[Two Cases in Which Simultaneous Laparoscopic Surgery and Breast Cancer Surgery Using a Head-Mounted Monitor Were Useful].

Herein, we report on how we were able to reduce the operation time by simultaneously performing laparoscopic surgery and breast cancer surgery using a head-mounted monitor(HMS-3000MT, Sony corporation). Case 1: 60s, female. A 5.5 cm leiomyoma was found in the central thoracic esophagus, and a 1 cm breast cancer was found in the C region of the left mammary gland. Subtotal esophagectomy with right thoracotomy and laparoscopy and a left partial mastectomy were performed. For the abdominal surgery, HMS-3000MT was used under hand-assisted laparoscopy, and a left partial mastectomy was performed concurrently. Operation time was 367 minutes(simultaneous surgery for 56 minutes). Esophagus: leiomyoma, 50×45 mm; and mammary gland: 16×15 mm, pTis(DCIS), pN0(sn), cM0, and pStage 0. Case 2: 70s, female. A 3 cm sized GIST was found on the posterior wall of the middle gastric body, and a breast cancer of 1.3 cm was also found in the B region of the right mammary gland. Using HMS-3000MT, laparoscopic local resection of the stomach and right total glandectomy were performed concurrently. Operation time was 114 minutes(simultaneous surgery for 58 minutes). Stomach: GIST, 25×22 mm, and modified Flecher classification low risk; and mammary gland: invasive ductal carcinoma, 15×15 mm, pT1c, pN0(sn), cM0, and pStage Ⅰ. Conclusion: In 2 fields of surgery, simultaneous surgery using HMS-3000MT was considered to be a useful method to shorten the operation time.

[A Case of Ectopic Pheochromocytoma between the Abdominal Aorta and Inferior Vena Cava].

We report a case of ectopic pheochromocytoma which is relatively rare. A 50-year-old man was found to have an abdominal tumor on a medical examination, and contrast-enhanced computed tomography showed a retroperitoneal tumor between the abdominal aorta and the inferior vena cava. As a result of close examinations, an ectopic pheochromocytoma was suspected. He was asymptomatic and suspected infiltrating into great vessels, but possibility of a malignant neoplasm could not be ruled out for the tumor had a tendency to enlarge, the resection of the tumor was performed. During the operation, the invasion of the tumor into the great vessels was denied and the tumor was completely resected. Large fluctuation of the blood pressure was not observed during the operation. Histopathological evaluations of the resected specimen revealed the ectopic pheochromocytoma. A pheochromocytoma was newly defined as a tumor with malignant potential for metastasis in all cases by the WHO classification published in 2017. He was diagnosed as moderately malignant by GAPP score, therefore the careful follow-up was considered necessary in the future.

[A Case of Metastatic Breast Cancer with BRCA1 Mutation after Breast Reconstruction and Pregnancy].

We present the case of a 31-year-old woman with a chief complaint of a left breast mass. The patient visited our department for an evaluation of this left breast mass. Left breast cancer(cT1cN0M0, cStage Ⅰ, triple negative type)was diagnosed, and left partial mastectomy and sentinel node biopsy were performed. Although the pStage was the same prior to surgery, a BRCA1 mutation was identified on genetic testing. After administration of postoperative adjuvant chemotherapy (epirubicin, cyclophosphamide, and paclitaxel), consorted mastectomy, tissue expander insertion, and breast reconstruction with silicone implant were performed. Spontaneous pregnancy occurred 1 year and 10 months after the first operation. She had an uneventful delivery with a normal course of labor 2 years and 6 months after the surgery. Two years and 11 months after the first operation, she visited our institution with complaints of headache, dizziness, and difficulty eating. Upon assessment, brain, lung, liver, and bone metastases were identified on contrast-enhanced computed tomography. Concentrated glycerin and fructose, steroid administration, and whole-brain irradiation improved the symptoms due to cerebral edema. Thereafter, olaparib was started, and treatment was continued while maintaining partial response(PR).

[A Case of Laparoscopic Distal Gastrectomy for Gastric Cancer with an Adachi Type â ¥ Group 24 Vascular Anomaly].

We report a case of successful laparoscopic distal gastrectomy for gastric cancer with an Adachi type Ⅵ group 24 vascular anomaly. A male in his 60s exhibited a type 0-Ⅱa plus Ⅱc lesion at the lesser curvature of the gastric angle by esophagogastroduodenoscopy and was diagnosed with tub2. He was referred to us for surgical treatment. The clinical diagnosis was cT1bN0M0, and cStage Ⅰ. Preoperative multidetector-row computed tomography(MDCT)showed an Adachi type Ⅵ group 24 vascular anomaly. At laparoscopic surgery, we dissected No. 8a lymph nodes with exposure of the surface of the portal vein because the common hepatic artery was absent. The left gastric artery and splenic artery formed a common trunk. As there are various kinds of vascular anomalies of the celiac artery branch, we must understand the arterial running pattern prior to gastric surgery. This technique is more useful in laparoscopic surgeries where tactile sensation is limited. To prevent perioperative and postoperative complications, we must recognize the anomaly pattern prior to surgery using MDCT.

[A Case in Which Trastuzumab Combined Chemotherapy Was Effective for Recurrence of Post-Operative Gastric Cancer with Partial HER2 Overexpression].

We report a case in which recurrent partial HER2-positive gastric cancer showed complete clinical response to capecitabine (Cape)/oxaliplatin(L-OHP/OX)(CapeOX)plus trastuzumab(Tmab)combined chemotherapy for 32months. A 65-yearold man underwent distal gastrectomy, D2 lymph node dissection, and Roux-en-Y reconstruction for type 2 gastric cancer of the prepyloric anterior wall in December 2014. Pathological stage was as follows: L, ant, Type 2, 32×22 mm, tub1>tub2> por1, pT2(MP), int>med, INF c>a, Ly1a, V0, pN0, cM0, cH0, cP0, pCY0, pStage I B, pPM0(60mm), pDM0(75mm), pR0. Immunostaining of the tumor indicated overexpression of the HER2 gene in more than 10% of the well differentiated tubular adenocarcinoma(tub1). Nineteen months post-surgery, pancreatic head lymph node metastasis was diagnosed, and we started CapeOX plus Tmab combined chemotherapy. After 19 courses, the metastatic lymph node reduced its size until we could not detect it on CT. We continued treatment for 45 courses(about 32 months). During the courses, there were adverse events such as peripheral neuropathy(Grade 3, CTCAE v5.0), which required interruption of L-OHP, and oral mucosal ulcer (Grade 2).

[A Case of Locally Advanced Pancreatic Cancer Successfully Resected after S-1 Therapy in an Elderly Patient].

We report a case of locally advanced pancreatic body cancer, accomplishing R0 resection following preoperative chemotherapy. An 80-year-old female patient was admitted to our hospital because of high CA19-9 levels.Based on computed tomography images, she was diagnosed with locally advanced cancer of the pancreatic body.We started S-1 chemotherapy (100mg/day, 2 weeks administration 1 week rest)because the tumor was suspected to have invaded the celiac trunk and the common hepatic artery.The tumor decreased in size, and the encasement of the celiac trunk and the common hepatic artery were released, following 6 months of chemotherapy.Subsequently, distal pancreatectomy with D2 lymph node dissection was performed.The patient was healthy and showed no signs of recurrence 5 years and 9 months after surgery.

[A Case of Laparoscopic Low Anterior Resection and Adrenalectomy for Rectal Cancer and Adrenal Tumor].

A 70-year-old woman had consulted a doctor at a former clinic because of bloody stool and colonoscopy revealed a type 2 tumor of the rectum. She was referred to our hospital for further examinations and treatment. Preoperative blood examination showed an elevated HbA1c level of 10.2%. Abdominal CT showed a 25mm tumor in the left adrenal gland. The patient was diagnosed with adrenal Cushing's syndrome based on low ACTH levels, disappearance of circadian variation in blood cortisol levels, lack of inhibition by dexamethasone loading, and high urinary cortisol levels. Laparoscopic adrenalectomy for left adrenal tumor and low anterior resection for rectal cancer were performed. The pathological findings were rectal cancer, pap, pT1b(SM), pN0, cM0, fStageⅠof rectal cancer, and adrenal cortical adenoma. The postoperative course was uneventful with steroid replacement therapy. The ileal stoma was closed 4 months after surgery. Surgery in hyperadrenalism requires perioperative steroid replacement therapy because of the risk of postoperative acute adrenal failure. In addition, when diabetes is poorly controlled, we should be careful about risk of leakage and susceptibility to infection.

[Two Cases of Laparoscopic Resection of Colon Cancer Manifested by Liver Abscess].

We report 2 cases of laparoscopic surgery for patients who had liver abscess as the initial manifestation of underlying colon cancer. The first case was in an 80-year-old woman who presented to our hospital with a diagnosis ofliver abscess. Percutaneous transhepatic abscess drainage(PTAD)was performed as initial treatment. Subsequent colonoscopy revealed a type 1 tumor in the cecum, and biopsy results ofthe mass indicated adenocarcinoma. The patient underwent laparoscopic right hemicolectomy as curative treatment. The pathological findings were as follows: tub1, T2, N0, M0 and Stage I . Two years later, she remains disease free. The second case was in a 59-year-old man with liver abscess. Colonoscopy also revealed a type 2 tumor in the sigmoid colon. After treatment of the liver abscess with PTAD, laparoscopic sigmoidectomy was performed with a preoperative diagnosis of sigmoid colon cancer. The pathological findings were as follows: tub2, T3, N0, M0 and Stage II . Lung metastases appeared 10 months after surgery, and systemic chemotherapy was administered. In conclusion, liver abscess is occasionally caused by malignancy, and complete gastrointestinal evaluation should be conducted. Laparoscopic radical surgery can be safely performed in cases in which the liver abscesses are controlled.

[A Case of Infectious Pseudoaneurysm That Developed after Surgery for Local Recurrence of Rectal Cancer].

In February 2011, a male patient in his 60's underwent a low anterior resection and lateral lymph node dissection for lower rectal cancer. Due to large intestinal obstruction from local recurrence, an abdominoperineal resection was performed 5 years 8 months after his first surgery. Inflammation of the pelvic dead space persisted, requiring drainage after the surgery. Although bloody discharge was observed on the 12th and 30th postoperative day, the source of bleeding was not identified on contrast-enhanced CT. On the 35th postoperative day, the patient suddenly lost 700 mL of blood via the abdominal drain and perineal wound. Urgent angiography revealed an aneurysm on the branch of the left iliac artery. Therefore, transcatheter arterial embolization was performed for hemostasis. Infectious complications associated with surgery for locally recurrent rectal cancer frequently occur due to impaired tissue blood flow. This case highlights the importance of paying close attention to the possibility of infectious pseudoaneurysm.

Expression of syndecan-1 and E-cadherin is inversely correlated with poor patient's prognosis and recurrent status of extrahepatic bile duct carcinoma.

Extrahepatic bile duct carcinoma is one of the most extremely aggressive cancers with poor prognosis after curative resection. Syndecan-1 and E-cadherin are transmembrane glycoproteins, and have important roles in cell-cell adhesion and tumor progression. In this study, we examined 84 surgically resected cases of extrahepatic bile duct adenocarcinoma to clarify clinicopathological significance of syndecan-1/E-cadherin expression. Reduced expressions of syndecan-1 and Ecadherin were found in 69.0% (58/84) and 46.4% (39/84) of the bile duct carcinomas. Reduced syndecan-1 expression was correlated with lymphatic/venous/nervous invasion (P < 0.0001), and was associated with short overall survival (P = 0.0002). Reduced E-cadherin expression was correlated with lymphatic and nervous invasion (P = 0.008, P < 0.0001, respectively), and was associated with short overall survival (P = 0.0038). The results indicated that reduced syndecan-1/E-cadherin expression may be good indicators of recurrence and prognosis in extrahepatic bile duct carcinoma.

Cardiac tumor comprising two components including typical myxoma and atypical hypercellularity suggesting a malignant change.

BACKGROUND: Cardiac myxoma is a benign neoplasm and is not considered to carry a risk of malignant transformation. We describe a case of a cardiac tumor comprising typical myxoma and atypical cellular parts. METHODS AND RESULTS: A 72-year-old woman was found to have a tumor in the left atrial chamber after undergoing echocardiographic investigation and so she underwent tumor excision surgery. The excised tumor was composed of two components with different features with a smooth transition from one type to the other. The apex of the tumor showed a gelatinous and villous appearance on gross examination, and histological examination revealed that the tumor cells had small oval nuclei and eosinophilic cytoplasm and were arranged in cords and vasoformative structures in the myxoid matrix. The base of the tumor appeared as a solid mass on gross examination with hypercellular proliferation of spindle-shaped tumor cells and intersecting fascicles observed histologically. Nuclear mitosis was seen in more than 10/10 high-power fields, coagulation necrosis was prominent, and invasion of the atrial wall was seen. On immunohistochemistry, the tumor cells were found to be positive for alpha-smooth muscle actin, calretinin, and CD34, and this immunoreactivity was decreased at the tip. Ki-67 labeling index was increased at the apex. CONCLUSIONS: We diagnosed this tumor as cardiac myxoma with an atypical hypercellular component suggesting a malignant change. It is important to recognize that a cardiac myxoma could be accompanied by atypical change.

Resection of a locally advanced hilar tumor and the hepatic artery after stepwise hepatic arterial embolization: a case report.

We herein report a case of a hilar tumor with extensive invasion to the proper hepatic artery, which was successfully treated with a radical resection in a 57-year-old female patient after a stepwise hepatic arterial embolization. She underwent right colectomy and partial hepatectomy for advanced colon cancer two years ago and radiofrequency ablation therapy for a liver metastasis one year ago, respectively. A recurrent tumor was noted around the proper hepatic artery with invasion to the left hepatic duct and right hepatic artery 7 mo previously. We planned a radical resection for the patient 5 mo after the absence of tumor progression was confirmed while he was undergoing chemotherapy. To avoid surgery-related liver failure, we tried to promote the formation of collateral hepatic arteries after stepwise arterial embolization of the posterior and anterior hepatic arteries two weeks apart. Finally, the proper hepatic artery was occluded after formation of collateral flow from the inferior phrenic and superior mesenteric arteries was confirmed. One month later, a left hepatectomy with hepatic arterial resection was successfully performed without any major complications.

Decreased expression of claudin-1 is correlated with recurrence status in esophageal squamous cell carcinoma.

Claudins are transmembrane proteins and major constitutes of tight junctions, and participate in the paracellular barrior and cellular connecting functions. They have been shown to be differentially regulated in malignant tumors and play a role in carcinogenesis and tumor progression. Recent studies have shown changes in expression of claudins during tumorigenesis. However, a causal relationship between claudin expression and cancer recurrent status has not been established. In this study, we examined 54 esophageal cancer cases to assess immunohistochemical expression patterns of claudin-1. Eleven (20.4%) of 54 cases had negative immunostaining for claudin-1. Decreased expression of claudin-1 was statistically correlated with recurrence status (P = 0.018). The cases with lymphatic vessel permeation showed reduced expression patterns of claudin-1 (P = 0.033). Decreased expression of claudin-1 was also correlated with short diseasefree survival (P = 0.0003) and overall survival (P = 0.0045). The results indicated that claudin-1 expression was correlated with the recurrence status and poor prognosis in esophageal cancer and claudin-1 expression may be a good indicator of recurrence in esophageal cancer.