aggressive surgery for Stage IV gallbladder carcinoma].

A 67-year-old woman was referred to our hospital because of a gallbladder mass. Abdominal computed tomography revealed a protruding mass 34 mm in diameter in the body of the gallbladder with wall thickening and enhancement. Advanced gallbladder carcinoma was diagnosed by image analysis, with liver metastasis in segment 5 and lymph node metastasis in the hepatoduodenal ligament. Subsequently, S4a+S5 hepatic segmentectomy was performed with extrahepatic bile duct resection and regional lymphadenectomy. The final pathological diagnosis was pT2 pN1 pM1, Stage IV,according to the International Union against Cancer classification system. Curative resection was then performed. In addition, we performed adjuvant chemotherapy with 15 courses of 1,000 mg/m2 gemcitabine on days 1, 8, and 15 at every 28 days. At 5 years after the operation, the patient was alive and free of disease. Therefore, in cases of limited liver metastasis (within segments 4a and 5), aggressive surgery should be considered even for Stage IV gallbladder carcinoma. In such cases, long-term patient survival may be expected only when curative resection is achieved.

[A case of complex (type IV) paraesophageal hiatal hernia with herniation of the small intestine].

A 78-year-old woman was admitted to our hospital because of abdominal pain. She was diagnosed with complex (type IV) paraesophageal hiatal hernia, for which an operation was performed. At laparotomy, a 50 cm long ileum was found to have herniated into the thoracic cavity through the esophageal hiatus along with the sliding hiatal hernia of the stomach. Both the organs were reduced to the abdominal cavity. The hiatal hernia defect (diameter, 7cm) was repaired with a direct suture, and the gastric fundus was sutured to the diaphragm. Presently, 6 years have passed since the operation, there is no sign of recurrence.

[A case of hepatoid adenocarcinoma of the stomach].

The patient was a 76-year-old man with no chief complaint. He presented to an internist of our hospital for an evaluation of anemia. An upper gastrointestinal endoscopy revealed a type 2 tumor at the lesser curvature of the gastric body. Although the blood analysis showed a high amount of AFP(2, 328 ng/mL), there was no abnormality found in the liver with a CT scan. The tumor was presumed to be an AFP-producing gastric cancer on the basis of the tumor biopsy. We performed total gastrectomy, splenectomy and cholecystectomy. The tumor cells were positive for AFP by immunohistochemistry. The final diagnosis was hepatoid adenocarcinoma, pT3(SS), INF b, ly1, v2, pN1(3/42), pStage II B. Tumor cells were negative for antihepatocyte antibody and anti-HER2 antibody. The amount of AFP normalized postoperatively. After discharge, he was treated with S-1(80mg/day)orally. He is relapse-free now, 14 months after the operation. Hepatoid adenocarcinoma is an extremely aggressive tumor with a poor prognosis, and effective chemotherapy has still not been established. A larger number of analyses, along with a molecular biological approach, is sure to be helpful for the establishment of an effective treatment for hepatoid adenocarcinoma.

A rare case of esophageal cancer (T2N0) with a solitary cerebellar metastasis.

A 72-year-old man with a history of distal gastrectomy was diagnosed with esophageal cancer (EC). A subtotal esophagectomy and the residual total gastrectomy were performed via a right-sided thoracotomy and laparotomy with D2 lymph node dissection followed by reconstruction with a retrosternal right colonic interposition. The pathological diagnosis was Mt, 65 mm, moderately differentiated squamous cell carcinoma, pT2, ly0, v2, pN0, sM0, pStage II. The patient suddenly developed neurological symptoms 10 days after the operation, and brain magnetic resonance imaging detected a single solid left cerebellar tumor. This tumor was completely excised, and pathological diagnosis confirmed the tumor as an EC metastasis. He received adjuvant chemotherapy with cisplatin + 5-fluorouracil. Seven months later, he developed multiple brain metastases; however, no evidence of local recurrence or other metastatic sites was found. He died 8 months after the surgery. Solitary cerebellar metastasis from EC in which the primary tumor is T2N0 is rare, and the mechanism of this metastatic pattern is of particular interest. Our case study suggests that even if the primary tumor is in the limited stage and other metastatic sites are not identified at presentation, it seems reasonable to perform preoperative imaging of the brain for all patients with EC.

[Histological complete response in a case of primary squamous cell carcinoma of the stomach treated by chemotherapy with docetaxel and cisplatin plus 5-fluorouracil].

The patient was a 68-year-old man with melena. Endoscopic examination revealed a type 2 advanced tumor in the mid body and an elevated lesion in the upper body of the stomach. Biopsy specimens from both lesions were diagnosed histologically as squamous cell carcinoma. Abdominal CT showed thickening of the midbody in the greater curvature and bulky lymph nodes along the lesser curvature (No. 3), and the greater curvature(No. 4d). We diagnosed Stage IIIB (cP0, cH0, cT4, cN1, cM0) cancer, but we concluded radical resection would be difficult due to lymph node invasion to the diaphragm and mesocolon. DCF combination therapy (docetaxel 75 mg/m2 day 1, CDDP 75 mg/m2 day 1, 5-FU 750 mg/m2 day 1-5) was administered. After 3 courses of chemotherapy, endoscopic examination and abdominal CT findings showed remarkable reduction of the primary tumor and the lymph node metastasis, indicating a partial response (PR) to the chemotherapy. After consultation with the patient, total gastrectomy with lymph node dissection (D2) was performed. The pathological specimens showed no cancer cells in the gastric wall and lymph nodes, so the histological effect was judged as Grade 3. This case suggested that DCF combination chemotherapy may prove useful to treat patients with advanced squamous cell carcinoma of the stomach.

[A successful two-stage treatment with CDDP and CPT-11 for pancreatic neuroendocrine carcinoma with liver metastasis].

A 59-year-old man was diagnosed as having a pancreatic carcinoma with synchronous liver metastasis at initial surgery. After wedge resection of liver tumor for histopathological analysis and gastro-jejunostomy, he was treated with 3 cycles of combined systematic chemotherapy consisting of CDDP and CPT-11, because of histopathological diagnosis confirming a neuroendocrine carcinoma of the pancreas. After chemotherapy, there was no recurrence and the primary tumor was reduced in size. Therefore, pancreatico-duodenectomy was performed as a curative treatment in two stages. During the follow-up, the patient has been alive without any signs of recurrence for 20 months since the diagnosis. Recently, several consecutive chemotherapies have been an effective modality to improve a poor prognosis for unresectable neuroendocrine carcinoma.

[A successful treatment with down-staging chemotherapy for sigmoid colon cancer with unresectable multiple liver and lung metastases].

A 63-year-old woman was diagnosed as having a sigmoid colon cancer with synchronous unresectable multiple liver and lung metastases. After sigmoidectomy, she was treated with S-1 combined with CPT-11 as a down-staging chemotherapy. After 3 courses of chemotherapy, the liver and lung metastases reduced in size as partial response. In March 2005, extended right hepatectomy combined with MHV resection was performed. She was treated with 2 courses of chemotherapy after hepatectomy, and furthermore she underwent left lung upper lobectomy. She has been alive without any signs of recurrence for 33 months from the initial surgery. Recently, a progression of the systemic chemotherapy for colorectal cancer has been a promising modality to improve a poor prognosis for unresectable multiple liver or extrahepatic metastases from advanced colorectal cancer.

Reaction on D-glucal by an inverting phosphorylase to synthesize derivatives of 2-deoxy-beta-D-arabino-hexopyranosyl-(1-->4)-D-glucose (2II-deoxycellobiose).

Four derivatives of 2(II)-deoxycellobiose were synthesized from d-glucal and acceptor sugars (d-glucose, d-xylose, d-mannose, and 2-deoxy-d-arabino-hexose) using a cellobiose phosphorylase from Cellvibrio gilvus. The enzyme was found to be an effective catalyst to synthesize the beta-(1-->4) linkage of 2-deoxy-d-arabino-hexopyranoside. The acceptor specificity for the d-glucal reaction was identical to that for the alpha-d-glucose 1-phosphate reaction, but the activity of d-glucal was approximately 500 times less than that of alpha-d-glucose 1-phosphate, using 10mM substrates.

Port site recurrence diagnosed by positron emission tomography after laparoscopic surgery for colon cancer.

Port site recurrence after laparoscopic surgery for colorectal cancer patients is a rare complication. We report a case of port site recurrence in a 46-year-old woman that was detected by positron emission tomography (PET) using 18[F]-fluoro-deoxyglucose (FDG). Surgical treatment consisted of laparoscopic ileo-cecal resection and lymph node dissection. At her nine months postoperative follow-up examination, her serum carcinoembryonic antigen (CEA) levels had raised to 15.8ng/mL. Although computed tomography and colonoscopic examination were performed, lung, liver and local recurrence in the colon were not detected. FDG-PET was then performed and detected a higher concentration of FDG at the port site in the abdominal wall. Port site recurrence was diagnosed clinically and surgical resection of tumor at the port site was performed. Pathology revealed a moderately differentiated adenocarcinoma diagnosed as port site recurrence. This case suggests that FDG-PET is an important examination for the detection of port site recurrence when serum CEA levels are rising and routinely radiographic examinations are unable to detect the site of recurrence.

Early results of intersphincteric resection for patients with very low rectal cancer: an active approach to avoid a permanent colostomy.

PURPOSE: Abdominoperineal resection has been the standard surgery for very low rectal cancer located within 5 cm of the anal verge. However, permanent colostomy exerts serious limitations on quality of life. The present study aimed to investigate curability and functional results of intersphincteric resection and additional partial external sphincteric resection for carcinoma of the anorectal junction. METHODS: Thirty-five patients were prospectively studied from November 1999 to September 2002. All patients displayed adenocarcinoma (T3: n = 26; T2: n = 7; T1: n = 2) located between 0 and 2 cm above the dentate line. Abdominotransanal rectal resection with total mesorectal excision was performed in all patients (total intersphincteric resection: n = 14; subtotal intersphincteric resection: n = 5; additional partial external sphincteric resection: n = 6). All patients underwent diverting colostomy, which was closed at a median of six months postoperatively. Twenty patients received preoperative radiochemotherapy. RESULTS: All patients had curative intent with microscopic safety margins (mean surgical cut end: 4 mm; mean distal cut end: 10 mm). No postoperative mortality was encountered. Morbidity was identified in 13 patients (perianastomotic abscess: n = 4; anastomotic leakage and fistula: n = 4; postoperative bleeding: n = 2; wound infection: n = 1; anastomotic stenosis: n = 1; anovaginal fistula: n = 1). One of these patients received a permanent colostomy. Five patients developed recurrence (liver: n = 1; lung: n = 2; local and lung: n = 1; abdominal wall: n = 1) during the median observation period (23 months). Two of these patients underwent curative resection of liver or lung metastases. Twenty-one patients have received stoma closure, and although continence was satisfactory in all, 5 displayed occasional minor soiling 12 months after stoma closure. Anal canal manometry demonstrated significant reduction in maximum resting pressure (median: 50 cmH(2)O at 12 months after stoma closure), but acceptable function results were obtained. CONCLUSION: Curability and anal function were achieved by means of intersphincteric resection without or with additional partial external sphincteric resection. These procedures can be recommended for low rectal cancer patients who are candidates for abdominoperineal resection.

[Anesthetic management of a patient with deficiency of congenital coagulation factor XII].

A 63-year-old man with deficiency of congenital coagulation factor XII, was referred to our hospital for an operation of the hypopharynx cancer. The day before surgery under general anesthesia, fresh frozen plasma was administered to him with good response of APTT shortening from 397.0 to 36.4 seconds. During operation, bleeding tendency was controlled and fresh frozen plasma was administered. Total blood loss during the operation was 255 ml. During post-operative period, APTT was kept at an adequate level. The post-operative course was uneventful and he was discharged after the radiation and an adjuvant therapy.