[Osteosarcoma Secondary to Polyostotoic Fibrous Dysplasia of the Ribs].

Sarcomatous transformation of fibrous dysplasia is extremely rare. We present the case of a 54-yearold man with multiple rib masses, multiple enlarged lymph nodes throughout the body, and multiple osteolytic lesions on computed tomography( CT). A positron emission tomography( PET) scan showed abnormal enhancement in each. A needle biopsy of the right supraclavicular fossa lymph node revealed sarcoidosis. Considering the possibility of malignancy associated with sarcoidosis, a rib tumor resection and mediastinal lymph node biopsy were performed to confirm the diagnosis of the rib lesion. The pathology results showed that the rib mass was a low-grade central osteosarcoma and the mediastinal lymph node was sarcoidosis. The distribution of the lesions was consistent with osteosarcoma secondary to multiple fibrous bone dysplasia. As the osteosarcoma was low grade, the patient was followed up. Three years after surgery, there was no increase in residual disease.

[A Case of Stage â £ Gastric Cancer with Multiple Liver Metastases, Resected Primary Tumor after Chemotherapy, and Alive for 3.5 Years without Recurrence].

A 67-year-old man visited our hospital for epigastric pain. Esophagogastroduodenoscopy(EGD)revealed type 2 gastric cancer from the cardia to the gastric angle, and histopathological examination revealed papillary adenocarcinoma(pap), HER2-positive. Contrast-enhanced CT showed wall thickening mainly in the posterior wall of the gastric body, enlarged lymph nodes that were lumped together with the main lesion, and 8 low-absorption areas with ring shaped contrast effects in both lobes of the liver. The patient was diagnosed as gastric cancer cT4aN(+)M1[HEP], clinical Stage ⅣB. Six courses of capecitabine plus cisplatin plus trastuzumab(XP plus Tmab)therapy and 17 courses of capecitabine plus trastuzumab(X plus Tmab)therapy were performed. After chemotherapy, liver and lymph node metastases disappeared on CT and MRI. EGD showed residual gastric cancer, and the policy was to resect the primary tumor. Laparoscopic total gastrectomy with D2 lymph node dissection was performed. Pathological results showed T1b(SM)depth, no lymph node metastasis, and histologic response was Grade 2a. Six courses of X plus Tmab were administered as postoperative adjuvant chemotherapy, but were discontinued at the patient's request. Currently, 5 years have passed since the first chemotherapy and 3.5 years have passed since the surgery, and the patient is alive without recurrence, suggesting that the conversion surgery may have contributed to the prolonged survival.

[Thymoma with Pure Red-cell Aplasia and Hypogammaglobulinemia].

Thymoma presenting concurrent pure red-cell aplasia (PRCA) and hypogammaglobulinemia are extremely rare. A 67-year-old woman with a short of breath was referred to our hospital due to anemia and the chest abnormal shadow. Laboratory investigations revealed a hemoglobin level of 5.6 g/dl and reticulocyte percentage of 0.2%. Her serum gamma-globulin level was low. Chest computed tomography (CT) revealed a 7-cm tumor in the left upper mediastinum. We diagnosed the patient with thymoma accompanied by PRCA and hypogammaglobulinemia. The patient underwent thymectomy and PRCA has been successfully treated by postoperative cyclosporine administration. Monthly intravenous infusion of gamma-globulin has been necessary for the control of hypogammaglobulinemia. Currently, she is doing well without recurrence of thymoma or PRCA five years after the surgery.

[A Case of Postoperative Peritoneal Dissemination Recurrence of CY1 Gastric Cancer with cCR after Nab-PTX Therapy].

A 72-year-old man visited his local doctor for gastric discomfort. Esophagogastroduodenoscopy revealed a type 3 tumor on the gastric antrum, and histopathological examination revealed a moderately differentiated adenocarcinoma(tub2). The patient was referred to our hospital and CT scan revealed wall thickening with contrast effect in the gastric angle but no enlarged lymph nodes in the region. The patient was diagnosed as cT3N0M0, Stage ⅡB gastric cancer and underwent open distal gastrectomy and D2 lymph node dissection. No peritoneal dissemination was observed, but intraoperative laparoscopic cytology showed Class Ⅴ. The patient was diagnosed as CY1 Stage Ⅳ gastric cancer, and treated with S-1 plus Tmab therapy starting 1 month after surgery. One year postoperative follow-up CT revealed recurrence of peritoneal disseminations, and the patient was treated with nab-PTX as a second-line therapy. Tumor shrinkage was achieved steadily, and the peritoneal disseminations disappeared at the CT after 12 courses, resulting in cCR. Thereafter, cCR continued and treatment was terminated at the 17th course. Seven years have passed since the end of chemotherapy, and the patient is still alive without recurrence.

[A Case of Postoperative Recurrence of Liver Metastasis after Gastrectomy for Gastric Cancer-No Recurrence for Five Years after Twice Liver Resections].

The patient was an 89-year-old man. He underwent laparoscopic distal gastrectomy for gastric cancer and was diagnosed as T1bN1M0, Stage ⅠB. Eight months after surgery, a CT scan showed an 18 mm-sized hypodense mass in S6 of the liver, and the patient was diagnosed with recurrent liver metastasis. He was treated with 3 courses of CapeOX therapy, and the response was judged as partial response(PR). Laparoscopic partial hepatic S6 resection was performed for the single liver metastasis. The pathological results showed liver metastasis of gastric cancer. Capecitabine was started as adjuvant chemotherapy. Nine months after surgery for liver metastasis, CT scan showed a 12 mm-sized single tumor in S5 and the patient was diagnosed with recurrent liver metastasis. The patient underwent laparoscopic partial hepatectomy after 3 courses of weekly paclitaxel plus ramucirumab therapy. The pathological result showed liver metastasis of gastric cancer. After the surgery, adjuvant chemotherapy was not administered according to the patient's request. Seven years have passed since the resection of the gastric cancer, and 5 years have passed since the resection of the second liver metastasis, and the patient has not had any recurrence.

[Mucoepidermoid Carcinoma Suspectedly Developed from a Bronchogenic Cyst in the Posterior Mediastinum].

Mucoepidermoid carcinoma developing from a bronchogenic cyst is extremely rare. We present a case of a 74-year-old man with a cystic mass in the posterior mediastinum detected by chest computed tomography( CT) and magnetic resonance imaging. A bronchogenic cyst or neurogenic tumor was suspected. He did not accept surgical treatment and was followed up at outpatient. Since the enlargement of the mass was shown by chest CT after seven years, the resection of the mass was performed by thoracoscopic surgery, however the cyst wall remained due to the severe adhesion and the residual mucosa was cauterized. The mass was diagnosed as a mucoepidermoid carcinoma by pathology which was likely to develop from a bronchogenic cyst. After postoperative radiotherapy, the patient is well without recurrence 10 months after surgery.

[Effectiveness of Pembrolizumab for Pulmonary Pleomorphic Carcinoma with Pleural Dissemination and Gingival Metastasis].

We present a case of a 67-year-old woman who was pointed out a 1.8 cm nodule in the left inferior lobe by chest computed tomography( CT). Lung cancer was suspected and the surgery was scheduled. Before surgery, perioperative oral care was performed and gingival tumor doubtful of metastatic lesion was found. After the resection of the lung tumors, the diagnosis of pleomorphic carcinoma with pleural dissemination and gingival metastasis was established. Because high programmed cell death 1 ligand 1 (PD-L1) expression was demonstrated in the specimen of the lung, she was treated with pembrolizumab as an initial treatment, which led to a complete response. Twenty months after initiating of pembrolizumab therapy, she is doing well without recurrence of pleomorphic carcinoma.

[A Case of Rectal Neuroendocrine Carcinoma Treated with Multidisciplinary Therapy but with a Poor Prognosis].

A 70-year-old man presented to our hospital with weight loss. A colonoscopy revealed advanced cancer in the lower rectum. Computed tomography showed a tumor larger than 5 cm in the lower rectum with metastasis to the right lateral lymph node. The patient was diagnosed with advanced locally rectal cancer, and chemoradiotherapy(35 Gy plus S-1)was added after 6 courses of mFOLFOX6, and laparoscopic abdominal perineal resection and right lateral lymph nodes dissection were performed. Histopathological examination revealed endocrine cell carcinoma(pT3[A], pN0, M0, pStage Ⅱa). Four months after the operation, recurrence was found in the pelvis, lymph nodes, and lungs, and he died 9 months after the operation. Neuroendocrine carcinoma is relatively rare, so the further accumulation of cases and establishment of treatment methods are desired.

[A Case of Laparoscopic Abdominoperineal Resection of Anorectal Malignant Melanoma].

A 56-year-old woman with complaints of anal bleeding and pain visited our hospital, and an elastic soft mass was detected in the anal canal on digital examination.Colonoscopy showed a black Isp polypoid lesion with a black pit from the anal canal to the lower rectum(P-Rb).She was diagnosed with malignant melanoma based on colonoscopic biopsy.Tumor marker levels(CEA, CA19-9)were not increased.No distant metastasis was detected on abdominal CT.No direct invasion was detected on MRI of the pelvis.The patient underwent laparoscopic abdominoperineal resection and D2 lymph node dissection. Histopathology showed a malignant melanoma(pT4b, N0, M0, pStageⅡC).The patient received interferon therapy as adjuvant therapy.There is no sign of recurrence 2 years and 1 month after the surgery.Anorectal malignant melanoma is relatively rare, so establishment of therapy by the accumulation of cases is desired.

Complete torsion of gallbladder following laparoscopic cholecystectomy: A case study.

INTRODUCTION: Gallbladder torsion is mainly associated with a floating gallbladder. From an anatomical perspective, laparoscopic cholecystectomy is a more optimal treatment than open cholecystectomy. PRESENTATION OF CASE: An 84-year-old woman visited the Onomichi General Hospital because of progressive pain in the right upper quadrant of her abdomen. Physical examination revealed a positive Murphy sign and peritoneal irritation. Laboratory data demonstrated that inflammatory marker levels were increased. Abdominal ultrasonography showed that blood flow in the cystic artery was reduced and the gallbladder was swollen. Abdominal contrast-enhanced computerized tomography indicated that the swollen gallbladder was modestly enhanced and the fundus was displaced under the midline and detached from the gallbladder bed. The cystic duct was twisted. Magnetic resonance cholangiopancreatography showed that the root of the cystic duct was unclear and the extrahepatic bile duct had V-shaped distortion. The gallbladder neck showed a tapering interruption with the common biliary duct. We made a preoperative diagnosis of gallbladder torsion. Accordingly, emergency laparoscopic cholecystectomy was performed. The intraoperative findings included a dark swollen gallbladder that was twisted in the counterclockwise direction. The patient was discharged without any postoperative complications on day 7. DISCUSSION: Combined acute onset of abdominal pain with characteristic radiological findings made it possible to precisely diagnose gallbladder torsion. CONCLUSION: Laparoscopic cholecystectomy can be the gold standard treatment for gallbladder torsion after a preoperative diagnosis is made.

Large primary pleural synovial sarcoma with severe dyspnea: a case report.

BACKGROUND: Synovial sarcoma is a malignant neoplasm of soft tissues. It occurs mainly in the extremities and is closely related to tendons, tendon sheaths, and bursal structures. Primary synovial sarcoma of the pleura and lungs is extremely rare. CASE PRESENTATION: We present the case of a 62-year-old man with a large synovial sarcoma of the left pleura. He presented with general fatigue and severe dyspnea. Chest computed tomography (CT) revealed a 20-cm tumor in the left thoracic cavity. We first diagnosed the tumor as a sarcomatoid mesothelioma based on CT-guided needle biopsy. We speculated that his severe dyspnea was because of ventilation-perfusion mismatch due to the left pulmonary collapse. Furthermore, we thought that there was a discrepancy between the CT findings and the pathological findings from the biopsy specimen. We performed pleuropneumonectomy through an anterior approach with median sternotomy and 5th-intercostal thoracotomy. The resected specimen contained a 22-cm pleural tumor with parenchymatous hemorrhage. We diagnosed the tumor as monophasic synovial sarcoma based on its morphologic and immunohistochemical features. We suspected there was microscopic residual tumor in the left diaphragm and therefore performed radiation therapy. After radiotherapy, he received adjuvant chemotherapy with ifosfamide and Adriamycin. One year after surgery, the patient is alive with no signs of tumor recurrence. CONCLUSIONS: We report a case of a large synovial sarcoma of the pleura in a patient with severe dyspnea. He was treated with pleuropneumonectomy, radiotherapy, and adjuvant chemotherapy. Although the best treatment for this rare condition has not been defined, we thought that tumor resection and adjuvant therapy were appropriate to control the disease in this case.

[Twenty-Five Cases of Locally Advanced Rectal Cancer That Underwent Laparoscopic Surgery after Preoperative Chemotherapy].

Several recent reports have described the administration of preoperative chemotherapy for locally advanced rectal cancer. In our hospital, preoperative chemotherapy based on oxaliplatin was administered for locally advanced rectal cancer with a tumor diameter of 5 cm or more and half semicircularity or more, and curative resection with laparoscopic surgery was performed after tumor shrinkage. We have experienced 25 cases that underwent preoperative chemotherapy for local advanced rectal cancer in our hospital from May 2012 to April 2016. No tumor increased in size during preoperative chemotherapy and there were no cases where R0 resection was impossible. In addition, no distant metastasis during chemotherapy was observed. Postoperative complications were observed in 3 cases(12%), and anastomotic leakage was observed in 1 case (4%), but conservative treatment was possible. Multidisciplinary treatment of preoperative chemotherapy and surgery should be considered as a therapeutic strategy for locally advanced rectal cancer, mainly in medical institutions without radiation treatment facilities.

Late-onset diaphragmatic hernia after percutaneous radiofrequency ablation of hepatocellular carcinoma: a case study.

Percutaneous radiofrequency ablation (RFA) is widely used as an effective treatment of liver tumors. Several reported complications associated with RFA are due to thermal damage of neighboring organs. The present report presents a case of diaphragmatic hernia associated with RFA and hepatocellular carcinoma (HCC). A 72-year-old woman with S5 and S8 HCCs was treated repeatedly with RFA and transcatheter arterial chemoembolization for 3 years. After the third course of RFA to target the recurring S5 HCC, acute abdominal pain and dyspnea suddenly occurred. Contrast-enhanced computed tomography revealed intrusion of the transverse colon through the right diaphragmatic hernia. In addition, the colon was dilated and showed changes suggestive of ischemic conditions. An emergency surgery was performed to close the hernia by using non-absorbable sutures to preserve the colon. The patient was discharged without any complications 13 days after the surgery. The first-line treatment of this disease involves surgical intervention. Diaphragmatic hernia is a rare complication of RFA. The present case suggests that patients who undergo several rounds of RFA require surveillance for diaphragmatic hernias.

Follicular cholangitis associated with focal biliary stricture treated with left hepatectomy after 8 years of follow-up: A rare case report.

Follicular cholangitis may lead to severe focal biliary stricture, which is difficult to distinguish from cholangiocarcinoma. This is the report of a rare case of follicular cholangitis associated with an intrahepatic focal biliary stricture in a 69-year-old woman. The patient visited our hospital for upper abdominal pain in 2006. Computed tomography revealed common bile duct stones and focal stricture of the left intrahepatic duct. Endoscopic retrograde cholangiopancreatography revealed a severe B3 stricture and dilation of the peripheral biliary tract. Repeated cytology revealed no malignancy. The patient was followed up for 8 years and repeated attacks of cholangitis severely compromised her quality of life. A left hepatectomy was performed, and the pathological findings were consistent with follicular cholangitis. It is generally difficult to make a definitive diagnosis after identifying a biliary stricture, and the stricture is often treated with surgical resection. The clinical presentation and radiological findings of follicular cholangitis are similar to those of cholangiocarcinoma; therefore, if a conservative approach is selected, frequent follow-up is recommended. The present case suggests that follicular cholangitis should be considered in the differential diagnosis of biliary stricture.

[A Case of Long-Term Survival in a Patient with Small Intestinal Adenocarcinoma with Peritoneal Dissemination].

Primary small intestinal adenocarcinoma is rare and its outcome is poor. A 46-year-old man admitted for vomiting was found in enhanced abdominal CT to have local jejunum stenosis and dilation at its oral site. A partial jejunectomy was performed and a jejunal tumor with multiple disseminated nodules in the peritoneum was revealed. Histologically, the adenocarcinoma of the jejunum appeared to be a papillary adenocarcinoma, and also, in part, a moderately differentiated tubular adenocarcinoma. After the jejunectomy, the patient was treated with S-1 chemotherapy, but 22 months after the initial diagnosis, a recurrence was detected. The patient underwent a second partial jejunectomy, and a weekly dose of paclitaxel (PTX) plus doxifluridine (5'-DFUR) was selected as the second-line treatment. The patient is still responding to the treatment 55 months after the last operation. Combination chemotherapy with weekly PTX/5'-DFUR may improve the prognosis for S-1-resistant small intestinal adenocarcinoma.

[Mesothelioma of Unknown Primary Site with Resection of Mediastinal Lymph Node Metastasis].

A 63-year-old male underwent biopsy of a mediastinal lymph node. Intra-operative frozen section diagnosis was metastatic mesothelioma. The primary site of mesothelioma was not detected in the thoracic cavity. One year later, he was again removed a mediastinal lymph node metastasis, but the primary site was not detected. Eight months later, he was performed right neck and mediastinal lymph node dissection due to additionally appeared lymph node metastases, but the primary site was not detected. He is well 6 months after last surgery with postoperative adjuvant chemotherapy.

[Localized Malignant Mesothelioma of the Pleura].

A 65-year-old man presented with the chief complaint of cough. Chest computed tomography showed the mediastinal tumor. The tumor was resected under the 4th intercostal thoracotomy and the mediastinal approach. The biphasic type of localized malignant mesothelioma was diagnosed by the pathological findings. The postoperative course was uneventful. After postoperative adjuvant radiotherapy and chemotherapy (cisplatin and pemetrexed sodium hydrate), he is well without relapse 7 months after surgery.

[Pulmonary dirofilariasis].

A 70-year-old man was admitted to our department for pulmonary nodule of 15 mm in diameter in the left lower lobe detected by chest computed tomography (CT). A possibility of malignant tumor could not be ruled out, and lung partial resection was performed. Pathological examination during operation revealed a coagulation necrosis and the lesion was finally diagnosed as pulmonary dirofilariasis.

The potential of recombinant vesicular stomatitis virus-mediated virotherapy against metastatic colon cancer.

Colorectal cancer (CRC) is the fourth most frequently diagnosed cancer and the second leading cause of cancer-related mortality in the United States. The liver and lung are the most common sites of distant metastasis of CRC. The approval of newer chemotherapeutic agents such as oxaliplatin, irinotecan, bevacizumab, cetuximab and panitumumab has significantly improved survival, yet the majority of patients still succumb to the disease in less than 2 years. Novel therapeutic agents that can provide significant clinical benefit for metastatic CRC patients are needed. Oncolytic vesicular stomatitis virus (VSV) is a promising tool as a cancer therapeutic agent. In this study, we examined the feasibility of repeated intravenous infusions of rVSV in multiple CRC lung metastases, compared with repeated hepatic arterial administration in multifocal CRC liver metastasis in immune competent rats. We established a multifocal liver metastases model or the multiple lung metastases model using a CRC cell line, RCN-H4, implanted into syngeneic F344/DuCrj rats. 4.0x10(6) plaque-forming units (pfu) of recombinant VSV vectors expressing mutant (L289A) Newcastle disease virus fusion protein [rVSV-NDV/F(L289A)] were administered 3 times for 3 consecutive days locally via the hepatic artery for liver metastases or systemically via the penial vein for lung metastases. In the liver metastasis model, significantly enhanced survival was observed with rVSV-NDV/F(L289A)-treated rats (P=0.0196). Median survival was 110 and 25 days, respectively. In addition, 4 out of 7 of the rVSV-NDV/F(L289A)-treated rats demonstrated long-term survival exceeding 100 days. The long-term surviving rats were sacrificed to evaluate for residual malignancy. Liver tumors were not detected. In the lung metastasis model, median survival was 10 [VSV-NDV/F(L289A)-treated rats] and 7 days (control). Although survival was significantly prolonged (P<0.001), none of the rats achieved long-term survival. VSV virotherapy has potential for CRC liver and lung metastases, although systemic venous delivery is much less effective than locoregional delivery such as hepatic arterial infusion.

[Thymic carcinoma with vascular resection].

Thymic carcinomas are rare neplasm. The standard treatment for advanced thymic carcinoma has not yet been established, and the prognosis is poor. We report 3 cases of thymic carcinoma involving major vessely. Case 1:The aortic arch and the innominate vein were involved. Case 2:The left brachiocephalic vein was involved. Case 3:Tumor invaded to superior vena cava. Complete resection of the tumor was possible with vascular reconstruction.