Here, we report a long-term survival case treated with docetaxel and S-1 combination therapy(DS therapy)for peritoneal dissemination of gastric cancer. A 58-year-old man was diagnosed with gastric cancer in 2006. Distal gastrectomy, D2 dissec- tion, and RY reconstruction were performed. The pathological diagnosis was gastric cancer, por2, pT3(SS), pN3a(8/27), pStage ⅢB. S -1 monotherapy was administered as an adjuvant chemotherapy for 1 year from 3 months after surgery. Five years after surgery, peritoneal dissemination and bladder recurrence caused rectal stenosis and hydronephrosis. We performed ileostomy and left nephrostomy. DS therapy was started 5 years and 2 months after the initial surgery. A complete clinical remission was observed 2 years and 10 months after starting DS therapy(23 courses). Multiple lymph node metastasis and bone metastasis were confirmed at 5 years and 5 months(57 courses). Even though irinotecan monotherapy was performed for five courses, the bone and lymph node metastasis increased at 5 years and 9 months after starting DS therapy, and the patient died at 69 years of age. DS therapy may be a useful option for peritoneal metastasis of gastric cancer.

Case 1 was that of a 65-year-old woman. Radical esophagectomy was performed after neoadjuvant chemotherapy(NAC) for lower thoracic esophageal cancer. Nineteen months after surgery, local recurrence was indicated on the dorsal side of the descending aorta. After chemoradiotherapy(CRT)and chemotherapy, residual cancer with aortic invasion was diagnosed. Case 2 was that of a 64-year-old man. Radical esophagectomy was performed after NAC for middle thoracic esophageal cancer. Five months after surgery, local recurrence was indicated between the descending aorta and left inferior pulmonary vein. After CRT and chemotherapy, residual cancer with invasion of the aorta and left lung was diagnosed. In both cases, we inserted an aortic stent and safely performed residual cancer resection including the aortic adventitia. In summary, aortic stent insertion enables safe resection of local recurrent tumors in the aorta after radical esophagectomy.

An 82-year-old man receiving oral administration of warfarin for atrial fibrillation underwent distal gastrectomy for advanced gastric cancer. The postoperative diagnosis was pT3(SS)N2M1H1P0CY0, pStage Ⅳ,(HER2, score 3+)gastric cancer. He received chemotherapy for the treatment of multiple liver metastases, following which, he developed lymph node metastases. Grade 3 anemia was observed at 46 months after initiation of chemotherapy when he was treated with third-line irinotecan plus cisplatin. Abdominal CT showed that CR for liver metastases and SD for lymph node metastases were maintained. Esophagogastroduodenoscopy and colonoscopy showed no intraluminal bleeding. As the anemia progressed, blood transfusion was required repeatedly instead of withdrawal of chemotherapy and replacement therapy of iron and vitamin B12. Double- balloon endoscopy revealed hemorrhagic tumor at duodenal stump. We diagnosed tumor bleeding from metastatic lymph node around pancreatic head invading to duodenum. Palliative radiotherapy(40 Gy/20 Fr)for hemostasis was performed. Finally, hemostasis and tumor shrinkage were achieved.

We report a rare case of a resected recurrent lymph node on the posterior surface of the pancreatic head(lymph node No. 13)4 years after total gastrectomy. The patient was a 61-year-old man diagnosed with advanced gastric cancer. We performed total gastrectomy and splenectomy, after which histopathological analysis showed duodenal invasion and lymph node (No.17)metastasis. Because the pathological stage was Stage Ⅳ, he received chemotherapy(S-1 plus CDDP plus trastuzumab) for 1 year. Four years after primary surgery, lymph node(No.13)metastasis was detected on a CT scan. After 4 courses of chemotherapy(capecitabine plus CDDP plus trastuzumab), the size of the metastatic lymph node decreased. Subsequently, we performed surgical resection of the involved lymph node. Histopathological findings showed glanuloma and fibrous tissue without any remnant cancer.

A 67-year-old man was admitted to our hospital because of a type 2 tumor on the posterior wall of the cardia, and a biopsy resulted in a diagnosis of moderately differentiated tubular adenocarcinoma. Abdominal CT revealed swelling of the No. 1, 3, 11p(bulky N), and No.16a2lat lymph nodes. He was diagnosed with gastric cancer, T4aN2M1(LYM), cStage ⅣB, and was administered chemotherapy. After 2 courses of chemotherapy containing capecitabine plus cisplatin(XP), both the primary tumor and lymph nodes markedly decreased in size; then, total gastrectomy with D2+No.16a2lat was performed. Pathological examinations showed no residual cancer cells both in the primary lesion and lymph nodes; thus, the treatment effect of chemotherapy was Grade 3. Some gastric cancer patients may undergo curative resection even with extensive lymph node metastases when effective chemotherapy has been administered. Further discussions are needed about optimal chemotherapeutic regimens and surgical procedures.

We encountered a case of type 4 gastric cancer with esophageal invasion that responded to neoadjuvant chemotherapy containing S-1 and oxaliplatin(SOX)followed by surgery, which could be curative resection. A 46-year-old man was referred to our hospital because of abnormal upper gastrointestinal series findings. He was diagnosed with type 4 advanced gastric cancer with esophageal invasion, cT4b(diaphragm)N2M0, Stage ⅢC, and 3 courses of neoadjuvant SOX therapy were administered. Adverse events were minor. After NAC, the primary lesion and lymph nodes showed marked reductions on CT; total gastrectomy and subtotal thoracic esophagectomy were performed. The pathological response to NAC was evaluated as Grade 2 in the primary tumor and Grade 3 in the lymph node; overall, NAC showed considerable antitumor effects. The final diagnosis was ypT3N0M0P0CY0H0, StageⅡA, and was judged as curatively resected. Currently, we are continuing to administer adjuvant chemotherapy containing S-1.

We examined the influence of the sidedness of the primary tumor on survival of patients with colon cancer perforation. The subjects of this retrospective study were 52 patients who underwent surgery for colon perforation between April 2005 and December 2016 at our institution and survived more than 30 days. Patients with perforation of the oral side of the tumor were included. The background data and survival times were compared between 9 patients whose primary tumors were located in the cecum, ascending colon, or transverse colon(right-side group)and 43 patients whose primary tumors were located in the descending colon, sigmoid colon, or rectum(left-side group). There was no significant difference in terms of age, sex, Stage, or rate of chemotherapy, but Hinchey stage was significantly higher in the left-side group(p<0.05). The median survival time tended to be longer in the left-side group(68.2 months vs 21.2 months, p=0.05). These results suggest that right-side perforation might cause a poorer prognosis than left-side perforation in patients with perforative colorectal cancer.

We report a case of successful control of advanced duodenal cancer with paclitaxel chemotherapy. A woman in her 70s with epigastralgia was diagnosed with hemorrhagic duodenal ulcer upon upper gastrointestinal endoscopy. A type 3 tumor was found in the duodenal bulb upon upper gastrointestinal endoscopy and biopsy at our hospital. By contrast CT, we found wall hypertrophy of the duodenal bulb, lymph node metastasis, and liver metastasis and started chemotherapy. Four courses of SOX therapy were first administered. The wall hypertrophy of the duodenal bulb worsened, and new lesions appeared in the liver, so we diagnosed progressive disease. Next, 4 courses of wPTX therapy were administered. The wall hypertrophy of the duodenal bulb improved, and all liver metastatic lesions shrunk and became obscure. The reduction rate was 75%, so we diagnosed partial response. Accumulation in the primary tumor was observed on PET-CT, and the lymph node and liver metastases disappeared, so we considered radical curative resection. The patient underwent subtotal stomach preserving pancreatoduodenectomy, D2 lymph node dissection, reconstruction of the digestive tract by the modified CHILD method, partial hepatectomy, and Brawn's anastomosis. No cancer cells were found in the hepatectomized area. Paclitaxel chemotherapy may be useful for advanced duodenal cancer.

Here we report a case treated with conversion surgery combined with preoperative coil embolization of the hepatic artery after chemoradiation therapy for locally advanced unresectable pancreatic head cancer with hepatic artery invasion. A 63- year-old man was referred to our hospital for treatment of pancreatic cancer. Abdominal CT scan revealed a 30mm pancreatic head tumor with involvement of the common hepatic artery(CHA)and proper hepatic artery(PHA). The left hepatic artery diverged from the left gastric artery. Although S-1 with concurrent radiation therapy was performed, a follow-up CT scan revealed the progression of soft tissue shadow around the CHA. Subsequently, gemcitabine plus nab-paclitaxel(GnP)was administered 13 times. GnP helped achieve normalization of the tumor markers and long stable disease(SD)based on the Response Evaluation Criteria in Solid Tumors(RECIST). For the conversion surgery, embolization of the middle hepatic artery (MHA)was performed. Twelve days after, the right hepatic artery was embolized. Subtotal stomach-preserving pancreaticoduodenectomy was performed with resection of the CHA and PHA without arterial reconstruction 16 days after the hepatic arterial embolization. The patient was discharged from our hospital 33 days after surgery without complications related to hepatic ischemia. The patient is alive without recurrence 42 months after the initial diagnosis and 26 months after surgery.

We report a case of mediastinal lymph node recurrence of esophageal cancer after endoscopic submucosal dissection (ESD). We first administered chemotherapy and then performed esophagectomy. A 78-year-old man underwent ESD for early esophageal cancer at a different hospital in January 2015. H e was diagnosed pathologically with scc, pSM1, pHM1, pVM0, ly0, v0. Additional treatment was not administered because of his age. In June 2017, chest enhanced CT showed swollen mediastinal lymph nodes. This was diagnosed as a recurrence of esophageal cancer, and he presented at our hospital. We first performed chemotherapy for that lesion, because the swollen lymph node was large and may have invaded the surrounding organs. We then performed esophagectomy.

We report a rare case of esophageal carcinoma with gastric wall metastasis. A 73-year-old man with dysphagia underwent endoscopy and upper GI series and chest-abdominal computed tomography, revealing esophageal carcinoma and gastric cancer, which was diagnosed as squamous cell carcinoma by biopsy. The esophageal carcinoma was located in the lower thoracic esophagus(Lt). Total gastrectomy was performed. The resected specimen showed a type 3 tumor measuring 7×7 cm in the anterior wall of the stomach. Pathologically, the depth of invasion of the stomach was SE. He died 3 months after the operation. Esophageal carcinoma with gastric intramural metastasis is very rare and has a dismal prognosis. We report a rare case of esophageal carcinoma with large intramural metastasis to the stomach.

A 64-year-old man who suffered from colorectal cancer with multiple liver metastases underwent laparoscopic low anterior resection. He did not undergo partial liver resection. He was treated with mFOLFOX6 plus bevacizumab chemotherapy. The liver metastases had disappeared completely on Gd-EOB-DTPA(EOB)MRI after 6 courses of therapy with mFOLFOX6 plus bevacizumab. This chemotherapy was discontinued after 13 courses. At present, 86 months have passed since the laparoscopic low anterior resection. He is relapse-free and a long-term survivor.

We report a rare case of liver recurrence of gastric cancer 14 years and 3 months after curative gastrectomy. An 81-yearold man underwent total gastrectomy, D2 lymphadenectomy, Roux-en-Y reconstruction, and cholecystectomy for advanced gastric cancer in November 2002. H e was diagnosed pathologically with M, Type 5, 53×42 mm, tub2>tub1, pT4a, ly2, v2, pN1, pPM0, pDM0, M0, pStage ⅢA(JGCA 15th). Postoperative adjuvant therapy was not administered. He was followed up for 5 years after surgery without adjuvant therapy, and he did not exhibit recurrence. In February 2017, he experienced difficulties in swallowing and visited our hospital. Abdominal contrast-enhanced CT showed an 8×5 cm liver tumor in the lateral segment. Part of the tumor protruded to outside of the liver, and the tumor invaded and pushed the jejunum in the Roux limb. We performed liver biopsy and diagnosed him with liver metastasis of recurrent gastric cancer. Late relapse after gastrectomy, especially after 10 years or more, is very rare.

Regorafenib(Reg), a multikinase inhibitor proven to be effective against metastatic colorectal cancer(mCRC), is recommended for salvage-line treatment. There are some reported cases of treatment failure due to adverse events, and some reports that indicate prolonged overall survival(OS)following a reduction of the initial dose. Nevertheless, reports concerning the appropriate dose are lacking. Therefore, we evaluated the method of administration of various doses of Reg to patients with mCRC at our institute. We administered Reg to 25 patients with mCRC from April 2014. The patients were divided into the following dose groups: 160, 120, or 80mg/day for the initial treatment dose, administered orally once per day for the first 3 weeks of each 4 week cycle or for the first 2 weeks of each 3-week cycle. The patients were retrospectively analyzed for OS in each group. The median OS of all cases was 9.40 months. The median OS was 9.26 and 9.40 months for the 28-day and 21-day cycle groups(p=0.64), respectively, and 13.7, 9.40, and 17.6 months(p=0.564)for the 160, 120, and 80 mg groups, respectively. Our findings indicate that a lower dose of Reg suppressed severe adverse events and prolonged survivalin patients with mCRC.

We encountered a case of hepatic portal lymph node metastasis after repeated treatment for hepatocellular carcinoma (HCC)recurrence. A 73-year-old male patient underwent partial gastrectomy following rupture of a gastrointestinal stromal tumor 8 years ago. A 70mm tumor was simultaneously revealed in the posterior segment of the liver, and imatinib treatment was initiated based on the diagnosis of a metastatic liver tumor. Due to the absence of an increasing tendency in the tumor, extended posterior segmentectomy was performed, and the pathological diagnosis was moderately differentiated HCC. During observation, transcatheter arterial chemoembolization(TACE)plus radiofrequency ablation(RFA)therapy was performed twice, and partial resection of the liver was performed once again for HCC recurrence. Recently, PIVKA-Ⅱ showed a high value of 1,720mAU/mL, and follow-up computed tomography showed HCC recurrence in S4/8 and hepatic portal lymph node metastasis. TACE was administered for recurrent lesions in S4/8, and surgical resection of the hepatic portal lymph node was performed together. The pathological diagnosis revealed extensive liver tissue necrosis and moderately-topoorly differentiated HCC in the excised lymph nodes. Lymph node metastasis of HCC is rare, and in this case, a change in lymph flow caused by repeated treatment for HCC recurrence was considered a factor influencing the course.

We report a case involving a 65-year-old woman with skin invasion and destruction by left large breast cancer(T4cN0M0, Stage ⅢB). She had severe anemia with recurrent bleeding on the cancer surface and needed blood transfusion, and massive malodorous effusion from the skin lesion resulted in hypoalbuminemia and recurrent bacteremia. Metronidazole gel treatment for malodorous effusion and postmenopausal hormonal therapy were administered at first. After using Mohs' paste 4 times with 1- or 2-week intervals, the bleeding and effusion stopped, and the primary cancer tumor almost disappeared. Bacteremia also improved with antibiotics, and amelioration of distress was observed. Following this, systemic chemotherapy was performed. Mohs' paste was a very useful method for symptom management of malignant skin lesions with bleeding and massive effusion.

A 68-year-old man who had a history of bone marrow transplantation for acute myeloid leukemia was referred to our hospital due to an abnormal liver function test. Based on the clinical diagnosis of P-NET G2 with multiple livermetastases, pylorus-preserving pancreaticoduodenectomy with combined resection of the portal vein and liver sampling were performed (R2 resection). The resected specimen revealed NET-G2 tumorof the pancreatic head(Ki-67 proliferation index 5.0%)and hepatic metastasis(Ki-67 index 2.2%). Although CDDP/ETP(PE)and everolimus(AfinitorTM)regimen were started postoperatively, PE was discontinued due to bone marrow suppression. As the liver metastasis stayed SD for 4 months by everolimus single therapy, 6 hepatic metastases were resected for curative intent 5 months postoperatively. Thereafter, multiple liver metastases appeared 10 months after the metastasectomy. Everolimus single therapy was restarted. As the metastases were maintained SD for 4 months, repeat hepatectomy was performed for curative intent after right portal vein embolization. Multimodality therapy including repeat metastasectomy should be considered for selected patients with P-NET G2 with liver metastases for prolonged survival, if the operation can be performed with low perioperative morbidity.

We report a case of pelvic metastasis of rectal cancer that developed 10 years after curative resection. An 81-year-old woman underwent intersphincteric resection for lower rectal cancer 10 years previously. The tumor was pathologically diagnosed as T2N0M0, Stage Ⅰ. Nine years after the curative resection, serum carcinoembryonic antigen(CEA)levels were slightly elevated, but no recurrence was found on computed tomography(CT). Eleven months after CT, serum CEA levels elevated to 15.9 ng/mL. Pelvic metastasis in the piriformis muscle was detected on positron emission tomography(PET)-CT. Following CT-guided biopsy, she was pathologically diagnosed with metastatic rectal cancer. Radiotherapy (60 Gy/30 Fractions) was administered. Ten months after radiotherapy, PET-CT revealed no relapse in the pelvis with lung metastases.

According to the treatment guideline for rectal neuroendocrine tumor(NET), tumor with a diameter ofC10mm should be resected endoscopically, while tumor with a diameter of>10mm should be resected surgically with lymph node dissection. We experienced a case of a rectal NET with a diameter of 5mm with lymph node metastasis. A 69-year-old man underwent colonoscopy for positive fecal occult blood test. The colonoscopy revealed a submucosal tumor(SMT)with a diameter of 5 mm in the lower rectum. An endoscopic mucosal resection(EMR)was performed after SMT was diagnosed as NET by biopsy. Histopathological findings were NET-G1, 4.5×2.5 mm, v(+), ly(+). Then, laparoscopically assisted rectal resection with D2 lymph node dissection was performed. In histopathological examination, no tumor residue was observed in the specimu; however, a regional lymph node metastasis was detected. Risk factors of lymph node metastasis with rectal NET are a diameter of>10 mm, recessed or ulcerated surface, and lymphovascular invasion. However, we have to keep in mind that lymph node metastasis may occur even in small rectal NET with a diameter of ≤10mm.

A 50's woman referred to our hospital with high serum CEA level was found to have RAS-wild sigmoid colon cancer with a 15 cm size unresectable synchronous liver metastasis(LM)in the right lobe during the endoscopic, radiological, and immunohistological examinations. CapeOX was introduced, but the LM lesion enlarged to 18 cm after 2 courses. Therefore, the regimen was switched to FOLFIRI plus panitumumab. Six courses ofchemotherapy resulted in the reduction ofthe LM lesion to 11 cm, and the Response Evaluation Criteria in Solid Tumors revealed PR with no severe adverse effects, and curative surgical resection was planned. The patient underwent laparoscopic sigmoidectomy resection, followed by percutaneous transhepatic portal embolization(PTPE)ofthe right branch ofthe portal vein to secure the volume ofthe future remnant liver. Right lobectomy and partial resection ofsegment 4 ofthe liver and cholecystectomy was then performed. Currently, 28 months postoperatively, the patient continues to do well with no signs ofrecurrence. This case demonstrates that the sequential combination ofsystemic therapy with FOLFIRI plus panitumumab and PTPE enabled the curative surgical management ofthe sigmoid colon cancer with a large synchronous LM.