A desmoid tumor with fluorodeoxyglucose accumulation arising from the anastomotic site of postoperative gastric cancer: a case report.

BACKGROUND: Desmoid tumors are extremely rare borderline benign and malignant tumors that do not exhibit accumulation on fluorodeoxyglucose positron emission tomography-computed tomography. In the present study, we report a rare case of a desmoid tumor with fluorodeoxyglucose accumulation at the anastomotic postoperative gastric cancer site. CASE PRESENTATION: A 68-year-old Japanese man underwent robot-assisted laparoscopic distal gastrectomy for early-stage gastric cancer in 2019. The pathological diagnosis was stage IA cancer, and no adjuvant chemotherapy was administered. Two years after surgery, a soft mass appeared on the greater curvature side of the anastomosis on computed tomography. Fluorodeoxyglucose positron emission tomography-computed tomography revealed fluorodeoxyglucose accumulation, which suggested a malignancy; therefore, surgery was performed for diagnostic treatment. The histopathological findings led to the diagnosis of a desmoid tumor. The patient has not experienced recurrence to date. CONCLUSIONS: In the present study, we encountered a desmoid tumor arising from the anastomotic site of a postoperative gastric cancer. This case is rare as fluorodeoxyglucose positron emission tomography-computed tomography showed fluorodeoxyglucose accumulation in the desmoid tumor, and a preoperative diagnosis could not be reached. We hope that further studies will improve the accuracy of preoperative diagnosis.

Preoperative Magnetic Resonance Cholangiopancreatography for Detecting Difficult Laparoscopic Cholecystectomy in Acute Cholecystitis.

Previous studies have shown that signal intensity variations in the gallbladder wall on magnetic resonance imaging (MRI) are associated with necrosis and fibrosis in the gallbladder of acute cholecystitis (AC). However, the association between MRI findings and operative outcomes remains unclear. We retrospectively identified 321 patients who underwent preoperative magnetic resonance cholangiopancreatography (MRCP) and early laparoscopic cholecystectomy (LC) for AC. Based on the gallbladder wall signal intensity on MRI, these patients were divided into high signal intensity (HSI), intermediate signal intensity (ISI), and low signal intensity (LSI) groups. Comparisons of bailout procedure rates (open conversion and laparoscopic subtotal cholecystectomy) and operating times were performed. The recorded bailout procedure rates were 6.8% (7/103 cases), 26.7% (31/116 cases), and 40.2% (41/102 cases), and the median operating times were 95, 110, and 138 minutes in the HSI, ISI, and LSI groups, respectively (both p < 0.001). During the multivariate analysis, the LSI of the gallbladder wall was an independent predictor of both the bailout procedure (odds ratio [OR] 5.30; 95% CI 2.11-13.30; p < 0.001) and prolonged surgery (≥144 min) (OR 6.10, 95% CI 2.74-13.60, p < 0.001). Preoperative MRCP/MRI assessment could be a novel method for predicting surgical difficulty during LC for AC.

Impact of chest subcutaneous fat on the occurrence of central venous port-related infectious complications in cancer patients.

PURPOSE: There is no concrete evidence to support the association between the amount of subcutaneous fat area (SFA) in the central venous port-insertion site (precordium) and port-related complications. We aimed to investigate the relationship between SFA in the midclavicular line and postoperative infectious complications in patients undergoing port-insertion surgery. METHODS: This was a single-institute and historical cohort study of 174 patients who underwent first central venous port implantation surgery for chemotherapy between January 2014 and December 2018. SFA in the midclavicular line was measured using preoperative computed tomography scans. The patients were divided into three groups according to SFA amount tertiles, and we investigated the association of SFA with infectious and all-cause complication events within 1 year. RESULTS: Within a median follow-up of 306 days, the patients with intermediate SFA had significantly higher infection-free survival than those with low and high SFA (low vs. intermediate vs. high: 80.4% vs. 97.7% vs. 83.4%, respectively, p=0.034). In contrast, there was no significant difference in the overall complication-free survival among the groups (low vs. intermediate vs. high: 80.4% vs. 88.9% vs. 81.8%, respectively, p=0.29). Low SFA was independently associated with high risk of infectious complications (hazard ratio, 9.45; 95% confidence interval, 1.07-83.22, p=0.043). CONCLUSION: Low SFA in the midclavicular line was an independent risk factor for infectious complications in the chemotherapy setting. This practical indicator can be useful for optimizing patients' nutritional status and when considering other types of vascular access to support administration of intravenous chemotherapy.

A case of a jejunal gastrointestinal stromal tumor with significantly elevated CA19-9 levels.

INTRODUCTION: A gastrointestinal stromal tumor (GIST) with an elevated serum tumor marker level is very rare. We report a case of jejunal GIST associated with extremely elevated levels of serum carbohydrate antigen 19-9 (CA19-9). PRESENTATION OF CASE: A 61-year-old woman was referred to our hospital for examination of an abdominal tumor. Laboratory tests revealed extremely elevated CA19-9 levels (13,498 U/mL). Enhanced abdominal computed tomography demonstrated a well-enhanced, round 40 mm tumor. The patient underwent a jejunectomy and lymph node dissection. Based on the postoperative pathological findings, the tumor was diagnosed as a GIST. Microscopically, a solid region of the resected tumor showed negative staining for CA19-9. The serum CA19-9 level drastically decreased postoperatively. DISCUSSION: Increased proliferation of epithelial cells secondary to inflammation and ulceration of epithelia may lead to increased secretion and accumulation of CA19-9, which is consequently released into the blood circulation. CONCLUSION: In cases of GIST, an isolated increase of serum CA19-9 is extremely rare; but they are not necessarily associated with malignant transformation.

Total proctocolectomy with end ileostomy for acute onset of ulcerative colitis during chemoradiotherapy for lung adenocarcinoma (successfully treated by surgery): a case report.

BACKGROUND: Ulcerative colitis (UC) developing during chemotherapy is very rare. Here, we describe a case of acute onset during chemoradiotherapy for lung adenocarcinoma, requiring a total proctocolectomy. CASE PRESENTATION: A 52-year-old man was admitted to the hospital for chemoradiotherapy of lung cancer. He had no obvious history of gastrointestinal diseases, and concurrent chemoradiotherapy was initiated. Thirteen days after 2 cycles of cisplatin and vinorelbine, he experienced persistent hematochezia. Findings of the colonoscopy revealed edematous thickening from the rectum to the transverse colon, suggesting UC, drug-induced colitis, or infectious colitis. Results from bacterial culture were negative for Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA). Immunohistological staining for cytomegalovirus was also negative. Although he was clinically diagnosed with UC and treated with intravenous glucocorticoid, his symptoms gradually worsened and an abdominal X-ray revealed megacolon. Thirty-five days after conservative therapy, a total proctocolectomy with end permanent ileostomy was performed. Based on pathological findings and clinical course, he was diagnosed with UC. CONCLUSION: Although the pathogenesis of UC during chemotherapy has been unknown, chemotherapy could be one of the causes of UC in this case. UC should be included in the differential diagnosis in patients with progressive colitis during chemotherapy.

Intraductal dissemination of ampullary carcinoma after pancreatoduodenectomy.

BACKGROUND: Clinical evidence of intraductal dissemination through the pancreatic duct has been rare. We herein describe a case of ampullary carcinoma that disseminated in the remnant pancreas through the pancreatic duct. CASE PRESENTATION: A 68-year-old woman underwent SSPPD for ampullary carcinoma. The tumor was diagnosed as adenocarcinoma without lymph node metastasis (T2N0M0, stage IB). Computed tomography (CT) performed 3 years later revealed a 14-mm tumor near the site of the pancreaticojejunal anastomosis. Endoscopic ultrasound-guided fine needle aspiration showed adenocarcinoma that was morphologically similar to the specimen from the first surgery. We diagnosed recurrence of ampullary carcinoma in the remnant pancreas. A total remnant pancreatectomy was performed. We found a white solid tumor at the 20-mm distal side of pancreaticojejunal anastomosis. The tumor was morphologically similar and immunostaining showed a pattern identical to that of the original tumor, suggesting that the two tumors were of the same origin. CONCLUSION: The recurrent lesion was most likely the result of tumor cells leaving the tumor and implanting in the remnant pancreatic duct epithelium. Intraductal dissemination of adenocarcinoma is thought to be a cause of remnant recurrence after SSPPD in cases of obstruction of the pancreatic duct or an iatrogenic procedure.

Long-term survival after surgical resection for recurrent hepatic and pulmonary metastases of intrahepatic cholangiocarcinoma: a case report.

BACKGROUND: A few reports to date have described the effectiveness of surgical resection for recurrent intrahepatic cholangiocarcinoma (ICC). We report in this study a patient who achieved long-term survival after surgical resection for recurrent hepatic and pulmonary metastases of ICC. CASE PRESENTATION: A 62-year-old man was referred to our hospital for examination of a tumor in the left lobe of the liver. Computed tomography (CT) scans of the abdomen revealed a hypovascularized tumor, 30 mm in hepatic segment 2 (S2). The patient was diagnosed with a mass-forming type of ICC. A left lateral sectionectomy with regional lymph node dissection was performed. Histopathological examination showed moderately differentiated adenocarcinoma in the hepatic S2 with lymph node metastasis. There were two intrahepatic metastases around the main tumor. The pathological stage of the ICC was pT2pN1M0pStageIIIB. The patient did not receive adjuvant chemotherapy after surgery. Twelve months after surgery, liver lesions in S4/S8 and S7 were detected on CT scans. A partial hepatectomy was performed. The histopathological features were similar to those of the previous ICC. The patient did not receive adjuvant chemotherapy after the repeat hepatectomy. Four years and four months after this repeat hepatectomy, CT scans showed multiple nodes in S4 and S10 of the left lung and in S1 of the right lung. Wedge resection of the left upper lobe and sectionectomy in S10 of the left lung were performed. Histopathological findings of the resected lung nodules were compatible with metastatic ICC. The nodule in S1 of the right lung was too small to be diagnosed as metastasis; therefore, it was not resected. After pulmonary resection, the patient was treated with gemcitabine and cisplatin for 6 months. After chemotherapy, the size of the nodule in S1 increased gradually. One year and ten months after the pulmonary resection, we performed wedge resection of S1 of the right lung, and the histopathological findings were compatible with metastatic ICC. The patient is alive without evidence of disease 8 years after the initial surgery and 8 months after the last pulmonary resection. CONCLUSIONS: ICC with poor prognostic factors can frequently recur; however, surgical resection for recurrent ICC might, for selected patients, enable long-term survival.

Intraductal papillary neoplasm of the bile duct with rapidly progressive multicentric recurrence: A case report.

INTRODUCTION: Knowledge on the pattern of recurrence and prognosis of intraductal papillary neoplasms of the bile duct (IPNB) is limited. Few studies have reported IPNB recurrence in the remnant intrahepatic bile duct, which is indicative of the true multicentricity of IPNB. Herein, we report a case of IPNB with rapidly progressive recurrence in the remnant intrahepatic bile duct and review the literature for discussing the prognosis of IPNB with multicentricity. CASE PRESENTATION: A 72-year-old male was diagnosed with IPNB in the hepatic duct of segment 3 that had spread to the left hepatic duct. The patient underwent left hepatectomy, total caudate lobectomy, and extra-hepatic bile duct resection with biliary reconstruction. Histologically, the tumor was IPNB with noninvasive adenocarcinoma with a negative surgical margin. Although dilatation of B8 and biliary enzyme elevation were observed beginning at 7-10 months postoperatively, there was no evidence of recurrence. At 17 months postoperatively, the recurrent tumor diffusely spread throughout the remnant intrahepatic bile duct. Internal drainage stents were placed within the intrahepatic bile ducts with relapsed IPNB to relieve jaundice, and a course of chemotherapy was considered. However, the patient did not receive any therapies up to his death at 21 months postoperatively because of rapid disease progression. CONCLUSION: According to a literature review, some cases of multicentric IPNB have shown rapidly progressive recurrence and poor prognosis. We should consider multicentricity of IPNB even a few months after curative resection, and narrow examinations should also be considered.

Initial experience of laparoscopic pelvic exenteration and comparison with conventional open surgery.

BACKGROUND: Generalization of laparoscopic pelvic surgery has brought about profound knowledge of the pelvic anatomy and has encouraged expansion of indications for laparoscopic surgery to extended pelvic surgery. Pelvic exenteration (PE) is still a demanding surgical procedure and remains an essential technique for pelvic surgery although minimally invasive and function-preserving surgery is in the mainstream of surgical treatment. However, the techniques of laparoscopic PE (LPE) have been rarely explained nor has its feasibility been fully evaluated. The aim of this study was to describe important technical points and to assess the feasibility of LPE for pelvic malignancies. METHODS: Data on 67 patients with pelvic malignancies, who underwent PE between June 2006 and August 2014, were analyzed retrospectively. LPE has been indicated since 2013. Patients were divided into the LPE group (n = 9) and the conventional open PE (OPE) group (n = 58). RESULTS: Operative time in the LPE and OPE groups was similar (935 vs. 883 min, p = 0.398). Intraoperative blood loss in the LPE group was significantly less than that in the OPE group (830 vs. 2769 ml, p = 0.003). Pathological R0 resection rate was similar in both groups (77.8 vs. 75.9%). Overall incidence of any complication and major complications were much lower in the LPE group (66.7 and 0%) compared to the OPE group (89.7 and 32.8%), although not statistically significant (p = 0.094 and 0.053, respectively). Postoperative hospital stay was significantly shorter in the LPE group than in the OPE group (27 vs. 43 days, p = 0.003). CONCLUSIONS: We confirmed that LPE for pelvic malignancies resulted in less blood loss, a lower complication rate, and shorter postoperative hospital stay compared to OPE. LPE performed by an experienced pelvic surgeon was safe and efficient, and might be a promising option for carefully selected patients.

The feasibility of laparoscopic extended pelvic surgery for rectal cancer.

PURPOSE: The present study aimed to assess the safety and feasibility of laparoscopic extended pelvic surgery for primary or recurrent rectal cancer. METHODS: The data on 77 patients, who underwent extended pelvic surgery between February 2008 and June 2014, were retrospectively analyzed. The patients were divided, based on their treatment history, into an open surgery (OS) group (n = 41) and a laparoscopic surgery (LS) group (n = 36). RESULTS: The operative time in the LS group was significantly longer than that in the OS group (766 vs. 561 min; p < 0.001). In contrast, the LS group was associated with a significantly lower volume of intraoperative blood loss (195 vs. 923 ml; p < 0.001), fluid balance (5.38 vs. 8.23 ml/kg/h; p < 0.001) and rate of complications (40.0 vs. 68.3 %; p = 0.035), and a significantly shorter postoperative hospital stay. The postoperative levels of colloid osmotic pressure and albumin were significantly higher in the LS group. CONCLUSION: The operative time of the LS group was longer than that of the OS group; however, the LS group experienced less blood loss and fewer complications. Moreover, LS was associated with a reduction in intraoperative infusions and a reduced fluid balance, which maintained homeostasis.

Clinical Significance of Para-Aortic Lymph Node Dissection for Advanced or Metastatic Colorectal Cancer in the Current Era of Modern Chemotherapy.

BACKGROUND/AIMS: Surgical resection is not generally indicated for para-aortic lymph node (PALN) metastasis from colorectal cancer. However, the clinical significance of PALN dissection (PALND) in the current era of modern chemotherapy has not been fully discussed. METHODS: Between November 2006 and February 2013, 14 patients underwent PALND for colorectal cancer and were proven as having pathological PALN metastasis. The median follow-up was 33.2 months. RESULTS: Primary location was the right-colon in 2 patients, and the left-colon or rectum in 12 patients. The timing of metastasis was metachronous in 5 patients and synchronous in 9 patients. Eleven patients (79%) received perioperative aggressive modern chemotherapy. Neoadjuvant chemotherapy with targeted drugs was introduced in 9 patients (64%) and 6 patients received adjuvant chemotherapy. Recurrence after PALND occurred in 12 patients (86%). The most common site was the lung in 6 patients (43%). The 1- and 3-year disease-free survivals were 39.3 and 7.9%, respectively. The 3-year overall survival were 41.2%. CONCLUSION: The recurrence rate after PALND for strictly selected patients was quite high even in the current era of modern chemotherapy. However, some patients achieved long-term survival or could be cured. Therefore, we should re-evaluate the efficacy of PALND in a larger prospective study.

Role of bevacizumab in neoadjuvant chemotherapy and its influence on microvessel density in rectal cancer.

BACKGROUND: The role of bevacizumab (Bev) in neoadjuvant chemotherapy (NAC) without radiotherapy for rectal cancer has not been fully discussed. The purpose of this study is to assess the clinicopathological benefit of Bev in NAC for rectal cancer and to investigate its influence on microvessel status in cancerous tissue. METHODS: Data on 47 patients with rectal cancer, who received NAC with or without Bev between August 2008 and November 2012, were analyzed retrospectively. The objective response was evaluated using the maximum tumor diameter. Tumor regression grade 3/4 was classified as a pathological response. RESULTS: Thirty-one patients (66 %) received NAC that included Bev and the other 16 patients were treated without Bev. The objective response rate was significantly higher in the Bev group than in the non-Bev group (64.5 vs. 25.0 %, p = 0.015). The rate of pathological response was much higher in the Bev group (41.9 %) than in the non-Bev group (12.5 %), but did not reach significant difference (p = 0.052). Microvessel density (MVD) in the resected cancerous tissue was significantly lower in the Bev group than in the non-Bev group. CONCLUSIONS: We have confirmed that objective and pathological responses were better in patients treated with NAC that included Bev than in those who received NAC without Bev. Additionally, MVD in tumor tissues was inhibited in the patients treated with Bev. To investigate the impact of Bev in NAC on long-term survival, further follow-up is required.

[Complications after implantation of subcutaneous central venous port].

We retrospectively reviewed 500 cases who were implanted with subcutaneous central venous port(CV port)in our institution from Jan. 2007 to Nov. 2011, to investigate the complications arising after CV port implantation. The purpose of CV port implantation was chemotherapy access in 279 cases and home parenteral nutrition in 221 cases. The primary diseases were malignancy in 441 cases(colorectal cancer 252 cases, gastric cancer 54 cases, etc.)and benign diseases in 59 cases. Seven patients(1. 4%)had complications at implantation(pneumothorax 6 cases, catheter migration 1 case). Forty-three patients(8. 6%)had complications after port implantation. Among them, 18 suffered port infection, 10 had obstruction of the catheter system, 4 developed skin ulceration, 4 developed port rotation, 3 had venous thrombosis, and 3 developed catheter migration. The cumulative patency rates after 1, 2, and 3 years were 90. 7%, 81. 2%, and 74. 6%, respectively. Complications after port implantation were more frequently developed in home parenteral nutrition than in chemotherapy.