[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.

[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.

[A Case of Lung Adenocarcinoma with Pulmonary Hypertrophic Osteoarthropathy].

BACKGROUND: Hypertrophic osteoarthropathy(HOA)is a syndrome that has three signs, the digital finger, periosteal neoplasia of the iliac bone, and arthritis. Among them, the secondary 1 associated with lung disease is called pulmonary hypertrophic osteoarthropathy(PHO). It is reported that many of the underlying diseases are associated with primary lung cancer, but in Japan, this is a rare condition with about 0.2 to 5.0%. CASE: A 68-year-old man. The patient was complaining of an arthralgia, and treated by the department of rheumatology. The thoracic CT scan for a screening pointed out a tumor in the right lower lobe, and referred to the department of surgery. Blood test showed CEA 21.8 ng/mL and LH 10.2 mIU/mL, FSH 23.1 mIU/mL. Chest CT showed a lung mass measuring 6.5×3.5 cm in the right lower lobe, and tracheobronchial lymph- node swelling. Bone scintigraphy showed abnormal accumulations in the long bones. We performed right lower lobectomy by thoracoscope. The pathological results were adenocarcinoma, G2, pT3, pN1, pm0, pl1, Ly1, V1, stage ⅢA. The arthralgia was relieved early after surgery. The patient recovered uneventfully and was discharged after the operation. Adjuvant chemotherapy was started, he was been well without recurrence.

[Two Cases of Stage â £ Occult Breast Cancer].

The first case is a 62-year-old female who complained of painful left axillary lymph node swelling. Six months later, a CT scan revealed multiple lung nodules. Biopsies of the axillary lymph node and lung showed metastatic carcinoma from breast cancer. However, no breast tumor was found. She was diagnosed with occult breast cancer with metastasis to the axillary lymph node and lung. ER(+), PgR(±), HER2(1+). Letrozole was administered, and effective control was achieved for 20 months. The second case is a 62-year-old female who presented with back pain. A CT scan revealed left axillary lymph node swelling and multiple osteolytic changes in the thoracolumbar spine and rib. Biopsies of the axillary lymph node and thoracic spine showed metastatic carcinoma from breast cancer. However, no breast tumor was found. She was diagnosed with occult breast cancer with metastasis to the axillary lymph nodule and bone. ER(+), PgR(+), HER2(1+). Fulvestrant and denosumab were administered. However, after 6 months, she discontinued the treatment. Our results suggested that effective control could be achieved through systemic therapy and local therapy was not necessary for Stage Ⅳ occult breast cancer.

[A Case of Breast Metastasis of Gastric Cancer after an Eight Year Latency Period].

A 66-year-old woman underwent distal gastrectomy because of gastric cancer(stage ⅠB)and received no adjuvant chemotherapy. Eight years after the operation, computed tomography showed a small nodule in the right breast. Mammography did not reveal any abnormalities. Ultrasound sonography showed a diffuse and gradual non-mass-like low echoic lesion. Core needle biopsy indicated a malignancy. Partial resection of the right breast was performed to obtain a diagnosis. On postoperative histopathological examination, signet-ring cells were found in the tumor, and immunohistochemical analysis showed that both the breast tumor and the gastric carcinoma were MUC5AC-positive and MUC1-negative. We diagnosed this breast tumor as metastasis from gastric cancer. The patient has received chemotherapy with no subsequent metastatic tumors, and good control has been achieved for 21 months after the detection of the breast metastasis.

Metachronous colorectal carcinoma with massive submucosal invasion detected by annual surveillance in a Lynch syndrome patient: a case report.

BACKGROUND: Lynch syndrome is the most common form of hereditary colorectal carcinoma. It is characterized by the presence of germline mutations in DNA mismatch repair genes. Mutation carriers have a lifetime risk of developing colorectal carcinoma of approximately 80%. Current treatment guidelines recommend periodic surveillance for colorectal carcinoma in patients with Lynch syndrome. However, the optimal interval between colonoscopies has not yet been determined. CASE PRESENTATION: We describe a 54-year-old man with Lynch syndrome who was undergoing annual colonoscopy surveillance for the development of colorectal carcinoma. At 54, 57, 59, and 60 years old, a colonoscopy showed high-grade dysplasia and adenoma. Therefore, endoscopic mucosal resection was performed. At 61 years old, a colonoscopy showed metachronous colorectal carcinoma with massive submucosal invasion. He subsequently underwent laparotomy for colorectal carcinoma. CONCLUSIONS: Annual surveillance using colonoscopy can detect colorectal carcinoma at an early stage, leading to reduced mortality. However, some patients might require a laparotomy, as was the case here. More frequent colonoscopic surveillance might be necessary to avoid surgery for colorectal carcinoma in Lynch syndrome patients with multiple risk factors for interval cancer.

Preoperative Risk Factors for Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy and the Usefulness of the 2013 Tokyo Guidelines.

To identify predictive factors for conversion from laparoscopic cholecystectomy (LC) to open cholecystectomy performed for mixed indications as an acute or elective procedure. We retrospectively analyzed the data of 236 consecutive cases of LC performed in our department between January 2012 and January 2015, and evaluated preoperative risk factors for conversion and the usefulness of the 2013 Tokyo guidelines (TG2013) for diagnosing acute cholecystitis. The conversion rate in our series was 8% (19/236 cases). The following independent predictive factors of conversion were identified (p≤0.04): previous upper abdominal surgery (odds ratio (OR), 14.6), pericholecystic fluid (OR, 10.04), acute cholecystitis (OR, 7.81), and emergent LC (OR, 15.8). Specifically for patients with acute cholecystitis defined using the 2013 Tokyo guidelines, use of an antiplatelet or anticoagulant drug for cardiovascular disease (p=0.043), previous upper abdominal surgery (p<0.031) and a resident as operator (p=0.041) were predictive factors. The risk factors for conversion identified herein could help to predict the difficulty of the procedure and could be used by surgeons to better inform patients regarding the risks for conversion. The TG2013 can be an effective tool for diagnosing acute cholecystitis to make informed clinical decisions regarding the optimal procedure for a patient.

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.

Evaluation of surgical treatment for incidental gallbladder carcinoma diagnosed during or after laparoscopic cholecystectomy: single center results.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the accepted standard management for benign gallbladder disease. LC rarely results in a diagnosis of incidental gallbladder carcinoma (IGBC). The aim of our study was to report our experience with IGBC diagnosed during or following LC. METHODS: Between January 2008 and January 2015, 352 patients underwent LC at Iwakuni Clinical Center. Among these patients, 8 (2.3%) were diagnosed with IGBC. We evaluated their characteristics, surgical related variables, histopathological findings and surgical outcomes. RESULTS: Patient median age was 71 (range 49-88) years, and 3 out of 8 were female. All patients with IGBC were Japanese. The grade of cancer was as follows: pT1a (3 cases), pT2 (4 cases) and pT3 (1 case). Two patients with pT2 disease underwent radical surgery. The median follow-up time of these patients was 24 (range 11-80) months. All patients are still alive and two of three patients who refused radical surgery have developed recurrence (liver metastases and recurrence in the peritoneum). CONCLUSIONS: Although the number of cases was small, the results of this study further support the suggestion that gallbladder carcinoma may be curable if diagnosed as IGBC at an early stage. If the cancer has reached an advanced stage, radical surgery should be performed.

Synchronous coexistence of liver metastases from cecal leiomyosarcoma and rectal adenocarcinoma: A case report.

Multiple liver tumors represent a challenging condition for abdominal surgeons both in the selection of technique and the rarity of diagnosis. There are no case reports on co-existence of liver metastases from both intestinal leiomyosarcoma and adenocarcinoma. The patient described in this report successfully underwent resection of both primary lesions and liver metastases in combination with chemotherapy. As for the leiomyosarcoma, the primary cecal lesion was revealed more than three years after the patient's first visit. Peritoneal, lymph-node, and lung recurrences were observed afterward, and thus surgeries on those regions were performed. Pathologically, the peritoneal and lung recurrences comprised leiomyosarcoma and the lymph-node recurrence was diagnosed as adenocarcinoma. Despite newly discovered multiple lung recurrences and regional lymph-node metastases, the patient lived a normal life for 73 mo after the initial operation based on multidisciplinary therapy. He ultimately died of liver failure due to invasive lymph-node recurrence from the rectal adenocarcinoma, in addition to multiple lung recurrences from the leiomyosarcoma. Hepatic recurrence did not occur in this patient's case, which appears to be one reason for his long-term survival.

Surgical resection of splenic metastasis from the adenosquamous gallbladder carcinoma: A case report.

INTRODUCTION: Splenic metastasis of gallbladder carcinoma is extremely rare. Specific anatomical, histological, and functional properties of spleen are believed to be responsible for the rarity of solitary splenic metastasis. PRESENTATION OF CASE: We present the case of a 62-year-old female who developed metachronous splenic metastasis of adenosquamous carcinoma of the gallbladder. We performed central bisegmentectomy of the liver for gallbladder carcinoma. The patient subsequently presented 3 months later with isolated splenic metastasis and liver metastasis. Splenectomy and partial hepatectomy was performed at this time. Histological examination confirmed metastatic adenosquamous carcinoma of the gallbladder. No signs of recurrence were observed at 3 months after the second surgery. DISCUSSION: Although splenectomy provides a potential means of radical treatment in patients with isolated splenic metastases, it should be performed with caution as splenic metastatic lesions may represent the initial clinical manifestation of systemic metastases at multiple sites. In this case, radical surgery was performed following the confirmation of no new unresectable metastatic lesions or systemic dissemination. CONCLUSION: This is the first report on the adenosquamous splenic metastasis from the gallbladder carcinoma. Curative resection may be the treatment of choice for prolonging survival in patients with the splenic metastasis of gallbladder carcinoma.