[A Case of Unresectable Advanced Lower Esophageal Adenocarcinoma That Achieved Pathological Complete Response after Conversion Surgery following Nivolumab plus SOX Therapy].

An 80-year-old woman presented with epigastric discomfort and dysphagia, underwent upper gastrointestinal endoscopy, and was diagnosed with type 2 advanced lower esophageal adenocarcinoma. Computed tomography data revealed that there was the lower esophageal tumor is T3, but a large carina lymph node invading the left bronchus. We diagnosed this patient unresectable cT4bN1M0, cStage ⅣA advanced esophageal adenocarcinoma, and we administered nivolumab plus S-1 plus oxaliplatin(SOX)therapy. After 3 courses of the therapy, imaging showed marked reduction in the size of primary tumor and carina lymph node. We diagnosed partial response(PR)and attempted conversion surgery. Video-assisted thoracoscopic esophagectomy with 2 fields lymphadenectomy was performed. The pathological examination demonstrated no residual tumors and no lymph node metastases, and the histological response of primary tumor was determined to be Grade 3, with a pathological complete response(pCR). Currently, the patient is alive without recurrence for 1 year after surgery.

Peritonitis caused by group A streptococcus: A case report and literature review.

BACKGROUND: Group A streptococcus (GAS) occasionally causes life-threatening infections. We encountered a case of GAS peritonitis associated with bilateral salpingitis. CASE PRESENTATION: A 56-year-old previously healthy woman suddenly experienced a fever of 40 °C and lower abdominal pain, and was taken to the emergency room. She exhibited a condition of severe sepsis with pan-peritonitis. Although an intra-peritoneal source of infection was not detected preoperatively, an exploratory laparotomy was performed at 3 h after her arrival. During the surgery, bilateral salpingitis was observed. Peritoneal drainage was performed. Meropenem was administered and she was extubated on the next day. GAS was detected in the vaginal fluid culture and ascitic fluid culture. Antibiotics therapy was completed on postoperative day 9 and the patient was discharged on day 10 without any complications. METHODS: A literature review was performed using the following algorithm: "(group A streptococcus OR streptococcus pyogenes) AND (peritonitis)". All case reports and case series published in English after 1990 were reviewed. RESULTS: Fifty-six reports including 65 cases were eligible. There was a strong sex difference, with 80% of cases being female. All patients had symptoms of peritonitis, 80% had high-grade fever, and 74% had shock. The average time from onset to start of treatment was 3.8 days. Abdominal surgeries were required in 80% of cases. Multiple organ failure developed in 23%, and the mortality rate was 4.6%. DISCUSSION: GAS peritonitis is a rare but life-threatening disease. Emergency surgical exploration and drainage are required to prevent progression to multiple organ failure.

[A Case of Early Ascending Colon Cancer Complicated the Mesenteric Phlebosclerosis Who Underwent Laparoscopic Subtotal Colectomy].

A 71-year-old woman who have been taking Sanshishi for 50 years until the age of 70 for dermatitis underwent colonoscopy( CS)to reveal the reason of abdominal pain. CS showed ascending colon tumor(AT)with major axis 3 cm and suspicious of the mesenteric phlebosclerosis. Although endoscopic submucosal dissection(ESD)was performed for AT, colon perforation due to colonic wall fibrosis was occurred and ESD was suspended. Therefore, surgical resection was planned. Intraoperative observations by laparoscopy showed that the color of colon serosa from the cecum to the splenic flexure was grayish white and colonic wall thickening with lead tubular change was observed. From the descending colon to the sigmoid colon, wall thickening was mild, and Haustra was confirmed. Although the tumor location was in the ascending colon, laparoscopic subtotal colectomy and functional end-to-end anastomosis of ileum and sigmoid colon was performed for safe intestinal anastomosis. For treat of colon cancer complicated mesenteric phlebosclerosis(MP), endoscopic resection is considered difficult due to fibrosis and extended resection of the colon may be required to reduce the risk of anastomotic leakage. Herein, we report our case and details of past reported literatures.

[Two Cases of Locally Advanced Lower Rectal Cancer with Pathological Complete Response after Cetuximab plus SOX as Neoadjuvant Chemotherapy].

We have introduced neoadjuvant chemotherapy(NAC)for locally advanced lower rectal cancer(LARC)since 2014. We report 2 LARC cases in which a pathological complete response(pCR)was obtained by using cetuximab(Cmab)plus oxaliplatin plus S-1(SOX)for NAC. Case 1: A 68-year-old woman underwent 4 courses of Cmab plus SOX for Rb rectal cancer (well-differentiated adenocarcinoma, cStage Ⅲc: cT4b[vagina]N3M0). Lap posterior pelvic exenteration was performed. The pathological findings of the resected specimen revealed no carcinoma and we diagnosed it as pCR. As of 31 months after the operation, she is alive without recurrence. Case 2: A 72-year-old man underwent 4 courses of Cmab plus SOX for middle and lower rectal cancer(Rab, moderately differentiated tubular adenocarcinoma, cStage Ⅲc: cT3N3M0). After NAC, with the diagnosis of ycT3N0M0, laparoscopic-assisted(Lap)super-low anterior resection with bilateral lateral pelvic node dissection was performed. The pathological findings of the resected specimen revealed no carcinoma and we diagnosed it as pCR. As of 37 months after the operation, he is alive without recurrence. NAC with Cmab plus SOX may be an effective treatment for LARC.

Management of incidentally detected idiopathic pneumoperitoneum: A case report and literature review.

INTRODUCTION: Pneumoperitoneum usually requires emergency surgery. Asymptomatic idiopathic pneumoperitoneum is a rare subgroup of pneumoperitoneum for which a management algorithm has not been established. PRESENTATION OF CASE: In an 88-year-old female patient, pneumoperitoneum was found incidentally by chest computed tomography during a periodic follow-up for sarcoidosis. Emergency admission was ordered for conservative treatment. Upper gastrointestinal endoscopy revealed edematous mucosa in the entire gastric vestibule. After being discharged on the 7th day, her clinical course was uneventful over 2 months of follow-up. DISCUSSION: The initial clinical manifestations of pneumoperitoneum are variable and range widely from asymptomatic to septic shock. The etiology of pneumoperitoneum in our patient implied a subclinical visceral perforation that resolved without treatment. We advocate an algorithm for the initial management of pneumoperitoneum according to the extent of peritonitis and impaired conditions. CONCLUSION: Incidentally found asymptomatic pneumoperitoneum does not always require intervention. Careful and repeated physical assessment with investigation of underlying etiology is important in the management of pneumoperitoneum.

[A Case of Recurrent Gastric Cancer with Durable Complete Response after Short-Term Nivolumab Therapy].

We report the case of a patient with recurrent gastric cancer that showed a complete response(CR)after short-term nivolumab administration. A 76-year-old woman was diagnosed with unresectable advanced gastric cancer(T4b, N+, M0, cStage ⅣA). The patient was administered 7 courses of SOX. Since the primary lesion was reduced significantly after the chemotherapy, radical gastrectomy was performed. Although postoperative adjuvant chemotherapy with weekly nab-PTX was performed, cancer recurrence occurred in the abdominal cavity, and another surgery was performed. However, complete resection was difficult to achieve. Postoperatively, chemotherapy was continued; however, CEA levels increased, and thus RAM+PTX was administered as second-line treatment. Stable disease was maintained for a while; however, disease progression occurred eventually. Thus, RAM+PTX was discontinued after 8 courses, and nivolumab was administered as the third-line treatment. However, due to the rapid deterioration of renal function, nivolumab could not be continued after 3 courses. After nivolumab discontinuation, CEA levels normalized and the image showed CR. Approximately 1.5 years have passed since then, with no report of recurrence without any treatment. Although nivolumab has been shown to be useful as a third-line treatment for unresectable advanced/recurrent gastric cancer, there are few reports demonstrating CR and none showing maintenance of CR after short-term nivolumab administration. Moreover, the rationale of continuing nivolumab is unclear once clinical CR is achieved. Our experience shows the feasibility of discontinuation of short-term nivolumab if CR is achieved.

[Two Successful Cases of Surgical Treatment of Reconstructed Gastric Tube-Bronchial Fistula after Esophagectomy for Esophageal Cancer by Pedunculated Latissimus Dorsi Flap].

We herein report 2 cases of successful surgical treatment of reconstructed gastric tube-bronchial fistulas caused by leakage after esophagectomy for esophageal cancer. One patient was a 56-year-old man who developed a reconstructed gastric tube-bronchial fistula, and the fistula was closed by conservative treatment. However, he developed pneumonia on postoperative day 117, and the reconstructed gastric tube-bronchial fistula was found to have recurred. Fibrin glue was endoscopically injected into the fistula, but this treatment was unsuccessful. The other patient was a 60-year-old man who developed a reconstructed gastric tube-bronchial fistula and severe pneumonia, and his condition did not improve by conservative treatment. We performed a reoperation for both patients using a pedunculated latissimus dorsi flap, and both patients recovered well.

[Introduction and PDCA-Management of a Liaison-Clinical Pathway with Cancer Patients after a Curative Operation].

Our hospital was appointed as an Osaka designated cancer care hospital in April 2012. At that time, we introduced the same liaison-clinical pathway with cancer patients after a curative operation in all of Osaka. Based on the management of the plan-do-check-act cycle, we found problems in the clinical pathway. These problems included the following: the clinical pathway was not known, was complicated, was troubling for patients, and not well understood by doctors. To solve these problems, we planned and carried out the following five measures. The first was public information, followed by practice processes, informed consent, patient referral documents, and clinical pathway investigation reports. We were able to promote the use of the liaison-clinical pathway by constantly improving these measures.

[A Successfully Treated Case of Central Venous Catheter-Related Suppurative Thrombophlebitis of the Right Jugular Vein to the Superior Vena Cava Associated with Esophageal Cancer].

A 63 year-woman was diagnosed with esophageal cancer (Mt. T4N2M0, c-Stage IIIC) after full examination. She underwent chemotherapy with 5-FU+CDDP (FP) through a central venous line (CV). She developed a fever of more than 40°C 15 days after the first course of chemotherapy. We removed the CV owing to suspicion of catheter-related bloodstream infection (CRBSI) and initiated treatment with antibiotics (CFPM). Even so, she experienced swelling from the right cervix to the precordium. We confirmed suppurative thrombophlebitis from the right jugular vein to the superior vena cava by CT and blood culture. After anti-coagulation therapy, venous thrombosis diminished and inflammation was cured. The patient continued to receive chemotherapy, underwent a bypass operation, and completed chemo-radiotherapy successfully while receiving anti-coagulation therapy.

Comparison of intratumoral heterogeneity of HER2 expression between primary tumor and multiple organ metastases in gastric cancer: Clinicopathological study of three autopsy cases and one resected case.

Intratumoral heterogeneity of HER2 expression in the metastatic foci of HER2-positive advanced gastric cancer remains unclear. In this study, we compared HER2 expression between primary and metastatic tumors in HER2-positive three autopsied cases and one resected case with multiple organ metastases by immunohistochemistry (IHC) and dual color in situ hybridization (DISH). All four cases judged positive (IHC3+) at the primary tumor tissues showed varying HER2 gene amplification (GA) status. One homogeneously HER2-positive autopsied case (Case 1) and one intratumorally heterogeneous positive resected case (Case 2) with high GA showed a homogeneous positive staining pattern in all the metastatic foci. One heterogeneously HER2-positive autopsied case (Case 3) with low GA showed a partially heterogeneous HER2 staining pattern in all the metastatic foci. In contrast, one heterogeneously HER2-positive autopsied case (Case 4) with equivocal GA showed a completely heterogeneous HER2 staining pattern in the metastatic foci. These results indicate that HER2-positive gastric cancers with low to high GA at the primary tumor show substantially homogeneous HER2 overexpression in the metastatic foci, whereas HER2-positive gastric cancers with equivocal GA expressed HER2 heterogeneously within the metastatic tumor, suggesting that metastatic foci of the latter HER2-positive cases would be potentially resistant to trastuzumab.

[A Case of Local Recurrence of Bile Duct Cancer Completely Responding to Chemoradiotherapy with S-1].

An 80-year-old man with common bile duct cancer was treated by pancreaticoduodenectomy with D2 lymph node dissection in October 2005. The patient presented with frequent episodes of bloody-mucous rectal discharge in July 2009. An abdominal CT demonstrated local recurrence at the hepatoduodenal ligament. We treated him with concurrent chemoradiotherapy (CRT) with single-dose S-1 chemotherapy. After 6 months, we diagnosed a complete response (CR) by follow-up CT. The patient was treated with S-1 for 3 years after the diagnosis of a CR. He is alive without disease 6 years after the diagnosis of the recurrence. Concurrent CRT with S-1 chemotherapy may be the therapy of choice for recurrence of bile duct cancer.

Preferential HER2 expression in liver metastases and EGFR expression in peritoneal metastases in patients with advanced gastric cancer.

BACKGROUND: Despite recent clinical trials, the sensitivity and resistance of metastatic gastric cancer to anti-HER2 and anti-EGFR therapy are still unclear. MATERIALS AND METHODS: To clarify the HER2 and EGFR expression status in the metastatic sites, we immunohistochemically compared HER2 and EGFR expression between primary and metastatic tumors from 52 gastric cancer patients with liver metastases and 85 patients with peritoneal metastases. RESULTS: The HER2 positivity rate of primary and metastatic tumors in patients with liver metastases, especially with intestinal-type histology (70.6 and 80.0 %, respectively), was significantly higher than in primary and metastatic tumors (22.4 and 16.4 %, respectively) in patients with peritoneal metastases. HER2 positivity of the primary tumor and liver metastases showed good concordance (87.5 %) in patients with liver metastases. In contrast, the EGFR positivity rate of metastatic tumors (70.1 %) in patients with peritoneal metastases was significantly higher than that of metastatic tumors (37.5 %) in patients with liver metastases. HER2 and EGFR expression tended to be mutually exclusive, and HER2/EGFR double-positive cases were rare in patients with liver or peritoneal metastases. In four such patients with HER2/EGFR double-positive primary tumors, the HER2- and EGFR-positive areas were separate, and corresponding liver metastasis was only positive for HER2 and peritoneal metastasis only positive for EGFR. CONCLUSION: These results indicate that HER2 and EGFR are preferentially expressed in the liver and peritoneal metastases, respectively, which would be potential targets for anti-HER2 and anti-EGFR molecular therapy in metastatic gastric cancer patients.

[Multiple hepatic metastases from colon cancer successfully treated with irinotecan and S-1 plus panitumumab as second-line therapy-a case report].

The patient was a 55-year-old man who had been diagnosed as having liver metastases (S3, S4, S5, S6, and S7) from sigmoid colon cancer in March 2010. In June 2010, he underwent sigmoid colon cancer resection, followed by local ablation therapy for the liver tumors( S4, S5, and S6) and hepatic segmentectomy( S3 and S7). Subsequently, adjuvant chemotherapy with S-1 and oxaliplatin( SOX) was initiated. After 6 courses, hepatic metastasis from colon cancer recurred. Thus, primary treatment with SOX plus bevacizumab for advanced metastatic colorectal cancer was initiated. However, progressive disease was diagnosed after 10 postoperative courses of chemotherapy, and therefore, chemotherapy with irinotecan and S-1 (IRIS) plus panitumumab was initiated as secondary treatment. Tumor marker levels reduced with this treatment, and diagnostic imaging indicated a partial response. We report herein a case of a patient who was successfully treated with IRIS plus panitumumab. This therapeutic regimen is useful as second-line treatment because it has the advantage of not requiring a pump for administration and treatment can be tailored to an individual patient's condition, for example, according to pathology and the patient's lifestyle needs.

[A case of effective neoadjuvant chemoradiotherapy with capecitabine for locally advanced sigmoid colon cancer].

A 60-year-old man was hospitalized for urodynia. Clinical examinations demonstrated a locally advanced sigmoid colon cancer with direct extension to the bladder, rectum, and pelvic wall. We considered that curative resection was not possible and performed temporary colostomy for fecal diversion. After colostomy, he was treated with neoadjuvant chemoradiotherapy(NACRT)for down staging. The radiation therapy was delivered with 45 Gy(1. 8 Gy/fraction; 5 days/week×5 weeks), and the concurrent chemotherapy was performed with capecitabine(825mg/m2 twice daily on radiotherapy days). CT scan confirmed a dramatic response with downstaging of the tumor following NA-CRT(clinical response, PR in the RECIST criteria). Invasion of the tumor to pelvic wall disappeared on CT scan, and[18F]fluorodeoxyglucose positron emission tomography( FDG-PET)failed to demonstrate any distant metastasis. We considered that the tumor was hence resectable and performed total pelvic exenteration(TPE)1 month after NACRT. A pathological examination of surgical specimens confirmed a R0 resection. The patient made an unremarkable postoperative recovery. He went on to receive adjuvant capecitabine chemotherapy, completing four cycles. He remains well and disease-free 10 months following surgery. NACRT with capecitabine appears effective even for unresectable locally advanced sigmoid colon cancer.

Feasibility and accuracy of second-look laparoscopy after gastrectomy for gastric cancer.

BACKGROUND: A better method for detecting early peritoneal progression is needed. This study evaluated the feasibility and accuracy of second-look laparoscopy for patients with gastric cancer treated using systemic chemotherapy after gastrectomy. METHODS: Second-look laparoscopy was conducted for patients who had no clinical evidence of distant metastases but had peritoneal metastases or positive peritoneal cytology results without visible metastatic disease at initial surgery, patients who underwent systemic chemotherapy over a 6-month period after surgery, and patients who had no clinical evidence of disease based on imaging study after completion of primary chemotherapy. RESULTS: Between November 2004 and April 2008, 21 patients underwent second-look laparoscopy. At the initial surgery, 13 of these patients underwent total gastrectomy and 8 patients underwent distal gastrectomy. One or two sheets of adhesion barrier were received by 18 patients. The median interval between initial surgery and second-look laparoscopy was 9.8 months (range, 6.6-17.5 months). All second-look procedures were completed laparoscopically, and no patients required conversion to laparotomy. None of the 21 patients experienced postlaparoscopy complications. Whereas 12 patients showed no pathologic evidence of disease, 9 patients showed disease at second-look laparoscopy. There was a significant difference in median survival between the groups with negative and positive results (p = 0.017). The median survival for the negative group has not been determined. All the patients in the positive group received further chemotherapy while showing a good performance status (PS). Six patients were PS 0, and 3 patients were PS 1. The median survival time for this group was 10.1 months. CONCLUSIONS: Second-look laparoscopy was a safe and promising approach to reassessment of peritoneal disease for patients with gastric cancer. The incidence of complications was low, particularly in this group of patients, all of whom had undergone prior gastrectomy.

[Evaluation of the preserved function of the remnant stomach in pylorus preserving-gastrectomy by gastric emptying scintigraphy].

This study evaluated the preserved function of the remnant stomach by gastric emptying scintigraphy 1 year postoperatively in 49 patients who underwent pylorus-preserving gastrectomy (PPG), and it investigated whether this examination method is a useful tool for evaluation. The residual stomach function was classified as rapid, intermediate, and delayed emptying types according to gastric emptying curves. Then, the relationships were examined between the gastric emptying types and postprandial symptoms, food intake status, body weight changes, and endoscopic findings. Seventy-three percent of the PPG patients were classified as belonging to the intermediate emptying type, and the remainder (27%) to the delayed type. The frequencies of complaints such as epigastric fullness, nausea, and vomiting were high in the delayed emptying-type patients. The intermediate emptying-type patients consumed larger amounts of food and gained more weight than the delayed emptying-type patients. In conclusion, gastric function was evaluated by gastric emptying scintigraphy in PPG patients. This method might be useful not only for evaluating the motor function of the remnant stomach, but also for predicting postoperative status. Although PPG is a function-preserving operation, it should be considered that a quarter of the patients showed delayed emptying type which related to poor quality of life.

Sequential endoscopic findings and histological changes of N-nitrosomethylbenzylamine-induced esophageal carcinogenesis in rats.

We performed a sequential endoscopic examination of esophageal carcinogenesis induced by N-nitrosomethyl-benzylamine (NMBA) in F344 rats. The endoscopic findings were consistent with the histological changes observed in the specimens obtained by a biopsy and/or an autopsy. Seven-week-old male F344 rats received a weekly subcutaneous injection of 0.5 mg/kg NMBA for 15 weeks. The first endoscopic change that was detected was redness of the musosa due to the dilatation of the submucosal blood vessels. Subsequently, the mucosal redness became obscure, and we observed a focal loss of the visible blood vessel network due to hyperkeratosis, followed by the appearance of plaque-like elevated lesions due to acanthosis. Then, smooth and irregular polyps appeared as a result of the development of papilloma without or with dysplastic potential, respectively. Finally, rough elevation appeared as a result of carcinoma in situ and invasive squamous cell carcinoma. The present endoscopic findings correlated closely with the histological changes, indicating that sequential fiberscopic examination may be useful for monitoring esophageal carcinogenesis.