Laparoscopic deroofing for a giant hepatic cyst with biliary communication: a case report.

Previous reports describing laparoscopic deroofing as a management modality for a hepatic cyst with biliary communication remain limited. We present the case of a 76-year-old woman who was monitored for 4 years for a giant hepatic cyst in the right lobe of the liver. She presented to our department with a chief complaint of abdominal distension. Moreover, imaging revealed a 24-cm giant hepatic cyst. During laparoscopic deroofing, minimal bile leakage from the intra-cyst wall was observed, which was laparoscopically closed with sutures. No bile leakage or cyst recurrence was observed 18 months postoperative. This highlights that laparoscopic surgery may be used in managing hepatic cysts with biliary communication. Intraoperative findings may reveal biliary communication, which requires careful observation of the cyst wall after deroofing.

[A Case Report of Rectal MiNEN Surgical Resection].

A 56-year-old man with diarrhea and bloody stools was found to have a type 2 tumor in the rectosigmoid region. A biopsy revealed well-differentiated tubular adenocarcinoma(tub1), and laparoscopic high anterior resection was performed. The final diagnosis was MiNEN(NEC:adenocarcinoma=6:4), RS, type 2, Ly0, V0, pT3(SS), pN0, M0, and pStage Ⅱa. He has been followed up without postoperative adjuvant chemotherapy and has been alive without recurrence for 1 year and 4 months after surgery. MiNEN is a rare disease, and most of them are mixed with NEC components or high- grade NET G3 and have a poor prognosis. We present an important case of rectal MiNEN.

[Long-Term Survival after Resection of Two Lung Metastases That Appeared Five Years after Pancreatic Cancer Surgery-A Case Report].

A woman in her 70s was diagnosed with cancer of pancreatic head. She underwent subtotal stomach-preserving pancreatoduodenectomy. Moderately differentiated adenocarcinoma, positive peripancreatic exfoliation surface, and R1 resection was diagnosed by histopathological examination. She underwent adjuvant chemotherapy(S-1), but 5 years and 6 months after the operation, a single nodule(16×9 mm)appeared on anterior segment of left lung. She underwent thoracoscopic left upper lobectomy on suspicion of primary lung cancer. Adenocarcinoma consistent with pancreatic cancer metastasis was diagnosed by histopathological examination. She didn't choose chemotherapy after second operation. 1 year and 1 month after the left pneumonectomy, a single nodule(11×10 mm)reappeared in lateral basal segment of right lung. Although it was difficult to diagnose whether it was primary or metastatic, she decided to undergo thoracoscopic partial lung resection. Histopathological examination revealed that the histology was similar to that of the previous lung lesion and was consistent with pancreatic cancer metastasis. After that, she also didn't choose chemotherapy. She has been alive for 7 years and 7 months after her first pancreatic cancer surgery without any new obvious recurrence.

[A Case Report of Appendiceal NET G1 Diagnosed by Histopathological Examination after Appendectomy for Acute Appendicitis].

A 36-year-old woman was diagnosed with acute appendicitis after a close examination of her abdominal pain and nausea. Laparoscopic appendectomy was performed, and pathological examination revealed a NET G1. They were localized lesions on the tips and body of the appendix, with no additional resection because the tumor size was less than 2 cm and no risk factors for recurrence and metastasis(vascular invasion, NET G2 or higher, or invasion of the mesentery). The patient was followed up with contrast-enhanced CT every 6 months and has been recurrence-free for 2 years postoperatively.

[Laparoscopic Resection of a Liver and Ovarian Metastasis of Transverse Colon Cancer-A Case Report].

A 60s woman was diagnosed to transverse colon cancer and she underwent laparoscopic right hemicolectomy. Localized peritoneal dissemination surrounding tumor was detected during surgery. She was administrated to chemotherapy due to a hepatic metastasis in S2/3 postoperatively. Subsequently, PET-CT revealed a left ovarian metastasis in addition to a liver metastasis during chemotherapy. Laparoscopic hepatic left lateral segmentectomy and bilateral adnexectomy was performed at 1 year and 9 months after the first surgery and histopathological examination showed a metastasis of transverse colon cancer. The growth of liver and lung metastases and peritoneal disseminations was detected at 6 months later after the second surgery and the patient is currently receiving palliative treatment. Previous literatures described that ovarian metastasis of colon cancer showed bilateral metastasis and resistance to chemotherapy frequently and ruptured in some cases. We should consider to resect bilateral ovary even if unilateral metastasis alone was detected by imaging examination.

[A Case Report of Pancreatic Tail Carcinoma with Positive Periotoneal Washing Cytology with Recurrence-Free Survival after Surgery and Chemotherapy].

A woman in her 70s underwent distal pancreatectomy(D2 dissection)for a pancreatic tail carcinoma after a close examination of the cause of her poorly controlled diabetes mellitus. Intraoperative rapid peritoneal washing cytology showed no malignant findings, but histopathological examination revealed Ptb, TS2, tub2, pT3, ly1, v3, ne3, mpd0, pS0, pRP1, pOO0, pPCM0, pDPM0, pN0, pM0, pCY1, pStage ⅡA, R0(Pancreatic Cancer Treatment Protocol 7th Edition). The patient was treated with S-1 therapy for 6 months postoperatively and is alive 1 year and 9 months without recurrence. The prognosis after resection of pancreatic cancer with positive peritoneal washing cytology is said to be worse than that of patients with negative, because of the high recurrence rate of peritoneal metastasis. We report a case of pancreatic tail carcinoma with positive peritoneal washing cytology with recurrence-free survival after surgery and chemotherapy.

[A Difficult Case of a Huge Cystic Gastrointestinal Stromal Tumor of the Stomach with CA125-Level Elevation].

A 67-year-old woman presented with abdominal distention. Computed tomography and magnetic resonance imaging revealed a huge tumor measuring >30 cm with solid and cystic regions. The serum level of CA125 was elevated. An exploratory laparotomy was performed by a gastroenterologist and a gynecologist for the purpose of diagnosis and tumor removal. During laparotomy, the ovary and uterus were found to be intact. The tumor was found to originate from the greater curvature of the stomach and invade the mesentery of the transverse colon. Histopathologically, tumor cells were positive on c-kit immunohistochemical staining. A high-risk gastrointestinal stromal tumor of the stomach was diagnosed according to the modified-Fletcher classification. Because cystic GIST is relatively rare and CA125 was elevated similar to that in Pseudo-Meigs syndrome, preoperative diagnosis was difficult in this case.

[Surgical Resection of Gastric MANEC-Two Case Reports].

Case 1 was a 78-year-old woman with a tumor in the stomach on preoperative CT of an inguinal hernia. The patient was diagnosed with advanced gastric cancer at posterior wall of fornix and underwent total gastrectomy and splenectomy. Postoperative pathological diagnosis was gastric mixed adenoneuroendocrine carcinoma(MANEC), T1b2, N1, M0, StageⅠB. She has been alive without recurrence for 3 years without postoperative adjuvant chemotherapy. Case 2 was a 78-year-old man who was admitted to the hospital with acute pancreatitis and had a thickened wall of the lesser curvature of the gastric antrum on CT. He was diagnosed with advanced gastric cancer and underwent distal gastrectomy and D2 dissection. Postoperative pathological diagnosis was gastric MANEC, T1b2, N1, M0, Stage ⅠB. Oral administration of S-1 was started as postoperative adjuvant chemotherapy, but he was very tired and ended in 1 course at his request. Computed tomography 6 months after the operation revealed multiple liver metastases, and he was transferred to best supportive care at his request. He died 1 year after surgery. We experienced 2 valuable cases of gastric MANEC.

[A Case of Pancreatic Body Cancer with Peritoneal Dissemination Followed Up for 15 Months without Recurrence].

A 72-year-old woman was admitted to the gastroenterology division of our hospital due to abdominal pain and vomiting. Dynamic contrast-enhanced CT showed a tumor at the body of the pancreas and main pancreatic duct dilation. She was diagnosed with carcinoma of the body of the pancreas via EUS-FNA. There was no vascular invasion or distant metastasis on preoperative imaging. She was introduced to the Gastrointestinal Surgery division where a mesenteric nodule was found at the time of the surgery. Intraoperative frozen section confirmed the diagnosis of occult peritoneal metastases. After consulting with her family, we completed the pancreatosplenectomy. On histopathological examination, this case was TS2, tub2, pT3, mpd0, S1, RP1, PV0, A0, PL0, OO0, N0, M1(PER), CY1, PCM0, DPM0, R1, stage Ⅳ. After the operation, we treated the patient with gemcitabine(GEM)plus nab-paclitaxel for 3 months(4 courses). She then developed side effects such as anorexia and tiredness. After discussing with the patient, chemotherapy was discontinued. The patient remains alive without recurrence 19 months after the operation. Patients with metastatic pancreatic adenocarcinoma have poor prognoses because they are no longer candidates for surgical therapy. We encountered a case of pancreatic body cancer with peritoneal dissemination, followed up for 15 months without recurrence.

[A Case of Synchronous Triple Cancer of the Stomach, Intrahepatic Bile Duct, and Prostate].

A 73-year-old man presented with the chief complaint of hematemesis(bloody vomiting). Upon examination, he was diagnosed as having gastric cancer with liver metastasis. He consulted our hospital for a second opinion. Gastrointestinal endoscopy showed a 50 mm early stomach cancer. Contrast-enhanced CT showed a progressive contrast-enhanced tumor in the S7 segment of the liver. FDG-PET/CT showed increased FDG uptake in the prostate. High PSA levels were also observed. He was diagnosed as having gastric cancer and prostate carcinoma. Intrahepatic cholangiocarcinoma and metastatic liver cancer were mentioned as differential diagnoses of the liver tumor. Hormonal therapy for prostate carcinoma failed to reduce the size of the liver tumor. PSA staining of the liver biopsy revealed negative results. As gastric cancer rarely metastasizes, metastatic liver cancer was unlikely. The patient was diagnosed as having intrahepatic cholangiocarcinoma. He underwent distal gastrectomy with hepatic posterior sectionectomy. The treatment strategy for multiple cancers depends on the primary lesion and the stage of cancer progression. Therefore, adequate evaluation is necessary before initiating treatment.

[A Case Report of a Patient Over 90 Years of Age with Liver Metastasis after Sigmoid Colectomy Controlled by a Combination Oral UFT/LV Chemotherapy Regimen].

A92 -year-old woman underwent laparoscopic sigmoid colectomy with D3 lymphadenectomy. Histological examination confirmed a pT3(SS), pN0, pM0, pStageⅡ tumor. Abdominal CT 6 months after surgery revealed liver metastasis close to the right branch of the portal vein in the S6 region of the liver. There were no indications for transcatheter arterial embolization, radiofrequency ablation, or hepatectomy. Although she had Grade 3 neutropenia, the patient received 15 courses of oral UFT/LV. Three courses of UFT/LV plus bevacizumab were also administered. She was judged to have achieved stable disease (SD); however, Grade 4 proteinuria was observed. After she was administered 2 courses of TAS-102, we shifted to best supportive care. She died of a sigmoid cancer 32 months after UFT/LV initiation. Careful adaptation of chemotherapy can be used to control a patient's condition during certain periods, even in patients with super-advanced age.

[A Case Report of Resectable Leiomyosarcoma of the Duodenum Origin Invading to the Inferior Vena Cava].

A 40's woman had a complaint of abdominal and back pain. Enhanced CT visualized a large retroperitoneal tumor and huge multiple myomas of the uterus. The tumor was 10cm in diameter and located in the anterior of the inferior vena cava, and progressed from the posterior of the duodenum to the abdominal aortic bifurcation. Diffusion-weighted MR image showed the tumor with high signal intensity. Upper gastrointestinal endoscopy revealed a type 2 tumor at the anal side of the Vater. The patient was performed curativly abdominal total hysterectomy and pancreaticoduodenectomy with inferior vena cava resection. Immunohistochemical examination showed that the tumor cells were negative for CD34 and c-kit, and positive for desmin and a-SMA. The tumor was histopathologically diagnosed as leiomyosarcoma originating from the duodenum.

[A Case of Double Lung and Gastric Cancer Involving Para-Aortic Lymph Node Metastasis with Difficult Preoperative Diagnosis].

A man in his 60s was admitted to our hospital with anemia. An endoscopic examination revealed advanced gastric cancer. CT revealed peri-gastric and para-aortic lymphadenopathy, and a nodular shadow(20mm)in the lower lobe of the right lung. PET-CT revealed abnormal uptake in the para-aortic lymph node and stomach wall and the nodular shadow in the right lung. A bronchoscopy revealed pulmonary adenocarcinoma. From the above, he was diagnosed with gastric cancer(cT4a, cN2, cM1, cStage IV )and lung cancer(cT2a, cN0, cM0, cStage I B). Because of gastric bleeding, we decided to operate on the gastric cancer before the lung cancer. First, total gastrectomy, splenectomy, and cholecystectomy were performed and then dissection of lymph node No. 16was performed. Histopathological examination indicated that lymph node No. 16was common to lung cancer, so the final diagnosis was gastric cancer(pT4a, pN0, cM0, fStage II A)and lung cancer(cT2a, cN0, pM1, fStage IV ). In this case, lymphadenectomy of No. 16in the first and pathological diagnosis during surgery could help us avoid splenectomy and cholecystectomy, and could reduce invasion.

[A Case Report of Chylous Ascites after Laparoscopic Sigmoid Colectomy Treated with Conservative Therapy].

A man in his sixties with a medical history of diabetes and dyslipidemia was detected with a tumor with massive submucosal invasion on colonoscopy. He was diagnosed with sigmoid cancer and underwent laparoscopic sigmoid colectomy with D3 lymph node dissection. An electric surgical knife and an ultrasonically activated device was used to perform D3 lymph node dissection with preservation of the left colic artery(LCA)and division of the S1A and S2A. On postoperative day 4(POD4), 1 day after oral intake was started, chylous ascites began to develop. Owing to the small volume of ascites, oral feeding was continued, and chylous ascites was treated successfully with a low-fat diet. Chylous ascites immediately reduced on POD6, after which the drain was removed on POD7. He was discharged on POD9. Fasting and complete parenteral nutrition are not necessarily required in the treatment of chyle leakage after laparoscopic colorectal cancer surgery.

[A Case of Ruptured Gastrointestinal Stromal Tumor of the Stomach with Intraabdominal Bleeding].

A 50s man visited our hospital because of abdominal pain that initiated 1 day prior. An approximately 4.0×5.0×4.5c m tumor, which was in contact with the greater curvature of the gastric body, was detected on contrast-enhanced computed tomography. He was diagnosed with a ruptured gastrointestinal stromal tumor and underwent emergency surgery. During the operation, about 250mL of bloody ascites and a ruptured tumor measuring 6-7 cm in size was observed in the middle of the gastric body. Partial gastrectomy was performed. The histopathological diagnosis was GIST of the stomach. In the gene search, PDGFR-a mutation D842V was detected in exon 18. Therefore, he is undergoing a follow-up examination without postoperative adjuvant therapy even though he is classified as high-risk. Currently, the patient has survived for 8 months after surgery without recurrence. We should perform careful follow-up of the patient.

[A Case of Mucinous Adenocarcinoma of the Descending Colon with Extramural Progression].

A 63-year-old man was admitted to our hospital with a cough. Based on imaging studies, the patient was diagnosed with locally advanced descending colon cancer with extensive infiltration into peripheral organs by extramural progression. There was no distant metastasis. Therefore, he received left hemicolectomy with splenectomy, partial gastrectomy, and partial diaphragm resection. Histopathological examination showed a mucinous adenocarcinoma, pT4b, pN1, cM0, fStage III A. We report a rare case of extramural progression colon cancer with invasion of various organs and review 12 previous case reports.

[A Case of Synchronous Multi-Centric Invasive Ductal Carcinomas of the Pancreas].

A 69-year-old man with left upper abdominal pain visited our hospital. Abdominal CT revealed a hypovascular mass(66× 57mm)in the pancreatic tail. MRI revealed hemorrhage and cysts in the caudal lesion of the tumor. The tumor involved the posterior wallof the stomach. Based on a diagnosis of pancreatic tailcancer with gastric posterior wallinvasion, distalpancreatectomy and partialgastrectomy were performed. Histopathologicalexamination indicated 2 adjacent tumors through a capsule in the pancreas tail. These tumors were diagnosed as synchronous invasive ductal carcinomas of the pancreas, which were anaplastic and papillary carcinomas. We report a rare case of synchronous multi-centric invasive ductalcarcinomas of the pancreas.

[A Case of Mixed Adenoneuroendocrine Carcinoma(MANEC)of the Duodenum].

A 79-year-old man was admitted to our hospital because of a positive fecal occult blood test. Gastrointestinal endoscopy revealed a tumor in the duodenal bulb. Histologically, biopsy specimens indicated adenocarcinoma. The patient underwent distal gastrectomy. Histopathological examination showed a neuroendocrine carcinoma with an adenocarcinoma. According to the 2010WHO Classification of Tumours of the Digestive System, this case was diagnosed as mixed adenoneuroendocrine carcinoma(MANEC). There was no metastatic lesion in the resected lymph node. The patient has been followed up for 2 years without evidence of recurrence. We report a rare case of MANEC in the duodenum.

[A case of multiple liver metastases after resection of gastrointestinal stromal tumor of the small intestine that was successfully treated with imatinib mesylate].

A 73-year-old man was found to have an intestinal tumor, approximately 10 cm in diameter, on computed tomography (CT). In September 2001, he underwent partial resection of the jejunum with partial colectomy and left nephrectomy. Pathological examination showed 2 mitoses per 50 high-power fields, and immunohistochemical analysis showed positive staining for c-kit. Based on the above findings, the tumor was diagnosed as a high-risk malignant gastrointestinal stromal tumor( GIST) of the small intestine; the patient was followed up and no adjuvant therapy was administered. In October 2005, an abdominal CT scan revealed 2 tumors with diameters of 21 and 28 mm in the S8 and S7 region of the liver, respectively, and the patient was diagnosed with liver metastases from GIST. After obtaining adequate informed consent, chemotherapy with imatinib (400 mg/day) was initiated. Although the patient experienced partial response (PR) 2 months after the treatment, grade 3 neutropenia and general fatigue were observed. Therefore, the treatment schedule was changed to 1 week of therapy, followed by 1 week of rest. At present, at 91 months after the diagnosis of liver metastases, the patient shows no signs of recurrence. Therefore, it is important that adjuvant chemotherapy should be considered for the treatment of patients with high-risk malignant GIST.

[Radiofrequency ablation for liver metastases from colorectal cancer after systemic chemotherapy].

PURPOSE: To evaluate the effectiveness and safety of radiofrequency ablation(RFA)for liver metastases from colorectal cancer after chemotherapy. PATIENTS: From January 2006 to June 2012, 27 tumors in 17 patients with liver metastases from colorectal cancer were treated using RFA after systemic chemotherapy. RESULTS: The median tumor diameter after chemotherapy was 12(range: 3-35)mm, and the mean number of tumors was 1.6(range: 1-4).The median time without local recurrence was 21.3(range: 2.2-61.9)months, and the median overall survival time was 38.0(range: 5.9-66.3)months. One patient had a complication(liver abscess).Of the 27 tumors, 9 were larger than 20 mm in diameter, and 4 of these 9 tumors showed local recurrence after RFA. In tumors smaller than 20 mm in diameter, only 1 showed local recurrence. The local recurrence rate was significantly higher for tumors larger than 20 mm than for tumors smaller than 20 mm(44.4% vs 5.6%,p=0.030). CONCLUSION: RFA was an effective and safe method for treating liver metastases from colorectal cancer, especially for tumors smaller than 20 mm and in cases of less than 3 tumors after systemic chemotherapy.