A case of long-term survival after resection of aortic arch for locally advanced non-small cell lung cancer with induction chemotherapy

Our patient was a 57-year-old male with a history of esophageal cancer. He was referred to our hospital for squamous cell lung carcinoma(SCC). Chest computed tomography identified a mass in the left lung field, which was suspected to be invading the reconstructed gastric tube, left subclavian artery, common carotid artery, and distal aortic arch. He was diagnosed as primary pulmonary squamous cell carcinoma(SCC)because six years had already passed since a previous surgery for early esophageal cancer. He received three courses of induction chemotherapy including S-1/CDDP. We evaluated the therapy as a partial response. He underwent an extended resection of distal aortic arch and left subclavian artery with left upper lobectomy, and those vessels were reconstructed using prosthetic grafts. Pathological findings showed the tumor as a well differentiated SCC of pT4N0M0 at stage III A, with a residual tumor on the reconstructed gastric tube, even though the effect of induction chemotherapy was Ef2. He received three courses of S-1/CDDP after surgery. The patient has been well without recurrence for 31 months after surgery.     

A case of curatively resected locally advanced cancer of the pancreatic body treated by distal pancreatectomy with en bloc celiac axis resection after neoadjuvant chemotherapy

A 68-year-old man with locally advanced pancreatic body cancer invading the celiac axis(CA, including common hepatic artery)and in contact with the superior mesenteric artery(SMA)underwent 2 courses of neoadjuvant chemotherapy(NAC); gemcitabine hydrochloride(GEM 1,000 mg/m / / 2, on day 1 and 15)and S-1(100mg/m2day, 2-weeks of continuous administration followed by 1-week rest). The tumor volume and the contact area to SMA were greatly diminished. All tumor markers were reduced. He underwent R0 resection by distal pancreatectomy with en bloc celiac axis resection(DP-CAR). After the surgery, he could continue adjuvant chemotherapy; (GEM 1,000 mg/m2)only twice because of malnutrition. Nine months later CT revealed local recurrence and multiple lung metastases. The patient died 371 days after surgery. Appropriate NAC can contribute to R0 resection in locally advanced pancreatic cancer.     

A case report of port-site metastasis of pancreatic cancer after laparoscope assistted distal pancreatectomy

Laparosopic port-site metastasis is rare, but a well recognized outcome following surgery in gastroenterological surgery for gastric cancer, colon cancer and gallbladder cancer with its etiology was not clearly understood. We report a port-site metastasis of pancreatic cancer diagnosed by position emission tomography( PET). A 49-year-old man was diagnosed as splenic tumor with pancreatic tail invasion due to malignant lymphoma, and received a laparoscope assisted distal pancreatectomy. Unsuspected pancreatic cancer was discovered with histological result of moderate differentiated invasive ductal adenocarcinoma of the pancreas infiltrating spleen. Systemic chemotherapy with 1,000 mg/m2 of gemcitabine (GEM) was performed for six months. Unfortunately, our patients relapsed one year after the surgery with multiple lesions in the peritoneum, abdominal wall, as well as a laparoscopic port-site metastasis. He was started on 100 mg/body of S-1 daily, subsequently, combined chemotherapy with GEM( 80 mg/m2) and S-1( 80 mg/body) was also performed. Furthermore, he underwent palliative radiation therapy( 40 Gy) to care the pain. Fortunately, a long-term survival of 3 years was elicited by these systemic treatments and radiography. Laparoscopic port-site metastases are associated with presence of advanced cancer. Therefore, we should carefully precede a laparoscopic resection against pancreatic cancer.     

A case of complete response of gemcitabine (GEM) monotherapy-refractive liver metastatic pancreatic cancer treated with GEM+S-1 combined chemotherapy

A 75-year-old man with pancreatic body cancer underwent distal pancreatectomy and was treated with gemcitabine (GEM) as an adjuvant therapy. Multiple liver metastases appeared three months after the surgery. With GEM+S-1 combined chemotherapy, liver metastatic lesions became unidentifiable upon imaging 7 months later. Complete response status had continued as long as 13 months. Though grade 3 neutropenia appeared after 2 courses of the combined therapy, the patient well tolerated it after controlling the dosing schedule. The GEM+S-1 combined chemotherapy was expected to have synergistic effects for GEM monotherapy-refractive pancreatic cancer.     

A long-term survival case of unresectable malignant pancreatic endocrine tumor successfully treated with systemic chemotherapy

A 55-year-old man was admitted to our hospital because of high grade fever in October 1999. Computed tomography showed a solid tumor in the tail of the pancreas with multiple liver tumors. We diagnosed him as unresectable pancreatic tail cancer with multiple liver metastases at first, so systemic chemotherapy using UFT was performed. Gradually, liver metastases were slightly reduced, and tumor markers (CEA, CA19-9) decreased to the normal range. In April 2001, percutaneous transhepatic tumor biopsy was performed. Histopathological examination revealed a malignant pancreatic endocrine tumor. Long NC had continued by using the UFT regimen. But because tumors had gradually grown since October 2003, the chemotherapy with S-1 was followed by gemcitabine (GEM). The patient has now survived for 7.5 years while receiving the combined chemotherapy of S-1/GEM.     

Two cases of advanced biliary tract cancer successfully treated with gemcitabine combination chemotherapy

Case 1: A man in his sixties underwent extended right lobectomy of the liver for hepatic hilar cholangiocarcinoma (stage III, fCur B)in July2002. CT scans revealed cancerous pleuritis in March 2005, and he was treated with the chemotherapy of GEM alone as first-line, combined chemotherapy of S-1 and GEM as second-line, and CDDP and GEM as third-line treatment. These therapies have been effective for about 20 months. Case 2: A woman in her sixties was diagnosed with advanced gallbladder cancer(stage IVb)in September 2005. She was given combined chemotherapy of S-1+GEM as first-line, and CDDP+GEM as second-line treatment. The main tumor and metastatic lymph nodes were shrunk, allowing us to perform extended hepatectomy. Histopathologic examinations of the resected specimen of the liver involved by the tumor showed the increased infiltration of inflammatorycells and fibrosis. These patients have been managed on an outpatient basis with good QOL and cancer controlled. Although there has been no established standard regimen, the combined chemotherapy based on GEM will be a provisional standard regimen for patients with advanced biliarytract cancers.     

Two cases of curatively resected intrahepatic cholangiocellular carcinomas through effective response to neoadjuvant chemotherapy

Case 1:A 61-year-old man was diagnosed as cholangiocellular carcinoma with para-aortic lymph node metastasis (T4N1M0, cStage IV B). After 9 courses of chemotherapy using gemcitabine(GEM), CT scan showed that primary lesion and metastatic lymph nodes were reduced in size, and FDG-PET showed no FDG accumulation in the lymph nodes. The patient decided to continue additional chemotherapy with GEM and hyperthermia. Despite the chemo-hyperthermia, the primary tumor re-grew. He then underwent right trisegmentectomy, lymph node dissection, and reconstruction of the biliary tract. The final stage was T3N0M0, fStage III . Case 2: A 65-year-old man was diagnosed as cholangiocellular carcinoma with massive arterial invasion(T3N1M0, cStage IV B). After 3 courses of chemotherapy for GEM plus S-1, a CT scan revealed that the main tumor and metastatic lymph nodes were reduced in size, and he underwent extended left lobectomy of liver, lymph node dissection, and reconstruction of the biliary tract. The final stage was T1N0M0, fStage I . These cases indicated that neoadjuvant chemotherapy by gemcitabine was indeed promising for some cases of biliary tract cancer.     

A case of gemcitabine-based chemo-radiation therapy for locally advanced unresectable pancreatic cancer

A 49-year-old man was admitted to our hospital with vomiting. Abdominal CT revealed an avascular tumor at the uncinate process of the pancreas measuring 36x30 mm. Preoperative serum CA 19-9 was 361 U/ml. During laparotomy,the tumor was deemed unresectable (T4NXM0, Stage IVa),and duodenojejunostomy was performed. External-beam radiotherapy (EBRT) (50.4 Gy/28Fr) with concurrent twice-weekly gemcitabine (GEM) (40 mg/m(2)/day) was delivered. In the outpatient setting, and 1,000 mg/m(2) of GEM was administered intravenously on days 1, 8, and 15. Cycles were repeated every 28 days. The patient received 13 cycles of GEM chemotherapy until the appearance of a grade 2 facial rash. A decrease in tumor size was observed, and the serum CA 19-9 level dropped to 16 U/ml. He remained well without any symptoms and pursued normal activity for 33 months. He died of peritoneal dissemination 43 months after diagnosis. Gemcitabine-based chemo-radiation seems to be a safe and effective regimen for unresectable pancreatic cancer.     

A case of advanced pancreatic cancer treated with chemoradiation

A 56-year-old man is presented with diarrhea, which he had experienced since February 2004. He was diagnosed as having advanced pancreatic cancer by enhanced abdominal CT scan in May 2004. He was diagnosed with unresectable pancreatic cancer, and treated with a combination of radiation (3 Gy/day) and injections of gemcitabine (GEM) 1,200 mg/week (800 mg/m2, BSA 1.6). Abdominal CT scan revealed a minor response (tumor diameter 5.7 x 4.8 --> 5.2 x 4.4). Accordingly, the improvement of performance status and reduction in serum levels of arcinoembryonic/carbohydrate antigen 19-9 (CA19-9) were observed. In July 2004, chemotherapy and radiotherapy were switched to GEM+UFT (UFT 360 mg/day, a total of 4,320 mg, GEM 1,200 mg according to the body mass, a total of 2,400 mg). The patient's performance state was stable for 6 months but serum levels of CA19-9 increased from March 2005, and he complained of diarrhea and back-pain. Therefore, the combination chemotherapy with GEM and cisplatin (CDDP) was started in April 2005, but there was no clinical effect. GEM and TS-1 are currently being administered. Pancreatic cancer is one of the worst prognoses of any malignant disease. Although the prognosis of unresectable pancreatic cancer is very poor, we presented a case where performance status and survival benefits were obtained by undergoing chemoradiation with GEM and combination chemotherapy with UFT and GEM.     

Local recurrence of pancreatic cancer successfully treated with gemcitabine

We report a patient for whom systemic chemotherapy using gemcitabine was effective against local recurrence of pancreatic cancer. A 58-year-old man underwent pancreatoduodenectomy for a pancreatic head cancer. The diagnosis was Stage IVb poorly-differentiated tubular adenocarcinoma, scirrhous type, pT4, PL (+), P0, H0, pN2. However, after 21 months, gastrointestinal bleeding occurred. Gastroscopy and CT examination revealed a mass at the cut-end of the pancreas invading the stomach. The serum CA19-9 level was found to be elevated. Systemic chemotherapy was performed with a regimen of gemcitabine 1,000 mg/m2/week for 2 weeks, followed by a week rest. The recurrent tumor in the stomach disappeared, and the mass at the cut-end of the pancreas became small. The serum CA 19-9 level regained the normal value. Two years after the diagnosis of recurrence, he returned to work, and his chemotherapy is being continued as an outpatient.     

A case of advanced gastric cancer successfully treated with S-1 and paclitaxel followed by curative resection

A 59-year-old man diagnosed with Stage IV advanced gastric cancer due to pancreatic invasion(T4)and splenic hilum lymph node metastasis(N3)was initially treated with neoadjuvant chemotherapy using S-1 and CDDP. However, it was discontinued because the tumor marker increased after 1 course. Instead of S-1 and CDDP, S-1 and paclitaxel were then administered. After 4 courses, CT scan revealed reduced tumor size and the disappearance of splenic hilum lymph node swelling that indicated PR of the chemotherapy. Moreover, serum CEA was remarkably decreased to 77 ng/mL from 1,092 ng/mL. He could undergo subtotal gastrectomy(Billroth II)with lymph node dissection(D2)and cholecystectomy. Histopathological examination revealed Stage II (pT2(SS), pN1, CY0, ly1, v2)advanced gastric cancer that showed good effect of S-1 and paclitaxel. At this writing (October 2007), the patient has remained free of disease for more than 1 year and 6 months with good nutrition. Neoadjuvant chemotherapy using S-1 and paclitaxel for advanced gastric cancer seems to have been effective.     

A case of advanced pancreatic cancer successfully treated by combined chemotherapy of S-1 and gemcitabine as second-line chemotherapy

The patient was a 63-year-old man who suffered from advanced pancreatic cancer (T 4 N 3 M 0, Stage IVb). Palliative operation was performed for obstructive jaundice. He was treated with chemotherapy of gemcitabine (GEM) alone as first-line, and combined chemotherapy of GEM and S-1 as second-line. Both therapies were effective for this patient. Tumor marker (CA 19-9) decreased after chemotherapies (first-line: 5,692 U/mL to 70 U/mL, second-line: 4,877 U/mL to 562 U/mL). No toxic events were observed due to these therapies, so he was treated as an outpatient for about 2 years. It was considered that he had a good quality of life.     

A case of liver metastasis of pancreatic cancer that was resistant to S-1 and gemcitabine successfully treated by 5-FU and cisplatin hepatic arterial infusion

We report a case of postoperative liver metastasis of pancreatic cancer that was resistant to S-1 and gemcitabine (GEM) successfully treated by hepatic arterial infusion of 5-fluorouracil (5-FU) and cisplatin (CDDP). A 70s woman was referred to our hospital for treatment of a pancreatic head cancer in November 2007. Pancreaticoduodenectomy with a regional lymphadectomy was performed in December 2007 and the pathological stage was Stage IVa. Adjuvant chemotherapy of UFT was administered one month after operation. However, a second chemotherapy of S-1 was administered because DUPAN-2 levels showed a high range 8 months after operation. Ten months after operation, abdominal computed tomography demonstrated a 2 cm tumor in the liver. Although, we performed a systemic GEM infusion and a combination of GEM and S-1, the liver metastasis had progressed. Then, hepatic arterial infusion (HAI) chemotherapy of 5-FU/CDDP was instituted weekly. This efficacy maintained a Partial Response from the start of HAI to the fifth month. She is alive to date, maintaining a stable tumor growth of 30 months after surgery. We suggest that HAI chemotherapy of 5-FU+CDDP might be an effective treatment to liver metastasis of pancreatic cancer and prolong prognosis of those patients.     

A case of advanced pancreatic cancer responding well to S-1/gemcitabine combination therapy after gemcitabine therapy

A 71-year-old male with unresectable pancreatic cancer treated with gemcitabine (GEM) by another doctor came to our hospital because of stenosis of duodenum and hydronephrosis. There was peritoneal dissemination in his abdominal cavity, and gastro-jejunostomy was performed. After surgery, GEM therapy was continued until he was judged as PD. The regimen was switched to S-1/GEM combination therapy. After that, the tumor marker was down to within normal range, and abdominal symptoms improved. He is now being treated as an outpatient. S-1/GEM combination therapy is effective for patients with unresectable advanced pancreatic cancer.     

Treatments of pancreatic cancer from the standpoint of medical oncology

The early diagnosis of pancreatic cancer is difficult because of the lack of specific early symptoms,and surgery with curative intent can be performed in only 20% of patients. Chemotherapy for unresectable pancreatic cancer has been advancing ever since gemcitabine (GEM) was confirmed to provide a survival advantage in patients with advanced pancreatic cancer. For more than 20 years, the standard treatment for locally advanced diseases has been chemoradiotherapy using 5-FU, but more effective chemotherapy regimens are required. New standard treatments for locally advanced pancreatic cancer, including GEM chemotherapy and chemoradiotherapy using new agents, should be investigated. Several randomized clinical trials comparing GEM-based chemotherapy and GEM alone for the treatment of unresectable pancreatic cancer have been conducted, but a new standard chemotherapy regimen superior to GEM alone has not established. In Japan, phase II studies of S-1 or a combination of GEM and S-1 have produced promising survival rates, and a large phase III study using GEM and S-1 is necessary to establish the standard chemotherapy. Furthermore, second-line chemotherapy regimens for use after GEM chemotherapy should be investigated to improve the survival of patients with advanced pancreatic cancer.     

A 6-year survival case of locally advanced unresectable pancreatic tail cancer treated with chemo-radiation therapy

We report a case of locally advanced unresectable pancreatic tail cancer patient who survived over 6 years by chemo-radiation therapy (CRT). A 61-year-old male was pointed out by CT to have pancreatic tail cancer of 5.6 cm in diameter that invaded to the stomach, left kidney and adrenal gland, nerve plexus of celiac and superior mesenteric artery, was diagnosed as locally advanced unresectable pancreatic tail cancer. CRT of gemcitabine (GEM) with RT to a primary lesion was successful. After two years and 11 months, Schnitzler's metastasis appeared and RT was effective to recover from rectal stricture. At three years and 3 months, GEM was converted to S-1. After 4 years and 5 months, paraaortic lymph node metastasis was enlarged, so chemotherapy was changed to combination of GEM + S-1. After 4 years and 10 months, upper mediastinal lymph node metastasis appeared. At 6 years and 1 month, RT to upper mediastinum for pain control was performed. Finally, 6 years and 6 months after the first diagnosis, he died of pancreatic cancer. A long-term survival of locally advanced unresectable pancreatic cancer is very rare. In the case of pancreatic cancer that CRT is effective to the remission of primary lesion, CRT is potentially useful to perform for the control of metastatic lesion or palliative therapy.     

A case of locally advanced pancreas cancer effectively treated by multidisciplinary strategy

A 64-year-old female with a primary complaint of abdominal and back pain was diagnosed as locoregionally advanced pancreas cancer. She underwent distal pancreatectomy and received postoperative adjuvant chemotherapy of gemcitabine (GEM). Abdominal CT after 14 months showed a local recurrence without far organ metastasis. She was treated with radiation and the chemotherapy of S-1, which resulted in a stable control by a follow up CT. Then she is undergoing the combination chemotherapy of GEM and S-1. The patient is alive for 26 months after the operation.     

A case report of successful control of liver metastasis from duodenal cancer with combined S-1 and docetaxel chemotherapy

A 70-year-old man with abdominal pain and anemia was diagnosed with duodenal cancer upon upper gastrointestinal endoscopy and biopsy. Pancreatoduodenectomy was performed. Pathological findings were duodenal cancer, T 4 SI (Panc) N0P0V0A0H0. Three months after operation, abdominal CT showed multiple liver metastasis. He then underwent combined chemotherapy consisting of two weeks administration of S-1 (80 mg/body) followed by one week rest and injections of docetaxel (40 mg/body) every three weeks as one course. Metastatic tumors were gradually reduced and successfully controlled,and there was no other recurrence until he died about three years later of another illness. Combined S-1 and docetaxel chemotherapy is known to be effective for esophageal cancer, gastric cancer and other digestive cancer, as well as for duodenal cancer.     

A case of S-1-resistant resected advanced gastric cancer with para-aortic lymph node recurrence responding to bi-weekly CPT-11 and CDDP

A 64-year-old man with advanced gastric cancer who underwent a curative total gastrectomy(LM, Less, Type 3, 70×55 mm, por1>tub2>sig, pT3(ss), med, INF b, ly3, v3, pN3b(41/61), pPM0, pDM0, pT3N3bM0, Stage III B)followed by adjuvant chemotherapy(paclitaxel+S-1)a year ago, revealed an increasing level of serum CEA and para-aortic lymphnode (#16b1)recurrence on abdominal CT. He was given chemotherapy with low-dose weekday CDDP+S-1 for the recurrence, after which he failed to respond. Thereafter, he received 2nd-line chemotherapy with bi-weekly CPT-11+CDDP as a S-1- refractory regimen. 3 courses of the regimen reduced the serum CEA level accompanied by grade 3 of anemia. After recovery from the adverse event, another 4 courses at a 20% lower dosage for safety were administered. Complete response to the lymphnode was ensured on the abdominal CT with a reduced serum CEA level into the normal range. The patient has no signs of recurrence and has survived in fair condition for more than 5 years after the surgery. The combination treatment of biweekly CPT-11+CDDP can be a worthwhile regimen for patient with S-1-refractory recurrence of the resected advanced gastric cancer.     

A case of effective treatment with chemosensitivity test-guided chemotherapy for advanced pancreatic and gastric cancer with peritoneal metastasis

A 63-year-old man with abdominal pain was diagnosed as locally advanced pancreatic tail cancer and gastric cancer with peritoneal metastasis based on computed tomography (CT) and gastrointestinal series. Preoperative serum CA19- 9 was 1,357 U/mL. During laparotomy, peritoneal dissemination was observed and confirmed pathologically. An ileoileostomy was performed and peritoneal tissue was submitted to a chemosensitivity test. Based on the chemosensitivity test, CPT-11 (50 mg/body), 5-FU (750 mg/body), and Leucovorin (375 mg/body) were administered intravenously once a week for 3 weeks with a 1-week rest as 1 course. The patient received 9 courses of chemotherapy until progressive disease. Stable disease in tumor size was observed and serum CA19-9 level dropped to 81 U/mL. He remained well without any symptoms and pursued normal activity for 15 months. He died of peritoneal dissemination 26 months after diagnosis. Chemosensitivity test-guided chemotherapy seems to be an effective regimen as individualized chemotherapy for advanced pancreatic and gastric cancer.