[The case of a giant malignant phyllodes tumor of the breast].

A 75-year-old female patient complained of a mass in her left breast 2 years ago. The patient experienced a rapid enlargement of the mass 2 months later and visited our hospital. A computed tomography (CT) scan indicated a 25-cm tumor with infiltration of the left breast skin. Pectoral muscle invasion was considered. Swelling of the axillary lymph node and remote metastases were not found. A needle biopsy indicated a phyllodes tumor. A pectoral muscle-preserving mastectomy was undertaken. The tumor weighed 7.1 kg. Pathological examination indicated hyperplasia of the stroma and part of the epithelium, which had invaded the skin layer and fatty tissue. The pathological diagnosis was a malignant phyllodes tumor. This paper reports the case of a giant malignant phyllodes tumor.

[A case of locally advanced breast cancer successfully treated with Mohs paste].

We report a case of primary advanced breast cancer that was locally controlled by treatment with Mohs paste. A 57- year-old woman presented with right locally advanced breast cancer with massive exudate and oozing blood. Histopathological examination indicated an invasive ductal carcinoma. Moreover, the patient had lung, liver, and bone metastases. She received chemotherapy, following which the breast tumor was treated using Mohs paste and dissected. The bleeding and exudate stopped almost completely, and the breast tumor became flat. Therefore, it is suggested that locally advanced breast cancer could be controlled by treatment with Mohs paste.

Surgical resection of solitary metastatic liver tumor arising from lung cancer: a case series.

Resectability of hepatic metastases which have developed from lung cancer is limited and only a few reports have been published. We report two cases of a surgical resection of liver metastases arising from lung cancer. A 77-year-old male underwent a lower left lobectomy to treat a primary large cell lung carcinoma. Eight months later, abdominal computed tomography revealed a slightly enhanced heterogeneous tumor measuring 50 mm in diameter in the right liver, segment 8. We performed a hepatic anterior sectionectomy. The pathological findings were similar to those of the primary carcinoma. After six months, there was no evidence of a recurring lesion. A 65-year-old female underwent an upper right lobectomy to treat a primary adenocarcinoma. Twenty months later, abdominal computed tomography revealed a heterogeneous tumor measuring 20 mm in diameter in the right liver, segment 7. We performed a hepatic posterior sectionectomy. The pathological findings were similar to those of the primary lung carcinoma. After twenty months, the patient died from an unresectable recurrent carcinoma in the lung and brain. No recurrence was detected in the liver. We recommend that surgical resection be considered for solitary metastatic liver tumors which develop from lung cancer.

Utility of Robot-assisted Laparoscopic Transabdominal Preperitoneal Repair of Inguinal Hernia Following Robot-assisted Laparoscopic Radical Prostatectomy.

BACKGROUND: To evaluate the utility of robot-assisted laparoscopic transabdominal preperitoneal repair (R-TAPP) of postprostatectomy inguinal hernia (PIH) in patients who underwent robot-assisted laparoscopic radical prostatectomy (RALP). PATIENTS AND METHODS: This was a prospective, single-centre retrospective cohort study. R-TAPP was conducted in 74 consecutive patients from September 2016 to March 2020. With the exception of women and patients who underwent previous abdominal surgery, 70 patients were classified into two groups based on the absence or presence of PIH. Their data were retrospectively compared to those who had not undergone RALP. RESULTS: The median operative time for the PIH group was longer compared to the non-PIH group. However, postoperative complications, including seroma formation, haematoma and surgical site infections, were not significantly different between the groups. The estimated blood loss was small, and hospitalisation duration was 1 day in all cases. Moreover, there were no hernia recurrences within the 90-day follow-up period in either group. CONCLUSION: R-TAPP is a feasible and safe approach for inguinal hernia repair, even in patients who undergo RALP for prostate cancer.

Shunting and nonshunting procedures for the treatment of esophageal varices in patients with idiopathic portal hypertension.

BACKGROUND/AIMS: We evaluated the results of shunting and nonshunting procedures for the treatment of esophagogastric varices in patients with idiopathic portal hypertension (IPH). METHODOLOGY: Between 1981 and 2008, surgery was performed in 9 patients with IPH. Three patients were bleeding before operation, and the other 6 were treated prophylactically. Patients were divided into 2 groups, a shunting group (4 underwent distal splenorenal shunt) and a nonshunting group (3 underwent esophageal transection and 2 underwent Hassab's procedure). RESULTS: Esophagogastric varices were completely eradicated in 3 (75.0%) patients in the shunting group and 4 patients (80.0%) in the nonshunting group. Additional endoscopic treatment (one session) was performed in 2 patients with incompletely eradicated varices. There was no recurrence in the shunting group. In the nonshunting group, esophagogastric varices recurred in all 4 patients with completely eradicated varices. All recurrent esophageal varices were completely eradicated. Postoperative platelet counts (x10(4)/microL) were significantly lower in the shunting group (10.0 +/- 2.6) than in the nonshunting group (42.0 +/- 14.0) (p = 0.0029). The increase in the platelet count after operation was significantly lower in the shunting group (1.7 +/- 0.2 times) than in the nonshunting group (5.8 +/- 2.9 times) (p = 0.0267). No patient received anticoagulants postoperatively. Portal venous thrombus did not develop in the shunting group, but appeared in 4 patients (80.0%) in the nonshunting group. No patient had loss of shunt selectivity or portal-systemic encephalopathy. One patient in the nonshunting group died of cerebral hemorrhage; all others are alive. CONCLUSIONS: Shunting procedure, distal splenorenal shunt, was suggested to be useful for the management of esophagogastric varices in patients with IPH.

A case of spontaneous rupture of a simple hepatic cyst.

We describe the spontaneous rupture of a simple hepatic cyst associated with a benign course. A 64-year-old woman was admitted for right upper quadrant pain. The patient denied a history of abdominal trauma. Abdominal computed tomography (CT) showed a huge solitary hepatic cyst (diameter, 10 cm) in the right lobe. Part of the cyst surface was irregular, and the interior was heterogeneous on ultrasonography. Fluid retention was detected under the liver capsule. Spontaneous rupture of a nonparasitic hepatic cyst was suspected. The patient was admitted to our hospital for further evaluation and treatment. Examination of the abdomen revealed right upper quadrant pain but no signs or symptoms of peritonitis. One week after admission, CT revealed that the volume of fluid retained under the liver capsule had decreased. Percutaneous puncture was performed with a needle and an 8-French pigtail catheter under ultrasonographic guidance. Serous, brown fluid was aspirated. After percutaneous aspiration, the patient's symptoms resolved. Minocycline hydrochloride was given daily by intravenous injection for 7 days. The catheter was then removed. There has been no evidence of recurrence after 1 year.

Huge caudate lobe of the liver due to Budd-Chiari syndrome.

Budd-Chiari syndrome is characterized by hepatic venous outflow obstruction. We describe a patient with a huge caudate lobe of the liver due to Budd-Chiari syndrome. A 49-year-old woman was referred to Nippon Medical School Hospital to receive treatment for enlarged gastric varices. She had been followed up for idiopathic portal hypertension with deformity of the liver for 7 years and had undergone surgery for pharyngeal carcinoma 5 years earlier. Upper gastrointestinal endoscopy revealed solitary gastric varices without esophageal varices. Abdominal computed tomography revealed obstructions and scars of the right, middle, and left hepatic veins. The caudate lobe was enlarged, and the portal vein was displaced ventrally, without thrombus. The drainage vein of the caudate lobe, the short hepatic vein on the left side of the inferior vena cava, was dilated. The portal vein and drainage vein of segment 6 were visualized and showed no atrophy. Venography revealed no obstruction of the inferior vena cava. Budd-Chiari syndrome with solitary gastric varices was diagnosed on the basis of these findings. We performed balloon-occluded retrograde transvenous obliteration and partial splenic embolization to treat the gastric varices. The posttreatment course was uneventful, and the patient was discharged 8 days after embolization. The gastric varices shrank.

Interactions between anti-ulcer drugs and non-steroidal anti-inflammatory drugs in cirrhotic patients with bleeding esophagogastric varices.

BACKGROUND/AIMS: Bleeding from esophagogastric varices is a life-threatening complication of chronic liver disease. As compared with esophageal varices (EV), the risk factors for bleeding from gastric varices remain unclear. This study examined interactions between anti-ulcer drugs and non-steroidal anti-inflammatory drugs (NSAIDs) as related to bleeding esophagogastric varices in cirrhotic patients. METHODOLOGY: Eighty-eight cirrhotic patients with an initial episode of bleeding esophagogastric varices who had not received prior treatment studied. The patients were divided 3 groups: 58 with bleeding from EV, 13 with bleeding from cardiac varices (CV), and 17 with bleeding from cardiofundic or fundic varices (FV). The use of "standard" NSAIDs on 4 or more of the last 7 days before the initial episode of bleeding was defined as "regular" use; all other use was considered "occasional". RESULTS: The number of anti-ulcer drug users was 16 (27.6%) in the EV group, 4 (30.8%) in the CV group, and 5 (29.4%) in the FV group. The number of NSAID users was 9 (15.5%) in the EV group, 4 (30.8%) in the CV group, and 11 (64.7%) in the FV group. The proportion of NSAID users was significantly higher in the FV group than in the EV group (p < 0.0001). All 16 users of anti-ulcer drugs who were nonusers of NSAIDs had varices with red color signs. All NSAID users had used NSAIDs orally within a day before the initial episode of bleeding. All "regular" NSAID users were nonusers of anti-ulcer drugs. All anti-ulcer drug users without red color signs were "occasional" NSAID users. CONCLUSIONS: "Occasional" oral NSAID use is an important step leading to variceal hemorrhage, especially in FV, even if the mucosa is protected by anti-ulcer drugs. The ability to use NSAIDs for several days without variceal bleeding in some patients with esophagogastric varices who are concurrently receiving anti-ulcer drugs suggests that such drugs might protect the esophagogastric mucosa.

Simultaneous evaluation of portal hemodynamics and liver function by scintiphotosplenoportography in pediatric recipients of living-donor liver transplants.

BACKGROUND/AIMS: The aim of this study was to simultaneously evaluate portal hemodynamics and liver function by scintiphotosplenoportography (SSP) using technetium-99m-diethylenetriaminepentaacetic asid-galactosyl-human serum albumin (99mTc-GSA) in recipients of living-donor liver transplants (LDLT). METHODOLOGY: Three LDLT recipients with biliary atresia who underwent SSP using 99mTc-GSA were studied. The clearance index of 99mTc-GSA (HH15) was calculated by dividing the radioactivity of the heart region of interest (ROI) 15 minutes after injection (H15) by that of the heart ROI 3 minutes after injection (H3), (HH15=H15/H3). The hepatic uptake ratio of 99mTc-GSA (LHL15) was calculated by dividing the radioactivity of the liver ROI at 15 minutes (L15) by H15 plus L15, (LHL15=L15/(H15+L15)). H/L15 (HH15/LHL15). RESULTS: Patient 1: On SSP before transplantation, digital images showed hepatofugal flow, but not the portal vein in early phase (HH15: 0.647, LHL15: 0.861, H/L15: 0.751). On SSP after transplantation, digital images showed the portal vein clearly, and the hepatofugal flow had disappeared (HH15: 0.633, LHL15: 0.971, H/L15: 0.652). Patient 2: On SSP before transplantation, digital images showed hepatofugal flow, and the liver was slightly visible in early phase (HH15: 0.673, LHL15: 0.869, H/L15: 0.774). Patient 3: On SSP before transplantation, digital images showed splenorenal shunt, but not the liver in early phase (HH15: 0.697, LHL15: 0.838, H/L15: 0.832). CONCLUSIONS: SSP using 99mTc-GSA is useful for the simultaneous evaluation of portal hemodynamics and liver function in pediatric recipients of LDLT.

Successful management of a symptomatic splenic artery aneurysm with transcatheter embolization.

We describe a symptomatic splenic artery aneurysm (SAA) with occasional left-sided abdominal pain which was successfully treated with transcatheter embolization. A 65-year-old man was referred to a nearby clinic because of left shoulder and abdominal pain developing the day after blunt trauma to the shoulder and abdomen. Radiography revealed no fracture, and the patient went home. He stopped working for 7 months. Left-sided abdominal pain then developed several times after strenuous physical labor, and the patient was referred to a nearby hospital. The patient had a history of asthma and untreated hypertension; the use of iodinated contrast material was therefore avoided. Unenhanced computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen revealed a hematoma in the splenic hilum. The patient was referred to Nippon Medical School Hospital. His neurologic status was stable. Unenhanced CT of the abdomen at a nearby hospital revealed a low-density area in the splenic hilum. Fat-suppressed, T1-weighted images showed a hyperintense lesion adjacent to the splenic hilum. Fat-suppressed, T2-weighted images showed a dark hemosiderin rim, a bright ring, and an intermediate central core, which indicated a recurrent chronic hematoma in the abdomen. Dynamic contrast-enhanced MRI revealed a small hyperenhanced lesion adjacent to the hematoma, which appeared to be an SAA. After an injection of corticosteroids, selective splenic arteriography was performed. The splenic artery was catheterized via a right femoral approach. Arteriography showed an SAA, 1 cm in diameter with extravasation of contrast material. The neck of the SAA was catheterized with a microcatheter, and coils were placed successfully into the SAA to prevent recurrent bleeding. Postembolization angiography showed total occlusion of the SAA. The patient was discharged 7 days after embolization and has since resumed normal activities, with no residual symptoms.

Recurrence of colonic cancer twice at the site of stapled colorectal anastomosis.

Recurrence at the site of a stapled anastomosis is generally believed to result from the luminal implantation of viable cancer cells during stapling. We report a case in which colon cancer recurred twice at the site of a stapled anastomosis, despite povidone iodine (PVP-I) lavage consisting of an enema with 5% PVP-I solution before the operation and intraoperative lavage of the rectal remnant and the descending colon with a 10% PVP-I solution. Three months after sigmoidectomy to resect a carcinoma of the sigmoid colon, a circular anastomotic recurrence was found at the suture line after anastomosis with a stapler. However, 11 months after the subsequent resection and reanastomosis to remove the first anastomotic recurrence, another anastomotic recurrence was found. We performed abdominoperineal resection for the second recurrence at the site of the stapled anastomosis. Suture-line recurrence could not be prevented in the present case despite lavage with a PVP-I solution for prophylaxis.

Resection of asynchronous quadruple advanced colonic carcinomas followed by reconstruction with ileal interposition between the transverse colon and rectum.

We report an extremely rare case of resectable asynchronous quadruple advanced colonic carcinomas. Successful reconstruction was performed after resection with an ileal interposition between the remaining colon and rectum, and the patient recovered bowel function. Resections of the four colonic lesions in three operations allowed us to leave a portion of the large bowel and to thereby preserve the rectum and a portion of the transverse colon. After resection of the third and fourth cancer lesions, we reconstructed the large bowel with ileal segment interposition between the residual transverse colon and rectum, leaving a 15-cm-long segment portion of the transverse colon. This surgical procedure is an option for reconstruction after left-sided colectomy.

Chronic anisakiasis of the ascending colon associated with carcinoma.

Chronic anisakiasis of the colon is rare and difficult to diagnose. We report a case of chronic anisakiasis associated with advanced colonic carcinoma. A 69-year-old man was admitted for abdominal pain, diarrhea, and urticaria. Right hemicolectomy was performed because of an obstruction of the ascending colon and a palpable tumor of the right lower abdomen. The lesion was thought to be located in the deeper layers of the ascending colon. Preoperative examinations failed to detect the coexistence of anisakiasis and carcinoma of the colon. The anisakis was identified morphologically in the intestinal wall of the resected specimen and by an elevated titer of an IgE antibody specific to the parasite. Seventy-five cases of colonic and rectal anisakiasis, including the present case, have been reported in Japan. This is the only reported case of anisakiasis to appear in association with colonic carcinoma.

Changes in distribution of splenic venous flow in the patients with cirrhotic liver.

BACKGROUND/AIMS: The aim of this study is to prove the hemodynamic change in distribution of splenic venous flow in the liver, especially in the cirrhotic liver, and to reveal and evaluate a participation of splenic venous flow in regeneration or enlargement of the hepatic lobe. METHODOLOGY: We studied the distribution of splenic venous flow in the liver of patients with normal liver (NL group, n=15), chronic hepatitis (CH group, n=8), and liver cirrhosis (LC group, n=13) with the technique of scintiphotosplenoportography after percutaneous intrasplenic injection of Technetium-99m-diethylenetriaminepentaacetic acid-galactosyl-human serum albumin. The index of splenic venous flow volume per unit hepatocytes (Vunit) was calculated in each hepatic lobe. To compare V value of the left lobe (VLunit) with that of the right lobe (VRunit), predominant index of the left lobe (L/R index) was defined as L/R index = VLunit/VRunit. RESULTS: The median (interquartile range) of L/R index of the LC group; 1.22 (1.06-1.70) was significantly higher than that of the NL group; 0.83 (0.66-0.92), p<0.001 and the CH group; 0.79 (0.69-0.92), p<0.001. CONCLUSIONS: L/R index reflects the change of portal hemodynamics in cirrhotic liver and is useful for discrimination between noncirrhosis and cirrhosis. These results suggest that in the liver exposed to continuous damages, splenic venous blood promotes liver fibrosis in the right lobe and eventually flows more into the left lobe with milder fibrosis.

Infected hepatic cyst.

We describe an unusual case involving an infected hepatic cyst. An 88-year-old woman presented with acute onset of right upper quadrant abdominal pain, mild left lower abdominal pain, diarrhea, and fever. On admission, computed tomography revealed multiple hepatic cysts including an 8-cm cyst located in the left medial segment of the liver, which demonstrated a thickened wall enhanced with contrast media. Ultrasonography showed an 8-cm hypoechoic lesion which differed in appearance from the other, anechoic hepatic cysts. The serum concentration of C-reactive protein was 29.8 mg/dL; white blood cell count, 12,800/microL; CA19-9, 96 U/mL; and CEA, 2.2 ng/mL. Diagnosis of infected hepatic cyst was made by percutaneous transhepatic drainage of the cyst. Milky fluid was obtained and the patient's right upper quadrant abdominal pain resolved after drainage. The cyst fluid CA19-9 concentration was 18,000 U/mL. Cytology of the cyst fluid was negative. Serum CA19-9 (41 U/mL) and CEA (1.8 ng/mL) concentrations were improved 1 week after drainage. Escherichia coli was cultured from the drainage fluid. The patient was discharged 27 days after admission. Percutaneous transhepatic drainage is effective in the treatment of infected hepatic cysts.

Graft survival following three occurrences of hepatic arterial thrombosis after living-related liver transplantation. A case report.

Hepatic arterial thrombosis is a major cause of morbidity and graft loss in patients undergoing liver transplantation. We report the case of a patient who underwent living-related liver transplantation and suffered three instances of early hepatic arterial thrombosis requiring revascularization in the first 8 days after grafting. The patient was discharged with good graft function. A 21-month-old female with biliary atresia underwent living-related liver transplantation using her mother's extra-lateral segment. The donor middle hepatic artery was anastomosed end-to-end to the posterior branch of the donor's hepatic artery. The time of operation was 8 hr 36 min, and the blood loss was 193 mL. On postoperative day 5, the patient was returned to surgery to close a perforation in the transverse colon. At operation we found hepatic arterial thrombosis and performed a thrombectomy and redid the arterial anastomosis. Hepatic arterial thrombosis recurred during the operation, so we interposed the recipient's right radial artery between the graft artery and recipient posterior branch. On postoperative day 8, ultrasound showed a fluid collection in Winslow's pouch. After removing the fibrin clot, we discovered that hepatic arterial thrombosis had recurred in the interposed artery. We revascularized the graft using the right gastroepiploic artery. Arterial blood flow was restored, and graft function remained excellent.

New techniques: combined endoscopic injection sclerotherapy and ligation for acute bleeding from gastric varices.

BACKGROUND/AIMS: Combined endoscopic injection sclerotherapy and endoscopic variceal ligation was used for the treatment of acute bleeding from gastric varices. METHODOLOGY: Between July 1995 and August 1998, three cirrhotic patients with acute bleeding from gastric varices were treated. Endoscopic variceal ligation of the puncture point and bleeding point was performed simultaneously. RESULTS: Acute bleeding from the gastric varices was successfully stopped in all cases. CONCLUSIONS: Combined endoscopic injection sclerotherapy and endoscopic variceal ligation can be used to stop bleeding and prevent rebleeding from gastric varices.

Control of isolated gastric varices by combination therapy using embolization and endoscopic scleroligation therapy.

Balloon-occluded retrograde venous obliteration is a powerful new technique for eliminating gastric varices. However anatomic considerations may preclude its use in some instances. Two cases are reported in which combination embolization followed by endoscopic injection scleroligation therapy eradicated isolated gastric varices where balloon-occluded retrograde venous obliteration was impossible. Two men with alcoholic cirrhosis were admitted with bleeding gastric varices. Inability to access variceal venous drainage precluded balloon-occluded retrograde venous obliteration. In Case 1, transileocolic vein obliteration left gastric embolization, and partial splenic embolization only partially eradicated gastric varices. In Case 2, percutaneous transhepatic obliteration, left gastric embolization, and partial splenic embolization were only partially successful. In both cases, endoscopic injection scleroligation therapy was performed adjunctively. Endoscopic injection scleroligation therapy completely eradicated gastric varices in both patients following partially successful embolization therapy. These cases demonstrate the importance of individualizing treatment of esophageal varices, the value of combination therapy, and the effectiveness of endoscopic injection scleroligation therapy for treating varices.

Surgical resection of a solitary para-aortic lymph node metastasis from hepatocellular carcinoma.

Lymph node (LN) metastases from hepatocellular carcinoma (HCC) are considered uncommon. We describe the surgical resection of a solitary para-aortic LN metastasis from HCC. A 65-year-old Japanese man with B-type liver cirrhosis was admitted for the evaluation of a liver tumor. He had already undergone radiofrequency ablation, transcatheter arterial chemoembolization, and percutaneous ethanol injection therapy for HCC. Despite treatment, viable regions remained in segments 4 and 8. We performed a right paramedian sectionectomy with partial resection of the left paramedian section of the liver. Six months later, serum concentrations of alpha-fetoprotein (189 ng/mL) and PIVKA-2 (507 mAU/mL) increased. Enhanced computed tomography of the abdomen revealed a tumor (20 mm in diameter) on the right side of the abdominal aorta. Fluorine-18 fluorodeoxyglucose positron emission tomography revealed an increased standard uptake value. There was no evidence of recurrence in other regions. Esophagogastroduodenoscopy and colonoscopy revealed no malignant tumor in the gastrointestinal tract. Para-aortic LN metastasis from HCC was thus diagnosed. We performed lymphadenectomy. Histopathological examination revealed that the tumor was largely necrotic, with poorly differentiated HCC on its surface, which confirmed the suspected diagnosis. After 6 mo tumor marker levels were normal, with no evidence of recurrence. Our experience suggests that a solitary para-aortic LN metastasis from HCC can be treated surgically.

A case of xanthogranulomatous cholecystitis preoperatively diagnosed with contrast-enhanced ultrasonography.

We report a case of xanthogranulomatous cholecystitis (XGC) that was diagnosed preoperatively by means of ultrasonography (US) with the contrast-enhancement agent Sonazoid after a false-positive result had been obtained with fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET). A 69-year-old woman was admitted because of right upper quadrant pain. Blood tests revealed a serum CA19-9 level of 749.8 IU/L. Computed tomography (CT), US, and magnetic resonance imaging of the abdomen showed abnormal thickening of the gallbladder wall but no stones. The border between the gallbladder and the liver was unclear. FDG-PET revealed a lesion with increased uptake of tracer in the gallbladder wall. The thickness of the lesion was similar to that on CT. We suspected gallbladder carcinoma with hepatic invasion. To confirm the tentative diagnosis, we performed US with the contrast-enhancement agent Sonazoid. The gallbladder wall was homogeneously enhanced in the early vascular phase and remained enhanced for 90 seconds. Enhancement of the gallbladder wall was smooth and regular. The border between the gallbladder and liver was clear and smooth. On the basis of these examinations, we diagnosed chronic cholecystitis (XGC suspected), not gallbladder carcinoma. At surgery, the gallbladder wall was observed to be extremely thick because of severe inflammation, and cholecystectomy was performed. XGC was diagnosed on intraoperative pathological examination. Histopathological examination showed XGC, severe proliferative fibrosis with formation of multiple yellow-brown intramural nodules, and foamy histiocytes without malignant cells. In conclusion, the present case of XGC was diagnosed preoperatively with contrast-enhanced US after a false-positive result had been obtained with FDG-PET. Contrast-enhanced US can thus play important roles in diagnosing gallbladder disease and selecting treatment.