Purpose: High preoperative visceral fat is reported to increase postoperative complications in patients with gastric cancer, and the occurrence of these complications is associated with a poor prognosis. In this study, we investigated the effects of high preoperative visceral fat on short and long-term postoperative outcomes for patients with gastric cancer. Materials and Methods: A total of 485 patients with advanced gastric cancer with p-T2 (MP) or deeper who underwent gastrectomy between April 2008 and April 2018 were included in the study. Before surgery, the visceral adipose tissue index (VAI) was calculated by dividing the area of visceral fat mass at the umbilical level on computed tomography by the square of height. A ROC curve for severe complications with Clavien-Dindo classification 3 or higher was used to calculate a cut-off value for VAI. Cases were then classified into high VAI and low VAI groups. Result: The high VAI group included 270 patients (55.7%). In multivariate analysis, high VAI emerged as an independent risk factor for severe complications in gastric cancer (OR 2.130, 95% CI 1.110–4.080, P=0.024). High VAI was also found to be an independent prognostic factor for overall survival (HR 0.508, 95% CI 0.363–0.711, P<0.001). Conclusion: Preoperative high VAI is a significant factor that contributes to increased postoperative complications, but improves long-term prognosis, in patients with gastric cancer.

A 66-year-old man underwent a medical examination for weight loss, dysphagia and dyspnea. He was diagnosed with unresectable esophageal cancer that had invaded the left main bronchus with para-aortic lymph node and multiple lung metastases. Esophageal bypass surgery using the Postlethwait procedure was performed because an esophago-bronchial fistula developed after chemotherapy. However, intractable anastomotic leakage via an ante-thoracic route occurred 14 days after the operation. Debridement, re-suture and pectoralis major myocutaneous flap repair were performed for this leakage. The postoperative course was uneventful and the patient has achieved long-term survival with improvement of his general condition and quality of life. This case shows the value of pectoralis major myocutaneous flap repair for anastomotic leakage after ante-thoracic esophageal bypass surgery.

Primary malignant melanoma of the esophagus (PMME) is a highly malignant disease with a poor prognosis. In recent years, immune checkpoint inhibitors such as anti-PD-1 antibody have been approved and experiences with this therapy have been described. The patient was a 75-year-old man with PMME in the lower thoracic esophagus. Subtotal esophagectomy was performed and the histopathological diagnosis was pT1b(SM1)N1M0 pStage II. During follow-up without adjuvant therapy, a recurrent tumor in the liver was detected on CT 14 months after surgery. Nivolumab was administered and the tumor decreased in size. Complete response (CR) was achieved after 18 cycles and the therapy was discontinued. There has been no recurrence in 20 months of follow-up after termination. This is the first report of a case of recurrent PMME after surgery for which CR was achieved with an anti-PD-1 antibody and maintained after termination of the antibody.

We herein report three surgically resected cases of esophageal gastrointestinal stromal tumor (GIST) using different treatment strategies. The first case was a 51-year-old man diagnosed with a small low-risk GIST, who underwent thoracoscopic enucleation of the tumor. The second case was a 77-year-old woman with a large GIST located in the lower esophagus, for which esophagectomy with reconstruction via a thoracoabdominal approach was initially required. After preoperative treatment with imatinib, transhiatal lower esophagectomy and proximal gastrectomy were successfully performed. The third case was an 84-year-old woman with a submucosal tumor at the esophagogastric junction, for which definitive diagnosis of GIST was not possible before surgery. Because the tumor increased in size, it was clinically suspected to be GIST and transhiatal lower esophagectomy and proximal gastrectomy were performed. Enucleation for a small low-risk esophageal GIST (case 1) and preoperative treatment with imatinib for a large esophageal GIST (case 2) can avoid invasive esophagectomy and reconstruction. A therapeutic strategy avoiding thoracic esophagectomy should be selected for treatment of esophageal GIST, based on the balance between surgical invasiveness and curability.

A 77-year-old man was diagnosed with gastric cancer and underwent robot-assisted total gastrectomy, D2 lymph node dissection, and Roux-en Y reconstruction. The histopathological diagnosis was pT4a (SE)N3aM0 Stage IIIB. CEA showed a temporary increase after three courses, but postoperative adjuvant chemotherapy with S-1 was ended without recurrence, with this decision made based on normal tumor markers and CT. Acute cholangitis and gallbladder stones were observed 26 months after gastrectomy, and thus, laparoscopic cholecystectomy was performed following conservative treatment. There were no specific findings in the gallbladder in preoperative CT or intraoperatively, but postoperative histopathological diagnosis revealed that the gallbladder had many nodules of metastatic gastric cancer. Thus, this case is a rare example of gallbladder metastasis of gastric cancer.

A 72-year-old man was diagnosed with gastric cancer by biopsy. CT showed no distant metastasis, but indicated hepatic and pancreatic infiltration of the primary tumor. Examination laparoscopy showed peritoneal dissemination metastasis: cT4b (liver, pancreas) N2M1H0P1bCY0, cStage IV, unresectable. The primary tumor was reduced in size and hemostasis was achieved by palliative radiotherapy (30 Gy/10 Fr) for tumor hemorrhage. After radiotherapy, fatigue appeared and performance status (PS) worsened, which made it difficult to introduce chemotherapy. Thereafter, the patient was placed on best supportive care. After starting steroid administration, PS improved with a reduction in fatigue, and oral intake became possible. In this case of unresectable advanced gastric cancer with hemorrhage and stenosis caused by the tumor, radiotherapy achieved hemostasis and release of stenosis, and successive concomitant steroids improved QOL at the end of cancer treatment.

Immune checkpoint inhibitors have attracted attention as new anticancer agents, but there are many reports of unprecedented immune-related adverse events. The patient was a 70-year-old male who received chemotherapy for unresectable gastric cancer due to para-aortic lymph node metastases. S-1+cisplatin and subsequent paclitaxel chemotherapy were ineffective, but the primary tumor and lymph node metastases were reduced after three courses of nivolumab. However, after four courses, the patient developed painful tense bullae on his whole body, which was diagnosed as bullous pemphigoid, an immune-related adverse event of nivolumab. The blisters were improved with discontinuation of nivolumab and starting of oral steroids. However, the primary tumor then regrew without distant metastases. Total gastrectomy was performed with para-aortic lymph node dissection as conversion surgery. A pathological examination revealed R0 resection of the primary tumor and a complete response for all metastatic lymph nodes. This case shows the effectiveness of curative resection for initially unresectable gastric cancer with appropriate control of adverse events of nivolumab.

A 63-year-old man was diagnosed with borderline resectable pancreatic tail cancer with peritoneal plexus invasion by endoscopic ultrasound-guided fine-needle aspiration (EUS FNA). Distal pancreatectomy with celiac axis resection was performed after neoadjuvant chemotherapy. Ten months after surgery, during adjuvant chemotherapy, a submucosal tumor appeared on the posterior wall of the body of the stomach, which had been the puncture route in EUS FNA. The gastric tumor was diagnosed as adenocarcinoma and total gastrectomy was performed. The diagnosis of the resected specimen was metastasis of pancreatic cancer caused by needle tract seeding because the immunohistological findings of the gastric tumor were consistent with pancreatic cancer, and the tumor was positive for a RAS gene mutation. Twelve metastases were found in the regional lymph nodes of the stomach. Two months after gastrectomy, numerous multiple liver metastases appeared, and four months later, the patient died of cancer. Needle tract seeding of pancreatic cancer is difficult to prevent even with neoadjuvant or adjuvant chemotherapy. EUS FNA for pancreatic cancer intended for resection with a puncture route outside the excision range should be performed with consideration of the risk of needle tract seeding.

A 37-year-old woman was admitted to our hospital for a detailed examination of ascites and a lower abdominal mass. Abdominal CT and MRI showed pleural effusion, ascites, a tumor in the descending colon, and a right ovarian tumor. The patient was diagnosed with descending colon cancer by total colonoscopy. Resection of the descending colon and right oophorectomy were performed under a preoperative diagnosis of synchronous right ovarian metastasis from the descending colon cancer or the primary right ovarian tumor. A diagnosis of pseudo-Meigs syndrome due to synchronous ovarian metastasis from the descending colon cancer was made, based on the right ovarian tumor being immunohistochemically positive for CDX2 and disappearance of pleural effusion and ascites after surgery. Postoperative chemotherapy was performed for 36 months and the patient is alive 70 months after surgery without recurrence.

We report a case of a 67-year-old woman who presented with high fever and epigastric pain. Examinations had already shown serious disseminated intravascular coagulation (DIC). Colonoscopy revealed moderately differentiated adenocarcinoma of the sigmoid colon and FDG-PET/CT showed diffuse abnormal activity involving the entire skeleton．Disseminated carcinomatosis of the bone marrow from sigmoid colon cancer was the final diagnosis, and chemotherapy with modified FOLFOX 6 (mFOLFOX6) was immediately initiated. DIC promptly improved after one course of administration. Outpatient chemotherapy using panitumumab in combination with mFOLFOX6 was continued．The treatment was extremely effective，resulting in complete disappearance of all signs of cancer in FDG-PET/CT, including the primary lesion, lymph nodes and multiple bone metastases, after 12 courses, at 6 months after disease onset. This may be the first case to achieve a clinical complete response after chemotherapy for colon cancer with disseminated carcinomatosis of the bone marrow.