[A Resected Case of Intussusception Due to Undifferentiated Carcinoma of the Colon].

An 89-year-old woman was pointed out to have anemia for a routine blood examination by her family doctor and was referred to our gastroenterological department for further examination. Colonoscopy showed a type Ⅰ tumor in the transverse colon and insertion of fiber across the tumor was difficult. On contrast enema using gastrographin, a crab's claw-like appearance was found. CT after contrast enema revealed a tumor, 5 cm in diameter with pseudokidney sign near the hepatic flexure of the transverse colon. Pathological examination of biopsy specimen proved the tumor to be a poorly differentiated adenocarcinoma. Thus, she was diagnosed with intussusception due to transverse colon cancer and we performed partial resection of the transverse colon without regional lymphadenectomy. Final pathological diagnosis of the tumor was undifferentiated carcinoma and tumor stage was pT3pN0cM0, pStage Ⅱa. She was discharged 13 days after surgery and alive without tumor recurrence at 7 months after surgery, not undergoing adjuvant chemotherapy.

[A Case of Conversion Surgery following Chemotherapy for HER2-Positive Advanced Gastric Cancer].

A 73-year-old female was referred to the gastroenterological department of our hospital for examination because of anemia. CA19-9 increased to 1,392 U/mL, and upper endoscopy revealed type 2 gastric cancer extending from the anterior wall to the lesser curvature in the lower part of the gastric body. Biopsy specimens revealed well-differentiated tubular adenocarcinoma, and HER2 was positive immunohistologically. Contrast-enhanced CT revealed wall thickness of the lower part of the gastric body with marked lymph node swelling beside the lesser curvature and a low-density nodule measuring 10 mm in diameter with rim enhancement in segment 5 of the liver, indicative of liver metastasis. Thus, she was diagnosed with unresectable advanced gastric cancer(cT3cN2M1, HEP, cStage ⅣB), and combined chemotherapy with capecitabine, cisplatin, and trastuzumab was administered. After 7 courses, CA19-9 normalized, and upper endoscopy revealed a scar of the primary tumor, and cancer was not detected in the biopsy specimen. On contrast-enhanced CT, lymph nodes beside the lesser curvature shrank significantly, and liver nodules disappeared. She was referred to our department for conversion surgery, and distal gastrectomy with D2 lymph node dissection was performed 7 months after her first visit to our hospital. Pathologically, tumor invasion was restricted to the lamina propria, and lymph node metastasis was not observed(ypT1aN0M0, ypStage Ⅰ A). She was discharged on postoperative day 13 and is alive without tumor recurrence at 7 months after surgery. She is not currently undergoing adjuvant chemotherapy.

[Case of Resected Retroperitoneal Dedifferentiated Liposarcoma Extending to the Posterior Mediastinum].

A 71-year-old woman visited our hospital for the examination and treatment of retroperitoneal tumor. CT showed a retroperitoneal tumor extending to the posterior mediastinum; the tumor pressed the IVC and widely abutted the aorta. On MRI, the tumor showed low intensity on T1WI and high intensity on T2WI and DWI. However, the tumor did not show signal reduction on an ADC map. PET-CT showed high accumulation at the tumor. The patient was diagnosed with sarcoma arising from the retroperitoneum. The tumor located on a part of the diaphragm was resected. Histological examination revealed spindle cells with atypical nuclear and multinuclear cells. There were no lesions of well-differentiated liposarcoma. Both CDK4 and MDM2 tested positive on immunohistological staining. Histopathologically, the tumor was diagnosed as dedifferentiated liposarcoma without any well-differentiated liposarcoma component. The postoperative course was uneventful, and she was discharged on the 13th day after surgery. Two months after surgery, no recurrence has been detected.

Cholecystohepatic duct detected during laparoscopic cholecystectomy: a case report.

BACKGROUND: The cholecystohepatic duct is a rare form of an aberrant hepatic duct that connects to the gallbladder. Although cholecystohepatic duct is reported to be a very rare anomaly, injury of cholecystohepatic duct during cholecystectomy may result in serious complications. Herein, we present a case of cholecystohepatic duct in the ventral branch of the right posterior inferior segmental bile duct detected during laparoscopic cholecystectomy. CASE PRESENTATION: A 77-year-old woman with cholecystolithiasis had been referred to our hospital for surgery. Drip infusion cholecystocholangiography-computed tomography revealed a bile duct branch without communication between the intra- and extrabiliary systems, although the existence of this aberrant hepatic duct was not suspected preoperatively. A 4-port laparoscopic cholecystectomy was performed. After critical view of safety was confirmed, the cystic artery and duct were divided after double clipping. During antegrade mobilization of the gallbladder from the gallbladder bed, a thin, white cord-like material connecting the gallbladder neck and bed was detected. After clipping and dividing it, a cholecystohepatic duct injury was recognized through rechecking the results of the preoperative examinations. Biliary reconstruction was considered unnecessary because of the lesion's small drainage area. The postoperative course was uneventful, and an enhanced computed tomography performed 6 months after the surgery revealed a dilation in the ventral branch of the right posterior inferior segmental bile duct. The patient's liver function remained normal, and she had no symptoms of cholangitis 42 months after the surgery. CONCLUSIONS: Although cholecystohepatic duct is a rare anomaly compared to other aberrant hepatic ducts, surgeons performing cholecystectomy should always keep its existence in mind to avoid serious postoperative complications. Ideally, preoperative detection of cholecystohepatic duct is preferable, but even if it is detected during surgery, the appropriate management according to the drainage area is also important.

[Two Cases of Gastric Cancer Diagnosed after Omental Patch Repair for Gastric Perforation].

Case 1: A 62-year-old man was urgently admitted to our hospital because of left lower abdominal pain. Abdominal CT showed gastric perforation and we performed omental patch repair emergently. Postoperative upper gastrointestinal endoscope revealed an ulcerative lesion in the lesser curve of upper area of gastric body, which proved to be a poorly differentiated adenocarcinoma by biopsy. Thus, we performed total gastrectomy with D2 lymph node dissection. Resected specimen revealed type 2 gastric cancer in the perforated area. Pathological stage was pT3pN0M0, pStage ⅡA. Adjuvant chemotherapy by S-1 was performed and he is alive without tumor recurrence 12 months after the first operation. Case 2: A 71-year- old man was urgently admitted to our hospital because of upper abdominal pain after dinner. Abdominal CT suggested gastric perforation and we performed emergent laparoscopic operation. Perforated lesion about 8 mm in diameter was found in the anterior wall of gastric body. After debridement, perforated lesion was closed with a running suture and additionally omental patch repair was performed. Pathologically, well-differentiated adenocarcinoma was detected in the debridement tissue, and he was diagnosed with perforated gastric cancer. Thus, we performed total gastrectomy with D2 lymph node dissection 28 days after surgery. Pathological stage was pT3pN0M0, pStage ⅡA. Adjuvant chemotherapy by CapeOX was performed and he is alive without tumor recurrence 12 months after the first operation.

[Resected Cases of Primary Duodenal Carcinoma-A Ten-Year Experience].

Primary duodenal carcinoma excluding tumors of the ampulla of Vaterare are rare, thus, therapeutic strategy has not been established. In this study, we investigated the treatment outcome of 7 cases of duodenal carcinoma resected in our hospital between January 2010 and December 2019. The tumor locations were the duodenal bulb in 5(71%), the descending part and the transverse part in 1, respectively. Distal gastrectomy was performed in 4 out of 5 bulbous cases, and pancreatoduodenectomy was performed in the other 3 cases. The pathological stage by the 8th edition of the UICC TNM classification was Stage Ⅰ(T1a/T2, N0)in 3 cases, ⅡA(T3, N0)in 1, ⅢA(N1)in 2, and ⅢB(N2)in 1. R0 resection was achieved in all cases. Adjuvant chemotherapy with S-1 was performed in 3 of 4 patients with Stage Ⅱ or more advanced Stage. There were no tumor recurrences in 4 patients with Stage Ⅰ and Stage ⅡA, but recurrence was occurred in 2 of 3 patients with Stage ⅢA or more. The surgical outcome for duodenal carcinoma without lymph node metastasis were good. On the other hand, the prognosis for advanced cases with lymph node metastasis were poor. Thus, the development of effective adjuvant chemotherapy is strongly expected.

[Two Cases of Complete Response to Trastuzumab Combined with Chemotherapy for Recurrence of HER2-Positive Gastric Cancer].

Case 1: A 67-year-old male underwent distal gastrectomy for advanced gastric cancer. Postoperative histopathological examination indicated pT2a, pN2, M0, pStage ⅢA. He received 4 courses of TS-1 with paclitaxel chemotherapy and TS-1 chemotherapy for 2 years. Three years and 5 months after surgery, computed tomography suggested lymph node metastasis of the mediastinum, so TS-1 with cisplatin(CDDP)therapy was administered. Five years and 10 months after surgery, recurrence occurred and docetaxel and CPT-11 were administered with no response. Since HER2 was overexpressed in the primary tumor, he was treated with capecitabine, CDDP, and trastuzumab(XPT)therapy. After 1 year and 6 months, the patient was considered to have achieved a complete response(CR), and after further trastuzumab therapy for half a year, CR was maintained for 12 years and 3 months after surgery. Case 2: A 59-year-old female underwent total gastrectomy for advanced gastric cancer. Postoperative histopathological examination indicated pT3, pN3a, M0, pStageⅢB. She received TS-1 chemotherapy for 1 year and 8 months. Computed tomography suggested paraaortic lymph node metastasis, and XPT therapy was administered. The patients responded well, and alternate administration of XPT and capecitabine and docetaxel(XT) was performed. Three years and 5 months after surgery, recurrence of lymphadenopathy occurred and intensity-modulated radiation therapy in addition to XPT/XT alternate therapy was introduced, leading to a CR 5 years and 8months after surgery. XT therapy was continued afterward, and CR was maintained for 9 years and 2 months after surgery.

[A Resected Case of UR-LA Pancreatic Tail Cancer with Aortic Invasion after Chemoradiotherapy].

A 70-year-old male was referred to our hospital because of weight loss and epigastric discomfort. CT showed an irregularshaped, low-density tumor, 12 cm in diameter in the tail of the pancreas. This tumor widely invaded to the left kidney and to the anterior and left lateral sides of the aorta in spite of no involvement of celiac and superior mesenteric arteries. Moreover, it closely contacted with the stomach and the spleen. EUS-fine-needle aspiration biopsy of the tumor detected adenocarcinoma. Thus, he was diagnosed with UR-LA pancreatic cancer with aortic invasion. He received combination chemotherapy(S-1 plus gemcitabine[GEM])and 50.4 Gy 3-dimensional conformal radiation therapy, but this therapy had no expected effect. We changed the regimen to GEM plus nab-PTX. After 1 course of changed regimen, the tumor ruptured into the stomach and endoscopic debridement of the necrotic tissue was performed. Twenty-six days later, We performed distal pancreatectomy with splenectomy, total gastrectomy, left nephrectomy, left adrenalectomy, and segmental resection of the colon. The tumor was detached from the aorta as much as possible. The final diagnosis was pT3N0M0, pStage II A. Fifty-nine days after operation, we restarted GEM plus nab-PTX therapy. However, a cerebral infarction suddenly occurred, and we discontinued the chemotherapy. Five months after the operation, he died of cancerous peritonitis.

[A Case of Small Intestinal Neuroendocrine Tumor Detected One Year after Resection of Liver Metastasis].

A 49-year-old woman received a detailed examination for a myoma uteri, and a hepatic tumor was detected incidentally. A CT scan showed a tumor 6 cm in diameter in the posterior segment, which was irregularly enhanced. The tumor showed a low signal intensity on T1WI MRI and a slightly high intensity with high-density spots on T2WI. The tumor showed a low signal intensity in the hepatobiliary phase of the EOB-enhanced MRI. Percutaneous liver biopsy proved that this tumor was a grade 1 neuroendocrine tumor(NET G1). We examined her whole body in detail but found no primary lesions. Therefore, we made a diagnosis of primary hepatic NET or hepatic metastasis of an unknown origin and performed right hepatectomy. A year after the operation, a tumor was found in the jejunum. We made a diagnosis of NET by using endoscopic biopsy and performed partial intestinal resection. Histological findings showed NET G2(Ki-67 labeling index: 3.5%), which had venous invasion and one lymph node metastasis, suggesting that the jejunum was a primary lesion of NET. Three years and 2 months after the first operation, multiple liver metastases were found, and bland TAE was performed three times. Four years and 6 months after the first operation, we started sustained-release somatostatin analogues for tumor progression. She is still alive 5 years and 6 months after the first operation.

[A Case of Primary Peritoneal Cancer Successfully Treated with Debulking Surgery and Postoperative Chemotherapy].

A 52-year-old woman with abdominal pain and a feeling of incomplete evacuation visited a local clinic. Enlargement of the right ovary was detected, and the patient was referred to the gynecological department of our hospital. CT and MRI revealed a round-shaped mass, 8 cm in diameter, with cystic and solid components in the Douglas pouch. The patient underwent a laparotomy under the diagnosis of ovarian cancer. Intraoperatively, both the ovaries appeared normal and the tumor strongly adhered to the rectum and uterus. An exploratory laparotomy was performed; the tumor was identified as unresectable, and the patient was referred to our department after the surgery. PET-CT revealed nodules in the liver and peritoneum, in addition to the main tumor. Gastrointestinal endoscopy and immunohistochemical examination of a needle biopsy of the main tumor did not lead to the identification of the primary lesion. Thus, debulking surgery was performed to alleviate the patient's complaints. Histologically, the tumor was diagnosed as a primary peritoneal clear cell carcinoma. One month after surgery, multiple liver metastases and swelling of the peritoneal lymph nodes occurred. Six courses of dose-dense TC therapy were administered, and the patient achieved a complete response. At 8 months after surgery, the patient is still alive without tumor recurrence.

Basket pattern blood flow signals discovered in a case of splenic hamartoma by power Doppler ultrasonography.

We present the gray-scale ultrasonography (GSUS), power Doppler ultrasonography (PDUS), abdominal computed tomography (CT), and magnetic resonance imaging (MRI) findings for a case of splenic hamartoma in a 27-year-old man, showing a phi 50 mm homogeneous, iso- and hypo-echoic splenic mass with evidence of a small plural cystic lesion. This splenic hamartoma showed increased vascularity on power Doppler sonograms. PDUS showed multiple circular blood flow signals inside the mass (i.e. a basket pattern), which was consistent with the small plural cystic lesion shown by GSUS. Spectral analysis also confirmed arterial and venous flow. CT scans showed that the mass had low-density relative to the normal spleen and MRI showed that the mass was isodense, relative to the normal spleen. Therefore, CT and MRI are not useful for the diagnosis of splenic hamartoma. Ultrasonography can be used to diagnose splenic hamartoma without administration of a contrast material and therefore is an indispensable method for the diagnosis of splenic hamartoma.