[A Case of Long-Term Remission with Surgical Therapy and Chemoradiotherapy for a Rapidly Increasing Large Cell Neuroendocrine Carcinoma(LCNEC)].

BACKGROUND: Large cell neuroendocrine carcinoma(LCNEC)is a relatively rare disease classified as a subtype of neuroendocrine tumor. LCNEC has clinical and histological similarities to small cell lung cancer, both of which have a similarly poor prognosis. There are also unclear points regarding treatment. CASE: 43-years-old, male. He had repeated intermittent fever from 1 month before the consultation. Cough appeared 4 days before the consultation, and the family doctor pointed out an abnormal shadow in the right lung field, and the patient was referred. Blood test showed increased CRP 1.34 mg/dL and mild inflammatory response. Chest CT showed an increased tumor with a major axis of 16 cm in the right thoracic cavity compared to 6 months ago. FDG-PET showed accumulation of SUVmax 11.83 in the same area. A CT-guided needle biopsy was performed, and although tumor cell hyperplasia of like a plasma cells was suspected, but most of them were coagulative necrotic images and could not be diagnosed. After hospitalization, fever continued and the general condition became poor, so surgery was performed for the purpose of diagnostic treatment. Preoperatively, Interventional Radiology was used to embolize the tumor-feeding blood vessels. Intrathoracic tumor resection and partial upper and lower lobe resection were performed under thoracotomy. Postoperative histopathological examination revealed that large round to polyhedron tumor cells proliferated in sheet-like or intercellular binding sparsely, and synaptophysin was positive, which was a diagnosis of large cell neuroendocrine cell carcinoma. The general condition improved promptly after the operation, and the patient was discharged 14 days after the operation without any complications. After discharge, 4 courses of adjuvant chemotherapy (CDDP plus CPT-11)were performed. Six months after the operation, the disseminated nodule recurred in the right thoracic cavity. Chemotherapy(CBDCA plus PTX plus BEV)and radiation therapy were performed and the patient was in remission. It has been 5 years since the operation and has not recurred. SUMMARY: We report a case of rapidly increasing LCNEC with long-term remission by surgical treatment and chemoradiotherapy, with some review of the literature.

Evaluation of additional gastrectomy after noncurative endoscopic submucosal dissection for early gastric cancer.

BACKGROUND: Performing additional surgery after noncurative endoscopic submucosal dissection (ESD) for early gastric cancer is controversial. Our aims are to clarify the risk factors for lymph node metastasis (LNM) and local residual cancer (RC) after noncurative ESD and to determine recommendations for additional treatment. METHODS: Of the 1483 patients who underwent ESD for early gastric cancer between January 2012 and April 2020, we retrospectively analyzed 151 patients diagnosed as having a lesion not meeting the curative criteria after ESD. Of these patients, 100 underwent additional gastrectomy, and 51 were observed without surgery. RESULTS: Surgical specimens showed LNM in 14 patients (14.0%) and local RC in 7 (7.0%). However, 81 patients (81.0%) had neither of these malignancies. Multivariate analysis revealed that a positive lymphatic invasion (P = 0.035) and an undifferentiated type (P = 0.047) were independent risk factors for LNM, whereas a positive horizontal margin (P = 0.010) was an independent risk factor for local RC. Furthermore, the prevalence of LNM was significantly higher in patients with both positive lymphatic and vascular invasions. In the additional gastrectomy group, 3 patients (3.0%) had recurrences, and 2 patients (2.0%) who had distant recurrences died of gastric cancer. In the observation group, recurrence was observed in 3 patients (5.9%). One patient (2.0%) who had liver metastasis died of gastric cancer. Of the 2 patients (3.9%) who had local recurrences, one underwent additional ESD, and the other without additional ESD died of other disease. The 5-year overall survival rates in the additional gastrectomy and observation groups were 87.4% and 73.8%, respectively (log-rank test, P = 0.008). CONCLUSION: Following noncurative ESD for early gastric cancer, we recommend an additional gastrectomy with lymph node dissection for patients with lymphovascular invasion and/or undifferentiated type. Careful follow-ups without additional surgery may be acceptable for patients with advanced age, severe comorbidity, or no lymphovascular invasion.

Liver Abscess and Prolonged Postoperative Intra-Abdominal Free Air without Anastomotic Leakage after Laparoscopic Gastrectomy.

An 84-year-old thin, i.e., body mass index of 17.8, woman with gastric cancer underwent laparoscopic distal gastrectomy and lymph node dissection followed by Roux-en-Y reconstruction. During the operation, Nathanson liver retractor (NLR) was used to press the left lobe of the liver. The patient recovered uneventfully and was discharged on the 9th postoperative day. The patient, however, developed abdominal pain just on the day of discharge. Sudden onset of the abdominal pain and massive free air on computed tomography made us do diagnostic laparoscopy. Detailed laparoscopic observation showed slight liver swelling at the pressure site of the NLR, superficial band-shaped color change on the left lobe of the liver, and no anastomotic leakage, suggesting the massive free air caused by prolonged retention of postoperative intra-abdominal air. Two days later, persistent fever, inflammatory findings, and presumed liver abscess showing no healing tendency made us do ultrasound-guided aspiration to the liver focus. Bacterial culture test showed the bacterium Escherichia coli, being sensitive to meropenem. Despite the failure of abscess drainage, antibiotic therapy using meropenem gradually alleviated her symptoms and the patient was discharged from the hospital in 15 days after the abscess aspiration. Surgeons should note possible prolonged postoperative intra-abdominal free air and liver abscess without anastomotic leakage after laparoscopic gastrectomy especially in thin patients to avoid inappropriate postoperative management.

Successful Enucleation of Intra-Nipple Recurrence of Breast Cancer.

A 36-year-old unmarried woman had undergone nipple-preserving mastectomy and immediate breast reconstruction using extended latissimus dorsi muscle flap for her left breast cancer. During adjuvant endocrine therapy, the patient sometimes developed faint bloody nipple discharge with negative cytological results. More than 9 years after operation, the patient developed left nipple swelling with evident bloody nipple discharge. A small tissue, spouted from the single duct orifice of the nipple by manual compression, showed atypical cells growing in papillary fashion, leading to the diagnosis of intra-nipple recurrence. Based on both the strong request from the patient and high probability of noninvasive nature of the recurrent cancer, we tried to enucleate the intra-nipple recurrence. In the operation, we first threaded the nipple skin at the affected duct orifice of the nipple, second incised the nipple with horizontal skin incision between the bilateral edges of the left areola via a small spindle skin resection just around the affected duct orifice, third threaded the intact lateral nipple skin for countertraction, and finally enucleated the intra-nipple recurrence. After completely enucleating the recurrent focus without any macroscopic cancer residuals in the nipple, we reproduced the nipple into the original shape, resulting in excellent cosmesis without any nipple necrosis. Histological study showed the intra-nipple recurrence to be noninvasive papillary cancer. Approximately a quarter of the main tumor and a small part of one ductal spread focus were pathologically exposed but were present without any missing boarders, suggesting complete resection of the intra-nipple recurrence. This is the first case of intra-nipple recurrence of breast cancer successfully enucleated without any complications.

Unilateral Axillary Lymphadenopathy due to Toxoplasmosis: A Ubiquitous Infectious Disease Important for Differential Diagnosis of Solid Malignancies.

A 30-year-old woman was pointed out for her right axillary lymphadenopathy in a medical checkup. Ultrasonography showed two swollen lymph nodes and the presence of lymph node hilum with a convex shape in the larger lymph node. Under the tentative diagnosis of lymphadenitis, the patient was initially treated with antibiotic therapy, leading to no improvement in her lymphadenopathy for 1 month. Positron emission tomography after antibiotic therapy showed a maximum standardized uptake value of 7.0 in the swollen lymph nodes without any other avidities. Neither mammography nor ultrasonography showed any abnormalities in the breasts. The serum IL-2R level was within the normal range. Despite the lack of malignant cells in the aspiration biopsy cytology specimen, the patient received lymph node excisional biopsy to avoid undertreatment. A postoperative pathological study showed a swollen lymph node with preserved lymph node structure, follicular hyperplasia, and lymphoid hyperplasia. The irregularly dilated germinal center had microglanulomas, tingible body macrophages, enlarged aggregation of monocytoid B cells with neutrophil interminglement, and no giant cells, leading to the diagnosis of toxoplasmosis. A detailed interview after the lymph node biopsy revealed that she did not have any cats but had chickens and had her right forearm a little injured by the roof edge of a chicken coop 5 weeks before the medical checkup. Postoperative serologic testing to further confirm the toxoplasma infection showed elevated IgG and IgM antibody levels. Oncologists and infectious disease specialists should note this type of transmission of toxoplasma gondii and unilateral lymphadenopathy as an important clinical manifestation of toxoplasmosis.

Nipple Preservation through Partial Nipple Incision and Partial Areola Resection for a Breast Cancer Adjacent to the Nipple-Areolar Complex.

A 45-year-old woman with a tumor just beneath the left areola was referred to our hospital. Magnetic resonance imaging (MRI) findings made us perform a core needle biopsy of the tumor, leading to the diagnosis of invasive lobular carcinoma (cT1N0M0). MRI also depicted three daughter nodules located medially to the main tumor in a linear fashion. Patient's strong request for nipple preservation made us try to resect the breast cancer in a manner to possibly preserve the nipple-areolar complex. First, to resect the target four tumors, medial horizontal skin incision at the nipple level and subsequent lower semicircular peri-areolar incision were done to the left breast. Second, small skin resection in a triangle shape and a radial fashion from the nipple bottom, i.e., orthogonal skin resection to the peri-areolar incision, was done to the areola just above the main tumor. Third, the triangle resection line was extended to the center of the parietal part of the nipple via a longitudinal skin incision on the lateral side of the nipple. Intra-nipple tissue adjacent to the sub-areolar tumor was resected as much as possible. Partially resected areola and partially incised nipple were sutured into the original shape. Pathological study showed invasive lobular carcinoma with lymphovascular invasion and widespread, i.e., total size of 60 mm, noninvasive lobular carcinoma and negative surgical margins in the nipple-areolar complex. The patient was discharged on the second day after operation, developed temporary superficial partial dermal necrosis of the nipple-areolar complex, and received adjuvant endocrine therapy, i.e., tamoxifen and luteinizing hormone-releasing hormone agonist scheduled for 10 years, and normofractionated radiotherapy to the conserved breast after full wound healing of the nipple-areolar complex.

Prolonged Large Seroma Formation after Breast-Conserving Therapy.

A 78-year-old obese woman with breast cancer underwent breast-conserving surgery and axillary lymph node dissection. Due to the prior exposure to long-term taxan chemotherapy for her recurrent gastric cancer, the patient did not undergo adjuvant chemotherapy and began to receive radiotherapy to both the conserved breast and supraclavicular region on the 39th day after operation. Two aspiration therapies were done to the enlarging seroma only at the initial phase of the radiotherapy. No further aspiration therapies were done to the seroma during and after radiotherapy for more than 3 months despite the undoubtable seroma formation. High degree of tension due to large seroma formation, extended from the axilla to deep into the breast parenchyma, made the patient request us to heal the long-lasting seroma. Five aspiration therapies and one simultaneous minocycline intrathecal injection therapy did not bring about wound healing. To heal the persistent seroma, capsulectomy was done to the encapsulated lesion 7 months after the operation. Resected capsule was 110 × 45 mm in size and had smooth inner surface. Pathological study showed the seroma capsule mainly consisting of fibrous tissue with some inflammatory changes. Postoperative course was uneventful, and wound healing was promptly obtained after capsulectomy. Breast surgeons and radiation oncologists should note this type of unfavorable radiation-induced adverse event after breast-conserving therapy.

[A Case of Preoperative Diagnosis of Intraductal Papillary Tumor with Good Course after Surgical Resection].

BACKGROUND: Intraductal papillary neoplasm of bile duct(IPNB)is a papillary tumor that develops in the bile duct inside and outside the liver, and is a relatively new disease concept recognized as a precancerous/early cancer lesion of bile duct cancer. CASE: A 74-year-old woman. A nearby doctor pointed out liver dysfunction in a medical examination, and he was introduced for the purpose of detailed examination. No subjective symptoms were observed. The blood sampling test showed no increase in tumor markers. Abdominal CT/MRI examination and abdominal echo examination showed multiple nodules from the origin of the left intrahepatic bile duct and intrahepatic bile duct dilation predominantly on the left side. No other findings indicating metastasis were found, including the PET-CT test. Endoscopic retrograde cholangiography revealed a poorly contrast-enhanced area in the B3 region, and intraluminal ultrasonography confirmed a mass that coincided with the poorly contrast-enhanced area and grew papillary. No tumor growth was observed in the other branches or common bile ducts, but all ducts were filled with suspended matter, which was thought to be mucus. Histopathological examination of the tumor biopsy revealed atypical epithelium with papillary structure and moderate nuclear atypia. A diagnosis of intraductal papillary tumor was made, and left hepatic lobectomy was performed. Postoperative histopathological examination revealed a complex papillary growth of highly dysplastic mucus-producing epithelium similar to the pancreatic duct/bile duct epithelium, and no obvious infiltrative growth. The postoperative course was uneventful, and the patient was discharged 16 days after the operation. Currently, 6 months after the operation, he is outpatient without recurrence. We report a case of intraductal papillary tumor that had a favorable course after surgical resection in the preoperative diagnosis, with some review of the literature.

Pitfall in the Surgical Management of a Shrunken Skin Defect after Neoadjuvant Chemotherapy for Locally Advanced Breast Cancer.

A 53-year-old woman with a large, easy-bleeding, and ulcerated breast tumor visited our hospital due to severe anemia. Transfusion and Mohs' chemosurgery gave the patient marked improvement of her local and general condition. After confirming the human epidermal growth factor receptor type 2 (HER2)-positive breast cancer with no distant metastasis, anti-HER2 agents-containing chemotherapy brought about clinical complete response of the locally advanced breast cancer with a shrunken but still large skin defect. We, therefore, treated the patient with mastectomy and axillary node dissection but failed to directly close the skin even after full skin undermining. We then tried to cover the skin defect using a latissimus dorsi flap, that is, horizontal spindle skin 12 × 6 cm in size, but again failed to fully cover the skin defect. We finally and ostensibly covered the skin defect through an additional skin incision to the recipient skin, but could not get complete wound healing. Pathological study showed a marked collagen fiber around the skin defect and faint viable cancer cells beneath the nipple. The patient required 3 months of wound management for complete wound healing, leading to the application of anti-HER2 agents without anticancer agent to the patient during that time as an adjuvant therapy. Regrowth of her hair once lost by the neoadjuvant chemotherapy (NAC) made the patient refuse the adjuvant anthracycline-containing chemotherapy after wound healing. The patient, therefore, received trastuzumab-emtansine for a year and has been well for 17 months postoperatively. Breast surgeons should note that a skin defect after favorable response to NAC is often surrounded by less stretchable skin due to chemotherapy-induced massive collagen fiber and requires careful preoperative planning for skin closure.

Confirmed complete response to nivolumab for advanced gastric cancer with peritoneal dissemination: a case report.

BACKGROUND: Recent advances in cancer immunotherapy have been remarkable, with many reports on the clinical effects of immune checkpoint inhibitors. Nivolumab has been covered by the national health insurance in Japan as a third-line agent for advanced and recurrent gastric cancer since September 2017. The objective response rate for nivolumab for gastric cancer is 11.2%. However, patients' quality of life during this treatment has not been examined. Here, we report a case in which multidisciplinary treatment, including with nivolumab, resulted in long-term survival and improved quality of life. CASE PRESENTATION: A 70-year-old Asian woman was referred for surgery for gastric cancer. Postoperative pathological examination revealed peritoneal dissemination, and the patient was diagnosed with stage IV gastric cancer. Therefore, she was treated with S-1 and cisplatin based on negative immunohistochemical staining of resected specimens for human epidermal growth factor receptor 2. However, owing to instability and adverse events, treatment was subsequently changed to S-1 monotherapy. Two years after changing to S-1 monotherapy, she developed recurrence of peritoneal dissemination and was treated with docetaxel. Radiation therapy was also used because the recurrent lesions were local. However, 6 months later, new peritoneal dissemination and lymph node metastasis were observed and nivolumab was started. Subsequent abdominal computed tomography revealed a marked reduction in the disseminated nodules and lymphadenopathy. After 54 cycles of nivolumab, the lesions had disappeared completely. The patient has not developed side effects, including immune-responsive adverse events, has improved quality of life, and is returning to work. She is currently taking nivolumab, and there is no evidence of recurrence approximately 3 years after starting nivolumab. CONCLUSIONS: Nivolumab may have beneficial effects in some patients with advanced or recurrent gastric cancer. Although the prognosis for gastric cancer and peritoneal dissemination is poor, multidisciplinary treatment that includes nivolumab may lead to long-term survival.

Surgery to Oligometastatic Breast Cancer after Excellent Response to Palbociclib and Letrozole Therapy: Pitfall of Ultrasound Therapeutic Evaluation.

A 48-year-old woman with regional recurrences of breast cancer in the axillar and supraclavicular regions was referred to our hospital. Under the diagnosis of recurrent luminal breast cancer with a high Ki-67 labeling index of >30% and a disease-free interval of 13 years, the patient began to receive palbociclib, letrozole, and luteinizing hormone-releasing hormone agonist, resulting in marked response of the supraclavicular lesion and stable disease of the axillar lesion on ultrasound (US) evaluation. Positron emission tomography (PET)/computed tomography of the axillar and supraclavicular foci showed high and no avidities before and after treatment, respectively. The unmovable neck lesion became movable with the treatment. The patient, therefore, underwent surgical resection of the 2 metastatic foci to examine the discordant therapeutic efficacy against the 2 metastatic foci on 2 image modalities, that is, US and PET, and to possibly get a cure of the breast cancer oligometastasis. Pathological examination showed marked fibrosis and scant cancer cell residuals with microcalcifications in the neck tumor and massive sarcoid-like reaction with scant cancer cell residuals in the axillary nodes. The residual cancer cells showed estrogen and progesterone receptor positivities, human epidermal growth factor receptor type 2 negativity, and an extremely low Ki-67 labeling index of 2.5%. The patient recovered uneventfully and has continued palbociclib-containing endocrine therapy for 1 year without any recurrences. Breast oncologists should well understand the basic principles of internal echo formation on US and take the presence of sarcoid-like reaction in the cancer cell clusters into consideration on the therapeutic evaluation of metastatic breast cancer.

Monomorphic Epitheliotropic Intestinal T-Cell Lymphoma in the Ileum with Successful Preoperative Endoscopic Evaluation.

A 80-year-old man with the history of operations for gastric cancer and adhesive ileus developed abdominal pain. Positron emission computed tomography (CT) showed prominent wall thickening in the ileum with a maximal standardized uptake value of 12.1. Prior CT to diagnose adhesive ileus just taken only 4 months before did not show any masses in the abdomen. Single-balloon enteroscopy via colon showed a protruding mass at approximately 40-50 cm proximal point from the ileum end. Pathological examination of the biopsied specimen showed diffuse infiltration of medium- to large-sized atypical lymphocytes. Immunohistochemistry analysis showed that the atypical cells were positive for CD3 and CD56 and negative for CD8 and CD20. MIB-1 labeling index was extremely high as 80%. Under the diagnosis of intestinal T-cell lymphoma, the patient underwent tumorectomy, leading to the diagnosis of monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL) after the negativity confirmation of Epstein-Barr virus-encoded mRNAs. The patient recovered with manageable complication and is going to receive chemotherapy. This is the first case of MEITL with extremely rapid progression in the distal ileum to be observed and diagnosed with single-balloon enteroscopy.

A Case of Lung Adenocarcinoma with Pulmonary Hypertrophic Osteoarthropathy Showing Pathological Complete Response to a Pembrolizumab-Containing Chemoimmunotherapy.

A 65-year-old woman with prolonged cough and presumed pulmonary hypertrophic osteoarthropathy was referred to our hospital. Computed tomography showed 2 tumors larger than 3 cm in size and massive hilar lymph node enlargement in the right lung. Pathological examination of the transbronchial lung biopsy specimen showed atypical malignant cells, presumed adenocarcinoma, with 1% positivity of programmed cell death 1 ligand (PD-L1). Three courses of chemoimmunotherapy with pembrolizumab (400 mg q3w), carboplatin (AUC 5 mg/mL · min q3w), and pemetrexed (500 mg/m2 q3w) were well tolerated and brought about a quasi-complete response both of the lung tumors and lymph nodes and complete symptom relief of the pulmonary hypertrophic osteoarthropathy, finally leading to the surgical intervention, that is, lobectomy and lymph node dissection. Postoperative pathological examination showed no viable cancer foci both in the lung tumors and lymph nodes. The patient recovered uneventfully. Physicians should note the combination chemoimmunotherapy including pembrolizumab, with curative intent, to optimally treat patients with locally advanced non-small cell lung cancer (NSCLC) even if the NSCLC bears a small amount of PD-L1.

Presumed Solitary Dissemination of Colon Cancer Mimicking Primary Cancer of the Small Intestine.

A 69-year-old man with abdominal distention was referred to our hospital. The patient had undergone laparoscopic surgery for his Borrmann type 2 rectal cancer 2 years before. In addition to the re-elevation of serum CEA and CA19-9 levels, computed tomography (CT) showed intestinal dilatation, and positron emission CT showed a presumed tumor with abnormal fluorodeoxyglucose accumulation in the small intestine. We judged the small intestinal dilatation was highly due to the solitary recurrent peritoneal dissemination of rectal cancer and performed laparoscopic evaluation of the abdominal cavity followed by laparoscopic resection of the affected small intestine. The small intestinal tumor resembled the rectal cancer both on macroscopical and microscopical findings, that is, Borrmann type 2 phenotype and adenocarcinoma that was well differentiated in the part that protruded into the small intestinal lumen and whose degree of differentiation gradually decreased toward the serosa. In addition, abrupt disruption of the normal small intestinal epithelium and the lymphocytic aggregation, presumed tumor-infiltrating lymphocytes, just between the tumor and the small intestinal epithelium highly suggested the tumor originating from the colon cancer. The patient recovered uneventfully with marked decrease in tumor marker levels 1 month after the operation but did not receive colon cancer-oriented chemotherapy as adjuvant therapy for his financial reasons. Oncologists should note this type of recurrence to properly treat the patients with recurrent colorectal cancer.

Subclinical Needle Tract Seeding by Endoscopic Ultrasound-Guided Fine-Needle Aspiration for Pancreatic Cancer.

A 77-year-old woman with epigastralgia was referred to our hospital. Abdominal computed tomography showed a hypointense mass in the pancreatic tail. Abdominal and endoscopic ultrasonography (EUS) showed a hypo-echoic mass, 25 × 25 mm in size, with pancreatic duct dilatation. EUS-guided fine-needle aspiration (EUS-FNA) was performed to the mass through gastric posterior wall. Pathological examination showed atypical cells growing papillary or tubular fashion, leading to the diagnosis of adenocarcinoma. Under the preoperative diagnosis of T2N0M0 pancreatic cancer, the patient underwent distal pancreatectomy and splenectomy. Macroscopic view of the resected specimen showed a presumed puncture-induced pancreatic pseudocyst adjacent to the pancreas. Pathological examination showed well-differentiated adenocarcinoma and a pseudocyst with presumed migrated atypical cells in the pseudocyst wall. The patient recovered uneventfully and has been on outpatient follow-up with adjuvant TS-1 therapy. Optimal treatment of pancreatic cancer naturally needs preoperative definitive diagnosis more strictly than other solid malignancies due to its much higher operative harm to the patients. EUS-FNA is a safe and effective diagnostic method but needs careful attention to the needle tract seeding.

Subdiaphragmatic abscess due to penetration of a duodenal ulcer successfully treated with endoscopic transgastric drainage: a case report.

BACKGROUND: Subdiaphragmatic abscesses are sometimes caused by intraabdominal infections. We report a case of endoscopic ultrasound-guided transgastric drainage. CASE PRESENTATION: A 75-year-old Asian man was referred to our hospital for treatment for upper gastrointestinal bleeding. On admission, blood tests showed a marked inflammatory response, and abdominal computed tomography showed free air in the abdominal cavity and a left subdiaphragmatic abscess. Therefore, the patient was diagnosed with an intraabdominal abscess associated with a perforated duodenal ulcer. Because he did not have generalized peritonitis, fasting and antibiotic treatment were the first therapies. However, because of the strong pressure on the stomach associated with the abscess and difficulty eating, we performed endoscopic ultrasound-guided transgastric drainage. After treatment, the inflammatory response resolved, and food intake was possible. The patient's condition remains stable. CONCLUSIONS: Drainage is the basic treatment for subdiaphragmatic abscesses; however, percutaneous drainage is often anatomically difficult, and surgical drainage is common. We suggest that our success with endoscopic ultrasound-guided transgastric drainage in this patient indicates that this approach can be considered in similar cases and that it can be selected as a minimally invasive treatment method.

Hepatocellular Carcinoma Showing Pathological Complete Response to Lenvatinib Monotherapy.

A 61-year-old man was referred to our hospital due to the liver dysfunction without hepatitis B or C infection. In addition to the elevated levels of α-fetoprotein (AFP) and protein induced by vitamin K absence or antagonist-II, a large tumor, 10.8 cm in size, and multiple small tumors, up to 1.6 cm in size, in the liver on computed tomography (CT) led to the diagnosis of unresectable advanced hepatocellular carcinoma (HCC). Levatinib monotherapy resulted in complete disappearance of the small liver tumors and marked shrinkage of the largest tumor with complete disappearance of intratumoral enhancement on CT and normalization of serum AFP levels. After 2 months' cessation of lenvatinib monotherapy due to side effects, the patient underwent residual tumor resection. The pathological findings showed no viable tumor cells, i.e. pathological complete response. The patient was discharged from the hospital on the twelfth day after the operation without any complication. Lenvatinib monotherapy appears to be more effective for HCC than other conventional treatments. In addition, oncologists should take into consideration the possibility of pathological complete response with newly developed anticancer agents including lenvatinib to develop therapeutic strategies to avoid unnecessary overtreatment.

Recurrence of Gastric Cancer in the Jejunum Close to the Anastomotic Site after Total Gastrectomy.

A 61-year-old man underwent total gastrectomy with esophago-jejunostomy for Borrmann type I gastric cancer. Postoperative intra-abdominal abscess made the patient unable to receive adjuvant chemotherapy. Only 23 weeks after operation, the patient developed melena and anemia, leading to the diagnosis of recurrence in the jejunum close to the anastomotic site. The patient received salvage resection of the recurrence. Pathological study showed that the tumor was composed of atypical cells similar to those of the primary gastric cancer. Normal jejunal mucosa was observed between the esophagus and the recurrent tumor. We judged that exfoliation of the gastric cancer cells caused the recurrence due to both the very short disease-free interval and pathological findings. Surgeons should pay attention to this type of recurrence especially for Borrmann type I gastric cancer. In addition to the adjuvant chemotherapy, gastric irrigation using distilled water during the operation seems to be a feasible measure to prevent this type of recurrence.

Successful Enucleation of a Large Pancreatic Head Schwannoma.

A presumed benign cystic tumor in the pancreatic head had been pointed out to a 78-year-old man 4 years ago. In addition to no communication between the tumor and the main pancreatic duct, magnetic resonance imaging showed that the cystic fluid was serous. Gradual tumor enlargement from 2.1 to 4.0 cm urged us to resect the tumor. In order to safely enucleate the tumor, we preoperatively placed a pancreatic duct stent and covered the pancreatic parenchyma with a polyglycolic acid sheet, fibrin glue, and thrombin after tumor enucleation. The patient postoperatively developed grade B pancreatic fistula but recovered with antibiotics therapy. Postoperative computed tomography showed successful preservation of the main pancreatic duct. Pathological study showed a well-defined tumor mainly composed of loosely textured and S-100-positive spindle cells with abundant and hyalinized blood vessels in the cystic walls with palisading spindle cells, leading to the diagnosis of Antoni B schwannoma. The patient was discharged on the 11th day after operation. Both pancreatic duct stunting and covering the exposed pancreatic parenchyma with a polyglycolic acid sheet, fibrin glue, and thrombin are feasible measures to enucleate large benign tumors in the pancreatic head.

Solitary Lung Metastasis of Prostate Cancer with a Long Disease-Free Interval and Normal Prostate-Specific Antigen Level.

An 83-year-old man with core needle biopsy-proven Gleason score 5 prostate cancer had received radiotherapy including 18 Gy brachytherapy to the prostate cancer, leading to no locoregional and distant recurrence for more than 5 years with the normalization of elevated prostate-specific antigen (PSA) level before the radiotherapy. Due to the enlargement of coexisting ground glass nodule (GGN) in the left lung from 1 to 2.1 cm, the patient underwent wide resection of the GGN 7 years later. Under the diagnosis of adenocarcinoma in situ of the lung, follow-up computed tomography 6 months after the wide resection showed a rapid enlargement of a solid nodule having been judged as a presumed inflammatory nodule in the middle lobe, highly suggesting a malignant neoplasm of the lung. Due to both the tall columnar atypical cells with trabecular pattern on frozen section and no elevation of serum PSA level, we judged the nodule as a primary adenocarcinoma of the lung and further resected the middle lobe with lymph node dissection. Immunostaining of the tumor showed all the CK7, CK20, TTF-1, napsin A, synaptophysin, chromogranin, CD56, CDX2, p53, beta-catenin, and MUC2 negative, and PSA highly positive, clearly showing the solid nodule as a solitary lung metastasis of the prostate cancer. Physicians should note the possible solitary lung metastasis of prostate cancer, especially bearing indolent biology, with no elevation of the PSA level even after the completion of standard 5-year follow-up.