[A Case of Small Thymic Carcinoma with Pleural Dissemination Preoperatively Suspected as Pulmonary Metastasis from Rectal Cancer].

A case was 73-year-old man, who had history of laparoscopic high anterior resection surgery for rectal cancer, followed by adjuvant chemotherapy 2 years ago. Preoperative diagnosis was anterior mediastinal tumor, with multiple intrapulmonary nodules noted, though no increasing tendency. During adjuvant chemotherapy for colorectal cancer, the anterior mediastinal tumor showed some shrinkage, while that and 3 intrapulmonary nodules slowly increased in size after completion, thus rectal cancer pulmonary and mediastinal metastasis were suspected. Complete resection of the intrapulmonary nodules and anterior mediastinal tumor was considered feasible. Thoracoscopic observation revealed multiple small pleural seeding lesions and all speculated to be intrapulmonary metastases before surgery were also pleural lesions. Intraoperative rapid diagnostic findings of a biopsy section revealed possible colorectal cancer metastasis, though histological type was not revealed. Final histopathological diagnosis was pleural dissemination of thymic carcinoma. Lenvatinib was introduced 2 months later for thymic carcinoma with pleural dissemination. Two years after surgery, the anterior mediastinum primary tumor had slightly decreased and the pleural nodules also showed a shrinking tendency. In such cases of small tumor with increasing tendency and irregular margins, thymic carcinoma should be considered when planning treatment.

[A Case of Primary Liver Cancer and Gastric Glomus Tumor Diagnosed Preoperatively and Treated with Liver Segmentectomy and Local Gastrectomy].

A man in his 70s was concurrently suspected of having a submucosal tumor(SMT)of the stomach and a liver tumor during a medical examination. Abdominal contrast-enhanced CT scan revealed S8 hepatocellular carcinoma(HCC)and an SMT of the stomach, which was strongly enhanced from the early to the later phase. Upper gastrointestinal endoscopy revealed a 20 mm SMT in the antrum of the stomach. Endoscopic ultrasonography showed a hyperechoic tumor in the fourth layer of the gastric wall. T2-weighted MRI showed a 25 mm SMT in the antrum of the stomach with a faint high signal intensity compared with that of the gastric wall. The patient was diagnosed with HCC and gastric glomus tumor, and a liver segmentectomy and a local gastrectomy were performed. Immunohistochemistry of the SMT revealed the expression of α-SMA but no expression of desmin, c-kit, CD34, or S-100. Therefore, a diagnosis of a Glomus tumor of the stomach was made. Gastric Glomus tumors are very rare; therefore, we have reviewed some citations and would like to discuss our case.

[Two Cases of Recurrent Colon Cancer with BRAF Mutation].

We report 2 cases of recurrent colon cancer with BRAF mutation. Case 1, a 75-year-old man, had rapid progress of multiple liver metastasis 5 months after curative resection, and died on 37 days after recurrence without induction of systemic therapy. Case 2, a 67-year-old man with diagnosis of peritoneal dissemination at 8 months after curative resection, received encorafenb and cetuximab (doublet-therapy) with certain effect, nevertheless advanced triplet-therapy with binimetinib was forced to pause due to severe skin disorders and he died on 123 days after recurrence. We considered that closed follow- up should be required after curatively resected colorectal cancers with BRAF mutation for early detection of recurrence, and prompt induction and evaluation of systemic treatment also should be required after unresectable recurrence including careful management with the attention to the features of doublet and triplet-therapy.

[A Case of Hypertrophic Pulmonary Osteoarthropathy Associated with Pulmonary Pleomorphic Carcinoma].

Hypertrophic pulmonary osteoarthropathy(HPO)is a tumor-associated syndrome that features the triad of clubbed fingers, periosteal bone growth in long bones, and arthritis, and is often associated with an adenocarcinoma or squamous cell carcinoma. This report presents details of a case of HPO associated with pleomorphic carcinoma, which was relieved by treatment. A 47-year-old woman was presented with a complaint of generalized arthralgia. A physical examination showed swollen joints in the body and clubbed fingers. Chest CT revealed a mass shadow in the left upper lobe and ultrasound- guided biopsy findings led to a diagnosis of non-small cell lung cancer. Furthermore, bone scintigraphy indicated symmetrical accumulation in bones and joints throughout the body. A right upper lobectomy was performed along with combined chest wall resection and mediastinal lymph node dissection with an open chest, and the presence of lung cancer complicated with HPO was indicated. Pathological examination results revealed a diagnosis of pleomorphic carcinoma(pT4N0M0, Stage ⅢA). Systemic arthralgia was resolved on the first postoperative day. One year after surgery, a solitary brain metastasis developed and was removed, with no recurrence at the time of writing. Joint symptoms related to HPO can be expected to improve with treatment of pulmonary lesions, thus aggressive procedures for diagnosis and treatment are desirable.

[Could Preoperative Conditions Be Preserved or Improved by the Support of Preoperative ONS Administration in Patients with Gastric Cancer?]

INTRODUCTION: In our hospital, we measure the body composition of patients undergoing gastrointestinal surgery. For patients who have a skeletal muscle mass(SMM)of less than 90% of the ideal, we provide them with guidance on having oral nutritional supplements(ONS)and self-exercise therapy. Therefore, we perform operations after taking measures on preserving/improving patient's preoperative conditions. This study was aimed to evaluate the effects on body weight, SMM, and fat mass(FM)in the patients scheduled for gastrectomy. PATIENTS AND METHODS: From January 2017 to December 2020, we retrospectively analyzed 64 gastric cancer patients whose body composition changes were measured at the time of initial diagnosis and immediately before surgery. The body composition was measured by a nutritionist using the BIA method, while the self-exercise therapy was instructed by a rehabilitation therapist. RESULTS: A total of 64 patients were divided into 2 groups: ONS group(36 patients)and Non-ONS group(28 patients). The median preoperative ONS administered to the ONS group was 15 packs. Body weight change showed a significant difference between the 2 groups(+0.73% and -0.91%[p<0.01]in the ONS group and Non-ONS group respectively). SMM change showed no significant difference between the 2 groups(+1.18% and +0.64%[p=0.19]in the ONS group and Non-ONS group respectively). Likewise, FM change showed no significant difference between the 2 groups(-1.08% and -3.50%[p=0.39]in the ONS group and Non-ONS group respectively). CONCLUSION: This study suggested that SMM and FM could be preserved, and body weight could be increased by the support of preoperative ONS administration even in patients with gastric cancer close to having sarcopenia.

[A Case of Three Metachronous Metastases Excised Non-Simultaneously More than Six Years after Resection of Sigmoid Colon Cancer].

A 57-year-old man underwent curative resection for Stage Ⅰ sigmoid colon cancer; 6 years later, lung metastasis was detected and subsequently resected. Eight years after the first curative resection, retroperitoneal metastasis was detected and subsequently resected. Nine years after the first curative resection, a growing tumor was detected at the bottom of the right lower lobe of the lung. Partial lung resection was performed; pathological examination revealed a secondary tumor formed as a result of colon cancer metastasis. When we searched previous cases of late recurrence in colorectal cancer, the primary colorectal cancer was classified as StageⅠ or Ⅱ in more than half of the cases. Therefore, even after curative resection of Stage Ⅰ colon cancer, late recurrences may occur.

[A Case of Complete Pathological Response in a Patient with Advanced Ascending Colon Cancer That Invaded the Liver and Duodenum after FOLFOXIRI plus Bevacizumab Chemotherapy].

A 71-year-old woman with advanced ascending colon cancer was admitted to our hospital. Abdominal computed tomography( CT)revealed locally advanced sigmoid colon cancer with suspected invasion of the liver and duodenum. The clinical stage of the disease was cT4bN3M1a, cStage Ⅳa, with wild-type RAS and UGT1A1 expression. An ileostomy was performed because of bowel obstruction. The patient received 6 courses of FOLFOXIRI plus bevacizumab(Bev). The only adverse event was Grade 3 neutropenia. Laparoscopic right hemicolectomy with lymph node dissection was performed. The pathological diagnosis was the absence of viable, Grade 3 carcinoma cells. This result suggested that preoperative FOLFOXIRI plus Bev chemotherapy is useful for the treatment of locally advanced colon cancer.

[A Case of Elderly Advanced Rectal Cancer Treated with Abdominoperineal Resection after 16 Months of Chemoradiotherapy].

An 81-year-old woman underwent preoperative chemoradiotherapy(CRT)for advanced lower rectal cancer with vaginal invasion. However, she refused surgery and received additional radiotherapy. We detected a rectal-vaginal leak, so we performed ileostomy with double orifices and chemotherapy. As the tumor and vaginal leak increased, we performed laparoscopy- assisted abdominoperineal resection and vaginal posterior wall resection after 16 months of CRT. Although adhesion occurred due to inflammation and tumor invasion after the CRT, surgery could be performed safely. Despite the advanced age of the patient, complications did not occur, and no recurrence was observed for 66 month after the surgery. In rectal cancer, operation is usually performed until 6 to 8 weeks after CRT, but in our case, the surgery was performed after a long interval, with good results. Thus, we report the case herein.

[A Case of Advanced Sigmoid Colon Cancer That Was Resected after Chemoradiation Therapy Following Ineffective Chemotherapy].

We report a case of advanced sigmoid colon cancer that was resected after chemoradiation therapy(CRT)following ineffective chemotherapy. A 59-year-old woman harbored a lower abdominal tumor the size of an infant's head and was diagnosed with a huge sigmoid colon cancer with invasion to the urinary bladder and metastases to the para-aortic lymph nodes. The patient received 2 courses of modified FOLFOX6(mFOLFOX6)plus cetuximab therapy, which was assessed as ineffective; She then received CRTwith 50.4 Gy in 28 fractions plus concurrent oral S-1(100mg/day for 28 days). Tumor shrinkage in the primary lesion was achieved after CRT; total pelvic exenteration with the removal of metastatic para-aortic lymph nodes was then performed 5 months after the first diagnosis. This case of locally distant advanced colon cancer in the pelvic cavity coexisting with resectable metastatic lesions suggested that CRTmight contribute to successful local treatment after the failure of preoperative chemotherapy.

[A Case of Resected Combined Pancreatic Mixed Ductal Adenocarcinoma and Neuroendocrine Tumor].

A 63-year-old man was followed-up for diabetes mellitus. During follow-up, computed tomography(CT)showed dilatation of the main pancreatic duct in the tail of the pancreas. Abdominal enhanced CT revealed a 25 mm tumor in the body of the pancreas. Endoscopic ultrasound-fine needle aspiration(EUS-FNA)was performed, and the pathological diagnosis was adenocarcinoma. Therefore, based on the diagnosis of pancreatic body carcinoma, distal pancreatectomy with splenectomy was performed. The postoperative course was uneventful. Histological and immunohistochemical examination revealed that the tumor consisted of a ductal carcinoma and a neuroendocrine component. Therefore, combined pancreatic tumor (fT3N1M0, StageⅡB)was diagnosed. The patient subsequently received postoperative adjuvant chemotherapy(S-1 100mg/ day), and survived without recurrence 6 months after the operation. We report this case of combined pancreatic tumors with a review of the literature.

[A Case of Advanced Sigmoid Colon Cancer Successfully Resected via Laparoscopic Surgery after Preoperative Chemotherapy].

We report a case of advanced sigmoid colon cancer resected via laparoscopic surgery after preoperative chemotherapy. A- 55-year-old man visited our hospital with diarrhea. CTrevealed a giant tumor in the sigmoid colon, and surrounding lymph node enlargement was also noted. The tumor appeared to be locally advanced; thus, preoperative chemotherapy was started. Due to the possibility of obstruction, we constructed an ileostomy laparoscopically. The tumor was found to be RAS wild, and 4 courses of mFOLFOX6 plus panitumumab were given. Follow-up CTshowed remarkable tumor reduction allowing laparoscopic resection; as such, laparoscopic sigmoidectomy was performed successfully. Chemotherapy with molecular-targeted drugs is a promising method to make laparoscopic surgery possible for advanced colorectal cancer.

[Can Lateral Pelvic Node Dissection Omitted in Rectal Cancer with Suspected Lateral Node Metastasis after Chemoradiotherapy ?]

To elucidate ideal strategy of treatment for advanced lower rectal cancer, we investigated 11 patients with clinically suspected lateral pelvic node(LPN)metastasis among 36 patients who received neoadjuvant chemoradiation therapy(NCRT). Nodal metastasis was diagnosed as positive when the major axis of a lymph node was over 7mm in computed tomography(CT). Both tumor and nodal downstaging were observed in CT after NCRT; pathological complete response and ypN0 was obtained in 2(18.2%)and 6(54.5%)cases, respectively, and positive LPN was observed only in 2 cases. All of 4 cases who were diagnosed as ycN0 in CT after chemoradiation were confirmed as ypN0. Extended examination with 36 patients who underwent NCRT showed that 85% of 21 ycN0-cases were confirmed to be ypN0. As a conclusion, NCRT for lower rectal cancer with suspected LPN metastasis was highly effective, and omitting lateral node dissection when all nodes turned to be less than 7mm on CT, can be a hopeful option.

[A Case of Resected Metachronous Cholangiocarcinoma after Pancreaticoduodenectomy].

The patient was a 79-year-old woman, who had undergone pancreaticoduodenectomy(PD)for lower bile duct carcinoma in our hospital(pT3N0H0P0M0, fStage III ). Four years 6 months after the initial operation, abdominal CT revealed left bile duct expansion and hilar bile duct thickening. Therefore, based on the diagnosis of perihilar cholangiocarcinoma originating from the left hilar duct, we performed left lobectomy with caudate lobectomy and biliary tract reconstruction. The surgical specimen showed a tumor in the left hilar bile duct. Histopathological diagnosis of the tumor was a moderately differentiated adenocarcinoma(pT2aN0H0P0M0, fStage II ). Surgical margins were histologically negative. Since the tumor was located away from the anastomosed site of the cholangiojejunostomy, we determined that the tumor was not a recurrence but a metachronous cholangiocarcinoma. The postoperative course was uneventful. The patient survived without recurrence 2 years after the second operation. The possibility of heterochronic biliary carcinomas should be considered during follow-up evaluation. We report this case of metachronous cholangiocarcinoma that occurred 4 years 6 months after PD, with a review of the literature.

[A Case of an IgG4-Related Inflammatory Pseudotumor of the Liver Showing Enlargement That Was Difficult to Differentiate from Hepatic Cancer].

A 60-year-old man was admitted for a liver mass(S3), which rapidly increased in size during intraductal papillary mucinous neoplasm(IPMN)follow-up. Although EOB-MRIwas performed, the mass could not be accurately diagnosed as hepatic cancer. Thus, we performed a lateral segmentectomy. In the resected specimen, a solid tumor mass was clearly bound in segment 3 of the liver. Since histopathology revealed no malignant cells and many IgG4-positive cells, we confirmed the diagnosis as IgG4-related inflammatory pseudotumor of the liver. IgG4-related diseases occur in various organs in the body, and they are known to associate with autoimmune pancreatitis and sclerosing cholangitis, but an IgG4-related inflammatory pseudotumor of the liver is a rare disease. It is often difficult to distinguish from hepatic cancer and surgical resection is performed.

[A Case of Xanthogranulomatous Cholecystitis That Changed Over Time and Was Difficult to Distinguish from Advanced Gallbladder Cancer].

A 70-year-old man was referred because of suspected gallbladder cancer and gallstones. Contrast-enhanced CT, EOB-MRI and PET-CT could not completely rule out gallbladder cancer. The patient preferred follow-up without surgery. At 4 months after initial examination, the gallbladder wall thickening showed improvement, but appeared worse at 9 months after initial examination. Therefore, we decided to perform surgery. Since malignant findings were not observed on rapid intraoperative pathology, we performed a cholecystectomy and right hemicolectomy because of inflammation in the transverse colon. Pathological examination diagnosed xanthogranulomatous cholecystitis. The imaging appearance of xanthogranulomatous cholecystitis varies, and also changes over time, making it difficult to distinguish from advanced gallbladder cancer. We experienced a case of xanthogranulomatous cholecystitis that changed over time, and report this case with a review of the literature.

[The Implications of Primary Tumor Resection during Recent Chemotherapy of Unresectable Colon Cancer].

Some patients with unresectable colorectal cancer can be treated by chemotherapy leaving the primary tumor unresected, but indications and implications of a later resection of the primary tumor (RPT) are often controversial. We investigated 5 patients whose primary tumors were resected during chemotherapy, either panitumumab or bevacizumab. The median age of these patients was 63 years and all were men. The unresectable disease was liver metastases in 4 patients and a primary tumor in 2 patients. A diverting stoma was constructed before initiation of chemotherapy in 2 patients. The median interval until RPT was 8.3 months and the reasons for resection were the appearance of obstructive symptoms in 3 patients and a desire for stoma closure in 2 patients. The size of the primary tumor had decreased until RPT in all patients. RPT was performed successfully in all patients, but 2 of the 3 operations that were initiated laparoscopically had to be converted to open surgery. Intensive chemotherapy was resumed in all patients and median survival after RPT was 19 months, including a patient whose liver metastasis was also resected later. RPT can relieve obstructive symptoms and close stomas. Because intensive chemotherapy is still possible and a lengthy survival can be expected after RPT, it should be considered not merely as a palliative option but also as a treatment strategy.

[Resected Focal Nodular Hyperplasia That Was Difficult to Differentiate from Hepatocellular Carcinoma--A Case Report].

We report a case of a 62-year-old woman with a growing liver tumor that was difficult to differentiate from hepatocellular carcinoma (HCC). Abdominal CT revealed a hypervascular tumor (36 mm in diameter) in segment 3 of the liver that showed early enhancement and which had grown from 30 mm to 36 mm over the previous year. A fatty liver and gallstones were also detected. Magnetic resonance imaging (MRI) showed high intensity staining of the tumor on both T1- and T2-weighted images, and EOB-MRI revealed a mass that showed high signal intensity in the hepatobiliary phase. The imaging findings were not typical for HCC; however, the possibility of malignancy could not be ruled out due to the enlargement of the mass. Therefore, in February 2015, we performed a laparoscopic left lateral segmentectomy with cholecystectomy. After a good postoperative course, the patient was discharged from the hospital 11 days after surgery. Histological assessment revealed the tumor was focal nodular hyperplasia (FNH).

[Adjuvant therapy with WT1 peptide-pulsed dendritic cell therapy in combination with TS-1 for pancreatic cancer with positive peritoneal cytology after curative operation].

A 66-year-old woman was diagnosed with pancreatic tail cancer, and she was referred to our hospital. Abdominal computed tomography(CT)revealed a tumor(2.5 cm in diameter)in the pancreatic tail, with invasion to the spleen and splenic vein. In February 2013, we performed distal pancreatectomy with splenectomy, left adrenal gland resection, and D2 lymph node dissection. Diagnostic peritoneal lavage cytology during surgery was positive; however, we performed curative resection because there were no signs of peritoneal dissemination and distant metastasis. The patient was discharged from the hospital 23 days after the operation, with good postoperative course. Histological diagnosis was pancreatic tail cancer, pT4N0H0P0M(-) fStage IVa. Subsequently, the patient received postoperative adjuvant chemotherapy(TS-1: 100mg/day, 4 courses)combined with Wilms'tumor 1(WT1)peptide-pulsed dendritic cell therapy. No serious adverse events occurred during the postoperative adjuvant therapy. The patient remains alive without recurrence 16 months after the operation.

[A case of curatively resected advanced intrahepatic cholangiocellular carcinoma through effective response to neoadjuvant chemotherapy].

A 67-year-old-man came to our hospital for further evaluation of a liver tumor detected by abdominal ultrasonography at another hospital. Abdominal computed tomography showed a tumor (8 cm in diameter)in the left lobe of the liver, with invasion of the left and middle hepatic veins, and multiple lymph node metastases. Liver biopsy examination revealed intrahepatic cholangiocellular carcinoma (cStage IVB). Therefore, chemotherapy with gemcitabine(GEM)was administered. The hepatic tumor and multiple lymph nodes were reduced in size after eight courses of GEM chemotherapy. In May 2013, we performed an extended left hepatectomy with biliary tract reconstruction and extended lymph node dissection. The histological diagnosis was intrahepatic cholangiocellular carcinoma, pT3N0H0P0M (-), fStage III. The patient's postoperative recovery was good, and 1 month after surgery, the patient received 6 course of postoperative adjuvant GEM chemotherapy. No serious adverse events occurred during the postoperative adjuvant therapy period. The patient is alive without recurrence 14 months after surgery and 23 months after diagnosis.

[A case of curative resected pancreatic cancer coincident with a retroperitoneal abscess].

A 64-year-old man presented with a chief complaint of abdominal pain. An abdominal computed tomography (CT) scan showed a mass 30-mm in diameter at the splenic flexure, and we diagnosed a retroperitoneal abscess. Conservative therapy was successful, and the patient was discharged. However, 1 month later, he again experienced abdominal pain. To reassess the abscess, contrast-enhanced abdominal CT was performed. In addition to the retroperitoneal abscess, the CT scan showed an approximate 30-mm mass in the head of the pancreas with no contrast uptake. The abscess was also detected by endoscopic retrograde pancreatography. We suspected but could not confirm pancreatic cancer. Two months later, the patient developed obstructive jaundice. At this time, we diagnosed pancreatic cancer, and subtotal stomach-preserving pancreaticoduodenectomy was performed. The histopathologic diagnosis was pancreatic cancer, T4, N0, M0, Stage IVa. The postoperative course was favorable, and the patient received postoperative adjuvant chemotherapy. He remains alive without recurrence 15 months after surgery.