[Long-Term Survival of a Patient with Advanced Antral Gastric Cancer Successfully Treated with Multidisciplinary Therapy].

We report the case of long-term survival of a patient with advanced antral gastric cancer with multiple paraaortic lymph nodes metastasis who was successfully treated with multidisciplinary therapy. A 70-year-old female was admitted to our hospital complaining of vomiting. Upper gastrointestinal endoscopy revealed a Type 3 tumor in the gastric antrum. Computed tomography(CT)showed a marked decrease in the size of the primary gastric tumor and lymph nodes after 9 courses of mFOLFOX6 therapy. Subsequently, 7 courses of paclitaxel plus ramucirumab(PTX plus Rmab)therapy and 10 courses of nivolumab therapy were administered. After nivolumab therapy, marked shrinkage of the lymph nodes was observed on CT. Distal gastrectomy with D2(+ #16a2+b1)lymph node dissection was performed. The pathological finding was ypT0N1M0 with a Grade 3 effect of the chemotherapy. After 6 months of adjuvant chemotherapy with S-1, CT revealed supraclavicular lymph node metastases. After 4 courses of nivolumab therapy, CT showed a marked increase in the size of the lymph node. Consequently, the regimen was changed to irinotecan. After 16 courses of irinotecan therapy, CT showed a marked shrinkage in the size of the lymph node. The patient is currently alive with no signs of recurrence for 5 years, ie, since the initiation of the multidisciplinary therapy.

[A Case of Long-Term Survival with Tumor Resection and DOX plus DTIC Therapy for Desmoid Tumor after FAP Surgery].

The patient is a 22-year-old, female. She had a family history of familial adenomatous polyposis(FAP)and a prophylactic total colorectal resection was performed for FAP at age of 18. She presented with fever and abdominal distention and palpated a mass with tenderness in the right lower abdomen. Contrast-enhanced CT scan of the abdomen showed a heterogeneous contrast effect around the tumor margins. With the diagnosis of intra-abdominal desmoid tumor, a partial duodenal resection, small bowel mass resection, and right fallopian tube resection were performed along with the tumor, and an artificial anus was created with the jejunum. Contrast-enhanced CT scan of the abdomen 16 months after resection of desmoid tumor showed a 6.5 cm long desmoid tumor recurrence in the mesentery. She received 5 courses of doxorubicin (DOX)plus dacarbazine(DTIC)therapy followed by continued NSAIDs. Seven years after the operation, she has been able to maintain the shrinkage of the recurrent tumor and is still on medication. Long-term surveillance is necessary because of the possibility of the appearance of other associated lesions in the future.

[An Experience of Multidisciplinary Treatment for Advanced Esophageal Cancer with Tumor Perforation during Preoperative Chemotherapy].

Perforation of esophageal cancer is one of the fatal oncologic emergencies, and a prompt and accurate treatment strategy is required. Here, we report a case of advanced esophageal cancer that had perforated during preoperative chemotherapy and was successfully resected with multidisciplinary treatment. The prognosis of perforated esophageal cancer can be expected to improve by multidisciplinary treatment appropriately combining initial treatment for infection control and subsequent cancer treatment.

[A Case of Right Hemicolectomy for Inflammatory Myofibroblastic Tumor Arising in the Right Transverse Colon].

The patient was a 21-year-old male. He presented with right lower abdominal pain and showed tenderness in the same area. An abdominal contrast-enhanced CT examination revealed a 45 mm tumor that continuously stained in the right transverse colon. The patient presented with tenderness and rebound tenderness. Due to a suspected submucosal tumor, laparotomy was performed and an elastic hard tumor of 5 cm in size was found on the serous membrane side of the right transverse colon. As malignancy could not be ruled out, a right hemicolectomy with lymph node dissection was performed. The pathological diagnosis was an inflammatory myofibroblastic tumor(IMT), characterized by the proliferation of spindle- shaped spindle-shaped fibroblast-like cells with inflammatory cell infiltration. As of 9 years post-surgery, there has been no recurrence. However, long-term surveillance is necessary.

[A Case of Surgery for Skin Metastasis of Papillary Thyroid Carcinoma in a Very Elderly Patient to Improve the Quality of Life].

The patient was a 100-year-old woman who underwent right lobe thyroidectomy for papillary thyroid cancer in another hospital around 1990. She developed local recurrence in 2010 and underwent anterior tracheal local recurrence resection in May 2017. Subsequently, metastases were confirmed in the lateral cervical lymph nodes, but the patient only received TSH suppression because of her advanced age. Multiple pulmonary metastases developed in November 2020 and supraclavicular lymph node metastases in July 2021, but the patient was under the care of a visiting physician on best supportive care. The patient was referred to our hospital in January 2022 due to the appearance of a cutaneous mass in the sternal incision area, which gradually increased in size. A well-mobile, well-defined, spherical mass was found in the sternotomy area. The maximum diameter was 19 mm. The cytological findings were consistent with cutaneous metastasis of papillary thyroid carcinoma. As the patient was elderly and had multiple pulmonary metastases, she was temporarily observed. However, by June 2022, the mass had increased from 19 mm to 33 mm with cutaneous discoloration. There was no tendency for multiple pulmonary metastases to grow during this period. The decision was made to operate in order to prevent a decline in quality of life due to self-destruction of the cutaneous metastasis. The tumor was removed under general anesthesia, including the cutaneous discoloration, and reconstructed with a rhomboid skin flap. Post-operatively, there was no local recurrence or significant increase in pulmonary metastases. It is suggested that resection of cutaneous metastasis of malignant tumors may be effective in preserving quality of life even in a 100-year-old elderly patient like the present case and should be considered as an indication.

[A Case of Malignant Rectal B Cell Lymphoma That Was Difficult to Differentiate from Rectal Neuroendocrine Tumor].

A 74-year-old woman with a chief complaint of hematochezia was admitted to our hospital. Colonoscopy revealed a 2 cm submucosal tumor with an erosion in the Rb of the rectum. Biopsy showed various inflammatory cell clusters, but no malignant findings. Thoracoabdominal CT and abdominal MRI showed no abnormal findings other than that of rectal wall thickening. Somatostatin receptor scintigraphy performed on suspected rectal NET showed no abnormal accumulation. A total of 3 biopsies were performed, but a definitive diagnosis was not confirmed, and transanal rectal mucosal resection was performed for diagnostic purposes. Immunohistochemistry showed CD20(+)and bcl-2(+), and the lesion was diagnosed as malignant rectal B cell lymphoma. For 1 year postoperatively, the patient showed no recurrence. For this case, biopsy often failed to confirm a definitive diagnosis on rectal submucosal tumors. If the tumor is >1 cm in diameter in a rectal NET, a rectal resection with lymph node dissection is required, and anal function may be impaired. Local tumor excision for diagnosis and treatment may be worthwhile in rectal submucosal tumors if pre-resection diagnosis with biopsy is difficult.

[A Case of Nivolumab Responding to Multiple Lymph Node Metastases during Multidisciplinary Treatment for Esophageal Cancer].

In nivolumab therapy for unresectable advanced esophageal cancer, there are a few cases that show a complete response, and long-term survival can be expected in such cases. Here, we report a case in which nivolumab had a complete response to multiple lymph node metastases during multidisciplinary treatment for esophageal cancer and survived for a relatively long period despite being elderly. Examination of complete response cases provides us with significant insights in considering the unexplained biomarkers of immune checkpoint inhibitors and treatment discontinuation during complete response.

[A Case of Anal Canal Adenocarcinoma with Perianal Pagetoid Spread without a Macroscopic Finding].

We report a case of anal canal cancer with Pagetoid spread without a macroscopic skin lesion. A 54-year-old man was admitted to a hospital with complaints of bloody stools. Endoscopic examination revealed a polyp in the anal canal, and endoscopic mucosal resection was performed. Pathological examination revealed an adenocarcinoma accompanied by Pagetoid spread and the positive surgical margin. We additionally performed trans-anal resection twice, but the resected horizontal margin was positive. Mapping biopsy of rectal mucosa and perianal skin revealed adenocarcinoma in only rectal mucosa. Abdominoperineal resection was performed. Histopathological examination showed invasive adenocarcinoma with pagetoid spread and that the surgical margin was negative. Pagetoid spread of anal canal adenocarcinoma usually showed macroscopic abnormal findings, but in this case, there was no skin lesion. It suggests that preoperative mapping biopsy is helpful for determining the excision range. It is necessary to keep in mind that anal canal adenocarcinoma with no skin lesion may cause Pagetoid spread.

27-gauge trocar-assisted sutureless intraocular lens fixation.

BACKGROUNDS: However there have been numerous investigations of intrascleral intraocular lens (IOL) fixation techniques, there is room for improvement in terms of simplifying complicated techniques and reducing the high levels of skill required. This study aimed to report a novel technique for sutureless intrascleral fixation of the IOL using retinal forceps with a 27-gauge trocar. METHODS: Nineteen eyes of 18 patients underwent intrascleral fixation of the IOL from July 2018 to September 2019 were enrolled in this study. A 27-gauge trocar formed 3-mm scleral tunnels positioned at 4 and 10 o'clock, 2 mm from the corneal limbus. We used a 3-piece IOL haptic grasped by a 27-gauge retinal forceps and pulled from the 27-gauge trocar. The IOL was fixed by making a flange. Main outcome measures were visual acuity, corneal endothelial cell density, IOL tilt, decentration, predicted error of refraction and complications. RESULTS: The 19 eyes were followed up for 1 month. The mean pre- and postoperative logMAR uncorrected visual acuity (UCVA) was 1.06 ± 0.63 and 0.40 ± 0.26, respectively (p < 0.01), while the mean pre- and postoperative logMAR best corrected visual acuity (BCVA) was 0.27 ± 0.51 and 0.06 ± 0.15, respectively (p = 0.09). The mean corneal endothelial cell density was 2406 ± 625 to 2004 ± 759 cells/mm2 at 1 month (p = 0.13). The mean IOL tilt was 3.52 ± 3.00°, and the mean IOL decentration was 0.39 ± 0.39 mm. There was no correlation among IOL tilt, decentration and BCVA (p > 0.05). The mean prediction error of the target refraction was - 0.03 ± 0.93 D. The complications were vitreous hemorrhage (3 eyes), hyphema (1 eye), IOP elevation (1 eye), iris capture of the IOL (1 eye) and hypotony (2 eyes). No IOL dislocation occurred. CONCLUSIONS: IOL intrascleral fixation with a flange achieved good IOL fixation and visual outcome in the scleral tunnels created with the 27-gauge trocar.

[Disseminated Bone Marrow Carcinomatosis from Colon Cancer-A Case Report].

A 77‒year‒old man came to our hospital with complaints of abdominal pain and difficulty to defecate. Abdominal CT scan showed an abnormal region in the ascending colon, which was suspected to be an ascending colon cancer. D‒dimer was remarkably high, and the platelet count was 63,000/µL; these results suggested disseminated intravascular coagulation caused by tumor activation. After he was admitted, we performed a contrast enhanced CT, and found no signs of remote metastasis. We decided to resect the tumor without colonoscopy examination in order to release the DIC state. After the surgery, the platelet count did not increase, and leukopenia was observed. We conducted a bone marrow biopsy, and made a diagnosis of disseminated carcinomatosis from colon cancer. The patient's condition did not improve, and he died on day 42 after admission. Pathological autopsy was performed and several minimal remote metastases were found throughout the body.

[A Case of Recurrent Hepatocellular Carcinoma Successfully Treated by Radiation Therapy].

We report a case of recurrent hepatocellular carcinoma(HCC)successfully treated by radiation therapy. A 79-year-old woman was diagnosed with HCC and underwent liver resection. Seven months after resection, CT and MRI detected a new HCC, and she had a surgery again. One year after the surgery, CT and MRI detected local recurrence, and she underwent the third operation. Three months after the operation, the third liver recurrence was treated by transcatheter arterial chemoembolization( TACE). Four months later, a new lesion was detected and treated by stereotactic body radiation therapy(SBRT) twice. She remains alive without recurrence 27 months after the last radiation therapy. Very few evidence is reported of radiation therapy for HCC, but this case suggests that radiation therapy provides a benefit for patients with HCC after other treatments.

[Tumor Embolisms from Colon Cancer Detected on Transcatheter Examination-A Case Report].

A 58-year-old woman underwent surgery and systemic chemotherapy(FOLFIRI plus panitumumab)for ascending colon cancer with multiple lymph node and liver metastases; the preoperative Virchow lymph node aspiration cytology showed adenocarcinoma.After 4 courses of chemotherapy, contrast-enhanced CT showed an embolus in the left subclavian vein.An anticoagulation therapy was started, but the embolus tended to increase.Three months later, the patient developed dyspnea and was diagnosed with pulmonary artery thromboembolism and superior vena cava thrombosis.Transcatheter examination was performed because of the anticoagulation-resistant embolism, and the biopsy revealed tumor embolism due to colon cancer.She died of respiratory failure 10 days after the biopsy.The tumor directly infiltrating the vein because of left subclavian lymph node metastases might have resulted from increased tumor emboli.Although cases of tumor emboli infiltrating the veins and developing from lymph node metastases are rare, a transcatheter biopsy may help to detect them.

[A Case of Advanced Gastric Cancer with Peritoneal Metastasis Achieved Pathological Complete Response by Chemotherapy(SOX Regimen)].

A 68-year-old woman was presented with anorexia. Upper gastrointestinal endoscopy revealed type 4 gastric cancer at corpus of the stomach. Peritoneal metastasis was detected by staging laparoscopy. After a diagnosis of cT4aN1M1, cStage ⅣB advanced gastric cancer, we performed chemotherapy(SOX regimen; S-1 100 mg/body on day 1-14, followed by 7 days of rest, oxaliplatin 130 mg/m2 on day 1). After the 3 courses of chemotherapy, the primary tumor had been reduced. Second staging laparoscopy revealed no peritoneal metastasis. Then, we performed total gastrectomy with D2 lymph node dissection. Histopathological examination revealed no residual cancer cells, indicating a pathological complete response (Grade 3). We report a case of advanced gastric cancer with peritoneal metastasis achieved pathological complete response by chemotherapy.

[A Case of Stevens-Johnson Syndrome Induced by Chemotherapy for Metastatic Colon Cancer].

A 78-year-old woman had a semicircular ulcerative lesion of AV 7 cm, as detected using colonoscopy, and pathologic examination based on a biopsy showed well-differentiated adenocarcinoma. On contrast-enhanced CT of the liver, a number of nodular lesions that seemed to be liver metastases were observed. It was decided to administer chemotherapy containing mFOLFOX6 plus panitumumab. Bilateral hemorrhage of the ocular conjunctiva and eyelid edema were observed from the 4th day of chemotherapy. Edema of the lips, epidermolysis, and erythema appeared in addition to vision impairment. We diagnosed her with SJS based on these symptoms. We also administered steroid pulse therapy. Eyelid edema improved, and vision impairment improved 24 hours after the initiation of treatment. For severe cases with visual impairment, systemic administration of corticosteroids is recommended. In this case, administering steroid pulse therapy from an early stage resulted in improvement without sequelae.

Increase in incidental detection of thyroid cancer in Osaka, Japan.

Using Osaka Cancer Registry data, we examined age-specific and age-adjusted incidence rates of thyroid cancer according to the route of thyroid cancer detection from 1992 to 2012. The detection routes were categorized into "symptomatic" and "incidental detection." Age-specific incidence rates of incidentally-detected thyroid cancer consistently increased during the study period, especially after 2001, for all sex and age groups other than childhood. The rate of symptomatic thyroid cancer did not largely differ among groups. Age-adjusted incidence rates of symptomatic thyroid cancer were around 1.5 and 4.5 per 100 000 among men and women, respectively. The rate of incidentally-detected thyroid cancer increased from 0.1 and 0.1 per 100 000 person-years among men and women in 1992-1994 to 2.0 and 4.9, respectively, in 2010-2012. Age-adjusted mortality rates among both sexes during the study period leveled off. This finding suggests that the thyroid cancer incidence rate in Osaka increased with incidental detection. We need to continue careful monitoring to confirm these findings.

[A Case of an Elderly with Locoregional Recurrence of ER-Negative HER2-Positive Breast Cancer Successfully Treated with Local Therapy].

An 80-year-old woman who received on anticoagulant therapy for atrial fibrillation was diagnosed with ER-negative HER2-positive breast cancer(cT4bcN1M0, Stage ⅢB). She underwent mastectomy with skin graft and lymphadenectomy, but was evaluated to be too old for standard chemotherapy and HER2-directed therapy. Four months after the operation, she was diagnosed with regional lymph node metastasis and underwent radiotherapy. Moreover, 9 months later, other recurrent sites were revealed in the parasternal lymph node and thoracic wall without distant metastasis. Radiotherapy could be performed around these secondary recurrent sites while avoiding overlap. After 2 years, solitary contralateral axillary lymph node metastasis was diagnosed by PET-CT. She underwent Lt axillary lymphadenectomy. The intrinsic breast cancer subtype did not change. Patient performance status was kept to achieve a good quality of daily life. Eight months later, she diagnosed with primary pancreatic cancer and received 13 cycles of chemotherapy until her death from pancreatic cancer 14 months later. During chemotherapy, no recurrence of breast cancer was observed.

[A Case of Extended Mediastinal and Retroperitoneal Emphysema after Transanal Local Excision of an Early Lower Rectal Adenocarcinoma].

We observed a case of a large collection of mediastinal and retroperitoneal emphysema, which developed after a transanal local excision for an early lower rectal carcinoma and was treated conservatively. An 80's female patient presented with a chief complaint of bowel difficulty, which was diagnosed as mucosal prolapse syndrome with anal sphincter dysfunction. Endoscopic colonoscopy showed full circumferential proliferation of the mucosal membrane including a semicircular protruding lesion, on the upper side of the dentate line. Biopsy revealed findings indicative of an adenocarcinoma(tub1/pap), Group 4. After a sufficient informed consent was taken, a transanal local excision under spinal anesthesia was conducted discontinuously over half of the circumference. The patient underwent partial-thickness excision, partially full-thickness, and the defects are closed as much as possible. A fever of 38 degrees Celsius was recognized on the 1st postoperative day, and a CT scan, on the 2nd postoperative day, showed a large collection of retroperitoneal and mediastinal emphysema tracking upwards to the nasopharynx. Since fever was the only subjective symptom present, antibiotic therapy under fasting was chosen. The mediastinal emphysema had mostly resolved by the 10th postoperative day. Even though standard transanal excision is not a treatment under air supply there is a risk leading mediastinal and retroperitoneal emphysema.

[A Case of HER2-Positive Breast Cancer with Newly Diagnosed Stage IV That Responded to First-Line Pertuzumab and Trastuzumab-Based Therapy].

A 48-year-old woman who observed swelling and erosion in her left breast was diagnosed with locally advanced, ERnegative, HER2-positive breast cancer with de novo liver metastasis, T4cN1M1, Stage IV . She underwent primary systemic therapy with weekly paclitaxel, and pertuzumab and trastuzumab every 3 weeks. The tumor responded remarkably with 57.0% reduction in 5 weeks of treatment. Because of an anaphylactic shock to paclitaxel in day 8, exchanging to eribulin was considered less toxic than taxane, and was continued for 8 cycles until local relapse. The liver metastasis showed 75.4% reduction. The patient received bilateral mastectomy, which resulted in histological response Grade 1b of the left breast and the right breast of DCIS. After the left thoracic radiation, marginal liver metastasis was observed in the S4 segment on PET-CT. Treatment consisted of docetaxel and dual HER2 blockade therapy in 6 more cycles. As a result, complete remission was achieved.

[A Case of Inflammatory Breast Cancer with Very Severe Obesity].

A 39-year-old woman with very sever obesity was admitted to our hospital for a right breast redness and hardness. Her height, weight and BMI were 166 cm, 145 kg and 52.6 kg/m2. Her breast had peau d'orange. CT scan showed swelling of whole right breast and Level I , II lymph node. We performed core needle biopsy and diagnosed as the inflammatory breast cancer with ER and HER2 positive. We introduced chemotherapy(pertuzumab, trastuzumab and paclitaxel)and nutrition counseling in order to reduce her body weight. After 4 courses of chemotherapy, the clinical complete response was obtained and her body weight decreased to 125 kg. We performed mastectomy and axillary node resection and confirmed pathological complete response. Adjuvant chemotherapy(5-FU, epirubicin and cyclophosphamide), adjuvant trastuzumab therapy, postmastectomy radiation therapy and adjuvant hormonal therapy were administered. There have been no signs of recurrence as of 2 years after the operation.

[A Case of Advanced Transverse Colon Cancer with Relapse behind the Rectum after Laparoscopic-Assisted Resection].

A 60's male patient underwent laparoscopic left hemicolectomy with D3 lymph node dissection for transverse colon cancer. Adjuvant chemotherapy with tegafur-uracil and leucovorin was administered.Thirty -four months later, MRI scan revealed a mass with sacrum invasion.Radiation therapy(39 Gy/13 Fr)was performed followed by chemotherapy(modified oxaliplatin, leucovorin, and 5-fluorouracil plus bevacizumab).Two weeks after the completion of radiation therapy, staging laparoscopy and tissue biopsy was performed in the hard tumor, which was located at the caudal end of the incisional scar of the retroperitoneum, in front of the sacrum.The pathological diagnosis revealed metastasis from transverse colon cancer.Radiographic examination showed partial response to radiochemotherapy, and buttock pain decreased.CT review before pain developed showed a small tumor located mainly in the mesorectum slightly adjacent to the sacrum, suggesting the implantation of cancer cells to the stripped plane behind the mesorectum during the surgery.