Kazuhiro Hiramatsu

Neoadjuvant Oxaliplatin and Capecitabine and Bevacizumab without Radiotherapy for Poor-risk Rectal Cancer: N-SOG 03 Phase II Trial

OBJECTIVE This Phase II trial was designed to evaluate the safety and efficacy of neoadjuvant oxaliplatin and capecitabine and bevacizumab without radiotherapy in patients with poor-risk rectal cancer. METHODS Patients with magnetic resonance imaging-defined poor-risk rectal cancer received neoadjuvant oxaliplatin and capecitabine and bevacizumab followed by total mesorectal excision or more extensive surgery. RESULTS Between February 2010 and December 2011, 32 patients were enrolled in this study. The completion rate of the scheduled chemotherapy was 91%. Reasons for withdrawal were refusal to continue therapy in two patients and disease progression in one, with two of these three patients not undergoing surgery. Among the 29 patients who completed the scheduled chemotherapy, one refused surgery within 8 weeks after the completion of chemotherapy, which was the period stipulated by the protocol, and another had rectal perforation, requiring urgent laparotomy. As a result, the completion rate of this experimental treatment was 84%. Of the 30 patients who underwent surgery, the R0 resection rate was 90% and a postoperative complication occurred in 43%. A pathological complete response was observed in 13% and good tumor regression was exhibited in 37%. CONCLUSIONS Neoadjuvant oxaliplatin and capecitabine plus bevacizumab for poor-risk rectal cancer caused a high rate of anastomotic leakage and experienced a case with perforation during chemotherapy, both of which were bevacizumab-related toxicity. Although the short-term results with the completion rate of 84.4% and the pathological complete response rate of 13.3% were satisfactory, we have to reconsider the necessity of bevacizumab in neoadjuvant chemotherapy (UMIN number, 000003507).

Conversion Chemotherapy Using Cetuximab plus FOLFIRI Followed by Bevacizumab plus mFOLFOX6 in Patients with Unresectable Liver Metastases from Colorectal Cancer

Recently, in patients with unresectable colorectal liver metastasis, liver resection sometimes becomes possible by intensive systemic chemotherapy, i.e. conversion therapy. However, among cases that do not respond well to first-line chemotherapy, it is rare that second-line chemotherapy results in a marked response allowing liver resection. We consider that the liver resection rate may be increased by initiating second-line treatment at an earlier stage before progression subsequent to first-line chemotherapy. We are conducting a multicentre Phase II study to evaluate the efficacy and safety of sequential chemotherapy using six cycles of cetuximab plus FOLFIRI (5-fluorouracil, folinic acid and irinotecan) followed by six cycles of bevacizumab plus FOLFOX (5-fluorouracil, folinic acid and oxaliplatin) as conversion chemotherapy. The primary endpoint is the liver resection rate during the bevacizumab + FOLFOX phase. Fifty patients are required for this study.

A case of gastric glomus tumor resection using laparoscopy endoscopy cooperative surgery (LECS)

Highlights • Glomus tumors are rare submucosal tumors of the stomach, and they are resembling other gastric submucosal tumors.• Immunohistochemical studies are necessary for the diagnosis of gastric glomus tumor.• We present a case of gastric glomus tumor that was removed by laparoscopy endoscopy cooperative surgery (LECS).

Phase II trial of neoadjuvant chemotherapy with S-1 and oxaliplatin plus bevacizumab for colorectal liver metastasis (N-SOG 05 trial)

Purpose This Phase II trial evaluated the safety and efficacy of neoadjuvant chemotherapy (NAC) with S-1 and oxaliplatin (SOX) plus bevacizumab (Bev) in patients with colorectal liver metastasis (CRLM). Methods Patients with initially resectable CRLM received four cycles of SOX plus Bev as NAC. We adopted the R0 resection rate as the primary endpoint, and the threshold R0 resection rate was set at 80%. Results Between December 2010 and August 2014, 61 patients were enrolled in this study and all started NAC. The completion rate of NAC was 82.0%. Three patients (4.9%) developed severe liver dysfunction caused by NAC and one patient finally decided against resection. Three patients (4.9%) were judged as having progressive disease during or after NAC and did not undergo liver resection. Among 57 patients who underwent liver resection after NAC, three patients were diagnosed with CRLM by pre-treatment imaging modalities and received NAC although a final pathological diagnosis was another malignant disease or benign condition. Finally, 47 of the 54 patients (87.0%) with resected CRLM achieved R0 resection. The pathological complete response rate of the 54 patients was 13.0%, and 31.5% were judged as pathological responders. However, the R0 resection rate of 77.0% in the entire cohort did not meet the endpoint. Conclusions NAC with SOX plus Bev has an acceptable toxicity profile and achieved a satisfactory pathological response. However, accuracy of pre-operative diagnoses and liver dysfunction caused by NAC were serious problems. Easy introduction of NAC for initially resectable CRLM should not be performed.

Presence of Aberrant Anatomy Is an Independent Predictor of Bile Duct Injury During Cholecystectomy

The aim of this study is to investigate the impact of an aberrant anatomy diagnosed with MR cholangiography on the occurrence of bile duct injury. Although many authors report that aberrant anatomy is a strong risk factor for the occurrence of bile duct injury during cholecystectomy, no reports have examined the incidence of aberrant anatomy and its association as an independent risk factor for bile duct injury while controlling for potential confounding factors. This study involved 1289 patients. All images of MR cholangiography were reviewed and the findings, including the presence of aberrant anatomy, thickening of the gallbladder wall, and cystic duct stones—which may be related to the occurrence of bile duct injury—were recorded. The surgical outcome was compared according to the presence or absence of an aberrant anatomy and the predictive factors for bile duct injury were investigated. Aberrant anatomy was present in 11.2% of cases. The incidence of bile duct injury was significantly higher in pati...

Sewing needles in the abdominal cavity assumed to have been ingested and to have penetrated the GI tract 40 years ago: A case report: Needles that penetrated gut long ago

A 60‐year old woman had been hospitalized in a psychiatric hospital for 40 years for schizophrenia. An X‐ray was performed when she fell, which showed needles in the abdominal field. After additional examinations and questioning, the patient was diagnosed with needles in the abdominal cavity, which were assumed to have been ingested and to have perforated the GI tract 40 years ago. They were removed by laparoscopic surgery. The needles were found in the omentum and near the left ovary. There were no inflammatory reactions around them. There have been previous reports about the removal of intra‐abdominal foreign bodies, but foreign body reaction occurred in most of the reports. Our case had the longest period from ingestion of the foreign bodies to their removal. Laparoscopy and intraoperative fluoroscopy are useful for removing intra‐abdominal foreign bodies because of their ability to help discriminate between structures and to navigate in real time.

Two Cases of Refractory Enterocutaneous Fistula which were Treated Effectively with Somatosatin Analogue and Proton-Pump Inhibitor

ソマトスタチンアナログ (サンドスタチン® somatostatin analogue; 以下, SMS)とプロトンポンプインヒビター (proton pump inhibitor; 以下, PPI)の併用が有効であった難治性消化管皮膚瘻の2例を報告する. 症例1は87歳の女性で, 上腹部痛を主訴に当院を受診した. 十二指腸潰瘍穿孔による汎発性腹膜炎と診断され, 充填術が施行された. 第2病日より充填部のドレーンより消化液の排液を認め, 難治性十二指腸皮膚瘻となった. SMSの投与に加え, PPIも併用すると排液量は急速に減少し, SMS投与後19日目に瘻孔は閉鎖した. 症例2は65歳の男性で, 上行結腸癌の診断で結腸右半切除術が施行されたが, 第10病日にドレーン内容が混濁し縫合不全と診断された. 第12病日よりドレーン部とは別の正中創より消化液の排液を認め, 難治性回結腸吻合部皮膚瘻となった. SMSの投与に加え, PPIも併用すると排液量は急速に減少し, SMS投与後11日目に瘻孔は閉鎖した.

A Case of Lymphangioma of the Duodenum.

十二指腸リンパ管腫はまれな疾患で本邦では1965年から16例の報告があるのみである.今回われわれは特徴的な肉眼所見を呈した十二指腸リンパ管腫の1例を経験したので報告する.症例は45歳の女性で, 胃集団検診で異常を指摘され精査目的で当院を受診した.低緊張性十二指腸造影検査, 胃内視鏡検査にて十二指腸第2部に中心陥凹を伴う隆起性病変を認め, 肉眼的には表面が透明, 平滑で光沢があり, その下に黄色, 小結節集族様の腫瘍本体を透見できた.同部の生検ではリンパ管腫が疑われた.十二指腸部分切除術にて腫瘍を摘出し, 病理組織学的に海綿状リンパ管腫と診断された.自験例を含めた本邦報告17例を検討し, 若干の文献的考察を加えて報告した.