A successfully resected case of colorectal cancer with multiple liver metastases treated with FOLFIRI after failure of mFOLFOX6

A sixty-year-old man was admitted with anorexia and abdominal mass. Colonoscopy revealed type 2 tumor at sigmoid colon. Computed tomography (CT) demonstrated multiple liver metastases. The patient was diagnosed as sigmoid colon cancer with multiple liver metastases. The patient was treated with mFOLFOX6 as neoadjuvant chemotherapy because the liver metastases were unresectable. However, after 2 cycles of mFOLFOX6, the level of CEA and CA19-9 much increased. The regimen was replaced by FOLFIRI. The level of CEA and CA19-9 decreased after 2 cycles of FOLFIRI. CEA and CA19-9 further decreased and colonoscopy and CT revealed a partial response after 5 cycles of FOLFIRI. The patient was subjected to curative resection. Sigmoidectomy and liver resection were performed. Histological response was Grade 1b at liver metastasis. The patient was discharged and had an uneventful recovery. Six months after surgery, CEA and CA19-9 decreased to normal level, and the patient is free of recurrence. Neoadjuvant chemotherapy for metastatic colorectal cancer may render some unresectable patients resectable, affording these patients the possibility of prolonged survival. However, the optimal approach is unknown.     

A resected case of effective treatment with gemcitabine for advanced pancreatic cancer with peritoneal metastasis

We report a resected case of advanced pancreatic cancer after successful chemotherapy. A 69-year-old man with abdominal pain was diagnosed as locally advanced pancreatic tail cancer with peritoneal metastasis based on computed tomography (CT). Preoperative serum CA 19-9 was 5,046 U/mL. In the outpatient setting, gemcitabine (GEM) at a dose of 1,000 mg/m(2)was administered once a week for 3 weeks with a 1-week rest as 1 cycle. Abdominal CT scan after 5 cycles of chemotherapy revealed that ascites disappeared and the tumor dramatically shrank. Serum CA 19-9 also dropped to 12 U/mL. Thus, we considered the patient had a partial response, and performed distal pancreatectomy and splenectomy with D 3 lymph node dissection. Peritoneal seeding was not found and peritoneal washing cytology was negative. Histological examination of the primary lesion revealed a small amount of residual cancer cells. However, he died of peritoneal metastasis only 3 months after the operation. Surgical resection following chemotherapy should be performed carefully after close evaluation of the antitumor efficacy including residual isolated tumor cell for patients with previously distant metastases.     

Serial levels of CA 19-9 and CEA in colonic cancer

The use of serial carbohydrate antigen (CA) 19-9 assays was assessed by comparison with serial carcino-embryonic antigen (CEA) levels on the plasmas of 53 patients with colorectal carcinoma. The patients had all undergone resection for their primary tumors and in six instances subsequent resections for hepatic metastases. Initial CA 19-9 levels were greater than or equal to 37 U/mL in 22 of the 53 patients (41%) and in 68% of the patients with metastatic disease. Similar trends of serial CA 19-9 and CEA levels were found in 79% of the 53 patients. One patient with initially normal CEA levels had elevated CA 19-9 levels from the start. In ten of the 53 patients (19%), serial CA 19-9 levels remained low despite tumor recurrence or progression, and despite increasing CEA levels above 5 ng/mL. The increasing serial CEA trends predicted recurrence in 88% and increasing CA 19-9 trends in 50% of cases, which was increased to 70% by including trends of CA 19-9 levels below 37 U/mL. Following hepatic lobectomy, both serial CEA and CA 19-9 levels decreased rapidly. Used alone, serial CA 19-9 levels did not appear to be as sensitive as standard CEA in this retrospective study of selected patients.     

A case of gemcitabine-based chemo-radiation therapy for unresectable pancreatic cancer with liver metastases

We report a case of advanced unresectable pancreatic cancer with multiple liver metastases (cT4N x M1, stage IVb). The patient is a 68-year-old man. Serum DUPAN-2 was 15,800 U/mL. Abdominal CT scan revealed the body and tail of pancreatic cancer and multiple liver metastases. Chemo-radiation therapy (CRT) with GEM 1000 mg/body was given once a week on days 1, 8 and 15 for 3 weeks. The radiotherapy dose was 45 Gy (1.5 Gy x 2/day, 15 days). Hematological side effect such as anemia (grade 3) and thrombopenia (grade 2) appeared, but could be well controlled. Abdominal CT scan revealed no change in size, but serum DUPAN-2 decreased up to 4590 U/mL. After CRT, the patient was treated thereafter by the combination chemotherapy with GEM and S-1. After 7 months, CT scan revealed no change in tumor size.     

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 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.     

Prognostic study of preoperative serum levels of CEA and CA 19-9 in colorectal cancer

PURPOSE: Carcinoembrionic Antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9) are the most frequently used tumor markers in the clinical setting of colorectal cancer. The aim of this study is to evaluate the prognostic value of preoperative serum levels of CEA and CA 19-9 in colorectal cancer patients. METHODS: Serum levels of CEA and CA 19-9 were examined in 586 patients with colorectal cancer. Cut-off levels were calculated at reference value:<2.5 ng/mL (group A) versus >2.5 ng/mL (group B) for CEA and, <37 U/mL (group A) versus >37 U/mL (group B) for CA 19-9. RESULTS: According to tumor progression, each marker tended to show a higher level. Group A showed a significantly better prognosis than group B in both CEA and CA 19-9. In Dukes classification A, B and C, only CEA showed a better prognosis in group A than group B. At the time of recurrence compared to the pre-operative point, the CEA and CA 19-9 levels were significantly higher in both group A and B, however. In relation to the necessity of adjuvant chemotherapy (5-FU containing regimen) in Dukes A, the cases without adjuvant chemotherapy in group B of CEA showed a poor prognosis. CONCLUSION: The measurement of preoperative serum CEA and CA 19-9 is useful for prognostic prediction in colorectal cancer. Cut-off levels calculated at the reference value reflect the prognosis in this study. Especially, preoperative CEA reveals a potential high risk group in Dukes A which should be carefully treated by adjuvant chemotherapy to avoid recurrence.     

A case of salvage chemotherapy with gemcitabine hydrochloride and nedaplatin for gemcitabine-refractory pancreatic cancer

A 73-year-old woman with carcinoma of the pancreatic head underwent Whipple?s operation and intraoperative radiation therapy(20 Gy). After surgery, adjuvant chemotherapy with gemcitabine hydrochloride(GEM 1,000 mg every two weeks)was conducted. After 15 courses, the tumor marker CA19-9 gradually increased to 3,770 U/mL, and a supraclavicular lymph node metastasis(Virchow?s node)was detected. We selected the combination of GEM and nedaplatin(1,000 mg and 50 mg every two weeks, respectively)as salvage chemotherapy. After six courses of this nedaplatin/GEM combination, her CA19-9 level was markedly reduced to 657 U/mL and the lymph node metastasis disappeared. There were no adverse reactions. Combined nedaplatin/GEM therapy was continued for nine months(18 courses)until lung metastases occurred. This combination can be effective in some patients with GEM-refractory pancreatic cancer.     

Prognostic value of preoperative serum tumor markers in gastric cancer

AIM: To evaluate the prognostic value of preoperative carcinoembryonic antigen (CEA), carbohydrate antigen (CA)19-9, and CA50 in patients undergoing D2 resection.METHODS: We evaluated 363 patients with gastric cancer who underwent gastrectomy at our hospital from January 2006 to December 2009. Blood samples were obtained from each patient within 1 wk before surgery. The cut-off values for serum CEA, CA19-9, and CA50 were 5 ng/mL, 37 U/mL, and 20 U/mL, respectively. The correlation between preoperative tumor marker levels and prognosis was studied by means of univariate and multivariate analyses.RESULTS: The preoperative serum positive rates of CEA, CA19-9 and CA50 were 24.0%, 18.9% and 24.5%, respectively. The positivity rate of serum CEA was significantly correlated with age (P < 0.001), sex (P = 0.022), tumor size (P = 0.007) and depth of invasion (P = 0.018); CA19-9 with tumor size (P = 0.042) and lymph node metastasis (P < 0.001); and CA50 only with lymph node metastasis (P = 0.001). In multivariate analysis, tumor size, T category, N category, vascular or neural invasion, and adjuvant chemotherapy were independent prognostic factors for overall survival. CA19-9 had an independent prognostic significance in patients without adjuvant chemotherapy (P = 0.027).CONCLUSION: Preoperative serum CEA, CA19-9 and CA50 are prognostic in patients with gastric cancer. Only CA19-9 is an independent prognostic factor after surgery without adjuvant chemotherapy.     

60例进展期胃癌术中腹腔热灌注化疗的临床观察

目的:探讨术中腹腔热灌注化疗（CHPP）对进展期胃癌的疗效。方法:将60例进展期胃癌患者随机分为两组,常规行D2 根治术,根据术中是否应用腹腔热灌注化疗,随机分为腹腔热灌注化疗组（治疗组）和单纯手术组（对照组）,两组术后4 周均予以FOLFOX 4 方案静脉全身化疗12个疗程。测定患者手术前后外周血中CEA 和CA19-9 含量的变化,观察并比较患者术后生存和肿瘤复发情况。结果:两组60例胃癌患者术前外周血CEA 、CA19-9 均值高于正常参考值上限（55.89± 22.25μ g/L vs 0～5 μ g/L;125.35± 61.78U/mL vs0～39U/mL,P<0.01）;且术前治疗组与对照组外周血CEA 、CA19-9 均值的差异无统计学意义（54.67± 22.95μ g/L vs 56.09± 22.15μ g/L;126.16± 62.45U/mL vs123.35± 60.88U/mL,P>0.05）。 术后第7 天,治疗组患者血清CEA 、CA19-9 下降显著（7.58± 3.21μ g/L,31.35± 13.47U/mL,P<0.01）,对照组患者术后血清CEA 和CA19-9 下降缓慢（37.68± 20.59μ g/L,98.23± 36.28U/mL,P>0.05）。 术后第30天,两组患者的血清CEA 、CA19-9 均较术前有显著性差异（P<0.05）。 治疗组与对照组术后1 年生存率分别为83.3% 和80.0% ,两组差异无统计学意义（P>0.05）,3 年生存率分别为63.3% 和40.0% ,差异有统计学意义（P<0.05）;治疗组与对照组术后1 年肿瘤复发率分别为8.9% 和12.1% ,两组差异无统计学意义（P>0.05）,3 年复发率分别为21.6% 和43.5% ,两组差异有统计学意义（P<0.05）。 结论:手术联合 CHPP能够显著降低进展期胃癌患者的外周血CEA 和CA19-9 的含量,术中 CHPP有利于降低复发率和提高生存率。      

A case of unresectable hilar cholangiocarcinoma successfully treated by gemcitabine and S-1 combination chemotherapy

A 52-year-old male was presented with obstructive jaundice and liver dysfunction. He was diagnosed as hilar cholangiocarcinoma involving the confluence of the right and left hepatic duct and bifurcation of the main portal vein trunk. Swollen lymph nodes in the hepatoduodenal ligament were also detected. ERBD tubes were placed in each B2, 3, and 5 branch. GEM and S-1 combination chemotherapy was carried out for four months. As a reduction in the primary tumor and lymph nodes was observed on CT scan surgical exploration was conducted, and an extended left hepatectomy with partial resection of the portal vein and regional lymph node dissection was achieved. The postoperative course was uneventful, and the patient remained free of recurrence, 34 months after the original diagnosis was made, and 29 months after surgical resection. Thus, GEM and S-1 combination chemotherapy is one of the options for the management of advanced hilar cholangiocarcinoma.     

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.     

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 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.     

Marked effect of combination chemotherapy with tegafur-gimeracil-oteracil potassium and gemcitabine on a suspected case of pancreas cancer or gallbladder cancer metastasis to bone: further diagnosis of disseminated carcinomatosa of bone marrow recurrence after the 23 years of gastric cancer operation by autopsy findings

A 70-year-old woman who underwent proximal gastrectomy for gastric cancer (poorly-differentiated adenocarcinoma) of Stage IIIB at age 46 visited our hospital April 2004 because of exacerbated pain by movement in the buttocks since November 2003. She showed multiple bone metastasis by CT (computerized tomography). Pancreas cancer or gallbladder cancer was suspected by CT, and a high tumor marker score (CA19-9 18,625 U/mL, DUPAN-II 15,000 U/ mL elevations were acknowledged). Although her symptoms were severe with performance status (PS) 4, she was administered combination chemotherapy with gemcitabine and cisplatin. After 2 cycle therapy, her PS was improved to 2, but the tumor markers had elevated. So we changed the chemotherapy menu to S-1 and gemcitabine. Her tumor markers lowered and PS was improved to 1. There was a remarkable response to this chemotherapy, and the result of CT and bone scintigraphy suggested that her bone metastasis was improved. Because of hematologic relapse due to DIC at 1 year after the first treatment, she was readmitted to our hospital and later died. The autopsical result revealed recurrence of gastric cancer 23 years post-operatively.     

Two cases of pancreatic cancer with fairly good prognosis

We report two cases of advanced pancreatic cancer whose prognoses are fairly good with surgery and chemotherapy. Case 1: A 71-year-old male patient was diagnosed as pancreatic head cancer by abdominal ultrasound. The tumor size was about 2 cm in diameter. Whipple's procedure and regional lymphadenectomy were conducted. Pathological diagnosis was pT3N2 with s0 and rp1. Gemcitabine (GEM) was administered in a routine fashion at out-patient clinic. He is free of disease after three years and eight months. Case 2: A 63-year-old male patient was diagnosed as pancreatic head cancer although the mass was not so clearly visible by CT. Pylorus preserving pancreaticoduodenectomy was performed with D2 lymph node dissection. Pathological report was pT3N1 with s0 and rp0. GEM was started six months after the operation but continued for only six months. After the non-treatment interval of six months, GEM was restarted due to the sudden elevation of CA19-9. Soon the number dropped but instead of reaching normal range, it began to increase again. S-1 was added to the regimen which gave a great response. He is well after three and a half years. CA19-9 was almost being normal. Both patients had cancer within the pancreas without an invasion to the surrounding tissue. GEM is a standard regimen for adjuvant chemotherapy. However, S-1 may contribute to the outcome when GEM becomes powerless.     

A case of lung metastases after surgery for colon cancer demonstrating complete response for more than six years after treatment with UFT/LV

A 54-year-old female with cecal cancer underwent Rt. hemicolectomy in December 2000. The lesion was mod, ss, p1(+), n1, stage IV. The level of CEA increased around August 2002. Abdominal CT revealed a recurrent tumor in the RLQ in July 2003, peritoneal dissemination was suspected. In December 2003, we performed a partial resection of the ileum and transverse colon including initial anastomosis. Lung metastases were found by chest CT in right S4, S5, S9 and S3, S8 in February 2004. Because of experience of severe side effect of intravenous chemotherapy, UFT/LV was administered from February 2004. Chest CT revealed the disappearance of tumor in September 2004, and no signs of recurrence were observed for 65 months.     

A case of gastric cancer with multiple bone metastasis that responded to S-1 with low-dose cis-platinum

We report a patient with multiple bone metastasis who was treated successfully using S-1 and low-dose cis-platinum (CDDP). Metastasis was diagnosed 4 years after distal gastrectomy for early gastric cancer in a woman now 68 years old. Surgery was performed on February 9, 1999. The primary tumor was located in the midportion of the gastric body, and had invaded the submucosa with metastasis to lymph nodes in the area of the lesser curvature. She was discharged from our hospital 24 days after surgery. About 4 years after surgery, she experienced a backache and her CEA and CA19-9 levels had risen to 15.30 ng/mL and 996.5 U/mL, respectively. The results of an imaging examination were suggestive of multiple bone metastasis. Treatment with S-1+CDDP was started with the following regimen: daily oral administration of 100 mg/body/day S-1 for 14 days, followed by a 7-days rest and CDDP 20 mg/body infusion on day 1 and 8. Three months after initiation of therapy, the CEA and CA19-9 levels decreased 2.80 ng/mL and 36.8 U/mL, respectively. No severe adverse effects were observed with this therapy. The combination of S-1 and CDDP can be a good tool for the management of gastric cancer with bone metastasis.     

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.     

Which is the best monitoring study (tumor marker, computed tomography or 18F-fluoro-2-deoxy-D-glucose positron emission tomography) to evaluate efficacy of chemotherapy on unresectable pancreatic cancer ?

The objective of this study was to clarify the clinical features of long-time survivors with unresectable pancreatic cancer treated by gemcitabine(GEM)alone and to predict survival time by carbohydrate antigen(CA)19-9, enhanced computed tomography(CT), and 18F-fluoro-2-deoxy-D-glucose positron emission tomography(FDG-PET) in monitoring the response to chemotherapy. Twenty-one patients with unresectable pancreatic cancer were enrolled in this study. All patients were evaluated by serum CA19-9 level, tumor size of CT, maximum standardized uptake value (SUVmax)with FDG-PET and other factors before chemotherapy(GEM alone at a dose of 1,000 mg/m(2) weekly x 3 followed by 1 week of rest), and they received chemotherapy until obviously progressive disease. Serum CA19-9, tumor size of CT and SUVmax with PET were measured after three courses of chemotherapy in ten patients. We compared these three modalities in terms of two points: Which is the best modality to predict survival time ? Which is the best monitoring modality to evaluate the efficacy of chemotherapy on unresectable pancreatic cancer ? A significant difference in survival time was not found between high level group and low level group of serum CA19-9 level and SUVmax with FDG-PET and also longest length of tumor by enhanced CT. In ten patients we evaluated the response rate of each parameter CA19-9(IU/mL), CT(longest length of tumor), and SUVmax with FDG-PET. We defined the response rate(pretreatment level of CA19-9 or longest length of tumor or SUVmax-after 3 courses chemotherapy level of CA19-9 or longest length of tumor or SUVmax/pretreatment level of CA19-9 or longest length of tumor or SUVmax). Response rate of CA19-9 was significantly correlated with survival time(r=0.633, p=0.0481). However, the response rate of SUVmax with FDG-PET had no significant correlation with survival time(r=0.019, p=0.9630). In the present study, the response rate of CA19-9 is the best monitoring modality to evaluate the efficacy of chemotherapy.