Mild nonocclusive mesenteric ischemia associated with syncope.

Nonocclusive mesenteric ischemia (NOMI) is a life-threatening disease caused by a reduction in mesenteric blood supply without vascular occlusion. Early diagnosis of NOMI is often difficult because there are no specific findings suggesting NOMI. Here, we report a rare case of a very elderly patient with mild NOMI caused by dehydration due to short-term reduced oral intake and associated with syncope. A 90-year-old man was admitted to our hospital with syncope and melena. The syncope was thought to be caused by orthostatic hypotension due to dehydration owing to reduced oral intake for approximately 24 h. Abdominal computed tomography (CT) revealed marked bowel wall thickening with mesenteric stranding in the ileum and ascending colon, dilated small intestine with thinned bowel wall, collapsed superior mesenteric vein, hemorrhagic ascites, and absence of obvious vascular occlusion in the mesenteric vessels. Abdominal symptoms, laboratory abnormalities, and CT findings improved gradually with the correction of dehydration. Therefore, we diagnosed our patient with mild NOMI. NOMI can be associated with syncope and can occur even with dehydration due to short-term reduced oral intake. When examining elderly patients with hypovolemic signs, such as syncope, who exhibit abdominal symptoms, clinicians must keep in mind the possibility of NOMI.

Temporary spontaneous regression of male breast cancer: a case report.

BACKGROUND: Spontaneous regression (SR) of a malignant tumor is the partial or complete disappearance of primary or metastatic tumor tissue in the absence of treatment, which can be temporary or permanent. Here, we report an extremely rare case of male breast cancer that exhibited temporary SR followed by reappearance 8 months after tumor disappearance. CASE PRESENTATION: A 70-year-old man presented at our hospital with a primary complaint of pain and a lump in his left breast. Ultrasonography revealed a hypoechoic lesion measuring 12 mm × 10 mm × 8 mm. Fine-needle aspiration cytology revealed numerous necrotic and degenerated cells and few sheet-like clusters of atypical ductal epithelial cells. The atypical cells had mildly enlarged nuclei with nucleoli, were focally overlapped and formed tubular patterns. The cytological diagnosis indicated a suspicion of malignancy. Core needle biopsy (CNB) revealed necrotic and degenerated cells with microcalcification. The pathological diagnosis was indeterminate because there was no area of viable atypical cells. An excisional biopsy of the left breast lesion was scheduled one month later. However, it was difficult to detect the tumor during physical examination and ultrasonography performed 1 month after the patient's first visit. The operation was canceled, and the patient received follow-up observation. After 8 months of follow-up, ultrasonography and computed tomography (CT) revealed reappearance of a 0.6-cm-diameter breast tumor in the same place. CNB was performed again and revealed invasive ductal carcinoma. A total mastectomy with sentinel lymph node biopsy was performed 13 months after the first tumor disappeared. Histopathological examination revealed invasive cribriform carcinoma without sentinel lymph node metastasis. The patient did not have any complications, and adjuvant therapy with tamoxifen was started. The patient was alive without recurrence 7 months after surgery. CONCLUSIONS: Temporary SR followed by tumor reappearance can occur in breast cancer cases, and it is important to follow patients even if their breast tumor has seemingly disappeared. When breast tumors disappear without treatment, clinicians must be aware of the possibility of SR of cancer and should follow the patient for early detection of tumor reappearance.

[A Case of Intussusception Caused by Cancer of the Sigmoid Colon in an Adult].

A 55-year-old man complaining of difficulty in defecation was referred to our hospital. A digital examination and abdominal CT led to a diagnosis of intussusception due to tumor of the sigmoid colon. The intussusception was successful reduced by enema. Following colonoscopy and abdominal enhanced CT, a sigmoid colon cancer(cT3, cN1b, cM0, cStage Ⅲb)was detected. A laparoscopic sigmoidectomy and lymph node dissection were performed on 23 days after the hospitalization. Postoperative course was uneventful. Preoperative reduction of the intussusception in this case enabled us to perform an elective surgery. We report this case with a review of the relevant literature.

[A case of malignant peritoneal mesothelioma diagnosed with laparoscopic biopsy].

A 66-year-old woman was admitted to our hospital for massive ascites of unknown origin. Peritoneal mesothelioma was suspected because of her history of asbestos exposure. Diagnostic laparoscopy with biopsy of the peritoneum and greater omentum was performed. Pathological examination with immunostaining provided a definite diagnosis of malignant peritoneal mesothelioma. The patient underwent early postoperative induction therapy with pemetrexed and carboplatin, which resulted in a reduction in ascites. Laparoscopic biopsy contributed to the definite diagnosis of malignant peritoneal mesothelioma, and thereby, early induction of chemotherapy.

[A case of breast cancer treated with chemotherapy after resection of giant ovarian metastasis].

A 49-year-old female patient presented with lower abdominal pain and constipation. Computed tomography revealed left breast cancer with lymph node metastases, a peritoneal metastasis, bilateral hydronephrosis, and ovarian metastasis. The giant ovarian metastasis occupied the pelvic cavity and was responsible for her symptoms of digestive obstruction. Both ovaries were resected as a palliative measure. Three cycles of weekly paclitaxel were successfully administered, leading to the disappearance of malignant ascites. Hence, reduction surgery for ovarian metastasis in the treatment of breast cancer increased the effectiveness of the chemotherapy by improving the patient's general condition.

Saline-cooled radiofrequency coagulation during thoracoscopic surgery for giant bulla.

Two patients were admitted to our hospital due to giant bullae. During thoracoscopic surgery, saline-cooled radiofrequency coagulation devices were used to shrink the wall of the bulla. In each case, the volume of the bulla was gradually reduced and the boundary between the lung and bulla was clearly delineated. This method is considered to be useful for performing thoracoscopic surgery of giant bulla.

Perforated gastrointestinal stromal tumor (GIST) in a true jejunal diverticulum in adulthood: report of a case.

A 61-year-old man was referred to us for investigation of acute abdominal pain. Computed tomography showed a 5.9 × 5.3 × 5.0 cm lump of food residue in the jejunum, and a large amount of free air and ascites around the liver and right paracolic gutter. He underwent emergency laparotomy for suspected peritonitis from perforation by a foreign body in the small intestine. We identified purulent exudate in the abdominal cavity and perforation of a jejunal cystic mass, attached ~40 cm from Treitz's ligament at the anti-mesenteric side of the jejunum. Based on a diagnosis of jejunal duplication with perforation, we resected that part of the small intestine and performed intra-abdominal drainage. Pathological findings confirmed the diagnosis of a perforated gastrointestinal stromal tumor (GIST) in a true jejunal diverticulum. Histopathological evidence suggests that intestinal pressure and/or hemorrhage can cause perforation in the background of a true jejunal diverticulum. To our knowledge, this is the first case report of a perforated GIST in a true jejunal diverticulum.

Topical nitrate drip infusion using cystic duct tube for retained bile duct stone: A six patients case series.

A retained bile duct stone after operation for cholelithiasis still occurs and causes symptoms such as biliary colic and obstructive jaundice. An endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy (EST), followed by stone extraction, are usually an effective treatment for this condition. However, these procedures are associated with severe complications including pancreatitis, bleeding, and duodenal perforation. Nitrates such as glyceryl trinitrate (GTN) and isosorbide dinitrate (ISDN) are known to relax the sphincter of Oddi. In 6 cases in which a retained stone was detected following cholecystectomy, topical nitrate drip infusion via cystic duct tube (C-tube) was carried out. Retained stones of 2-3 mm diameter and no dilated common bile duct in 3 patients were removed by drip infusion of 50 mg GTN or 10 mg ISDN, which was the regular dose of intravenous injection. Three other cases failed, and EST in 2 cases and endoscopic biliary balloon dilatation in 1 case were performed. One patient developed an adverse event of nausea. Severe complications were not observed. We consider the topical nitrate drip infusion via C-tube to be old but safe, easy, and inexpensive procedure for retained bile duct stone following cholecystectomy, inasmuch as removal rate was about 50% in our cases.

[A case of colon cancer with chronic renal dysfunction responding to effective retreatment with FOLFIRI].

A 76-year-old man with renal dysfunction received FOLFIRI due to a relapse in his pelvis after surgery for sigmoid colon cancer. FOLFIRI was continued for approximately 21 months with stabilization of disease observed on CT scans, but his tumor marker levels increased and tumors showed progression. He then began treatment with cetuximab/CPT-11, but disease progression was observed. XELOX in a low-dose was then administered, but this therapy was discontinued because of progression. He could not receive the other antitumor agents, due to mutations of the KRAS gene and renal dysfunction. Therefore, FOLFIRI was restarted, because it can be continued for long periods of time. Consequently, his tumor marker levels decreased with stabilization of disease on CT scans, and he continued the therapy for 7 months while maintaining quality of life. Ultimately, this case suggested that if there was effectiveness from a previous treatment, retreatment would be successful as chemotherapy for colon cancer in the difficult situation of selecting the other effective antitumor agents.

A large cystic tumor with bile duct communication originating around the hepatic hilum.

Biliary cystic tumors are rare neoplasms occurring in the liver and less frequently in the extrahepatic biliary system. Recently, biliary cystic tumors in the liver are thought to be divided into a biliary mucinous cystic neoplasm and intraductal papillary neoplasm of the bile duct. We report a case of a large cystic tumor originating around the hepatic hilum which had luminal communication with the bile duct. A 74 year-old-woman underwent abdominal ultrasonography for a routine checkup. It revealed a large cystic tumor in the liver. CT scan and MRI showed a multilocular cystic tumor about 12 cm in diameter with a mural nodule occupying the medial and anterior segment of the liver. Intraoperative cholangiography showed a communication between the cystic tumor and the bile duct. Central bisegmentectomy of the liver and extrahepatic bile duct resection was performed. A papillary tumor existed in the common hepatic duct and was connected with the cystic tumor in the liver. The tumor was mostly composed of noninvasive papillary adenocarcinoma with adenoma components, and was associated with focal microinvasion of adenocarcinoma. Ovarian-like stroma was not observed. This lesion was diagnosed as a cystic variant of intraductal papillary neoplasm of the bile duct. The patient is alive with no recurrence for 18 months since the surgery.

Organizing pneumonia with an enlarging tumor-like lesion: immunohistochemical study.

An 86-year-old woman was transferred to our department for investigation of an abnormal enlarging pulmonary shadow with vascular convergence. She had no respiratory symptoms or laboratory data suggesting inflammatory disease. A pulmonary wedge resection was performed under video-assisted thoracic surgery. Pathology examination revealed that the tumor was organizing pneumonia and was composed of fibroblast-like spindle cells, macrophages, lymphoplasma cells, and collagen fibers. Immunohistochemical study revealed that the lesion was in the proliferative state with the relatively more Ki-67-positive fibroblast-like spindle cells. When a surgical resection is necessary for an enlarging abnormal pulmonary mass without any systemic inflammatory reaction or respiratory symptoms, a less invasive approach should be selected.

[Report of a case effectively treated by appropriate therapy for severe anticipatory nausea and vomiting due to FOLFOX or FOLFIRI].

To date, the standard treatments for severe anticipatory nausea and vomiting is not well established. 5-HT3 antagonist is one of the effective drugs to reduce chemotherapy-induced nausea and vomiting, but had no effect on these symptoms for this patient. The patient could be successfully administered standard chemotherapy(FOLFOX or FOLFIRI, q2w)without adverse reactions by appropriate treatments in the form of increased doses of dexamethasone and normal dose administration of prochlorperazine. This report suggests a possibility that FOLFOX or FOLFIRI may be successfully treated by appropriate treatments for severe chemotherapy-induced vomiting colon cancer patients, and that this observation may lead to the improved prognosis of these patients.

[A case of left urothelial carcinoma with multiple bone metastasis, liver metastasis and right adrenal metastasis successfully treated with combination chemotherapy of gemcitabine and carboplatin].

The patient was a 53-year-old male. He had been admitted to another hospital with a complaint of left sciatica. He was referred to our hospital for further examination and therapy. He was diagnosed as left urothelial carcinoma with multiple bone metastasis, liver metastasis and right adrenal metastasis. He was treated with combination chemotherapy of gemcitabine and carboplatin (1,000 mg/m2 day 1 and AUC 2 day 1, respectively) biweekly. After the ninth course, a significant tumor reduction was obtained, and has been maintained. He has been treated on an outpatient basis because of no grade 3 or severer adverse reactions. We report an effective case of biweekly chemotherapy with gemcitabine and carboplatin in the treatment of advanced urothelial carcinoma.

Intrapulmonary solitary fibrous tumor diagnosed by immunohistochemical and genetic approaches: report of a case.

Although solitary fibrous tumors (SFTs) of the pleura are not uncommon, intrapulmonary SFTs are extremely rare. A 72-year-old woman was admitted to our hospital for an investigation of an enlarging intrapulmonary tumor. Because a definitive diagnosis could not be readily established, a pulmonary wedge resection under video-assisted thoracic surgery was performed. Grossly, the tumor was white, well circumscribed, and separate from the pleural surface. Histologically, it consisted of spindle cells proliferating in a vague fascicular pattern, with many dilated capillaries, and intermingled glandular components. These findings suggested a differential diagnosis that included SFT and nonchondromatous pulmonary hamartoma. On immunohistochemical analysis, the spindle cells showed a strong positive reaction to the CD34 antigen. Interphase fluorescent in situ hybridization revealed an absence of HMGA-1 and -2 translocations. These results supported a diagnosis of SFT. A genetic approach may therefore be useful in the differentiation of SFT from nonchondromatous hamartoma.

FOLFIRI Is Tolerable after Subtotal Colectomy - A Patient with Familial Adenomatous Polyposis Who Developed Advanced Rectal Cancer.

A 40-year-old female with familial adenomatous polyposis (FAP) had a subtotal colectomy at 16 years of age. At 39 years, she had low anterior resection due to advanced rectal carcinoma. Thereafter, we administrated per os uracil and tegafur for 9 months. Metastatic rectal carcinoma was detected in the liver (S8) by computed tomography (CT). 2-[(18)F]-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) data did not show any other metastasis. This report presents a first case of a patient undergoing subtotal colectomy administered FOLFIRI (CPT-11 180 mg/m(2) as a 90-minute infusion on day 1; leucovorin 400 mg/m(2) as a 2-hour infusion during CPT-11, immediately followed by 5-FU bolus 400 mg/m(2) and 46-hour continuous infusion of 2,400 mg/m(2) every 2 weeks). This regimen was administered without grade 3 or 4 of any adverse reaction for 6 months, although there was a possibility that this patient with subtotal colectomy may have the cause for severe diarrhea. Further investigations are needed to assess the safety in clinical trials of FOLFIRI regimen for patients with subtotal colectomy.

[Treatment results of peritoneal dissemination from gastric cancer by neoadjuvant intraperitoneal-systemic chemotherapy].

UNLABELLED: No standard treatment exists for peritoneal dissemination from gastric cancer. We reviewed our experience using a novel treatment consisting of peritonectomy and intraoperative chemo-hyperthermic peritoneal perfusion (CHPP). Records of all patients who underwent CHPP and cytoreductive surgery from 1992 to 2001 were reviewed. RESULTS: Data from 107 patients (average age, 52 years) were available. P3 dissemination was found in 72 patients, and 8 and 27 patients showed P1 or P2 dissemination, respectively. Peritoneal metastasis was synchronous in 75 and metachronous in 32 patients. All patients received CHPP after cytoreductive surgery. Peritonectomy was performed in 42 patients. Complete cytoreduction (CC-0) was achieved in 47 patients (44%). Peritonectomy, resulted in CC-0 in 69% (29/42), but CC-0 was achieved in 18 of 65 (28%) patients by ordinary surgical techniques. There were 23 postoperative complications (21%) after operation. The overall operative mortality was 2.8% (3/107). Median follow-up for the entire study group was 46 months. Seventeen patients (15%) were disease-free, and 90 patients were dead at the time of analysis. Eighty-seven deaths were related to progression of disease. The median survival of all patients was 16.2 months, with an actual 5-year survival of 6%. Median survival of CHPP plus ordinary cyoreduction was 12.0 months and that after CHPP and peritonectomy was 22.8 months. Completeness of cytoreduction and peritonectomy were significant prognostic factors on univariate analysis and 5-year survival rate was 27%. Lymph node status, grade of peritoneal dissemination (P1-2 vs P3), age (>60 years vs <60 years), tumor volume of dissemination (>2.5 cm vs <2.5 cm in diameter), and histologic type (differentiated vs. poorly differentiated type) did not affect survival. The cox proportional model demonstrated that completeness of cytoreduction was the strongest prognostic factor. Patients who had an incomplete resection had 2.8-fold higher risk of dying from disease than patients who underwent complete cytoreduction. The 5-year survival after complete cytoreduction was 12%, compared with 2% for incomplete resection. Four patients lived more than 5 years. Cytoreduction was incomplete in one 5-year survivor who showed complete response to CHPP. CONCLUSION: Complete cytoreduction using peritonectomy and CHPP may improve survival of patients with peritoneal dissemination from gastric cancer. This procedure is most appropriate for highly motivated patients who are committed to survive as long as possible.