Dedifferentiated liposarcoma primary to the chest wall with spontaneous shrinking: report of a case.

An 80-year-old man presented to our emergency department complaining of a mass on the right side of his chest and pain in the right flank of his back. A chest computed tomography (CT) scan showed a relatively heterogenous oval-shaped tumor measuring 7.5 × 6.0 cm eroded to the 8th rib, with slightly dense fluid accumulation inside and calcification of the tumor wall. A 1-month follow-up CT scan showed spontaneous shrinkage of the tumor. The tumor was completely excised from the thoracic wall and the wall was reconstructed with a polytetrafluoroethylene mesh. Pathological examination showed coagulation necrosis in the chest wall tumor, but immunohistochemical staining revealed murine double minute 2- and Cyclin-dependent kinase 4-positive cells with irregular nuclear size and bizarre morphology. Therefore, dedifferentiated liposarcoma (DDLPS) was the final pathological diagnosis. Remarkable infiltration of CD8+ lymphocytes into the tumor was observed, along with a 90% positive ratio for programmed cell death-ligand 1. The patient has been followed-up for 1 year without any recurrence, despite not receiving any additional treatment. Liposarcoma is one of the most common types of soft tissue sarcomas; however, spontaneous regression of primary DDLPS arising from the chest wall is extremely rare. Herein, we report a case of DDLPS primary to the chest wall with spontaneous regression, probably due to a spontaneously induced T cell response.

Laparoscopic cholecystectomy after transcatheter arterial embolisation for haemobilia due to a pseudoaneurysm in the gallbladder: A case report.

Pseudoaneurysms of the cystic artery are a rare but significant complication of acute cholecystitis. Laparoscopic cholecystectomy may be a safe alternative to open cholecystectomy in such cases. We report the case of a female patient in her seventies, who presented with anaemia, jaundice, and hepatic dysfunction during hospitalisation for right knee pyogenic arthritis. The patient had no pain in the right upper quadrant. Her serum haemoglobin level was 6.5 g/dL, and upper gastrointestinal endoscopy revealed no abnormalities. Six days later, jaundice worsened, and endoscopic retrograde cholangiopancreatography revealed bloody bile. An endoscopic biliary drainage tube was inserted at the discretion of the gastroenterology department. Contrast-enhanced computed tomography revealed a haematoma in the gallbladder and a pseudoaneurysm in the lateral wall of the gallbladder. On the same day, the endoscopic biliary drainage tube was replaced with an endoscopic nasobiliary drainage tube, which indicated the degree of haemorrhage and enabled lavage of the lumen in cases of obstruction. The next day, angiography revealed a pseudoaneurysm of the deep branch of the cystic artery and coil embolisation was performed at the periphery of the cystic artery. Uninterrupted laparoscopic cholecystectomy was performed. Although laparoscopic cholecystectomy is difficult when bleeding is uncontrolled, it was safely performed following haemostasis using transcatheter arterial embolisation. Laparoscopic cholecystectomy is feasible in haemodynamically stable patients with cystic artery pseudoaneurysms after transcatheter arterial embolisation.

Total parenchymal pancreatectomy preserving the duodenum, choledochus and spleen for widespread intraductal papillary mucinous neoplasm: report of a case.

For patients with benign or low malignant diseases of the pancreas, several organ-preserving surgical techniques of pancreatectomy have been presented for localized lesions. In cases of widespread or multifocal neoplasms of the pancreas, however, it is difficult to treat with this limited pancreatectomy because of a possible risk of residual dysplastic foci. We herein report a patient with widespread intraductal papillary mucinous neoplasm treated successfully with total parenchymal pancreatectomy. A 73-year-old man was diagnosed as main duct intraductal papillary mucinous neoplasm. A papillary tumor was located in the body of the pancreas, and intraepithelial spreading reached almost the end of the pancreas tail and nearly over the midpoint of the pancreas head. We performed total parenchymal pancreatectomy, an initial surgical procedure in which almost all parenchyma of the pancreas was resected but the duodenum, the common bile duct and the spleen were preserved and no reconstruction was needed. The postoperative course was uneventful and his blood glucose level had been controlled carefully with insulin formulation. No recurrence was observed during over the 30-month follow-up period. For susceptible patients, total parenchymal pancreatectomy may provide clinical benefits of significant radicality and less invasiveness than classical total pancreatectomy.

Long-term survival after repeated resection of metachronous lung metastases from pStage IA pancreatic adenocarcinoma.

CASE REPORT: A 70-year-old woman with pancreatic ductal adenocarcinoma was initially treated by distal pancreatectomy (DP). Thirty-five months later, another tumor appeared in the pancreatic head and was treated by pancreaticoduodenectomy. Histopathological findings identified both tumors as pancreatic ductal adenocarcinoma pStage IA. Computed tomography (CT) of the chest 16 months after the second pancreatectomy revealed a ground-glass opacity in segment 3 of the right lung. Chest CT 23 months after the second pancreatectomy revealed a nodular shadow in segment 1a of the right lung. Chest CT 39 months after the second pancreatectomy revealed a nodular shadow in segment 5 of the left lung. These lesions were treated by video-assisted thoracoscopic surgery partial resection. Histopathological and immunohistochemical features (positive for cytokeratin (CK)7 and CK20, negative for transcription factor-1) for these three lesions and the secondary pancreatic ductal adenocarcinoma were similar, indicating a diagnosis of lung metastasis from the second pancreatic ductal adenocarcinoma. The patient has remained alive and free of new metastases for 8 years after initial DP, 3 years after the last lung resection. CONCLUSION: This patient has survived over the long term after undergoing three resections of lung metastases from resected pancreatic ductal adenocarcinoma.

[A case of recurrent breast cancer with multiple liver metastases responding to combination therapy of capecitabine and MPA].

The patient was a 68-year-old woman who underwent left partial mastectomy on February 1999. The stage was T2N1. There were positive for estrogen and progesterone receptors in the tumor. After operation, adjuvant therapy consisting of oral administration of tamoxifen and radiation was performed. On February 2005, she felt dyspnea and right femoral pain. After examinations, she was diagnosed as recurrent breast cancer with pleuritis carcinomatosa and bone metastasis. The patient was treated with oral administration of anastrozole and pamidronate disodium 90 mg intravenously every 4 weeks, radiation of her right femur, and OK-432 injection into the intrapleural cavity. On November 2005, she felt general fatigue and anorexia. CT examination revealed multiple liver metastases. She was treated with oral combination chemoendocrine therapy with capecitabine (2,400 mg/day) and MPA (600 mg/day). After the four courses, multiple liver metastases were remarkably reduced in the CT findings. After twelve courses, the partial response continued. No adverse reactions occurred except for gain in weight of grade 1. It is suggested that this oral combination chemoendocrine therapy may be useful for recurrent breast cancer with consideration for treatment effectiveness and the quality of life of the patient.

[A case of rectal cancer with multiple liver metastases responding to TS-1].

A 63-year-old woman was referred to our hospital with complaints of anal pain, constipation and abdominal distention caused by a rectal tumor. After examinations, she was diagnosed as rectal cancer with multiple liver metastases. The CEA level was 70.0 ng/ml and the CA19-9 level was more than 5,000 U/ml at admission. To prevent bowel obstruction, low anterior resection of the rectum was performed. At 34 days after operation, TS-1 chemotherapy was started as outpatient treatment (each course consisted of daily oral administration of 100 mg TS-1 for 4 weeks followed by 2 drug-free weeks). After the first course, the CEA level was reduced to 3.3 ng/ml and the CA19-9 level to 15 U/ml, both under the normal value. After the second course, administration was discontinued due to diarrhea, and restarted as a daily oral administration of 80 mg TS-1. After the five courses, the CEA level was 4.0 ng/ml and the CA19-9 level was 4 U/ml, both under the normal value. Multiple liver metastases had remarkably reduced in the CT findings. The patient continues to undergo outpatient treatment with good QOL.

Risk Factors for Difficult Laparoscopic Cholecystectomy in Acute Cholecystitis.

BACKGROUND AND OBJECTIVES: Factors that contribute to difficult laparoscopic cholecystectomy (LC) in acute cholecystitis (AC) that would affect the performance of early surgery remain unclear. The purpose of this study was to identify such risk factors. METHODS: One hundred fifty-four patients who underwent LC for AC were retrospectively analyzed. The patients were categorized into early surgery and delayed surgery. Factors predicting difficult LC were analyzed for each group. The operation time, bleeding, and cases of difficult laparoscopic surgery (CDLS)/conversion rate were analyzed as an index of difficulty. Analyses of patients in the early group were especially focused on 3 consecutive histopathological phases: edematous cholecystitis (E), necrotizing cholecystitis (N), suppurative/subacute cholecystitis (S). RESULTS: In the early group, the CDLS/conversion rate was highest in necrotizing cholecystitis. Its rate was significantly higher than that of the other 2 histopathological types (N 27.9% vs E and S 7.4%; P = .037). In the delayed-surgery group, a higher white blood cell (WBC) count and older age showed significant correlations with the CDLS/conversion rate (P = .034 and P = .004). CONCLUSION: In early surgery, histopathologic necrotizing cholecystitis is a risk factor for difficult LC in AC. A higher WBC count and older age are risk factors for delayed surgery.

Noninvasive management for iatrogenic splenic injury caused by chest tube insertion: a case report.

Splenic injury is one of the most critical complications of chest tube insertion and often requires invasive emergency management. However, noninvasive management such as delayed removal of the malpositioned tube may be considered for a stable patient without severe adverse event.

A calcitonin and vasoactive intestinal peptide-producing pancreatic endocrine tumor associated with the WDHA syndrome.

BACKGROUND: Although pancreatic endocrine tumor can produce a variety of hormones, few pancreatic tumors produce a high systemic calcitonin concentration. Furthermore, calcitonin-producing pancreatic tumors rarely produce elevations of VIP in addition. METHODS: We evaluated and treated a 50-yr-old woman with the WDHA syndrome. Abdominal computed tomography (CT) detected a tumor in the tail of the pancreas. Peripheral plasma calcitonin and VIP concentrations were markedly increased to 2000 pg/mL (normal, <74 pg/mL) and 7200 pg/mL (normal, <100 pg/mL), respectively. We diagnosed a calcitonin- and VIP-producing pancreatic endocrine tumor, which was removed by distal pancreatectomy including splenectomy. RESULTS: Plasma calcitonin and VIP were determined in blood from the vein draining the tumor and splenic vein, sampled at operation. These secreted concentrations were extremely high: 4640 and 3610 pg/mL for calcitonin; 24700 and 13500 pg/mL for VIP. Calcitonin and VIP were also highly elevated in the resected tumor. Plasma calcitonin and VIP rapidly decreased after tumor resection. The patient has been well without recurrence for over 20 yr. CONCLUSION: An unusual pancreatic tumor secreting vasoactive intestinal peptide (VIP) caused WDHA syndrome (watery diarrhea, hypokalemia, and achlorhydria/hypochlorhydria) and also hypercalcemia. The latter was only partially offset by a large excess of calcitonin also secreted by the tumor.

Primary sclerosing cholangitis associated with autoimmune pancreatitis.

We present 2 cases of primary sclerosing cholangitis complicated with autoimmune pancreatitis with narrowing of the pancreatic duct. In both cases, endoscopic retrograde cholangiography showed the characteristic findings of primary sclerosing cholangitis. In addition, positivity for autoantibody, hypergamma-globulinemia and narrowing of the pancreatic duct shown on endoscopic retrograde pancreatography were noticed in both. They were thu diagnosed as autoimmune pancreatitis. Whereas it is well known that primary sclerosing cholangitis is often complicated with chronic pancreatitis, it has rarely been studied whether the chronic pancreatitis is autoimmune pancreatitis or not. In English literature, possibly 7 equivalent cases have been reported so far. In those cases, the onset was in the post-prime of life, and the disease was frequently accompanied with Sjögren's syndrome, but not with ulcerative colitis; frankly the nature of the disease was slightly different from what has traditionally been thought as a typical primary sclerosing cholangitis. In primary sclerosing cholangitis complicated with autoimmune pancreatitis, the autoimmune mechanism seems to be much involved, and thus steroid therapy might be effective as in Case 2 in our series.

Blood stasis may cause thrombosis in the left superior pulmonary vein stump after left upper lobectomy.

BACKGROUND: We previously reported that arterial infarction of vital organs after lobectomy might occur only after left upper lobectomy and be caused by thrombosis in the left superior pulmonary vein stump. We hypothesized that changes in blood flow, such as blood stasis and disturbed stagnant flow, in the left superior pulmonary vein stump cause thrombosis, and this was evaluated by intraoperative ultrasonography. METHODS: From July 2013 to April 2014, 24 patients underwent lobectomy in the Steel Memorial Muroran Hospital. During the procedure, an ultrasound probe was placed at the pulmonary vein stump and the velocity in the stump was recorded with pulse Doppler mode. The peak velocity and the presence of spontaneous echo contrast in the stump were evaluated. After the operation, the patients underwent contrast-enhanced CT within 3 months. RESULTS: The operative procedures were seven left upper lobectomies, four left lower lobectomies, seven right upper lobectomies, and six right lower lobectomies. Blood flow was significantly slower in the left superior pulmonary vein stump than in the right pulmonary vein stumps. However, that was not significantly slower than that in the left inferior pulmonary vein stump. Spontaneous echo contrast in the pulmonary vein stump was seen in three patients who underwent left upper lobectomy. Of the three patients with spontaneous echo contrast, two patients developed thrombosis in the left superior vein stump within 3 months after the operation. There was no patient who developed arterial infarction. CONCLUSIONS: In patients who underwent left upper lobectomy, intraoperative ultrasonography to evaluate blood flow and the presence of spontaneous echo contrast in the left superior pulmonary vein stump may be useful to predict thrombosis that may cause arterial infarction.

Left upper lobectomy can be a risk factor for thrombosis in the pulmonary vein stump.

BACKGROUND: Thrombosis in the left upper pulmonary vein stump after left upper lobectomy is a very rare but important complication because it occurs in the systemic circulation system. We previously made the first ever report on the frequency and risk factors of thrombosis in the pulmonary vein stump after lobectomy. In this study, we conducted an investigation in a different hospital to determine whether this was a common complication. METHODS: From 2008 to 2012, 151 patients who underwent lobectomy and following enhanced CT within 2 years after the operation were studied. Postoperative contrast-enhanced CT imaging was retrospectively checked. RESULTS: We found thrombosis in the pulmonary vein stump in 5 of the 151 patients (3.3%). All 5 patients underwent left upper lobectomy (17.9% of the patients who underwent left upper lobectomy). These 5 patients did not have infarction of any vital organ. The thrombus was disappeared several months later on contrast-enhanced CT in 3 patients and followed in 2 patients. On univariate analysis, there was a significant difference only in the operative procedure (p<0.001). CONCLUSIONS: Thrombosis in the pulmonary vein stump occurred with high frequency in patients who underwent left upper lobectomy. Because the frequency of thrombosis in this study was the same as in our previous report, this might be a common complication.