[A Case of Late Recurrence of Gastric Cancer Over Ten Years Post Gastrectomy].

A 72-year-old woman underwent a low anterior resection of the rectum and a total hysterectomy with a bilateral salpingo- oophorectomy simultaneously for rectal and ovarian cancer, respectively. The pathological diagnosis was a moderately differentiated adenocarcinoma of the rectum with some poorly differentiated components signet-ring cell components. A mucinous adenocarcinoma, with similar characteristics as that in the rectum, was found in the ovary. Intraoperative findings revealed no direct invasion between the rectum and ovaries, with no peritoneal dissemination. She was, therefore, diagnosed with synchronous double cancer. The rectal cancer was pT3N0M0, Stage Ⅱ and the ovarian cancer pStage Ⅰ. Adjuvant chemotherapy with capecitabine was performed for high-risk Stage Ⅱ rectal cancer. At 3.5 years after surgery, her CA19-9 level was high and pleural dissemination and para-aortic lymph node metastasis were confirmed on thoracoabdominal CT. Twelve years after the gastrectomy for gastric cancer, a comparison of the pathological specimens of her stomach at that time with the current pathological specimens revealed that the rectal and ovarian tumors were metastases of gastric cancer and that the current recurrence was a late recurrence of this disease. Late recurrence after gastrectomy, especially 10 years or more after surgery, is extremely rare.

[Diffuse Malignant Peritoneal Mesothelioma with Secondary Liver Invasion Diagnosed Using Laparoscopy - A Case Report].

A 69-year-old man with right upper quadrant abdominal pain and fever was referred to our hospital. He had a history of asbestosis exposure. Computed tomography(CT)revealed a mass at the right subhepatic space, and an antibiotic was administered after a diagnosis of an abdominal abscess. However, the patient did not respond to the treatment, and finally, exploratory laparoscopy was performed. A sheet of combined white nodules surrounding the right lobe of the liver was found, and the mass was continuous with the covering particles. Biopsy of the mass and immunohistochemical examination was performed. The resulting diagnosis was diffuse epithelial malignant peritoneal mesothelioma(MPM). Postoperative systematic chemotherapy of pemetrexed and cisplatin was administered. Laparoscopy was useful to evaluate the distribution of the MPM, which led to adequate therapeutic determination.

[A Case of Metastatic Carcinoma of Anal Fistula].

A 58-year-old man underwent rectal resection(D2 dissection)for rectal cancer and liver/lung metastases in August 2009. Histopathological findings were Ra, type 2, 70×80mm, tub1>tub2, int, pSI(peritoneum), INF b, ly1, v1, pN1(2/13), pPM0, pDM0, M1a(H1, PUL1), fStage IV . The lung metastasis had disappeared on chest CT after postoperative chemotherapy and we were able to perform radical resection of the liver metastasis by performing hepatectomy twice. In October 2013, anal pain appeared and a painful tumor approximately 2 cm in size was found in the 5 o'clock direction of the anus. Biopsy revealed a well-differentiated tubular adenocarcinoma similar to rectal cancer, and it was diagnosed as a fistula metastasis of rectal cancer.We performed chemoradiotherapy(S-1 120mg/day plus RT 60 Gy/30 Fr)as surgery was recommended but refused. As a result, the tumor reduced markedly in size. In December 2015, the tumor enlarged in size and the patient and family requested surgery. We, therefore, performed abdominoperineal resection. Currently, the patient is alive at 18 months after surgery with no recurrence.

[Laparoscopic Distal Gastrectomy for Elderly Patients with Advanced Gastric Cancer and Gastric Outlet Obstruction - A Case Report].

A 90-year-old female patient was admitted to our hospital with a chief complaint of vomiting.Gastroscopy revealed type 3 gastric cancer and gastric outlet obstruction(GOO).Abdominal computed tomography revealed thickening of the antral wall and suggested the presence of 3 perigastric lymph node metastases, but there was no ascitic fluid or distant metastasis.The clinical diagnosis was T4a(SE)N2H0CYXP0M0, Stage III B, according to the Japanese Classification of Gastric Carcinoma.Her general conditions including kidney and cardiac function were good, we considered that she was able to tolerate radical distal gastrectomy.We planned laparoscopic distal gastrectomy(LDG)and D2 lymphadenectomy after getting sufficient informed consent.The patient experienced an uneventful post-operative recovery, and was discharged in good health 11 days after surgery.

[Early Liver Metastases after Curative Surgery for Stageâ Gastric Cancer with Neuroendocrine Differentiation-A Case Report].

An 87-year-old male patient was admitted to our hospital with a chief complaint of vomiting. Gastroscopy revealed Type 0-Ⅱc+Ⅱa tumor at the posterior wall in the middle third of the stomach. A biopsy indicated moderately differentiated adenocarcinoma. Abdominal CT revealed no lymph node or distant metastases. The clinical diagnosis was cT2(MP), N0, M0, cStage Ⅰ. Laparoscopic distal gastrectomy with D2 lymphadenectomy was performed. The pathological findings revealed moderately differentiated adenocarcinoma containing synaptophysin, chromogranin A, and CD56-positive tumor cells. He was then diagnosed with adenocarcinoma with neuroendocrine differentiation. The pathological diagnosis was pT2(MP), pN0, M0, pStage ⅠB. MRI revealed multiple liver metastases 5 months postoperatively. S-1 alone chemotherapy was started, and the patient showed partial response(PR)after 3 courses, according to the Response Evaluation Criteria in Solid Tumor (RECIST).

[Invasive Micropapillary Carcinoma of the Colon That Was Difficult to Diagnose Preoperatively].

A 73-year-old man was admitted with sigmoid colon diverticulitis. Although a biopsy did not indicate malignancy, the sigmoid colon was completely obstructed following conservative treatment. After sigmoidectomy, the histopathological findings revealed a well-differentiated adenocarcinoma localized to the mucosal surface; invasive micropapillary carcinoma (IMPC)accounting for>95% of the tumor volume spread extensively below the submucosal layer. IMPC is highly malignant and difficult to diagnose preoperatively, possibly due to the presence of poorly differentiated histological sub-types in the deepest portions of the tumor.

[Sigmoid colon cancer with intussusception prolapsing through the anus treated by elective laparoscopic radical surgery].

An 86-year-old man was brought in ambulance to our hospital because of sudden hematochezia and abdominal pain during defecation. Intestinal prolapse approximately 80mm from the anus and a type 1 tumor 50mm in size on the mucosal surface were detected. The intestinal prolapse was manually repositioned, and the reduction of the intussusception was confirmed by computed tomography (CT). Following colonoscopy and abdominal-enhanced CT, a sigmoid colon cancer without distant metastases was detected. Elective laparoscopic radical surgery was performed. The present study described a rare case of sigmoid colon cancer with an intussusception prolapsing through the anus and highlighted the treatment strategy by reviewing 48 previous cases. The treatment strategy employed was as follows:first, manual repositioning of the intestinal prolapse was attempted;and second, the presence of intussusception was confirmed by CT. In cases when repositioning of the intussusception was not possible, even with the use of an endoscope or contrast enema, emergency surgery was required.

Prediction of difficult laparoscopic cholecystectomy for acute cholecystitis.

BACKGROUND: No report has described the predictive factor of surgical difficulty for laparoscopic cholecystectomy (LC) by preoperative computed tomography (CT) findings. This study aimed to investigate whether dynamic CT findings can predict the difficulty of LC for acute cholecystitis. MATERIALS AND METHODS: Fifty-seven patients who underwent emergency LC and dynamic CT preoperatively were enrolled. Difficult LC (DLC) was defined as any patient with an operative time ≥3 h, bleeding volume ≥300 mL, common bile duct injury, partial cholecystectomy, the need for a second surgeon, and/or conversion to open surgery. Patients were assigned to either the DLC (+) or DLC (-) group. We determined the CT attenuation ratio of the arterial phase (ARAP) to represent the degree of transient focal enhancement of the liver adjacent to the gallbladder. The ARAP cutoff value for a DLC predictor was determined using receiver operating characteristic curve analysis. Patients' characteristics and CT findings, including the ARAP, were compared between the groups. The Fisher exact test for categorical variables and the Mann-Whitney U test for continuous variables with Bonferroni correction were used to evaluate the significance of differences. RESULTS: Fifteen patients were assigned to the DLC (+) group. The ARAP was significantly higher in the DLC (+) group than in the DLC (-) group (P = 0.006). The ARAP cutoff value was 1.55. Regarding the CT findings, an ARAP ≥1.55 (P = 0.005) was significantly correlated with DLC. CONCLUSIONS: Among dynamic CT findings, an increased ARAP is a predictive factor for DLC.

[A Case of Rectal Cancer Presenting with Schistosomiasis Japonica Eggs].

A 87-year-old man had used to live in Shizuoka Prefecture. He got colonoscopy due to melena, and a type 1 tumor about 3 cm was detected in the rectum. He was diagnosed with rectal cancer. We performed a laparoscopic low anterior resection with lymphadenectomy. Histopathological findings shows tub1, pSM(7mm), med, INF a, ly1, v0, pPM0, pDM0, pN0(0/7), T1bN0M0, Stage I . Schistosoma japonica eggs were seen in submucosal of the rectum not around the tumor but also normal tissue. The eggs embolized microvessels. It has been 5 year since the operation, the patient has survived without recurrence.

[Esophagogastric Junction Cancer Resection with Bilateral Adrenal Metastasis - A Case Report].

The patient was a 64-year-old man with esophagogastric junction cancer. We performed right thoracotomy-laparotomy for lower esophageal and cardiac gastric resection, D2 lymphadenectomy, and reconstruction of a gastric tube in October 2011. Histopathology confirmed T4aN1M1(LYM), Stage IV cancer(Japanese Classification of Gastric Carcinoma, 14th edition) with R0 resection. Because of preexisting alcoholic cirrhosis, postoperative chemotherapy was not an option. In March 2014, we performed left adrenalectomy for left adrenal metastasis, and in December 2014, we performed right adrenalectomy for metastasis to the right adrenal gland. The patient was prescribed 20mg/day of hydrocortisone postoperatively. Survival from the right adrenalectomy was 2 years and 2 months, and survival from the first operation was 5 years and 4 months, without recurrence. This case of esophagogastric junction cancer resection with bilateral adrenal metastasis is rare, with only one previously reported case in Japan.

Use of dynamic CT attenuation value for diagnosis of acute gangrenous cholecystitis.

OBJECTIVE: To determine if the increase in transient focal enhancement of the liver adjacent to the gallbladder seen on dynamic computed tomography (CT) is greater in gangrenous cholecystitis than in nongangrenous cholecystitis by determining the CT attenuation value. METHODS: We retrospectively reviewed the medical records of 57 patients who underwent emergency cholecystectomy for acute cholecystitis and preoperative dynamic CT scans between March 2011 and April 2016. Based on the pathology findings, patients were assigned to a gangrenous group or a nongangrenous group. The CT attenuation ratio (AR) was defined as the ratio of the maximum CT attenuation value in the region of interest in segment 5 (liver parenchyma adjacent to the gallbladder) and that in the control region of interest in segment 8. The patient characteristics and CT findings were compared between the groups. The appropriate AR of the arterial phase (ARAP) cutoff value for a diagnosis of gangrenous cholecystitis was determined using receiver operating characteristic curve analysis. RESULTS: The ARAP was significantly higher in the gangrenous group than in the nongangrenous group (P < .001); the area under the receiver operating characteristic curve was 0.849. The ARAP cutoff value of 1.46 had a sensitivity and specificity of 84.6% and 83.9%, respectively (odds ratio, 21.17; 95% confidence interval, 4.90-118.91), and ARAP ≥1.46 was significantly correlated with a diagnosis of gangrenous cholecystitis (P < .001). CONCLUSIONS: The increase in transient focal enhancement of the liver adjacent to the gallbladder during the arterial phase of dynamic CT was greater in gangrenous cholecystitis than in nongangrenous cholecystitis.

[A Case of a Large Gastric Gastrointestinal Stromal Tumor with a PDGFRA Exon 18 Mutation].

A 49-year-old man visited our hospital with a chief complaint of abdominal pain that began 1 day before his visit.An approximately 30 cm tumor that was extensively in contact with the gastric wall in the abdominal cavity was detected on computed tomography(CT).An elevated lesion covered with normal mucosa on the posterior wall of the greater curvature was detected on upper endoscopy.He was diagnosed with a submucosal tumor of the stomach, and he underwent surgery. Surgical findings revealed an elastic soft tumor with a maximal dimension of 38 cm that projected from the posterior wall of the stomach beyond the gastric wall.No invasion and metastasis to other organs were detected.Partial gastrectomy was performed.On histopathological examination, proliferation of atypical round and spindle cells was found, and immunostaining was negative for KIT but positive for CD34.In the gene search, an Asp842Val mutation was detected in exon 18 of the PDGFRA gene.Currently, the patient has survived for 7 months after surgery without recurrence.

[A case of HER2-positive breast cancer for which preoperative chemotherapy with pertuzumab resulted in a pathological complete response].

A right breast tumor was identified during screening in a 56-year-old woman, and she was then diagnosed with Stage II B breast cancer (T2N1M0) of Luminal -HER2 type. She was treated with preoperative chemotherapy with pertuzumab, trastuzumab, and docetaxel followed by epirubicin, cyclophosphamide, and fluorouracil. She was judged to have achieved a clinical complete response after 4 courses of pertuzumab, trastuzumab, and docetaxel, and she then underwent partial resection of the right breast and sentinel lymph node dissection. Pathological examination revealed that a pathological complete response was achieved. Combination therapy with pertuzumab, trastuzumab, and docetaxel seems to be a useful preoperative chemotherapy regimen for HER2-positive breast cancer.

Comparative outcomes of elderly and non-elderly patients receiving first-line palliative chemotherapy for advanced biliary tract cancer.

BACKGROUND AND AIM: Few studies have reported the efficacy and safety of palliative chemotherapy in elderly patients with advanced biliary tract cancer. We aimed to investigate the clinical outcomes of palliative chemotherapy for advanced biliary tract cancer in elderly patients. METHODS: We retrospectively evaluated 403 consecutive patients who received palliative chemotherapy between April 2006 and March 2009 for pathologically confirmed unresectable or recurrent biliary tract cancer. Clinical outcomes of the elderly group (≥ 75 years old; n = 94) were compared with those of the non-elderly group (< 75 years old; n = 309). RESULTS: Except for the extent of disease, patient baseline characteristics were well balanced between both groups. The median overall survival was 10.4 months in the elderly group and 11.5 months in the non-elderly group (hazard ratio, 1.14; 95% confidence interval, 0.89-1.45; P = 0.31). Although the frequency of adverse events between both groups was similar, interstitial pneumonitis was significantly more frequent in the elderly group than in the non-elderly group (4.3% vs 0%, P < 0.01). CONCLUSIONS: In advanced biliary tract cancer, overall survival of elderly patients receiving palliative chemotherapy is comparable with that of non-elderly patients. To our knowledge, this is one of the largest studies that have reported the clinical outcomes of elderly patients following palliative chemotherapy.

The association between gingivitis and oral spirochetes in young cats and dogs.

Although gingivitis frequently occurs in young cats, spirochetes are often found in the early stages of periodontal disease. This study was conducted to determine the association between gingivitis and oral spirochetes in young cats and dogs. The degree of gingivitis was evaluated in a total of 68 cats and 31 dogs under one year of age, and plaques were collected from each carnassial. To detect spirochetes or Porphyromonas gulae in plaque samples, 16S rRNA gene was amplified by polymerase chain reaction (PCR) using specific primers. All data were analyzed using Fisher's exact probability test and odds ratio (OR) with a 95% confidence interval (95% CI). The prevalence of gingivitis was significantly higher in young cats (92.6%) than in young dogs (45.2%). The positive rate of spirochetes by PCR in gingivitis cases was 85.4% in young cats and 15.4% in young dogs, and the positive rate of P. gulae was 66.7% in young cats and 15.4% in young dogs. Both results were significantly higher in young cats than in young dogs. In young cats, spirochetes were significantly associated with gingivitis (OR = 7.95; 95% CI = 1.17, 53.83; P < 0.05), but P. gulae was not (OR = 2.44; 95% CI = 0.38, 15.66; P = 0.23). These results suggest that spirochetes may be associated with the early stages of periodontal disease in cats.

Pathologic complete response with pembrolizumab plus axitinib in metastatic renal cell carcinoma.

Immunotherapy-based combinations have played a central role in the treatment of metastatic renal cell carcinoma, and long-term survival of patients is expected. In this context, it is clear that a certain number of patients can achieve a complete response. However, the diagnosis of complete response is usually based on imaging, and there are few cases of pathological complete response. In this study, we report a case of a patient with metastatic renal cell carcinoma who was treated with pembrolizumab plus axitinib, followed by resection of the primary tumor and metastatic lesions, and pathologically achieved a complete response.

Outcomes of lung metastasis from pancreatic cancer: A nationwide multicenter analysis.

BACKGROUND: Although distant metastasis from pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis, some single center studies reported that lung metastasis has a favorable prognosis. The aim of this study is to evaluate the prognostic value of site-specific metastasis after pancreatectomy for PDAC, with a focus on lung metastasis. METHODS: Data from 117 cases of lung metastasis after pancreatectomy were collected retrospectively from 23 institutions in Japan. To compare the sites of metastasis we also collected the data of 134 patients with liver only metastasis, 67 patients with peritoneal only metastasis and 121 patients with locoregional recurrence alone. RESULTS: In patients with lung only metastasis, the median time from recurrence to death (RTD) was 23.1 months, which was better in comparison to other sites of recurrence. In lung metastasis group, the patients who underwent pulmonary resection had better long-term outcomes in comparison to those who did not. (RTD: 29.2 vs 15.2, P < .001). In the multivariate analysis, solitary metastasis (HR 5.03; 95% CI 1.195-21.144, P = .022) and postoperative chemotherapy (HR 14.089; 95% CI 1.729-114.77, P = .023) were identified as significant prognostic factors after lung resection. CONCLUSIONS: Surgical resection is a favorable option for selected patients with a solitary lung metastasis and for whom adjuvant chemotherapy can be administrated.

Long-term follow-up study after administration of a canine interferon-α preparation for feline gingivitis.

Intraoral administration of canine interferon alpha (CaIFN-α) has been shown to reduce gingivitis in dogs, but has not been confirmed in cats. Therefore, in this study, a CaIFN-α preparation was used for feline gingivitis, and the degree and duration of its effects were examined. Cats were divided into two groups: one was administered CaIFN-α, and the other was not. They were observed up to 12 months. It was suggested that CaIFN-α have a reducing effect on gingivitis and halitosis for a certain period although may not on plaque or calculus. In addition, the duration of the CaIFN-α gingivitis-reducing effect was suggested to be about three months. The CaIFN-α preparation is considered to be a useful treatment for oral hygiene control.

A simple, noninvasively determined index predicting hepatic failure following liver resection for hepatocellular carcinoma.

BACKGROUND: A novel index, the serum aspartate aminotransferase activity/platelet count ratio index (APRI), has been identified as a biochemical surrogate for histological fibrogenesis and fibrosis in cirrhosis. We evaluated the ability of preoperative APRI to predict hepatic failure following liver resection for hepatocellular carcinoma. METHODS: Potential preoperative risk factors for postoperative hepatic failure (hepatic coma with hyperbilirubinemia, four patients; intractable pleural effusion or ascites, 30 patients; and variceal bleeding, one patient) as well as APRI were evaluated in 366 patients undergoing liver resection for hepatocellular carcinoma. Prognostic significance was determined by univariate and multivariate analyses. RESULTS: Hepatic failure developed postoperatively in 30 patients, causing death in four. APRI correlated with histological intensity of hepatitis activity and degree of hepatic fibrosis, and was significantly higher in patients who developed postoperative hepatic failure than in others without failure. Risk of postoperative hepatic failure increased as the serum albumin concentration and platelet count decreased and as indocyanine green retention rate at 15 min, aspartate and alanine aminotransferase activities, and APRI increased. Only APRI was an independent preoperative factor on multivariate analysis. Of the four patients who died of postoperative hepatic failure, three had an APRI of at least 10. CONCLUSIONS: Preoperative APRI independently predicted hepatic failure following liver resection for hepatocellular carcinoma. Patients with an APRI of 10 or more have a high risk of postoperative hepatic failure.

Reconstruction of hepatic veins by anastomosis with suprahepatic IVC in the posterior mediastinum in living donor liver transplantation for Budd-Chiari syndrome.

In living donor liver transplantation for Budd-Chiari syndrome, it is necessary to eliminate interference with outflow from the liver without the replacement of the involved retrohepatic segment of the inferior vena cava. A 34-year-old female patient underwent living donor liver transplantation for Budd-Chiari syndrome. During surgery, the fibrous tissue surrounding the recipient inferior vena cava was dissected after removal of the recipient liver. The diaphragm was dissected and mobilized from the inferior vena cava on the cranial side to expose the intact inferior vena cava in the posterior mediastinum. The left and middle hepatic veins in the graft liver were anastomosed to a horizontal anastomotic orifice prepared in the anterior wall of the intact inferior vena cava in the posterior mediastinum. Anticoagulant therapy was begun after liver transplantation. Dynamic computed tomography after living donor liver transplantation demonstrated patent hepatic veins. The patient has been doing well, without any episode of thrombosis or occlusion of the graft hepatic veins at 1 year and 6 months after liver transplantation.