[A Case of Hypertrophic Pulmonary Osteoarthropathy Associated with Pulmonary Pleomorphic Carcinoma].

Hypertrophic pulmonary osteoarthropathy(HPO)is a tumor-associated syndrome that features the triad of clubbed fingers, periosteal bone growth in long bones, and arthritis, and is often associated with an adenocarcinoma or squamous cell carcinoma. This report presents details of a case of HPO associated with pleomorphic carcinoma, which was relieved by treatment. A 47-year-old woman was presented with a complaint of generalized arthralgia. A physical examination showed swollen joints in the body and clubbed fingers. Chest CT revealed a mass shadow in the left upper lobe and ultrasound- guided biopsy findings led to a diagnosis of non-small cell lung cancer. Furthermore, bone scintigraphy indicated symmetrical accumulation in bones and joints throughout the body. A right upper lobectomy was performed along with combined chest wall resection and mediastinal lymph node dissection with an open chest, and the presence of lung cancer complicated with HPO was indicated. Pathological examination results revealed a diagnosis of pleomorphic carcinoma(pT4N0M0, Stage ⅢA). Systemic arthralgia was resolved on the first postoperative day. One year after surgery, a solitary brain metastasis developed and was removed, with no recurrence at the time of writing. Joint symptoms related to HPO can be expected to improve with treatment of pulmonary lesions, thus aggressive procedures for diagnosis and treatment are desirable.

[A Case of Rectal Neuroendocrine Tumor with a Major Axis of 10.7 mm with Lymph Node Metastasis].

The case is a 50-year-old woman. Colonoscopy performed by a local doctor for the purpose of stool occult blood positive revealed a 15 mm tumor in the lower rectum, biopsy showed chromogranin positive, synaptophysin positive, and Ki-67 index<1% showed a neuroendocrine tumor(NET), G1 was diagnosed and introduced. Colonoscopy revealed a smooth- surfaced circular hemispherical tumor with a lower edge 30 mm from the anal margin and 20 mm from the dentate line, and EUS showed 10.7×5.2 mm in layers 2 to 3. It was visualized as a well-defined hypoechoic tumor. Contrast-enhanced CT examination showed a 12×5 mm mass showing a contrast-enhancing effect, and no lymphadenopathy or distant metastasis was observed. Contrast-enhanced MRI showed no evidence of pelvic lymphadenopathy. Based on the above, it was diagnosed that NET, G1, and infiltration to the submucosa exceeding 10 mm. Although endoscopic resection as a diagnostic treatment was also an option, we determined surgical resection policy, therefore we performed laparoscopic rectal intersphincteric resection and upper D2 dissection. Histopathological findings showed a tumor of 11×8 mm infiltrating the submucosa( 5,000µm)with metastasis to the pararectal lymph nodes, and the diagnosis was T1b, N1, Ki-67 index 3%, Ly1, V1a, NET G2, pStage ⅢB. Her postoperative course was uneventful, and 6 months later, we performed her artificial anal closure. One year after the operation, there are frequent bowel movements but no fecal incontinence and she is alive without recurrence. For rectal NET with a tumor diameter of 10 mm or more, radical surgery with dissection is recommended because of the high risk of lymph node metastasis. In this case lymph node metastasis was observed surgical resection according to the above reason, but endoscopic resection was possible except that the preoperative size exceeded 10 mm to 0.7 mm and the distance from the anus was short, therefore it took some thought to decide the policy.

[Can Lateral Pelvic Node Dissection Omitted in Rectal Cancer with Suspected Lateral Node Metastasis after Chemoradiotherapy ?]

To elucidate ideal strategy of treatment for advanced lower rectal cancer, we investigated 11 patients with clinically suspected lateral pelvic node(LPN)metastasis among 36 patients who received neoadjuvant chemoradiation therapy(NCRT). Nodal metastasis was diagnosed as positive when the major axis of a lymph node was over 7mm in computed tomography(CT). Both tumor and nodal downstaging were observed in CT after NCRT; pathological complete response and ypN0 was obtained in 2(18.2%)and 6(54.5%)cases, respectively, and positive LPN was observed only in 2 cases. All of 4 cases who were diagnosed as ycN0 in CT after chemoradiation were confirmed as ypN0. Extended examination with 36 patients who underwent NCRT showed that 85% of 21 ycN0-cases were confirmed to be ypN0. As a conclusion, NCRT for lower rectal cancer with suspected LPN metastasis was highly effective, and omitting lateral node dissection when all nodes turned to be less than 7mm on CT, can be a hopeful option.

Usability of elective laparoscopic sigmoidectomy and feasibility of single-incision laparoscopic surgery for sigmoid volvulus: report of three cases.

A therapeutic guideline for sigmoid volvulus (SV) has not been established, and the most recommended surgical procedure for SV has not been determined. Our objective is to assess the usability of elective laparoscopic sigmoidectomy and the feasibility of single-incision laparoscopic surgery for SV following endoscopic reduction. SV typically affects the elderly and accounts for 1% to 7% of intestinal obstructions in Western countries. We report on 3 patients with SV who underwent elective laparoscopic sigmoidectomy following endoscopic reduction, and we first describe single-port surgery for SV. We discuss the 3 patients (a 79-year-old male, an 88-year-old female, and a 67-year-old female) with SV who underwent elective laparoscopic sigmoidectomy following endoscopic reduction. All 3 patients underwent laparoscopic sigmoidectomy, and 2 patients underwent single-port laparoscopic surgery without complications. Recurrence of volvulus was not seen during the course of 12 to 24 months. In experienced hands, elective laparoscopic sigmoidectomy after colonoscopic detorsion is a valuable alternative, and single-port surgery is also feasible.

[Efficacy of endoscopic gastroduodenal stenting for gastric outlet obstruction caused by unresectable gastric cancer].

BACKGROUND: In this retrospective study, we investigated the clinical outcomes of endoscopic gastroduodenal stenting (EGDS) for gastric outlet obstruction( GOO) caused by unresectable gastric cancer( UGC). METHODS: A retrospective study was performed on 20 UGC patients with GOO between 2007 and 2012. We compared the clinical outcomes of EGDS using the WallFlex stent( GDS group, n=8) and palliative Roux-en-Y gastrojejunostomy( RYGJ group, n=12). RESULTS: The numbers of patients with a poor performance status and prior use of chemotherapy were higher in the GDS group than in the RYGJ group. No postoperative complications were observed, and the GOO score improved in both groups. The median days taken to resume oral food intake, the median duration of oral food intake, and the median survival time in the RYGJ and GDS groups were 4 and 3 days( p=0.0008), 301 and 151 days( p=0.0698), and 345 and 161 days (p=0.0070), respectively. CONCLUSIONS: EGDS for GOO caused by UGC can be performed safely even after chemotherapy and is beneficial in terms of improvement of oral food intake.

[Efficacy of stereotactic radiotherapy for primary and metastatic liver cancer].

Twenty patients( 30 nodules) with metastatic liver cancer( MLC) and 10 cases with hepatocellular carcinoma( HCC) treated by stereotactic radiotherapy (SRT) were analyzed. SRT was administered at 48.0 or 52.8 Gy/4 Fr/1 wk. The response rate (RR) in MLC patients was 78%, and 11 patients survived longer than 1 year and 9 patients survived as long as 2 years. Clinical analysis suggests that the ideal indications for SRT in MLC are solitary nodules in patients without extrahepatic disease who have undergone systemic chemotherapy. Although RR of SRT for HCC was as high as 85%, intrahepatic recurrence was observed in all patients and 6 patients died within 1 year. Further analysis is needed to determine the indication for SRT in HCC patients.

The effects of chemotherapy on primary small bowel cancer: A retrospective multicenter observational study in Japan.

Small bowel cancer is relatively rare among gastrointestinal tract cancers, including esophageal, gastric and colorectal cancers. The majority of cases of small bowel cancer are diagnosed at an advanced stage, resulting in poor outcomes. The clinical effects of chemotherapy on small bowel cancer have been investigated in a limited number of studies from Europe and the USA. However, they have not yet been fully investigated in Asian countries, including Japan. This retrospective multicenter observational study was designed to investigate the efficacy of chemotherapy on small bowel cancer. A questionnaire survey was conducted in 28 hospitals affiliated with the Osaka University Hospital. We retrospectively reviewed the medical records of 61 patients with small bowel cancer (32 patients who were unable to undergo curative resection or had unresectable distant metastases and 29 who underwent curative resection), treated between 1996 and 2009, to evaluate the outcomes and the efficacy of chemotherapy. There was no significant difference in the overall survival between the patients undergoing curative resection with postoperative adjuvant chemotherapy and those without postoperative adjuvant chemotherapy. In patients with non-curative resection or unresectable distant metastases, the response rate to chemotherapy was 31.6% and the overall survival was significantly higher compared to that without chemotherapy (P=0.008). The study results suggested that chemotherapy is effective for Japanese patients with small bowel cancer who cannot undergo curative resection or have unresectable distant metastases.

[Stereotactic radiotherapy for metastatic liver cancer].

Twenty cases (27 therapeutic sites/30 nodules) of metastatic liver cancer treated with stereotactic radiotherapy (SRT)were analyzed. The original sites of cancer were colorectal(8 cases), breast(4 cases), stomach(3 cases), esophagus(2 cases), and other organs (3 cases). SRT was performed with 52.8 Gy·4 fr·-1·wk-1. The response rate was 78%, including complete response (CR) at 8 sites, partial response (PR) at 10 sites, stable disease (SD) at 2 sites, progressive disease(PD) at 3 sites, and not detected(ND) at 4 sites, thus demonstrating a potent local therapeutic effect. Ten patients survived for more than 1 year, 8 patients survived for 2 years, and 4 died before 6 months. Clinical analysis suggests that the ideal indications for SRT are patients with a solitary nodule and without extrahepatic disease who have undergone systemic chemotherapy.

[Complete remission of liver metastasis from gall bladder carcinoma after stereotactic radiotherapy-a case report].

A 75-year-old man was diagnosed as gall bladder carcinoma by postoperative histological examination following laparoscopic cholecystectomy. He underwent the second surgery of resection of liver bed and port sites with lymph node dissection. Isolated hepatic metastasis of 20 mm in diameter was found in S4/8 by MRI 18 months postoperatively, and stereotactic radiotherapy (52.8 Gy/4 Fr) was done for the metastatic lesion. The lesion could not be detected by CT 7 months after the radiotherapy, and thereafter no local recurrence has been observed for 24 months. However, lymph node metastasis of #9 was diagnosed 31 months postoperatively. Liniac radiotherapy (60 Gy/20 Fr)was performed and stable disease has been obtained for 9 months. The patient is alive at present of 43 months after surgery without any other site of the disease, and his quality of life is well maintained. Stereotactic radiotherapy showed an excellent local therapeutic effect without any serious complications, suggesting that this is a potent modality for isolated liver metastasis of gall bladder carcinoma.

[S-1 treatment for elderly patients over 75 years with gastric cancer].

BACKGROUND: In our hospital, the starting dose of S-1 for patients over 75 years of age with advanced gastric cancer was determined by body surface of area, creatinine clearance, performance status(PS)and the presence of complications. The objective of this retrospective study was to investigate the proper administration of S-1 in elderly patients by comparing patients given a standard dose of S-1 to those given a reduced dose. METHODS: Twenty patients participated. Six patients were administered S-1 at a standard dose(standard group)and fourteen patients with at a reduced dose(reduced group). Safety, feasibility and anti-tumor effects were assessed. RESULTS: Three cases of grade 3 adverse events were found in the standard group, and one case was found in the reduced group. Time to treatment failure was 4. 4 months for the standard group and 8. 2 months for the reduced group. The overall response rate was 25% in the standard group and 30% in the reduced group. CONCLUSIONS: It is important to reduce S-1 administration to patients over 75 years of age with caution, and take into account the patient's renal function, PS and Ccr complications.