Hepatoid adenocarcinoma of the stomach effectively treated with capecitabine with oxaliplatin as adjuvant chemotherapy: A case report and literature review.

INTRODUCTION: Hepatoid adenocarcinoma of the stomach (HAS) is an alpha-fetoprotein (AFP)-producing gastric carcinoma (GC) with a hepatocellular carcinoma-like histology. HAS is a relatively rare type of GC, with liver metastases being more common than peritoneal dissemination in the recurrent form, and the poor prognosis. PRESENTATION OF CASE: We present the case of a 70-year-old patient who underwent distal gastrectomy for GC and immunohistologically diagnosed as HAS. The patient had an intravenous tumor thrombus at the proximal margin of the resected stomach. Owing to the low possibility of radical resection and high probability of liver metastatic recurrence, capecitabine with oxaliplatin (CapeOX) was started as adjuvant chemotherapy (AC). After three courses of CapeOX, oxaliplatin was discontinued due to adverse events (peripheral neuropathy, grade3) and capecitabine alone was continued for 3 years postoperatively. Six years after surgery, no local recurrence or distant metastasis was detected on imaging studies. DISCUSSION: There is no established standard treatment for HAS. Recently, some studies have reported the efficacy of antimetabolites or platinum-based drugs as AC regimens. We thus decided to start a regimen consisting of a combination of antimetabolites and a platinum, i.e., CapeOX, which proved efficacious. CONCLUSION: CapeOX or capecitabine may be effective as AC for treating HAS.

A case of coexistent poorly differentiated adenosquamous carcinoma (glassy cell carcinoma), usual-type adenocarcinoma, and squamous cell carcinoma in situ of the cervix.

Poorly differentiated adenosquamous carcinoma (glassy cell carcinoma) of the cervix is extremely rare, accounting for 1-2% of all cervical cancers. Herein, we report a case with coexistent poorly differentiated adenosquamous carcinoma (glassy cell carcinoma), "usual-type" adenocarcinoma, and squamous cell carcinoma in situ of the cervix. A female patient in her 60 s was referred to our hospital and diagnosed with poorly differentiated adenosquamous carcinoma based on cervical cytology and biopsy. The tumor was classified as clinical stage IB1 cervical cancer following magnetic resonance imaging; radical hysterectomy was performed. Histopathological examination revealed poorly differentiated adenosquamous carcinoma (glassy cell carcinoma), usual-type adenocarcinoma, and squamous cell carcinoma in situ, all coexisting. All carcinoma regions showed identical sizes to high-risk human papillomavirus (HPV) in fragment analysis. The patient is currently alive, without evidence of recurrence, 31 months post surgery. In this case, three different carcinomas coexisted. Fragment analysis of the patient's HPV status suggested that all carcinomas were related to an infection with the same high-risk HPV type. To determine the precise mechanism of tumor development, i.e., whether the tumors were of the mixed or collision type, further studies are needed, including clonal analysis for the loss of heterozygosity pattern.

Acute necrotic disorder of the small intestine post-coronavirus disease-2019 vaccination.

The Pfizer-BioNTech coronavirus disease 2019 (COVID-19) vaccine is extensively used worldwide, and its safety has been proven. Herein, we report a case of an acute necrotic disorder in the small intestine post-COVID-19 vaccination. The patient developed severe abdominal pain the day after the first vaccination. Contrast-enhanced computed tomography showed extensive ileum wall thickening and ascites. Colonoscopy revealed a ring-shaped ulcer and stricture in the terminal ileum. Ileocecal resection was performed, and the patient did not have further episodes of a necrotic disorder in the small intestine. Although it is unknown if this event is associated with vaccination, and this occurrence also does not outweigh the efficacy and safety of the Pfizer-BioNTech COVID-19 vaccine, gastroenterologists need to be aware of this rare case, given its noteworthy timing.

Curative surgery for primary squamous cell carcinoma of the liver: a rare case study.

Primary squamous cell carcinoma (SCC) of the liver is an extremely rare disease with a very poor prognosis. An 83-year-old woman was referred to our hospital with left abdominal pain. Laboratory data showed mildly elevated C-reactive protein and biliary enzymes. The tumor markers carcinoembryonic antigen, alpha-fetoprotein, and carbohydrate antigen 19-9 were within normal ranges. Contrast-enhanced computed tomography revealed a 60 mm-sized low-density mass with poor contrast enhancement located in the lateral segment of the liver. The tumor showed low signal on T1-weighted magnetic resonance imaging (MRI) and high signal on T2-weighted MRI. The cytology of bile juice showed no malignant findings. Endoscopic ultrasound-guided fine-needle aspiration biopsy was performed, which was suggestive of primary hepatic SCC. Tumor markers cytokeratin 19 fragment (CYFRA) and SCC-related antigen were elevated, at 25.2 ng/mL and 14.7 ng/mL, respectively. Left lobectomy and hilar lymph node dissection were performed. One month after surgery, the tumor marker values showed a marked decrease of 1.8 ng/mL for CYFRA and 0.3 ng/dL for SCC-related antigen. The patient has been without recurrence for more than one and half year postoperatively. SCC-related antigen and CYFRA were markedly decreased after tumor resection in this case, which may suggest their utility as tumor markers for SCC of liver origin.

Abnormal growth of a pleomorphic leiomyosarcoma originating from the mesenteric vein associated with poor outcome after curative-intent resection: a case report.

BACKGROUND: A leiomyosarcoma (LMS) is a rare tumor that mainly originates from the urinary tract and digestive system; however, non-visceral organ-derived patterns are rare. Herein, we report that a vessel-derived pleomorphic LMS (PLMS) originating from the mesenteric vein has a poor prognosis even after curative-intent surgery. CASE PRESENTATION: The patient was a 41-year-old woman with no relevant medical history. The patient presented with abdominal pain and an abnormal bulge on the left lower abdomen. Magnetic resonance imaging revealed a large tumor occupying the left abdomen. Enhanced computed tomography revealed a bulky tumor with a maximum size of 13 × 13 cm with impending rupture, and a small amount of ascites was detected around the tumor. As the tumor directly invaded the small intestine and descending colon, left hemicolectomy and partial resection of the small intestine were performed. The patient was discharged on postoperative day 10, without any complications. On histopathological analysis, the tumor was diagnosed as a vessel-derived LMS with a pleomorphic pattern. The patient died due to disseminated intravascular coagulation because generalized peritonitis was induced by the super-early recurrence of the tumor 2 months after the surgery. CONCLUSIONS: Regardless of curative-intent surgery for a vessel-derived PLMS, super-early local recurrence and distant metastasis were observed. A vessel-derived PLMS requires further investigation to determine its characteristics and therapeutic strategies to improve long-term prognosis.

Metachronous colorectal liver metastasis that occurred 10 years after laparoscopic colectomy: a case report.

BACKGROUND: Delayed onset of colorectal liver metastasis (CRLM) > 5 years after primary colorectal surgery is rare. Herein, we report a case of delayed-onset CRLM that occurred 10 years after primary surgery, for which laparoscopic hepatectomy was performed. CASE PRESENTATION: A 68-year-old man was admitted to the hospital. His medical history revealed double colon cancer detected 10 years ago, for which laparoscopic colectomy was performed. The pathological tumor-node-metastasis stages were stages I and II. Thereafter, oral floor cancer occurred 7 years after the primary surgery and was curatively resected. The annual follow-up with positron emission tomography-computed tomography (CT) identified a tumor at segment 7/8 (S7/8) of the liver with an abnormal accumulation of fluorodeoxyglucose. Dynamic CT showed a 23-mm tumor, with ring enhancement in the early phase. Magnetic resonance imaging with gadolinium-ethoxybenzyl-diethylenetriamine penta-acetic acid demonstrated that the tumor had high intensity in T2 weighted sequences and low intensity in the hepatobiliary phase. With a preoperative diagnosis of intrahepatic cholangiocarcinoma or delayed liver metastasis, laparoscopic S7/8 partial resection was performed. The operative time was 324 min, and the intraoperative bleeding volume was 35 mL. The patient was discharged on day 15 without any postoperative complications. Upon histopathological examination, the final diagnosis was CRLM. The patient has survived for 1 year without any recurrence. CONCLUSIONS: It is important to pay attention to the occurrence of delayed-metachronous CRLM.

Gradually progressive cholangiolocellular carcinoma: a case report.

BACKGROUND: Cholangiolocellular carcinoma (CoCC) is a relatively rare primary liver tumor. We present a literature review and case report of a patient who presented with a slow-growing CoCC that was completely resected after a 5-year follow-up period. CASE PRESENTATION: The patient was a 66-year-old man with a history of inflammatory thoracic and intra-abdominal pseudo-tumors. He was regularly followed up at our hospital for partial dilation of the pancreatic duct branch located in the body of the pancreas. Five years earlier, computed tomography (CT) demonstrated a small tumor in liver segment 4. Radiological findings were suggestive of hemangioma. Tumor size gradually increased during the 5-year follow-up period. CT scans showed that the tumor had progressed in size from 10 to 20 mm. Positron emission tomography CT revealed an accumulation of fluorodeoxyglucose (standardized uptake value max 5.3) at the tumor site. The tumor exhibited high intensity on T2-weighted and diffusion-weighted images of ethoxybenzyl magnetic resonance imaging. The tumor showed high intensity during the early phase but low intensity during the hepatobiliary phase. Tumor markers were within their respective normal ranges. Suspecting intrahepatic cholangiocarcinoma, left hepatectomy was performed. The tumor was diagnosed as CoCC based on pathological findings. The patient's post-operative course was uneventful. The patient survived for a year, without any recurrence. CONCLUSIONS: In cases dealing with small tumor sizes, it is difficult to distinguish between CoCC and hemangioma due to their similar radiological findings. Thus, it is important to consider the diagnosis of CoCC in small benign hepatic tumors. As such, follow-up radiological examination is recommended.

Long-term survival by repeat resection for metastases from primary retroperitoneal leiomyosarcoma: A case report.

BACKGOUND: Retroperitoneal (RP) leiomyosarcoma (LMS) is a rare type of cancer, accounting for 0.1% of all malignancies. The gold-standard treatment for sarcoma is complete resection, and a 50% 5-year overall survival (OS) rate can be achieved by curative surgery. The survival benefits of radiotherapy and systemic chemotherapy for recurrence are not as good as those of surgical resection. To the best of our knowledge, there are a few reports that aggressive radical surgery significantly prolonged the survival period as our case. This case was reported in accordance with the SCARE 2020 Guideline (Ref). CASE PRESENTATION: An 84-year-old woman was referred to our hospital for treatment of a primary RP tumour. At the age of 52-year-old, she underwent complete resection of an RP mass in 1991. Twenty-four years after the primary resection, metachronous recurrences occurred within the soft tissues, which were repeatedly resected. From 2015-2019, liver resections were performed thrice, and the patient survived with no signs of recurrence 1 year after the last surgery. CONCLUSION: Long-term survival of 29 years was achieved after undergoing over 20 surgical resections. Herein, we report the long-term survival of a patient who underwent repeated aggressive surgical resections for RP LMS recurrence anda literature review.

Pathological Features and Imaging Findings in Pancreatic Carcinoma In Situ.

OBJECTIVES: This study aimed to evaluate the pathological features and imaging findings of pancreatic carcinoma in situ (PCIS). METHODS: Twenty patients with PCIS were categorized as flat (F) (n = 6) and low papillary (LP) (n = 14) types. RESULTS: None of F type and 8 (57%) of 14 with LP type lesions showed intraductal infiltrations of the main pancreatic duct (MPD) greater than 10 mm. None of F type and 3 (21%) of 14 with LP type lesions showed skip lesions in the MPD. Magnetic resonance cholangiopancreatography showed irregular MPD stenoses in 5 (83%) of 6 with F and 13 (100%) of 13 with LP type lesions. Magnetic resonance cholangiopancreatography determined that the median lengths of the irregular MPD stenoses were 3.6 mm for F, and 11.6 mm for LP type lesions. Endoscopic retrograde cholangiopancreatography determined that the median lengths of the irregular MPD stenoses were 2.8 mm for F, and 14.3 mm for LP type lesions. Pancreatic cancer recurrences limited to the remnant pancreas occurred in 2 patients with LP type lesions. CONCLUSIONS: In LP type PCIS, intraductal infiltration of the MPD occurs frequently. There may be multiple lesions, and lesions may recur in the remnant pancreas. Long-term strict follow-up assessments should be implemented for LP type PCIS.

Intrahepatic cholangiocarcinoma with clear cell type following laparoscopic curative surgery.

BACKGROUND: Intrahepatic cholangiocarcinoma (ICC) is the second most common malignancy of primary liver cancer. Among the several pathological types of ICC, only five cases of the clear cell type have been reported, including the one presented below. Here we report a unique case of clear cell type ICC following laparoscopic hepatectomy. CASE PRESENTATION: A 67-year-old woman had a history of hepatitis B virus. Computed tomography revealed a ring-like enhanced mass 35 mm in diameter at segment 7 in the early phase. The enhancement was prolonged to the late phase through the portal phase, while the shape was irregular. Ethoxybenzy magnetic resonance imaging revealed that the tumor had a low signal intensity on T1-weighted imaging and a high signal intensity on T2-weighted imaging. Diffusion-weighted images identified that the tumor had remarkably high signal intensity. Tumor enhancement was not detected throughout the tumor in the hepatocyte phase. Upon ICC diagnosis, a laparoscopic S7 subsegmentectomy was performed. The patient's postoperative course was uneventful. An immunohistochemical examination revealed that the cells tested positive for cytokeratin 7 (CK7), CK19, and CD56 and negative for CK20, CD10, α-fetoprotein, thyroid transcription factor-1. At 2 years after surgery, the patient remains alive without recurrence. CONCLUSIONS: Here we presented a case of clear cell ICC that was treated by laparoscopic hepatectomy. Immunological analysis, especially by CD56 and several CK markers, is helpful for diagnosing this disease.

Grade IV traumatic pancreatic injury with primary duodenum malignant lymphoma following pancreatoduodenectomy: a case report.

BACKGROUND: Traumatic pancreatic injury with a main pancreatic duct injury has a high incidence of mortality and requires a prompt and appropriate treatment. However, the best approach, and treatment options, which may be limited, remains controversial especially for the elderly patients. Herein, we present a case of traumatic pancreatic injury in an elderly patient for whom pancreatoduodenectomy was safe and effective. CASE PRESENTATION: An 87-year-old man was diagnosed with a traumatic pancreatic injury with a main pancreatic duct injury. In addition, the horizontal segment of the duodenum was largely eradicated. There were no comorbidities, and his vital signs were stable. A pancreatoduodenectomy was performed. The postoperative course was uneventful, and he was discharged. Pathological examination revealed a primary follicular lymphoma of the duodenum. CONCLUSIONS: This case demonstrated that pancreatoduodenectomy could be performed safely for a severe pancreatic injury in an elderly patient. However, special attention should be paid to select the optimal surgical procedure. Further, this was a rare case, as initially a primary follicular lymphoma of the duodenum was suspected as a duodenal injury coexisting with a traumatic pancreatic injury because of the increased duodenal thickness.

Amputation neuroma derived from a remnant cystic duct 30 years after cholecystectomy: A case report.

INTRODUCTION: Amputation neuroma is difficult to diagnose preoperatively. Amputation neuroma arising from a remnant cystic duct after cholecystectomy is rare. Herein, we present a case of amputation neuroma derived from a remnant cystic duct along with a review of the literature. PRESENTAION OF THE CASE: A 60-year-old woman visited our hospital due to a tumor located in the hepatoduodenal ligament. A gallbladder adenoma was resected by open cholecystectomy 30 years prior. Endoscopic ultrasonography demonstrated branched intraductal papillary mucinous neoplasm of the pancreas and a tumor with a low-echoic pattern in the extrahepatic biliary system. Enhanced computed tomography revealed a 6-mm tumor in the artery phase. Surrounding lymph nodes were not swollen. Magnetic resonance cholangiopancreatography showed that the tumor presented with slightly high intensity on T2 weighted imaging. Operative findings revealed that the whitish nodule was moderately attached to surrounding tissues. The remnant cystic duct and the tumor could not be separated; however, no direct invasion toward common bile duct was observed. Rapid intraoperative pathological examination demonstrated that the tumor was a neuroma. The peration time was 251 min and blood loss was 80 ml. The patient was discharged nine days after surgery with no postoperative complications. CONCLUSION: It is difficult to distinguish amputation neuroma from malignant tumors because radiological findings of a neuroma mimic findings of malignancy. Intraoperative diagnosis is necessary to select an appropriate surgical procedure due to the difficulty of preoperative diagnosis.

Adenocarcinoma of the duodenum arising from Brunner's gland resected by partial duodenectomy: a case report.

BACKGROUND: Duodenal carcinoma originating in Brunner's gland is rare. Herein, we report a case of duodenal carcinoma arising from Brunner's gland in a 63-year-old man. CASE PRESENTATION: On diagnostic imaging, the lesion presented as a non-invasive carcinoma; the patient also had uncontrolled diabetes and liver cirrhosis. Hence, we decided to perform partial duodenectomy to reduce operative stress. Pathological examination revealed that the tumor consisted of tissue from Brunner's gland. Additionally, the carcinoma cells were strongly positive for Mucin-6 protein, which is an epithelial marker of Brunner's gland. The patient's post-operative course was uneventful, and he has been well for 2 years after the surgery. CONCLUSIONS: This a rare case of an adenocarcinoma arising from Brunner's gland of the duodenum that was resected by duodenectomy.

Intracholecystic papillary neoplasm of the gallbladder protruding into the common bile duct: A case report.

The current study indicates the case of intracholecystic papillary neoplasm (ICPN) protruding into the common bile duct (CBD) without superficial spread. A 58-year-old woman presented to hospital with a fever that lasted for three days. Laboratory tests revealed elevated hepatobiliary enzyme levels. CT, MRI and endoscopic ultrasonography revealed a polypoid, papillary tumor inside the gallbladder cavity, which also extended to the CBD. On peroral cholangioscopy, a papillary tumor with mucin production was found at the middle bile duct. Biliary biopsy and bile cytology indicated adenocarcinoma. Based on a diagnosis of ICPN extending to the CBD, the patient underwent subtotal stomach-preserving pancreaticoduodenectomy and gallbladder bed resection. However, pathological examination revealed that the ICPN was confined to the gallbladder and cystic duct, whereas the CBD was tumor-free. The present case indicates that when ICPN increases in size, it may protrude into the CBD due to an increased intracholecystic pressure, which increases the risk of overestimation of tumor extension and may result in unnecessary additional bile duct resection.

Characteristics recurrence pattern of cholangiolocellular carcinoma as intrahepatic bile duct tumor growth following curative resection: a case report.

BACKGROUND: Cholangiolocellular carcinoma (CoCC) is a rare primary liver tumor that shows mass-forming growth in most cases. At present, no effective treatment for hepatic recurrence CoCC has been established. We present a case involving a patient with recurrent disease that showed an intraductal growth (IG type) pattern of recurrence. The patient was treated with repeat hepatectomy with bile duct reconstruction. CASE PRESENTATION: The patient was a 76-year-old man with a history of S8 subsegmentectomy for CoCC. At 8 months after surgery, tumor marker elevation was observed. Computed tomography revealed a tumor occupying the right hepatic duct (B5-8) to B4 and the junction of the cystic duct. Endoscopic retrograde cholangiopancreatography (ERCP) and a thrombus biopsy with peroral cholangioscopy (POCS) confirmed the recurrence of CoCC in the intrahepatic bile duct. Although extended right lobectomy with extrahepatic bile duct resection was the optimal curative procedure, it was thought that it would be difficult due to his poor liver function. However, a slow-glowing recurrent tumor blocked the posterior branch of the portal vein; thus, the right liver lobe gradually shrank, and the estimated remnant liver volume increased in response, allowing curative surgery to finally be performed. At 10 months after surgery, the patient is alive without recurrence. CONCLUSIONS: We reported a case of IG-type recurrence in the bile duct, which is an unusual pattern of intrahepatic recurrence, after initial surgery for CoCC. A slow-growing recurrent tumor exerted similar effects to PVE, which allowed for curative surgery to be performed.

Characteristics of 5015 Salivary Gland Neoplasms Registered in the Hiroshima Tumor Tissue Registry over a Period of 39 Years.

Salivary gland neoplasms are uncommon, and their epidemiology in Japan has not been well described. We conducted a retrospective review of salivary gland tumors registered in the Hiroshima Tumor Tissue Registry over a period of 39 years. The subjects were 5015 cases ranging in age from 6 to 97 (mean, 54.3) years old. The incidence of both benign tumors and malignant tumors increased with age until 60-69 years and then declined. Among the 5015 salivary gland neoplasms, 3998 (80%) were benign and 1017 (20%) were malignant. Pleomorphic adenoma (PA) was the most frequent benign tumor (68%), followed by Warthin tumor (26%). Adenoid cystic carcinoma (ACC) (27%) and mucoepidermoid carcinoma (MEC) (26%) were the two most frequent malignant tumors. Characteristically, there was a very low incidence of polymorphous adenocarcinoma in Japan. The average annual age-adjusted incidence rate per 100,000 population was 3.3 for benign tumors and 0.8 for malignant tumors. This is the large-scale multi-institutional analysis to describe the characteristics of salivary gland neoplasms, based on the pathological tissue registry data. We hope that the present data can contribute to early diagnosis and effective treatment of salivary gland tumors and to cancer prevention.

Roles of ERCP in the Early Diagnosis of Pancreatic Cancer.

It has been reported that endoscopic retrograde cholangiopancreatography (ERCP) is of value in evaluating precise pancreatograms of the pancreatic duct (PD). Recently, institutions have tended to perform magnetic resonance cholangiopancreatography (MRCP) for the diagnosis of PD due to post-ERCP pancreatitis (PEP). In small pancreatic cancer (PC), including PC in situ (PCIS) which is undetectable on cross sectional images, endoscopic ultrasonography (EUS) and MRCP serve important roles in detecting local irregular stenosis of the PD or small cystic lesions. Subsequently, ERCP and associated serial pancreatic juice aspiration cytologic examination (SPACE) obtained by endoscopic nasopancreatic drainage (ENPD) may be useful in the diagnosis of very early-stage PC. Further prospective multicenter studies are required to establish a standard method of SPACE for the early diagnosis of PC.

Cytomegalovirus enterocolitis in a patient with dihydropyrimidine dehydrogenase deficiency after capecitabine treatment: A case report.

INTRODUCTION: 5-Fluorouracil (5-FU) is widely used for cancer treatment. The reduced activity of dihydropyrimidine dehydrogenase (DPD), the key enzyme in 5-FU inactivation, increases a patient's risk of developing severe 5-FU related toxicity. However, screening for DPD deficiency is rarely performed before 5-FU administration. PRESENTATION OF CASE: Our patient was a 69-year-old man with rectal cancer (T2N1bM0 stage IIIA) who underwent laparoscopic low anterior resection. He developed severe neutropenia and diarrhea 15 days after the administration of capecitabine for adjuvant chemotherapy, and was admitted to our hospital. Four days after admission, he was transferred to the intensive care unit for sepsis. DPD protein screening revealed DPD deficiency. On day 27, massive melena suddenly appeared. He died of continual bleeding 41 days after admission. Pathological autopsy revealed cytomegalovirus enterocolitis. DISCUSSION: The administration of 5-FU to patients with DPD deficiency is lethal. Genotypic and phenotypic assessments are reliable tests for DPD deficiency. A genetic study can effectively screen for DPD deficiency; however, its use has not been established in the national insurance system. Patients with DPD deficiency tend to develop severe neutropenia, so clinicians should pay attention to opportunistic infections such as cytomegalovirus enterocolitis. CONCLUSION: Screening for DPD deficiency is necessary prior to 5-FU administration.