[Laparoscopic Abdominoperineal Resection with the Trans-Perineal Approach for Anal Canal Cancer in a Patient with Situs Inversus Totalis-A Case Report].

Situs inversus totalis(SIT)is a rare congenital condition that causes complete transposition of thoracic and abdominal viscera. Due to associated anatomical abnormalities and low frequency, surgery for affected patients is considered to be difficult. A 72-year-old man was referred to our hospital with a chief complaint of narrow stools. The diagnosis was anal canal cancer(cT1bN0M0)accompanied by SIT. A trans-perineal minimally invasive surgical procedure with laparoscopic abdominoperineal resection(Tp-APR)was performed. When mobilizing the sigmoid colon, the surgeon changed their position in consideration of anatomical abnormalities. On the other hand, manipulation around the rectum was possible using the same technique as in patients with normal anatomy. The postoperative course was uneventful, and he had no recurrence 18 months after surgery. This is the first case that showed Tp-APR for anal canal cancer with SIT performed safely and feasibly. Preoperative simulation of associated abnormal anatomical structures is considered crucial for a case of SIT.

[A Case of Giant Mesenteric Lymphangioma in an Adult].

A 26-year-old man with left inguinal pain and frequent urination was examined. An abdominal ultrasound revealed a cystic lesion. In further examinations, CT and MRI showed a large cystic lesion of about 20 cm in size, connected to mesenteric- derived blood vessels. We suspected a huge mesenteric lymphangioma and decided to perform a laparotomy. A tumor was seen in the mesentery of the jejunum and adhered to the duodenum widely. The tumor could be removed safely without resection of the duodenum by first sucking the contents and shrinking the tumor. The final pathological diagnosis was mesenteric lymphangioma. Adult mesenteric lymphangiomas measuring larger than 20 cm are relatively rare. We review the case in the context of the relevant literature.

[Surgical Technique for Prevention of Incisional Hernia in Laparoscopic Small Bowel Resection in the Obese Patient].

A 67-year-old woman reporting lower abdominal pain and anemia was examined. Small intestinal tumor was diagnosed by small intestinal radiographic contrast study and small intestinal endoscopy, and we decided to perform a laparoscopic partial resection of the small bowel. Since she was obese patients(BMI 36.3, abdominal wall 6 cm)at high risk of postoperative incisional hernia, we devised a way to make the wound smaller. We judged thick abdominal wall make umbilical wound larger in single port surgery. We performed multi-port surgery by using one 15 mm trocar, and removed small intestinal tumor from 15 mm port incision. In addition, to prevent incisional hernia, we used a trocar with a wound closure assist function for securely closing the port wound in all layers. Histopathological diagnosis was neuroendocrine tumor. The patient is being followed up without recurrence and without incisional hernia. In partial small bowel resection of obese patient, the use of a 15 mm port to minimize wound site and the use of trocar with a wound closure assist function may lead to prevent incisional hernia.

[A Case of Internal Hernia Incarceration of a Mesenteric Defect following Laparoscopic Ileocecal Resection].

A 75-year-old man underwent laparoscopic ileocecal and partial small bowel resections for the management of appendiceal cancer. The pathological diagnosis was cecal cancer(T4b[ileum, abdominal wall],N0[0/13], M0, pStage Ⅱc). After 4 months of surgery, he suddenly experienced abdominal pain and vomiting and was presented to our emergency room. He was diagnosed with bowel obstruction following which, conservative treatment was initiated through a nasogastric ileus tube implantation; however, he did not show any improvement. Subsequently, he underwent experimental laparotomy on the 18th day of the disease. Intraabdominal examination revealed herniated small intestine through a mesenteric defect, which was closed following repositioning of the herniated small intestine. The postoperative course was good, and the patient was discharged on the 10th day after surgery. No recurrence of intestinal obstruction has been observed after 1 year and 6 months. Closure of the mesenteric defect, although not commonly performed in laparoscopic colorectal surgery, is worth considering because of the risk of developing an internal hernia requiring surgical treatment, as in our case.

Long-Term Outcomes of Pulmonary Metastasectomy for Uterine Malignancies: A Multi-institutional Study in the Current Era.

BACKGROUND: Information on pulmonary metastasectomy (PM) for uterine malignancies in the current era is limited. In the present study, we analyzed the clinical course and results of PM for uterine malignancies in the era of modern imaging diagnostics to clarify the role of PM in the current era in a multi-institutional setting. METHODS: Fifty-seven patients who underwent PM for uterine malignancies between 2006 and 2015 were retrospectively reviewed. The short- and long-term outcomes, along with factors associated with the prognosis, were analyzed. Details of the clinical course after PM were described. RESULTS: The mean age of patients was 59.4 years. The primary tumor was located in the uterus corpus in 34 cases (60%) and in the uterus cervix in 23 cases (40%). The median disease-free interval (DFI) was 32 months. Forty patients (70%) received fluorine-18-2-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography before PM, and complete resection was achieved in 52 patients (91%). Postoperative complications occurred in 4 patients (7%). Of the 52 patients who underwent complete resection of pulmonary metastases, 28 experienced recurrence, and among these, 17 (60%) underwent local therapy, including six repeat PMs. Among the 52 patients who underwent complete resection, the 5-year relapse-free survival rate was 40.7% and the 5-year overall survival (OS) rate was 68.8%. The univariate analysis revealed that a DFI of ≤ 24 months was associated with significantly poorer OS. CONCLUSIONS: PM for uterine malignancies is safe and provides favorable long-term outcomes in selected patients. Patients with a DFI of > 24 months have better OS and are good candidates for PM.

[A Case of Fibrolamellar Hepatocellular Carcinoma in a 25-Year-Old Vietnamese Male].

We report a rare case of hepatic fibrolamellar hepatocellular carcinoma(FLC). A 25-year-old Vietnamese male experienced loss of appetite and abdominal pain. He was referred for further examination of a 20 cm tumor in the left lobe of the liver detected in mass screening ultrasonography. He tested negative for HBs-antigen and HCV-antibody. The serum PIVKA- Ⅱ level was elevated. Liver function test findings were normal. The arterial phase of contrast enhanced abdominal CT revealed a 20×30 cm tumor that was well-enhanced, except for a central scar in the left lobe of liver. Enhanced MRI showed a high intensity tumor. T2-weighted MRI showed an iso-intensity tumor with a low-intensity central fibrous scar. Upon diagnosing the patient with FLC, we performed left hepatic trisegmentectomy. Pathological findings of the surgical specimen showed eosinophilic large neoplastic cells surrounded by fibrous stroma arranged in a lamellar fashion. This confirmed the diagnosis. FLC, which occurs in noncirrhotic livers of young patients, is a distinct clinicopathological variant of hepatocellular carcinoma. Hepatectomy for FLC should be accompanied with regional lymphadenectomy because of its association with lymph node metastasis. We also reviewed cases reported in Japan.

[A Long-Term Survival Case of Neuroendocrine Carcinoma of Gallbladder-Report of a Case].

The patient is 77-year-old man. He received open cholecystectomy and choledocholithotomy when he was 74 years old. Because postoperative diagnosis was small cell neuroendocrine carcinoma(NEC), the resection of gallbladder bed and hilus lymph nodes were performed. During the follow up period, the liver metastases and portal vein tumor thrombosis appeared. Therefore, chemotherapy was performed according to small cell lung cancer. In addition to chemotherapy, radiation therapy was performed for the purpose of local control. He is still alive about 3 years after the first operation. This case suggested the efficacy of multidisciplinary treatment including operation, chemotherapy, and radiation therapy in NEC of gallbladder patient with liver metastasis.

[Pathological Complete Response in a Case of Advanced Gastric Cancer with Para-Aortic Lymph Nodes Metastasis Treated by Preoperative Chemotherapy with S-1 and Oxaliplatin(SOX Therapy)].

The patient was a 73-year-old man, diagnosed as advanced gastric cancer with para-aortic lymph nodes(PAN)metastasis. He was treated by 3 courses of neoadjuvant chemotherapy(NAC)with S-1 and oxaliplatin(SOX therapy). CT showed significant reduction of both primary tumor and metastatic lymph nodes. We performed distal gastrectomy with D2 plus PAN dissection. The histopathological findings showed no residual viable tumor cell. The pathological effect of chemotherapy was judged Grade 3(pCR)in both primary tumor and dissected lymph nodes. He is alive without recurrence 21 months after surgery.

[A Case of Pulmonary Carcinoid That Has Regressed Spontaneously].

A 65-year-old woman who had diabetes mellitus was referred to the Department of Diabetes Internal Medicine of our hospital in June 201X due to disease progression. Chest radiography revealed an abnormal shadow, and computed tomography( CT)showed a 2 cm nodular shadow in the right S10. Lung cancer was suspected because of increased serum progastrin- releasing peptide(ProGRP)level and smoking history. She was referred to our department and was diagnosed with carcinoid on transbronchial biopsy. After 1 month, CT demonstrated regression of the carcinoid and improved serum ProGRP level. After more than 1 month, the carcinoid size did not change, and serum ProGRP level slightly increased. We expected that it would be difficult for the carcinoid to regress. After glycemic control was improved, the patient underwent right lower lobectomy via video-assisted thoracoscopy. In the resected specimen, the border of carcinoid was clear. She was diagnosed with a typical carcinoid. The carcinoid was not accompanied by inflammation or necrotic tissue. A carcinoid is a low-grade malignant tumor and does not usually regress spontaneously. However, in this case, it regressed spontaneously.

[Two Cases of Pancreatectomy for Pancreatic Metastasis from Renal Cell Carcinoma].

Metastasis of renal cell carcinoma to the pancreas is a relatively rare condition. We encountered 2 such cases. The first case was a 72-year-old man who underwent a left nephrectomy owing to left renal cancer in 2005. An abdominal dynamic CT scan 12 years after surgery revealed tumors in the pancreatic body and right kidney. A PET-CT scan revealed low intensity uptake of both tumors, and therefore, metastasis of the left renal cell carcinoma to the pancreas was suspected. We then performed partial resections of the pancreatic tail and right kidney. Pathologic findings confirmed that the pancreatic tumor and right renal tumor were metastases of the left renal cell carcinoma. The postoperative course was favorable, and the patient has been followed up in an outpatient setting for 10 months with no signs of recurrence. The second case was a 51- year-old woman with tumors in the left kidney and pancreatic head that were detected by abdominal contrast CT and MRI. We diagnosed the patient with left renal cell carcinoma with metastasis to the pancreas. We performed a radical nephrectomy of the left kidney and full pancreatectomy. Pathologic findings confirmed left renal cell carcinoma, pStage Ⅳ, with metastasis to the pancreas. The postoperative course was favorable without recurrence for 14 years. We report on two cases of metastasis of renal cell carcinoma to the pancreas in patients who underwent radical resections and had favorable postoperative courses, with some bibliographic consideration.

[A Case of Resected Metachronous Pancreatic Metastasis from Rectal Carcinoma].

A 69-year-old man underwent a Miles operation with D3 lymph node dissection for rectal cancer. The pathological diagnosis was adenocarcinoma(Rb, A, ly2, v3, N2M0P0H0, Stage Ⅲb). Adjuvant chemotherapy was added for 6 months after the rectal resection. Metastasis in the left lung was detected 1 year and 10 months after rectal resection for which large segmental resection was performed. Without the onset of any new lesions, the patient underwent subsequent follow-up examinations. Abdominal CT performed for increased tumor marker levels observed at 6 years and 8 months after rectal resection revealed a mass suggestive of pancreatic ductal adenocarcinoma for which distal pancreatectomy was performed. The pathological diagnosis was metastasis to the pancreas from the rectal cancer as the tumor cells were immunohistochemically negative for cytokeratin 7 and positive for cytokeratin 20. There has been no indication of recurrence for 13 months after the pancreatic surgery. Resectable pancreatic metastasis from colorectal cancer is rarely reported. However, pancreatic resection may result in long-term survival in some cases. Patients that tolerate pancreatectomy and have no metastasis in the other organs should be considered good candidates for pancreatic resection. We present this case with a review of the literature.

[A Case of Cystic Biliary Hamartoma with a Difficult Preoperative Diagnosis].

Intrahepatic bile duct dilatation was detected in a 63-year-old man based on abdominal ultrasonography. The computed tomography and magnetic resonance imaging scans showed an intrahepatic cystic lesion in the hilar bile duct that led to intrahepatic bile duct dilatation. As a result, intraductal papillary neoplasm of the bile duct(IPNB)was suspected. Moreover, the intrahepatic bile duct dilatation was confirmed by endoscopic retrograde cholangiopancreatography(ERCP). Biliary and brushing cytology indicated that the cystic lesion was class Ⅱ and class Ⅲ, respectively. Radiological imaging test did not rule out the possibility of a malignant lesion. Hence, a radical left hepatectomy was performed. Histopathological examination of the resected specimen indicated that it was a non-malignant cystic biliary hamartoma. Cystic biliary hamartoma or the von Meyenburg complex is a relatively rare disease. Although this disease is categorized as benign, differential diagnosis between benign and malignant forms is difficult, and this is an important clinical issue.

[A Case of Long-Term Survival after Repeated Multidisciplinary Treatment for Liver Metastasis of Ampullary Cancer].

The patient was a 79-year-old man. He underwent endoscopic papillectomy for ampullary cancer when he was 70 years old. At the ages of 71 and 73 years, liver metastasis in segment 6 was detected, and radiofrequency ablation(RFA)was performed and adjuvant chemotherapy(gemcitabine, S-1)was administered. At the age of 79 years, recurrence of liver metastasis appeared. Because there were no other metastatic lesions, we performed S6 subsegmentectomy. Five months after the surgery, no recurrence was observed. In general, the prognosis of patients with ampullary cancer with distant metastasis is very poor. This case suggested the efficacy of multidisciplinary treatment, including surgery, RFA, and chemotherapy, in a patient with ampullary cancer with distant metastasis.

[A Case of Castleman's Disease with Lymphadenopathy during the Treatment of Gastric Cancer].

We report a patient who had Castleman's disease with lymphadenopathy during the treatment of gastric cancer. In May 2017, a 63-year-old man underwent gastrointestinal endoscopy, which revealed a tumor on the posterior wall of the lower part of the stomach. Based on a biopsy, he was diagnosed with suspected adenocarcinoma, Group 4. In June 2017, he visited our hospital, and endoscopic submucosal dissection(ESD)was performed. The pathological diagnosis of the resected specimens was L, Less, 20×10 mm, Type 0-Ⅱc, tub1, pT1a(M), UL(-), ly(-), v(-), pHM0, pVM0, pStage ⅠA. He was referred to our department for the treatment of abdominal lymphadenopathy. His lymphadenopathy was localized in the gastric lesser curvature as an enlarged lymph node 15mm in size, based on the findings of contrast-enhanced CT. On FDG- PET/CT, we found a slight accumulation of SUVmax 2.4 in the early phase in the same lymph node. We could not confirm a diagnosis, and we performed laparoscopic dissection of the lymph node for diagnosis and treatment. The size of the specimen was 14×14mm, surface was smooth, and lymph node was elastic and soft. We found lymphoid follicles with atrophic germinal center using HE staining. We also found increased hyperplastic blood vessels around the germinal center, and he was diagnosed with hypervascular Castleman's disease.

[Long-Term Survival of a Patient with Para-Aortic Lymph Node Recurrence Who Underwent Lymph Node Dissection and Received Chemotherapy Following Curative Gastrectomy].

A 66-year-old man underwent total gastrectomy for gastric cancer. S-1 was administered as adjuvant chemotherapy. Abdominal CT showed para-aortic lymph node recurrence 31 months after the surgery. There was no other recurrence according to PET-CT, and we performed para-aortic lymph nodes dissection 41 months after the surgery. Lymph node recurrence in the retrocrural space was observed 37 months after the 2nd surgery. We administered S-1 plus L-OHP chemotherapy. After 4 courses, CT revealed that he had achieved complete response, and he has remained disease-free for 79 months after lymph node dissection. Some patients with para-aortic lymph node recurrence after curative gastrectomy may benefit from treatment including chemotherapy and surgical dissection.

[A Case of Multiple Tumor Neurosurgery for Brain Metastasis of Colorectal Cancer].

We report a patient with brain metastasis of rectal cancer who underwent metastatic tumor resection 3 times. In March 2012, a 76-years-old man, diagnosed with Stage III a rectal cancer, underwent Hartmann's operation. The lung metastasis was confirmed in July and November 2013, surgical resection for pulmonary metastasis was performed 2 times. In January 2016, he had difficulty of speaking, and isolated brain tumor was found. We performed surgical resection of brain metastasis in February 2016. In March and July 2016, the gamma knife radiosurgery was performed for other brain metastasis. In July 2016, he occurred nausea, headache and right identity hemi-blindness. Two new brain tumors were revealed. We performed surgical resection again. Three months after second brain surgery, he had dysarthria and a solitary brain tumor was confirmed. We performed third neurosurgical resection. All tumors of brain were found to be metastasis from rectal cancer in histological study. Currently, 16 months have passed since the first diagnosis of brain metastasis of this patient, and the quality of life was good relatively. The prognosis of the patients with brain metastasis is poor generally. However, this case suggested that multiple surgical resection of brain metastasis could improve prognosis and quality of life of patients. Accumulation of further cases is needed.

[Two Resected Cases of Non-Isolated Splenic Metastasis of Colon Cancer].

We report 2 resected cases of patients with non-isolated splenic metastasis of colon cancer. Case 1: A 67-year-old man who underwent partial transverse colectomy and partial hepatectomy for transverse colon cancer and liver metastasis. Approximately 18 months after the operation, splenectomy and partial hepatectomy were performed for metastasis to the spleen and liver. After partial hepatectomy for another recurrence, no signs of new recurrence have been observed for 42 months after splenectomy. Case 2: A 53-year-old woman who presented with bloating. CT and MRI scans revealed masses of the ileocecum, both ovaries, and spleen. We performed right hemicolectomy, total hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy, para-aortic lymphadenectomy, omentectomy, and splenectomy. Histological findings showed cecal cancer metastasizing to the bilateral ovaries and spleen. Metastatic splenic tumor is relatively rare(0.3-7.3%). Splenectomy was reported to be an effective treatment modality for isolated splenic metastasis, while that for non-isolated metastasis is uncertain. Surgical resection should be considered even in non-isolated splenic metastasis cases because of the evidence of long-term survival in case 1.

[A Resected Case of Castleman's Disease That Was Difficult to Diagnose Preoperatively].

A 70-year-old man was referred to our hospital and admitted after abdominal computed tomography(CT)examination revealed a tumor in the retroperitoneum. The specific blood test findings were poor, and surveillance CT demonstrated a wellcircumscribed, enhanced mass measuring 40mm with calcification behind the horizontal portion of the duodenum. The tumor presented with a slightly high signal in low signal, T2 in T1, and it showed a diffusion decrease in DWI; the simple abdominal MRIrevealed heterogeneous accumulation of SUVmax 3.0 only for the lesion in FDG/PET-CT. Specific findings did not lead to a diagnosis, although EUS-FNA lower aspiration biopsy cytology was performed. Laparoscopic tumorectomy was performed to help determine the treatment strategy. Histopathological examination indicated that the tumor was composed of multiple lymph follicles with concentric layers of mantle zone cells, showing an onion skin-like lesion and atrophic germinal centers. The germinal centers had penetrating arterioles with hyalinized vessel walls, and Castleman's disease(hyaline vascular type)was therefore diagnosed. In this case, it was difficult to diagnose Castleman's disease before surgery. Surgical excision is a diagnostic as well as a curative method for management of this disease.

[Two Cases of Systemic Steroid Therapy for Hyperbilirubinemia after Right Hepatic Lobectomy of Liver Metastasis from Colorectal Cancer].

We report 2 cases of systemic steroid therapy for hyperbilirubinemia after right hepatic lobectomy for liver metastases from colorectal cancer.One of the patients was a 65-year-old man, diagnosed with transverse colon cancer with multiple liver metastases.After surgery for the primary lesion and chemotherapy(FOLFOX plus bevacizumab, FOLFIRI plus panitumumab), he underwent right hepatic lobectomy for the liver metastasis.His preoperative ICG 15 min was 8%.Conjugated hyperbilirubinemia without biliary stenosis occurred after the hepatectomy.Two courses of pulse steroid therapy were effective for only a limited period.After initiation of oral prednisolone therapy, his hyperbilirubinemia decreased.The other patient was a 66- year-old man with rectal cancer who underwent a low anterior resection.Postoperatively, a liver metastasis appeared.After CapeOX therapy, he underwent right hepatic lobectomy.His preoperative ICG 15 min was 5%.Conjugated hyperbilirubinemia occurred after hepatectomy.Pulse steroid therapy was effective for only a limited period.After initiation of prednisolone therapy, his hyperbilirubinemia decreased.In both cases, fatty changes in the liver were detected.Chemotherapy -associated hepatotoxicity may induce hyperbilirubinemia after hepatectomy.The effectiveness of systemic steroid therapy for hyperbilirubinemia is demonstrated by these cases.

[A case of primary unknown cancer difficult to distinguish from lung cancer].

A 26-year-old man was admitted to our hospital with dyspnea, fever, and weight loss. A chest X-ray showed multiple tumor shadows, and a computed tomography (CT) scan showed swelling of the mediastinal and hilar lymph nodes, a mass in the retroperitoneum, and an embolus in the inferior vena cava. A biopsy from the left cervical lymph node revealeda poorly differentiated adenocarcinoma. Metastatic lung cancer was suspected, but in spite of the examinations, its primary site was unknown. Serum alfa-fetoprotein(AFP)was slightly elevated, but an AFP stain of the tumor was negative. The patient's respiratory failure rapidly worsened, and therefore, additional examinations could not be performed. The patient received chemotherapy with carboplatin and paclitaxel. His condition improved, but the tumor increased in size after 5 courses of chemotherapy. He received chemotherapy with docetaxel as second-line treatment, but it was not effective. The third-line chemotherapy regimen with carboplatin and gemcitabine was effective. In total, he received 7 lines of chemotherapy, and he lived for approximately 12 months since receiving the first chemotherapy regimen. After he died, we were able to perform OCT-4 immunohistochemistry on a tumor biopsy specimen from the lymph node, which came back positive for OCT-4. Therefore, we made a final diagnosis of extragonadal germ cell cancer syndrome.