Multidisciplinary treatment of advanced cervical esophageal adenocarcinoma derived from a gastric inlet patch: A case report.

A gastric inlet patch (GIP) is an ectopic gastric mucosal lesion usually arising at the cervical esophagus that may rarely cause esophageal adenocarcinoma (EAC). To the best of our knowledge, this is the first case of a GIP-derived EAC that was successfully treated using a multidisciplinary treatment approach. A 64-year-old man was referred to the Department of Gastrointestinal Surgery, Kanazawa University Hospital (Kanazawa, Japan) for surgical treatment of refractory recurrent cervical EAC derived from GIP who had previously been treated with induction chemotherapy, definitive chemoradiotherapy and photodynamic therapy (PDT). Esophagogastroduodenoscopy revealed a stenotic tumor at the GIP site in the cervical esophagus and submucosal tumors with suspected multiple intramural metastases in the anal side of the thoracic esophagus. The patient underwent robot-assisted thoracoscopic esophagectomy with laryngopharyngectomy and cervical lymphadenectomy as radical salvage surgery 4 months after the last PDT procedure. After postoperative adjuvant chemotherapy using oral administration of tegafur/gimeracil/oteracil (oral 5-fluorouracil prodrug) for 1 year; at present, the patient is alive without recurrence 3 years after the operation.

Title: pancreatic-type mixed acinar neuroendocrine carcinoma of the stomach: a case report and review of the literature.

BACKGROUND: The majority of gastrointestinal tumors are adenocarcinomas. Rarely, there are other types of tumors, such as acinar cell carcinoma, and these are often called pancreatic-type acinar cell carcinomas. Among these tumors, some are differentiated into neuroendocrine components. A few of them are MiNENs. CASE PRESENTATION: The patient was an 80-year-old male who was referred to our hospital for treatment of a pedunculated gastric tumor. It was 5 cm in diameter and detected in the upper gastric body with upper GI endoscopy conducted to investigate anemia. In the biopsy, although hyperplasia of gastric gland cells was noted, no tumor cells were found. Retrospectively, the diagnosis was misdiagnosed. An operation was arranged because bleeding from the tumor was suspected as a cause of anemia and because surgical resection was considered to be desirable for accurate diagnosis. Hence, laparoscopic and endoscopic cooperative surgery was performed. In the pathological examination, several types of epithelial cells that proliferated in the area between the mucosa and deep inside the submucosa were observed. These consisted of acinar-glandular/trabecular patterns and solid. A diagnosis of pancreatic-type acinar cell carcinoma of the stomach with NET G2 and G3 was made based on characteristic cellular findings and the results of immunostaining tests. Each of them consisted of more than 30% of the lesion; a diagnosis of pancreatic-type mixed acinar neuroendocrine carcinoma (pancreatic-type MiNEN) of the stomach or a type of gastric MiNEN was obtained. Anemia was resolved after the operation, and the patient was discharged from the hospital without perioperative complications. CONCLUSIONS: Pancreatic-type ACC of the stomach that is differentiated into neuroendocrine tumors is very rare. Hence, we report this case along with a literature review.

[Highly Advanced Gastric Cancer Leading to Immediate Perforation on Day Three of Chemotherapy with S-1 plus Oxaliplatin].

A 68-year-old woman was diagnosed with advanced gastric cancer with a type 3 deep ulcer of the middle stomach by endoscopy. An abdominal computed tomography scan revealed multiple lymph node metastases and peritoneal disseminations. The clinical stage was determined to be T4a(SE), N2P1M1(PER), H0 and stage IV . A gastrectomy was scheduled after 2 courses of S-1 plus oxaliplatin(SOX)with curative intent. On day 3 after initiatingSOX therapy, the patient complained of severe abdominal pain. Because the abdominal CT scan showed intra-abdominal free air and a defect in the gastric wall, we performed an emergency total gastrectomy. The defect in the gastric wall was about 1 cm in diameter and was located in the anterior wall of the lower body, consistent with the center of the tumor. The operative findings suggested that the perforation was caused by chemotherapy-induced necrosis of gastric cancer cells. The patient was discharged 16 days after surgery and received post-operative chemotherapy. Our findings suggest that the risk of gastric perforation should be considered when administeringchemotherapy to patients with advanced gastric cancer and a deep ulcer.

[Poor outcome of a patient with early double cancers of the stomach and sigmoid colon in which liver metastases were detected postoperatively].

A 63-year-old man underwent laparoscopic-assisted distal gastrectomy (LADG) and laparoscopic assisted colectomy (LAC) simultaneously for double cancers of the gastric antrum and sigmoid colon in August 2012. Both cancers, considered to be at an early-Stage, were pathologically diagnosed as tub1, sm, and n0. The patient was observed but no adjuvant chemotherapy was administered. A follow-up computed tomography (CT) in December 2012 detected a 15 mm tumor mass in the lateral segment of the liver and another 5mm mass in the S4. Liver metastasis of the sigmoid colon cancer was suspected, and 6 courses of BEV+mFOLFOX6 were administered. The metastatic tumor in the lateral segment showed stable disease (SD) and the S4 tumor showed a complete response (CR). Thereafter, the lateral hepatic segment was partially resected in March 2013. Pathological examinations led to a diagnosis of stomach cancer liver metastasis, and the patient was given oral TS-1. During the first course of treatment, a CT showed new tumor masses in the lateral segment of the liver and S4. Treatment was changed to TS-1+CDDP in mid-May. However, after completion of the first course of treatment, the patient experienced exacerbation of the liver metastases, pulmonary metastasis, and inflammation of the intrahepatic bile ducts. The patient was hospitalized in mid-June to receive inpatient care, but died in early July.

Advantages of the rapid double-staining method for intraoperative detection of micrometastasis in sentinel lymph nodes.

For rapid intraoperative diagnosis of lymph node micrometastasis, we refined the rapid immunohistochemistry method by combining anti-cytokeratin antibody-labeled nanocrystal beads with rapid hematoxylin and eosin (H&E) staining on the same section, referred to as the rapid double staining (RDS) technique. Two frozen-section slices each were obtained from 372 lymph nodes of 100 breast cancer patients. We performed RDS for 1 slide and rapid H&E staining for the other. The results were compared with the corresponding final pathological data obtained from the permanent specimens. For specimens from patients with pN1(mi) as determined by final pathological examination, the false­negative rate was 33.3% for rapid H&E staining and 16.7% for RDS. For specimens from patients with pN0(i+) as determined by final pathological examination, the false­negative rate was 80% for rapid H&E staining and 0% for RDS. These results indicate that RDS is superior to conventional rapid H&E staining for intraoperative diagnosis of nodal micrometastasis and isolated tumor cells.

[A difficult to treat case of malignant peritoneal mesothelioma with peritoneal metastasis].

A 57-year-old man presented with abdominal discomfort. A computed tomography (CT) scan revealed a tumor, with a maximum diameter of approximately 5 cm, in the transverse mesocolon near the splenic flexure as well as a small nodular shadow suggestive of peritoneal dissemination on the greater omentum. Fluorodeoxyglucose (FDG)-positron emission tomography (PET) showed marked accumulations of FDG at the same sites. Laparoscopic examination revealed an elastic hard tumor, with a maximum diameter of slightly over 5 cm, at the posterior sheath of the transverse mesocolon and a small nodule on the greater omentum with apparent dissemination. Since radical surgery was considered to be difficult to perform, we only resected the disseminated nodule for diagnostic purposes. The final pathological diagnosis was biphasic- type (mixed epithelial and sarcomatoid type) malignant mesothelioma arising from the peritoneum. Approximately 20 days postoperatively, the patient received combination therapy with pemetrexed and cisplatin with a 3-week interval between the courses. Image assessment after completion of the third course revealed enlargement of the tumor mass and worsening of the peritoneal dissemination. Therefore, the treatment was switched to paclitaxel, which has been reported to be effective as a second-line therapy. The drug was scheduled to be administered on days 1, 8, and 15. However, after the first course on day 1, the patient's condition gradually deteriorated and he subsequently died.

PTD classification: proposal for a new classification of gastric cancer location based on physiological lymphatic flow.

BACKGROUND: We propose a new classification for the location of gastric cancer - the PTD classification (i.e., zones P, T, and D; see below), with the zones classified according to the physiological lymphatic flow. METHODS: Three hundred and thirty-six patients with T1 or small T2 gastric cancer who underwent sentinel node mapping at our hospital were enrolled. The relationship between the location of the gastric cancer and the physiological lymphatic flow derived from sentinel node mapping was investigated. Lymphatic basins were defined as lymphatic zones divided by the stream of stained lymphatic canals. RESULTS: One hundred and forty-six patients underwent standard gastrectomy with more than D2 dissection and the other 190 patients underwent function-preserving gastrectomy with the omission of lymph node dissection outside the lymphatic basin. In the former group, the progression pattern of lymph node metastasis was observed; nodal metastasis occurred in sentinel nodes first, and rarely extended outside the lymphatic basin. In the latter group, none of the patients have had a recurrence. The PTD classification we propose is as follows: the dividing line between the proximal region (zone P) and the transitional region (zone T) is the line that links the point of the watershed between the left gastroepiploic artery and right gastroepiploic artery, to the point that is the inflow point of the first descending branch of the left gastric artery; and the dividing line between zone T and the distal region (zone D) is an arc at a radius of 8 cm from the pylorus. There were no lymphatic basins within the right gastric artery area for tumors located in zone T. CONCLUSION: The advantage of the PTD classification is that if the PTD classification were to be used as a guide for gastric resection procedures, preservation of the pylorus would become possible without diminishing the prognosis in patients with cT1N0 cancer located in zone T.