[A Case of Primary Adenocarcinoma of the Duodenal Bulb with Laparoscopic Distal Gastrectomy].

A 66-year-old male presented with a torose lesion at the duodenal bulb, detected via endogastroduodenoscopy(EGD) during a medical check-up. It was histopathologically diagnosed as a low-grade adenoma. He was referred to the Department of Gastroenterology for follow-up observation. An endoscopic mucosal resection(EMR)was performed due to the increasing tumor size. The pathological findings of the resected specimen showed a tubular adenoma. The patient was then followed up as an outpatient. Two months later, a follow-up EGD revealed a mass lesion, suspected to be a remnant tumor. A laparoscopic distal gastrectomy, #3, #4sb, #5, #6 dissection, and Billroth Ⅱ+Braun anastomosis reconstruction were performed. Pathological examination showed a tubular adenocarcinoma in adenoma, tub1, with depth M, and no lymph node metastasis. Non-papillary duodenal carcinoma is a rare disease that has no established guidelines for radical surgery and the extent of lymph node dissection. Pancreaticoduodenectomy is often performed in advanced cases. However, due to the increasing number of patients and the risk of complications, limited resection should be considered as an alternative management option.

[Laparoscopic Surgical Treatment of Differentiated Intramucosal Gastric Cancer with Lymph Node Metastasis-A Case Report].

A 78‒year‒old man was admitted to our hospital with the chief complaint of 5 kg weight loss in 6 months. An esophagogastroduodenoscopy revealed a 0‒Ⅱa lesion in the posterior wall of the antrum, and biopsy findings showed a well‒differentiated adenocarcinoma. Endoscopic ultrasonography did not show an obvious invasion of the submucosal layer. Contrast‒ enhanced abdominal computed tomography(CT)revealed an enlargement of the #11p lymph node to approximately 30 mm, and positron emission tomography(PET)‒CT showed an accumulation in the same lymph node. Since no other apparent distant metastases were observed, laparoscopic distal gastrectomy and D2 dissection were performed. The postoperative pathological diagnosis was L, 7×8 mm, 0‒Ⅱa, tub1, pT1a, ly0, v0, pPM0(73 mm), pDM0(35 mm), N2, and pStage ⅡA. We report this case because the successful laparoscopic resection of a differentiated gastric mucosal cancer with lymph node metastasis has been considered to be extremely rare.

[A Case of Long-Term Survival after Multidisciplinary Treatment for Neuroendocrine Carcinoma of the Anal Canal].

A 75-year-old man presented to a local clinic with anal pain, and a palpable anal tumor on was found on digital examination of the rectum. A biopsy led to the diagnosis of neuroendocrine carcinoma. Besides the anal tumor, an right-inguinal lymph node was revealed on computed tomography(CT). Positron emission tomography-CT showed abnormal uptake in the 2 regions. He was diagnosed with lymph node metastases from anal canal carcinoma, and an abdominoperineal resection was performed. The resected specimen included the anal canal tumor with a size of 27×18 mm in diameter. On immunohistochemistry, the anal canal tumor was strongly positive for synaptophysin and positive for chromogranin A, with a Ki- 67 positivity index of 70%. After the surgery, he was administered chemotherapy with 4 courses of cisplatin and CPT-11. One year after the surgery, CT revealed lymph node recurrence. Therefore, cisplatin and CPT-11 therapy was repeated. After 11 courses of the cisplatin and CPT-11 treatment, tumor regrowth was still detected. The treatment protocol was changed to an amrubicin monotherapy regimen. However, the patient's general condition worsened after the therapies, and he died 38 months after the surgery.

[A Case of Long-Term Survival after Chemotherapy for Gastric Cancer with Peritoneal Dissemination].

The patient was a 58-year-old man who had undergone wide gastrectomy for gastric ulcer at 22 years of age. Endoscopic examination revealed an advanced type 3 gastric cancer in the anastomotic region. We performed total gastrectomy and D1 lymph node dissection because of the bleeding from the tumor, although peritoneal dissemination was found during the surgery. A post-operative pathological diagnosis of gastric cancer pT4b(SI, abdominal wall)N0M1(PER), pStage Ⅳ, was made. After the surgery, he was administered chemotherapy with S-1 and cisplatin. After 9 courses of the treatment, the treatment protocol was changed to an S-1 therapy regimen because of general fatigue. Four years and 8 months after the surgery, the tumor marker had increased, and CT scans revealed a dissemination nodule at the left back side of the bladder. Therefore, PTX plus Rmab therapy was administered as a second-line chemotherapy. Treatment with PTX plus Rmab resulted in tumor reduction, with an improvement of the QOL of the patient; partial response was maintained for 12 months. After 16 courses of the PTX plus Rmab treatment, tumor regrowth was detected. The treatment protocol was changed again to a nivolumab regimen. After 4 courses, the tumor marker was normalized, and CT scans revealed that the peritoneal dissemination had shrunk. Although the prognosis of gastric cancer with dissemination is very poor, it is possible to prolong survival with chemotherapy.

[A Case of HER2-Positive Gastric Cancer with Multiple Liver Metastases Treated with Curative Conversion Therapy after Chemotherapy].

A 66-year-old man underwent chemotherapy with S-1 plus cisplatin plus trastuzumab to treat advanced gastric cancer that was diagnosed as cStage Ⅳ adenocarcinoma(T3N1M1[P0, CYX, H1]). After 8 courses, liver metastases were absent on contrast-enhanced MRI. The patient underwent a laparoscopic distal gastrectomy with D2 lymphadenectomy. The gross appearance of the surgically resected specimen showed a shrunk gastric tumor measuring 1 mm. The postoperative course was uneventful, and the patient has been well, receiving maintenance chemotherapy of S-1 plus trastuzumab without evidence of recurrence for 15 months following the operation. Conversion surgery following chemotherapy might be an effective treatment for patients with advanced gastric cancer; however, further studies are needed to establish this treatment strategy.

[A Case of Hypophysitis Due to Immune Check Point Inhibitor Treatment].

The patient was a man in his 70s with bone metastasis from renal cell carcinoma who had received immune checkpoint inhibitors(ICI)therapy. After 2 courses of chemotherapy, he was admitted to our hospital with diverticulitis. His diverticulitis could be treated with antibiotics, but he presented with severe hyponatremia and consciousness disorder during hospitalization. Brain MRI showed pituitary swelling, and his serum TSH, ACTH, cortisol levels decreased. We therefore diagnosed him with hypopituitarism due to ICIs. Hydrocortisone improved his hyponatremia and consciousness disorder. Endocrine stimulation tests revealed no reaction of ACTH, and low-level reactions of TSH, LH and FSH, ICIs cause many types of immune- related adverse events(irAEs). The indications for ICI therapy are expanding; thus, we can expect to experience more cases of serious irAEs in association with ICI treatment. Further studies should be performed to improve our understanding of irAEs.

[Three Cases of Unresectable Colorectal Cancer Curatively Resected after Effective Chemotherapy].

Case 1: A60-year-old man underwent resection of a brain tumor, which was pathologically diagnosed as adenocarcinoma. As he was diagnosed with unresectable rectal cancer due to pulmonary metastasis, we performed abdominoperineal resection after chemotherapy. Since pulmonary metastasis and local recurrence were detected 1 year after the surgery, he was administered chemotherapy. He died 37 months after the surgery. Case 2: A6 4-year-old man was diagnosed with unresectable rectal cancer due to pulmonary and hepatic metastases, resulting in an examination for melena. We performed laparoscopic low anterior resection and hepatic partial resection after chemotherapy. No relapse has occurred 1 year after the surgery. Case 3: A39 -year-old man was examined for abdominal pain and distension and was diagnosed with unresectable rectal cancer due to invasion of the left ureter and multiple hepatic metastases. We performed anterior resection, hepatic partial resection, and RFAafter chemotherapy. He has remained in relapse-free survival for 15 months after the surgery. These results suggest that curative resection after chemotherapy improves the prognosis of unresectable colorectal cancer.

[Analysis of Renal Toxicity of S-1 plus CDDP Regimen with Short Hydration for Outpatients with Gastric Cancer].

BACKGROUND: Although the S-1 plus CDDP(SP)regimen is the standard treatment for advanced gastric cancer, hydration and admission have been recommended after cisplatin has been administered. In this study, short hydration(SH)method was used and SP was administered in outpatient settings. We evaluated renal toxicity of cisplatin in the SH-SP regimen at our hospital. METHODS: Eleven of 16 patients(5 underwent only 1 course and so were excluded)received the SH-SP regimen between January 2012 and January 2018 to present and were included. Serum creatinine(Cr)and estimated glomerular filtration rate(eGFR)were used to assess renalfunction. RESULTS: Median course was 5. Rate of 5-course accomplishment was 72.7%. Grade 1 Cr elevation was observed in only 3 patients and there was no severe renal disorder. CONCLUSION: The SHSP regimen could be administered in outpatient settings and was considered safe as it did not cause renal toxicity.

[A Case of Breast Cancer Liver Metastases with Jaundice Responding to Chemotherapy].

A 50-year-old woman was referred to our hospital due to breast cancer with multiple liver metastasis diagnosed by CT scan. Laboratory findings showed liver dysfunction(T-Bil 7.6mg/dL)with marked elevation of tumor markers(CEA 727.9 ng/mL). Breast tumor biopsy showed an invasive ductal carcinoma(scirrhous type), ER(+), PgR(-), and HER2(3+). Combination therapy with docetaxel, carboplatin and, trastuzumab was administered after the end of 1 course of weekly paclitaxel plus bevacizumab regimen. The patient maintained a good condition without liver dysfunction 8 months after the first visit. Follow-up CT scan showed partial response of breast and hepatic tumors. Our case suggests that careful chemotherapy can improve the prognosis of breast cancer with liver metastasis even if a patient is in an icteric condition.

Intraductal papillary mucinous neoplasm originating from a heterotopic pancreas within the jejunum: a case report.

We report a case of intraductal papillary mucinous neoplasm arising within the heterotopic pancreatic tissue which was found incidentally in the jejunum during surgery for bowel obstruction. A 54-year-old female patient was admitted to our hospital due to sudden abdominal pain. In preoperative findings, we diagnosed bowel obstruction and performed surgery. Intra-operative findings showed adhesive intestinal obstruction, we performed synechiotomy for adhesion release. During surgery, when searching the small intestine, we coincidentally found a tumor in the jejunum and partial resected the jejunum. Pathological examination revealed a 1.2 cm × 1.0 cm × 1.0 cm white yellow nodule with cystic spaces. Histological examination demonstrated heterotopic pancreatic tissue consisting of well-formed lobules of pancreatic acini and cystically dilated ducts containing intraductal papillary neoplasm. Moreover, in immunohistochemical staining, MUC5AC was diffusely expressed, but not MUC1, MUC2 and MUC6.

Intracystic papillary carcinoma of the male breast: a case report.

BACKGROUND: Intracystic papillary carcinoma (IPC) is defined as cancer that develops from the wall of a cyst in the breast. As breast cancer in men accounts for only 1% of all breast cancers, male IPC is an extremely rare form of the disease. The present case report examines IPC in a man, along with an in-depth literature discussion. CASE PRESENTATION: A 64-year-old Japanese man noticed a mass in the right breast and sought medical attention. An elastic and soft neoplastic 3-cm lesion was palpated in the right papilla. As a 1-cm solid tumor with a gradual rise from the cyst wall was confirmed within the cyst, vacuum-assisted biopsy (VAB) was performed on that site. Pathological examination of the biopsy revealed heterotypic cells with an enlarged oval nucleus forming dense papillary structures mainly of vascular connective tissue component. Contrast-enhanced computed tomography (CT) confirmed thickening of the wall that protruded outside the cyst. The preoperative diagnosis was right breast cancer (male IPC) TisN0M0 stage 0 luminal B-like. Total mastectomy and sentinel lymph node biopsy were performed. In the excised specimen, a 4.0-cm unilocular cyst was found, along with a 1-cm solid tumor with a gradual rise from the cyst wall. Pathological diagnosis of the resected specimen shared similar characteristics with the solid tumor in the cyst: notably, an oval nucleus with histologically clear nucleolus and fine granular chromatin, cylindrically shaped heterotypic cells, and the presence of basophilic cells in the papillary growth with a thin stem of fibrovasculature as the axis. Some invasion of tumor cells into the interstitium was confirmed. As such, the final diagnosis was right breast cancer (male IPC) T2N0M0 stage IIA luminal B-like. The expression of hormone receptor (ER and PgR) was high, and endocrine therapy was initiated postoperatively (20 mg/day tamoxifen). At the present time (3 months postoperation), there has not been any evidence of metastasis. CONCLUSIONS: We reported a rare case of an IPC in the male breast, along with a literature review.

[Usefulness of Vacuum-Assisted Biopsy(VAB)at Initial Biopsy].

In recent years, breast micro-lesions such as ductal carcinoma in situ(DCIS)were detected with progress of the image diagnosis. We investigated the usefulness of vacuum-assisted biopsy(VAB)for initial biopsy of breast tumors. We analyzed 32 cases of VAB performed for breast tumors. The pathological diagnosis of the biopsy specimens was malignant lesions in 10 cases, border-line lesions in 1 and benign lesions in 21 cases. 11 cases underwent surgery and the final histopathological diagnosis was the same in 10 of them. One case histopathology varied from DCIS to invasive ductal carcinoma(IDC). It was suggested that VAB at initial biopsy was a useful biopsy method.

[A Case of Breast Cancer with Infarcted Necrosis That Was Diagnosed Based on Axillary Lymph Node Metastasis].

A 61-year-old woman with a breast tumor detected by mammography examination was admitted to our hospital. Ultrasonography showed a 15.5×7.2mm sized irregular mass at the left BD area. Vacuum-assisted biopsy did not reveal any malignant cells. After 3 months, ultrasonography reexamination showed that the irregular mass had increased to 24.2×16.5mm in size, and it had spread to multiple axillary lymph nodes. The patient was diagnosed with breast cancer by core needle biopsy of the axillary lymph node. Total mastectomy with axillary lymph node dissection was performed. The pathological diagnosis was solid-tubular carcinoma with infarcted necrosis. The number of metastatic axillary lymph nodes was confirmed to be 23 in total. This case was considered very rare and important because there have been very few reports of breast cancer with infarcted necrosis.

[A Case of Apocrine Carcinoma in the Breast That Was Difficult to Distinguish from Axillary Apocrine Adenocarcinoma].

An 86-year-old woman visited our hospital with a tumor on her right axilla. Ultrasonography(US)showed a 4 cm tumor between mammary gland and axilla with swelling of some lymph nodes. No distant metastatic lesions were found. The pathological findings revealed breast apocrine carcinoma; therefore, we performed total mastectomy and axillary lymph node dissection. The postoperative pathological findings revealed breast apocrine carcinoma with pT4N2M0, Stage Ⅲb(ER positive, PgR negative, HER2 positive, Ki-67 6%). We present a case of breast apocrine carcinoma confused with axially apocrine adenocarcinoma during the diagnosis and report the relevant literature.

Kimura's disease affecting the axillary lymph nodes: a case report.

BACKGROUND: Kimura's disease (KD; eosinophilic granuloma of soft tissue) is an inflammatory granulomatous disorder of unknown cause with eosinophilic infiltration that occurs mainly in soft tissue. KD occurs mainly in the head and neck, but development in the axillary region is very rare. CASE PRESENTATION: A 74-year-old Japanese woman was evaluated for a mass that she noted in the left axillary region. On physical examination, there was a palpable, thumb-sized, hard, elastic, freely movable mass in the left axilla. Blood tests showed elevated soluble interleukin-2 receptor (sIL-2R), normal serum immunoglobulin (Ig) G4, and elevated serum IgE. Ultrasonography of the left axilla showed multiple lymph nodes (LNs) with irregular margins in which central hyperechogenicity was lost. A systemic search by computed tomography (CT) showed no systemic lymphadenopathy or other mass-like lesions suspicious for a primary tumour other than in the left axillary LNs. Biopsy of an excised LN was performed under local anaesthesia for a definitive diagnosis. Histopathology showed various-sized lymphoid follicles, large nodular lesions with an enlarged mantle zone, multiple various-sized germinal centres in single nodules, and eosinophilic infiltration between the nodes. Immunohistochemical (IHC) staining of the germinal centres was positive for cluster of differentiation (CD) 10, positive for B-cell lymphoma (bcl)-6, and negative for bcl-2. These findings led to a diagnosis of KD. Ultrasound after 3 months of follow-up showed disappearance of the axillary lymphadenopathy. CONCLUSIONS: A very rare case of KD in the axillary LNs was described. KD has the potential to occur in any region.

[A case of advanced gastric cancer responding to S-1/CDDP neoadjuvant chemotherapy, leading to a pathological complete response].

A 66-year-old man with cStage III B (cT4aN2H0P0M0) advanced gastric cancer in the cardia with esophageal invasion was treated with S-1/CDDP as neoadjuvant chemotherapy. After 3 courses of chemotherapy, a significant reduction in tumor burden was observed. Total gastrectomy and splenectomy with lymph node dissection (D2) were performed. Pathological specimens showed no cancer cells in the stomach and lymph nodes, indicating a pathological complete response.

Prognostic significance of the preoperative serum C-reactive protein level in patients with stage IV colorectal cancer.

PURPOSE: Previous studies have revealed that an elevated preoperative serum C-reactive protein (CRP) level is associated with a poor prognosis in patients with various malignant tumors. The aim of this study was to determine the clinical significance of the preoperative serum CRP level in patients with stage IV colorectal cancer. METHODS: We enrolled 144 patients who underwent surgery for stage IV colorectal cancer. A total of 53 patients with a serum CRP level of ≥ 1.0 mg/dl were classified as the high CRP individuals. The association between the preoperative serum CRP level and survival was retrospectively assessed. RESULTS: The cancer-specific survival of the patients with a high CRP level was significantly worse than that of the patients with a low CRP level. A multivariate analysis indicated that the curability (non-curative surgery), the number of organs with metastasis (more than one organ), the tumor diameter (≥ 5 cm), lymphatic involvement, histological differentiation (non-differentiated) and a high CRP level (≥ 1.0 mg/dl) were independent risk factors for a poor survival. CONCLUSIONS: A high preoperative serum CRP level is a convenient biomarker for identifying patients with a poor prognosis for stage IV colorectal cancer.

Thoracoscopic esophagectomy in the prone position versus in the lateral position for patients with esophageal cancer: a comparison of short-term surgical results.

AIM: Thoracoscopic esophagectomy (TE) in the prone position for patients with esophageal cancer has received a great deal of attention. We retrospectively compared clinical outcomes and surgical stress of TE in the prone position (TE-P) and in the lateral position (TE-L) at our institution. METHODS: A total of 58 consecutive patients (28 in the TE-L group and 30 in the TE-P group) were studied. Between the 2 groups, clinical outcomes and various parameters were compared. RESULTS: There were no hospital deaths in both TEL and TEP groups. Blood loss during the thoracoscopic part of the surgery were significantly (P<0.01) lower in the TE-P group (118±72 mL) compared with the TE-L (245±203 mL) group. The incidence of respiratory complications tended to be lower (P=0.07) in the TE-P group (3.3%) than in the TE-L (17.8%) group. The duration of systemic inflammatory response syndrome condition was significantly (P=0.02) shorter in the TE-P group (1.5±2.5 d) than in TE-L (3.6±3.5 d) group. The levels of serum C-reactive protein on postoperative days 1 and 2 were significantly (P<0.01) lower in the TE-P group than in the TE-L group. CONCLUSIONS: TE-P for patients with esophageal cancer was safe and feasible. TE-P might be a potentially less invasive procedure than TE-L.

[A case of rectal cancer with brain metastasis successfully treated with combined modality therapy - a case report].

The authors report their experience in a patient with brain metastasis from rectal cancer who has survived without recurrence after multidisciplinary treatment. A 60-year-old man presented to the Department of Neurosurgery with the primary complaint of spasm of the left side of the face. Examination revealed a tumor 2 cm in diameter in the right frontal lobe. The tumor was suspected to be metastatic, and brain metastasis from rectal cancer was diagnosed. The brain tumor was removed by a neurosurgeon, and the patient was transferred to the Department of Surgery. Removal of the primary lesion in the rectum was attempted, but only colostomy could be performed due to extensive anterior invasion. Postoperatively, 5 courses of capecitabine and oxaliplatin (XELOX) + bevacizumab were administered. The rectal tumor shrank in size, while another mass, suspected to be a lung metastasis, remained unchanged. Therefore, a second surgery on the rectum was scheduled, and abdominoperineal resection of the rectum and lateral lymphadenectomy were performed. Postoperatively, 4 courses of XE LOX therapy were administered. The patient is currently alive without recurrence at 1 year after surgery. Treatment (including timing) for brain metastasis from rectal cancer has not been established and prognosis is poor. However, multidisciplinary treatment may provide the possibility of cure.