[A Case of Late Recurrence of Gastric Cancer Over Ten Years Post Gastrectomy].

A 72-year-old woman underwent a low anterior resection of the rectum and a total hysterectomy with a bilateral salpingo- oophorectomy simultaneously for rectal and ovarian cancer, respectively. The pathological diagnosis was a moderately differentiated adenocarcinoma of the rectum with some poorly differentiated components signet-ring cell components. A mucinous adenocarcinoma, with similar characteristics as that in the rectum, was found in the ovary. Intraoperative findings revealed no direct invasion between the rectum and ovaries, with no peritoneal dissemination. She was, therefore, diagnosed with synchronous double cancer. The rectal cancer was pT3N0M0, Stage Ⅱ and the ovarian cancer pStage Ⅰ. Adjuvant chemotherapy with capecitabine was performed for high-risk Stage Ⅱ rectal cancer. At 3.5 years after surgery, her CA19-9 level was high and pleural dissemination and para-aortic lymph node metastasis were confirmed on thoracoabdominal CT. Twelve years after the gastrectomy for gastric cancer, a comparison of the pathological specimens of her stomach at that time with the current pathological specimens revealed that the rectal and ovarian tumors were metastases of gastric cancer and that the current recurrence was a late recurrence of this disease. Late recurrence after gastrectomy, especially 10 years or more after surgery, is extremely rare.

Benefits of using a self-expandable metallic stent as a bridge to surgery for right- and left-sided obstructive colorectal cancers.

PURPOSE: To assess the benefit of placing a self-expandable metallic stent (SEMS) as a bridge to surgery for obstructive colorectal cancer (OCRC) according to the tumor site. METHODS: The subjects of this retrospective multicenter cohort study were 201 patients with OCRC, but without initial bowel perforation, who were treated either with a self-expandable metallic stent (SEMS) as a bridge to surgery (n = 109) or with primary surgery (PS; n = 92) between 2014 and 2016. The cohort consisted of 68 patients with right-sided and 133 left-sided OCRC. We evaluated the short-term surgical outcomes for each side. RESULTS: The SEMS group of patients with left-sided OCRC had significantly higher rates of primary resection, primary resection with anastomosis, stoma-free surgery, and laparoscopic surgery than the PS group of patients with left-sided OCRC. In contrast, the SEMS group of patients with right-sided OCRC had only a significantly higher rate of laparoscopic surgery than the PS group of patients with right-sided OCRC, but they had a longer overall hospital stay. There were no significant differences between the two treatment groups in the rates of morbidity or mortality, for either right-sided or left-sided OCRC. CONCLUSION: The benefit of a SEMS as a bridge to surgery may be less for right-sided than for left-sided obstructions in colon cancer patients.

[Laparoscopic Distal Gastrectomy for Elderly Patients with Advanced Gastric Cancer and Gastric Outlet Obstruction - A Case Report].

A 90-year-old female patient was admitted to our hospital with a chief complaint of vomiting.Gastroscopy revealed type 3 gastric cancer and gastric outlet obstruction(GOO).Abdominal computed tomography revealed thickening of the antral wall and suggested the presence of 3 perigastric lymph node metastases, but there was no ascitic fluid or distant metastasis.The clinical diagnosis was T4a(SE)N2H0CYXP0M0, Stage III B, according to the Japanese Classification of Gastric Carcinoma.Her general conditions including kidney and cardiac function were good, we considered that she was able to tolerate radical distal gastrectomy.We planned laparoscopic distal gastrectomy(LDG)and D2 lymphadenectomy after getting sufficient informed consent.The patient experienced an uneventful post-operative recovery, and was discharged in good health 11 days after surgery.

[Diffuse Malignant Peritoneal Mesothelioma with Secondary Liver Invasion Diagnosed Using Laparoscopy - A Case Report].

A 69-year-old man with right upper quadrant abdominal pain and fever was referred to our hospital. He had a history of asbestosis exposure. Computed tomography(CT)revealed a mass at the right subhepatic space, and an antibiotic was administered after a diagnosis of an abdominal abscess. However, the patient did not respond to the treatment, and finally, exploratory laparoscopy was performed. A sheet of combined white nodules surrounding the right lobe of the liver was found, and the mass was continuous with the covering particles. Biopsy of the mass and immunohistochemical examination was performed. The resulting diagnosis was diffuse epithelial malignant peritoneal mesothelioma(MPM). Postoperative systematic chemotherapy of pemetrexed and cisplatin was administered. Laparoscopy was useful to evaluate the distribution of the MPM, which led to adequate therapeutic determination.

[A Case of Metastatic Carcinoma of Anal Fistula].

A 58-year-old man underwent rectal resection(D2 dissection)for rectal cancer and liver/lung metastases in August 2009. Histopathological findings were Ra, type 2, 70×80mm, tub1>tub2, int, pSI(peritoneum), INF b, ly1, v1, pN1(2/13), pPM0, pDM0, M1a(H1, PUL1), fStage IV . The lung metastasis had disappeared on chest CT after postoperative chemotherapy and we were able to perform radical resection of the liver metastasis by performing hepatectomy twice. In October 2013, anal pain appeared and a painful tumor approximately 2 cm in size was found in the 5 o'clock direction of the anus. Biopsy revealed a well-differentiated tubular adenocarcinoma similar to rectal cancer, and it was diagnosed as a fistula metastasis of rectal cancer.We performed chemoradiotherapy(S-1 120mg/day plus RT 60 Gy/30 Fr)as surgery was recommended but refused. As a result, the tumor reduced markedly in size. In December 2015, the tumor enlarged in size and the patient and family requested surgery. We, therefore, performed abdominoperineal resection. Currently, the patient is alive at 18 months after surgery with no recurrence.

[Early Liver Metastases after Curative Surgery for Stageâ Gastric Cancer with Neuroendocrine Differentiation-A Case Report].

An 87-year-old male patient was admitted to our hospital with a chief complaint of vomiting. Gastroscopy revealed Type 0-Ⅱc+Ⅱa tumor at the posterior wall in the middle third of the stomach. A biopsy indicated moderately differentiated adenocarcinoma. Abdominal CT revealed no lymph node or distant metastases. The clinical diagnosis was cT2(MP), N0, M0, cStage Ⅰ. Laparoscopic distal gastrectomy with D2 lymphadenectomy was performed. The pathological findings revealed moderately differentiated adenocarcinoma containing synaptophysin, chromogranin A, and CD56-positive tumor cells. He was then diagnosed with adenocarcinoma with neuroendocrine differentiation. The pathological diagnosis was pT2(MP), pN0, M0, pStage ⅠB. MRI revealed multiple liver metastases 5 months postoperatively. S-1 alone chemotherapy was started, and the patient showed partial response(PR)after 3 courses, according to the Response Evaluation Criteria in Solid Tumor (RECIST).

[Invasive Micropapillary Carcinoma of the Colon That Was Difficult to Diagnose Preoperatively].

A 73-year-old man was admitted with sigmoid colon diverticulitis. Although a biopsy did not indicate malignancy, the sigmoid colon was completely obstructed following conservative treatment. After sigmoidectomy, the histopathological findings revealed a well-differentiated adenocarcinoma localized to the mucosal surface; invasive micropapillary carcinoma (IMPC)accounting for>95% of the tumor volume spread extensively below the submucosal layer. IMPC is highly malignant and difficult to diagnose preoperatively, possibly due to the presence of poorly differentiated histological sub-types in the deepest portions of the tumor.

[A Case of Rectal Cancer Presenting with Schistosomiasis Japonica Eggs].

A 87-year-old man had used to live in Shizuoka Prefecture. He got colonoscopy due to melena, and a type 1 tumor about 3 cm was detected in the rectum. He was diagnosed with rectal cancer. We performed a laparoscopic low anterior resection with lymphadenectomy. Histopathological findings shows tub1, pSM(7mm), med, INF a, ly1, v0, pPM0, pDM0, pN0(0/7), T1bN0M0, Stage I . Schistosoma japonica eggs were seen in submucosal of the rectum not around the tumor but also normal tissue. The eggs embolized microvessels. It has been 5 year since the operation, the patient has survived without recurrence.

[Esophagogastric Junction Cancer Resection with Bilateral Adrenal Metastasis - A Case Report].

The patient was a 64-year-old man with esophagogastric junction cancer. We performed right thoracotomy-laparotomy for lower esophageal and cardiac gastric resection, D2 lymphadenectomy, and reconstruction of a gastric tube in October 2011. Histopathology confirmed T4aN1M1(LYM), Stage IV cancer(Japanese Classification of Gastric Carcinoma, 14th edition) with R0 resection. Because of preexisting alcoholic cirrhosis, postoperative chemotherapy was not an option. In March 2014, we performed left adrenalectomy for left adrenal metastasis, and in December 2014, we performed right adrenalectomy for metastasis to the right adrenal gland. The patient was prescribed 20mg/day of hydrocortisone postoperatively. Survival from the right adrenalectomy was 2 years and 2 months, and survival from the first operation was 5 years and 4 months, without recurrence. This case of esophagogastric junction cancer resection with bilateral adrenal metastasis is rare, with only one previously reported case in Japan.

Perforated Carcinoma in the Gastric Remnant: A Case of Conservative Treatment Prior to Successful Curative R0 Resection.

An 80-year-old man who had undergone distal gastrectomy and Billroth-II gastrojejunostomy 38 years previously, for a benign gastric ulcer, was diagnosed with remnant gastric cancer based on upper gastrointestinal endoscopy findings. He presented at our emergency department with acute-onset epigastric pain due to perforated remnant gastric cancer. Conservative medical management was selected, including nasogastric tube insertion, antibiotics, and proton pump inhibitors, because his peritonitis was limited to his epigastrium and his general condition was stable. Twenty-one days after the perforation occurred, curative total remnant gastrectomy and D2 lymphadenectomy were performed. Adhesion between the lateral segment of the liver and the dissected lesser curvature of the gastric remnant may have contributed to the peritonitis in this case, which was limited to the epigastrium. This is the first report of perforated remnant gastric cancer in which conservative treatment was effective prior to curative resection. The protocol reported here may be of use to other clinicians who may encounter this clinical entity in their practices.

[A Case of a Large Gastric Gastrointestinal Stromal Tumor with a PDGFRA Exon 18 Mutation].

A 49-year-old man visited our hospital with a chief complaint of abdominal pain that began 1 day before his visit.An approximately 30 cm tumor that was extensively in contact with the gastric wall in the abdominal cavity was detected on computed tomography(CT).An elevated lesion covered with normal mucosa on the posterior wall of the greater curvature was detected on upper endoscopy.He was diagnosed with a submucosal tumor of the stomach, and he underwent surgery. Surgical findings revealed an elastic soft tumor with a maximal dimension of 38 cm that projected from the posterior wall of the stomach beyond the gastric wall.No invasion and metastasis to other organs were detected.Partial gastrectomy was performed.On histopathological examination, proliferation of atypical round and spindle cells was found, and immunostaining was negative for KIT but positive for CD34.In the gene search, an Asp842Val mutation was detected in exon 18 of the PDGFRA gene.Currently, the patient has survived for 7 months after surgery without recurrence.