[A Case of Small Cell Carcinoma of the Pancreas].

A 55-year-old man was admitted to our hospital for jaundice. Magnetic resonance cholangiopancreatography showed a mass in the pancreatic head as well as biliary obstruction. We strongly suspected invasive ductal carcinoma of the pancreas. We performed pancreaticoduodenectomy with partial resection of the portal vein. The histopathological diagnosis was small cell carcinoma of the pancreas. We detected metastasis of the right hilar lymph node in PET-CT scan performed 2 months after the surgery and started chemotherapy with cisplatin(CDDP)plus irinotecan(CPT-11). However, we observed recurrent metastasis of the right hilar lymph node 12 months after the surgery. We started second-line chemotherapy with amrubicin( AMR)and radiotherapy. Unfortunately, the patient died from multiple metastases of the left adrenal gland and brain 26 months after the surgery. The prognosis of small cell carcinoma of the pancreas is extremely poor. Multimodal treatment such as chemotherapy, radiotherapy, and curative operation are required for long-term survival.

[A Case of Remnant Gastric Cancer That Completely Responded to Neoadjuvant S-1 and Cisplatin Therapy].

A 69-year-old man, who had undergone distal gastrectomy for duodenal ulcer, was diagnosed with remnant gastric cancer and jejunal mesenteric lymph node metastasis. To improve curability, we planned 2 courses of S-1 and cisplatin therapy. After chemotherapy, primary lesion and lymph node metastases reduced in size drastically. Completion gastrectomy and lymph node dissection were performed with curative intent. The tumor was found to have a pathological complete response(pCR) to chemotherapy on histological examination.

[Four Cases of Primary Small Intestinal Cancer].

Primary small intestinal cancer is very rare. We experienced 4 cases from 2001 to 2013. Case 1: A 46-year-old man presented with abdominal pain and melena. Computed tomography (CT) revealed a tumor in the jejunum. We performed partial resection and lymph node dissection. The histological examination confirmed the diagnosis of moderately differentiated adenocarcinoma, SEN0H0P0M0. He has been recurrence-free for 13 years. Case 2: An 84-year-old woman presented with abdominal pain and vomiting. Gastroscopy showed a tumor in the upper jejunum, and she was diagnosed with adenocarcinoma. Postoperative diagnosis was SEN0H0P0M0. She has been alive for 7 years. Case 3: A 66-year-old woman presented with epigastric discomfort and back pain. Examinations confirmed poorly differentiated small intestinal adenocarcinoma with multiple liver and lymph node metastases. She refused chemotherapy and died 1 month later. Case 4: A 60-year-old man presented with abdominal pain and vomiting. CT revealed a tumor in the jejunum. Gastroscopic biopsy led to a diagnosis of poorly differentiated adenocarcinoma. We performed partial resection but there was extensive lymph node metastasis and peritoneal dissemination (cSIN2H0P3M1) so curative resection was impossible. Two courses of chemotherapy with S-1 and CDDP were administered. However, chemotherapy was not effective. He died 3.5 months after the first operation. Based on 2 of our cases, the prognosis for primary small intestine adenocarcinoma with lymph node metastasis or peritoneal dissemination was poor, with survival of less than 6 months. However, N0 cases without peritoneal dissemination can achieve long-term survival with curative resection. We report these cases with a review of previously reported cases in the literature.

[Acute gastric mucosal lesions caused by acute Helicobacter pylori infection -clinical outcomes of six cases and problems in the diagnosis of H. pylori infection].

We analyzed the ratio of positive test results in various diagnostic methods for Helicobacter pylori infection and the clinical presentations in six cases of acute gastric mucosal lesions (AGML) caused by acute H. pylori. At onset, five cases tested negative for serum antibodies; one had a positive result, but the antibody titer increased with time. Some false negative results were obtained with the following tests: urea breath test, rapid urease test, microscopy, culture, and immunostaining; however, the feces antigen test gave positive results in all five cases. These data suggest that feces antigen test should be performed in all cases suspected of acute H. pylori infection. Where progress was monitored without eradication therapy, subjective symptoms were exacerbated in some patients, and one patient developed a persistent infection. Consequently, eradication therapy should be performed at an early stage of AGML.

Very rare case of large obstructive myxofibrosarcoma of the right ventricle assessed with multi-diagnostic imaging techniques.

Primary myxofibrosarcoma of the heart is quite rare. We herein present the case of a 56-year-old man who presented with large obstructive myxofibrosarcoma of the right ventricle (RV), as assessed on multi-diagnostic imaging techniques (multidetector row computed tomography, magnetic resonance imaging and positron emission tomography). Most previous cases of cardiac myxofibrosarcoma have been reported in the left atrium and ventricle. In this report, we describe a very rare case of large obstructive myxofibrosarcoma of the RV.

[A case of carcinoma arising in a diverticulum of the transverse colon].

A 64 year-old woman presented with advanced, transverse colon cancer arising in the diverticulum. Tumor invasion extended beyond the serosa to the anal side of the colon. Anemia and fatigue progressed after 6 months of iron administration. The hemoglobin value was 5.3 g/dL and carcinoembryonic antigen (CEA) level was elevated to 44.2 ng/mL. A palpable and tender fist-sized mass was found in the right upper abdomen. Computed tomography (CT) revealed a low-density mass in the transverse colon invading beyond the serosa to the anal side of the colon. Right hemi-colectomy with lymph node dissection was performed. The resected specimen contained multiple diverticula including the one from which the tumor arose. Histological examination revealed a well-differentiated, tubular adenocarcinoma (UICC TNM T4bN0M0) arising in a transverse colon diverticulum. There has been no recurrence for 2 years. Colon cancer arising in a diverticulum may expand to the extra-serosa and easily invade to the adjacent organ. In such cases, malignancy should be considered.

[A case of juvenile colon cancer with peritoneal dissemination treated effectively by use of resection and chemotherapy].

A 37 -year-old man experienced abdominal pain and vomiting. Computed tomography showed massive ascites and obstruction of the colon by a tumor at the left colic flexure. The tumor was classified as advanced Borrmann type 3 on the basis of a colonoscopy. Palliative resection of the colon and colostomy on the oral side were performed. Operative findings showed massive peritoneal dissemination of the tumor. We administered palliative chemotherapy consisting of capecitabine/oxaliplatin (XELOX) and bevacizumab. After 4 courses of chemotherapy, the primary and disseminated tumors and ascites had disappeared, and tumor marker expression levels were within normal range. Palliative resection and subsequent chemotherapy was effective for this young patient with very advanced colon cancer that had disseminated and caused obstruction.

[A case of small intestinal gastrointestinal stromal tumor (GIST) with peritoneal dissemination, treated effectively with molecular target drug after operation].

A 54-year-old man, presenting with sudden onset of abdominal pain, was admitted to our hospital. Blood examination revealed high white blood cell counts and elevated C-reactive protein (CRP) levels. Ultrasonography and computed tomography detected a 12 cm mass in the lower abdomen, some ascites, and multiple small nodules spread through the abdomen. The preoperative diagnosis of the tumor was either a gastrointestinal stromal tumor (GIST) or a possible lymphoma. The 12 cm tumor and greater omentum with multiple nodules were resected. Upon pathological examination, the tumor was diagnosed as a GIST, and appeared KIT positive by immunostaining. After the operation, imatinib was administered; however, psoriasis vulgaris developed within 5 months. As the next line of therapy, sunitinib treatment was initiated; however, since peripheral nerve disorder developed, sunitinib dose was halved and maintained. Two years after the operation, the patient is still alive. Small intestinal GISTs, which make up only 20-30% of all GISTs, are considered to be more malignant than others. We report a rare case of GIST with peritoneal metastases originating from the small intestine, which was treated effectively with molecular target drugs.

[A case of solitary ectopic medullary carcinoma in the right submandibular region].

A 77-year-old woman consulted our hospital because of an indolent mass in the right submandibular region, which developed approximately 4 months previously. Ultrasonography revealed a 19.5×9.2 mm homogeneous low echoic mass in the submandibular region and a 9.8×3.1 mm low echoic mass in the left thyroid lobe. Blood examinations revealed high levels of carcinoembryonic antigen (CEA) and calcitonin. Analysis of the cytological specimens obtained from the submandibular tumors indicated class IV disease. First, we resected the mandibular tumor for diagnosis, and the specimen showed medullary carcinoma. Later, the patient underwent left thyroid lobe resection. The pathological diagnosis was adenomatous goiter. We report a rare case of ectopic medullary carcinoma in the right mandibular region.

[A case of hepatectomy for gastrointestinal stromal tumor with multiple liver metastasis after size reduction in a Jehovah's Witness patient].

The patient is a 42-year-old man who is a Jehovah's Witness. For the duodenal gastrointestinal stromal tumor, duodenal segmental resection and a duodenal jejunum anastomosis were indicated. He took imatinib for 2 years after the operation. After 8 months, recurrent multiple liver metastases were found at S2-3 and S7, which were in contact with the inferior vena cava. Excessive intraoperative bleeding was expected. The patient hoped that a blood transfusion operation would not be required. He took sunitinib to reduce the size of the tumor, and the tumor had become smaller after 8 months. It was possible to resect the tumor without a blood transfusion. The patient has been on imatinib since 1 month after the operation. No recurrence was detected within 1 year of the operation.

[A case of advanced gastric cancer with esophageal severe dysplasia resected after neoadjuvant S-1+cisplatin therapy].

A 72-year-old man was admitted to our hospital complaining of upper abdominal pain and back pain. Advanced gastric cancer was found at the fundus of the stomach, and severe dysplasia was found at the lower esophagus. We proceeded with neoadjuvant chemotherapy (S-1+CDDP) because the lymph nodes in the lesser curvature of the stomach were metastasized and invasion of the pancreas and some vessels was suspected by computed tomography. The tumor size was reduced remarkably, the esophageal dysplasia disappeared after preoperative chemotherapy, and we were able to perform total gastrectomy.

Clinical characteristics of 12 cases of appendiceal diverticulitis: a comparison with 378 cases of acute appendicitis.

PURPOSE: Previous authors have suggested that a diverticulum of the vermiform appendix has a higher risk of perforation than acute appendicitis. Therefore, this study compared appendiceal diverticulitis with acute appendicitis to explain the characteristics of appendiceal diverticulitis. METHODS: Data for this study came from a retrospective analysis at the Department of Surgery at Fukuoka Tokushukai Hospital from January 2005 to June 2008. Twelve cases of appendiceal diverticulitis and 378 cases of acute appendicitis were analyzed. RESULTS: The patients with appendiceal diverticulitis were older than those with acute appendicitis (42.7 ± 15.4 vs. 29.1 ± 17.7; p = 0.009). The white blood cell (WBC) level was lower (11332 ± 4658 vs. 14236 ± 3861; p = 0.011) and the CRP level was higher (8.65 ± 8.94 vs. 4.34 ± 6.34, p = 0.022) in those with appendiceal diverticulitis than in those with acute appendicitis. A preoperative diagnosis for appendiceal diverticulitis was made in 4 out of 12 (33.3%) by ultrasonography (US). The perforation rate was higher in appendiceal diverticulitis than that in acute appendicitis (33.3 vs. 9.8%; p = 0.009). CONCLUSIONS: Appendiceal diverticulitis is more likely to perforate over the progression of the clinical course, which would mandate appendectomy when appendiceal diverticulitis is detected by US, even if the patient has no severe abdominal pain.

Differential transmission and postnatal outcomes in triplets with intrauterine cytomegalovirus infection.

We present a case of triplets with intrauterine cytomegalovirus (CMV) infection, each of whom showed differential transmission, placental pathology, and postnatal outcome. The first- and second-born infants were both vigorous and asymptomatic at birth, although the first-, but not the second-born, triplet had a high copy number of CMV DNA in the peripheral blood (1.2 × 10³ copy/mL). The third-born triplet suffered from symptomatic CMV infection with a high viral load (6.0 × 106 copy/mL). The triamniotic-trichorionic placentas were not fused to each other. The histopathologic analysis showed that CMV-positive cells were frequently found in the decidua, villi, and amnion of the third-born triplet's placenta but were limited and scattered in the decidua or villi but not amnion of the other 2 placentas. The third-born triplet underwent ganciclovir therapy. None of the infants had physical or auditory problems at 4 years of age, whereas the third-born triplet had been diagnosed with an autistic disorder. This observation exemplifies the preventive roles of the individual placentas of triplets with regard to virus infection, thus suggesting that developing CMV disease largely depends on the placental function.

[A case of ruptured gastrointestinal stromal tumor of the duodenum with intraabdominal bleeding].

We report a case of ruptured gastrointestinal stromal tumor (GIST) of the duodenum with intraabdominal bleeding. A 50-year-old man was admitted to our hospital because of sudden epigastralgia. Enhanced computed tomography (CT) showed a tumor measuring about 14 cm in diameter on the ventral side of the right kidney and intrapelvic fluid collection. We performed an emergency operation. At laparotomy, the tumor was originated from the 2nd portion of the duodenum without attaching to the retroperitoneum. We resected the tumor radically. Histopathologically, the tumor arose from the proper muscle layer of the duodenum, and was positive for c-kit and negative for CD34 and α-SMA on immunostaining. Then the tumor was diagnosed as GIST of the duodenum. Adjuvant therapy by imatinib 400 mg/day is now being done because this case is thought to be clinically malignant GIST.

[A case of mucinous adenocarcinoma of descending colon with abscess formation and solitary metastasis at right side of the abdomen].

A 59-year-old man realized a left lower abdominal pain and palpable mass about a month ago. He was admitted to our hospital because of the pain and high fever. Blood examinations revealed high levels of white blood cell count and CRP. Ultrasonography showed a wall thickness of the descending colon and 7 cm cystic mass with air around. Moreover, a 6 cm cystic mass was found an outside of the ascending colon. We first treated with antibiotics under the diagnosis of abscesses because of perforation of diverticulum. Colonoscopy revealed an obstructing tumor in descending colon and biopsy specimens of the tumor showed adenocarcinoma. The preoperative diagnosis of the right side tumor was unclear. We performed a partial resection of the descending colon, and the tumor outside of the ascending colon was resected. The pathological diagnosis of the tumors was both mucinous carcinoma of the colon. Mucinous carcinoma tends to be more found in the right side of the colon than in the left side. The rate of lymph node metastasis and dissemination is higher than that in differentiated adenocarcinoma. We report a rare case of mucinous carcinoma originated from the left side of the colon with a solitary dissemination in opposite side of the abdomen.

Squamous cell carcinoma of the hilar bile duct.

We herein report a rare case of squamous cell carcinoma of the hilar bile duct. A 66-year-old Japanese male patient was admitted to our hospital because of appetite loss and jaundice. Abdominal computed tomography revealed an enhanced mass measuring 10 × 30 mm in the hilar bile duct region. After undergoing biliary drainage, the patient underwent extended right hepatic lobectomy with regional lymph nodes dissection. The tumor had invaded the right portal vein. Therefore, we also performed resection and reconstruction of the portal vein. Histopathologically, the carcinoma cells exhibited a solid structure with differentiation to squamous cell carcinoma with keratinization and intercellular bridges. Immunohistochemical staining of the tumor cells revealed positive cytokeratin staining and negative CAM 5.2 staining. Based on these findings, a definitive diagnosis of well-differentiated squamous cell carcinoma of the hilar bile duct was made.

Suppression of the rice heterotrimeric G protein ß-subunit gene, RGB1, causes dwarfism and browning of internodes and lamina joint regions.

In the present study, we investigated the function of the heterotrimeric G protein ß-subunit (Gß) gene (RGB1) in rice. RGB1 knock-down lines were generated in the wild type and d1-5, a mutant deficient for the heterotrimeric G protein α-subunit (Gα) gene (RGA1). Both transgenic lines showed browning of the lamina joint regions and nodes that could be attributed to a reduction of RGB1 function, as the abnormality was not observed in d1-5. The RGB1 knock-down lines generated in d1-5 were shorter, suggesting RGB1 to be a positive regulator of cellular proliferation, in addition to RGA1. The number of sterile seeds also increased in both RGB1 knock-down lines. These results suggest that Gßγ and Gα cooperatively function in cellular proliferation and seed fertility. We discuss the potential predominant role of RGB1 in G protein signaling in rice.

[A case of giant presacral neurilemoma resected without blood transfusion after embolization of tumor vessels].

A 71-year-old man began feeling a lower abdominal pain at bowel movement about one year ago. He was found to have a pelvic tumor during a health examination and referred to our hospital for further evaluation. CT and MRI scans demonstrated a giant pelvic tumor, 10 cm in size, which compressed the rectum. The likely preoperative diagnosis was leiomyosarcoma from the rectum or neurilemoma. To regulate intraoperative hemorrhaging and to reduce the tumor size, angiography was performed at two days before the operation and embolization of the tumor vessels was done. He had a tumor resection and a low anterior resection of the rectum and a transient colostomy of the ascending colon without blood transfusion. The resected tumor was covered with thin yellowish-white capsule with smooth surface, elastic hard on palpation, and was measured 10.5 × 9 × 10.5 cm, and weighted 320 g. The pathological diagnosis was neurilemoma (schwannoma) consisting both Antoni type A and Antoni type B sections.

[Clinical improvement of membranous nephropathy after a resection of rectal cancer].

A 71-year-old man was admitted by systemically massive edema and advanced rectal cancer. His hemoglobin or serum albumin level was 7.5 g/dL or 1.2 g/dL. Proteinuria ranged from 1.8 to 3.8 g/day. Massive effusion in chest and abdomen was obvious with low oxygenation and unstable hemodynamic state. Renal biopsy showed membranous nephropathy. Abdomino-perineal resection of the rectum was performed. Specimens showed poorly differentiated adenocarcinoma. The classification was type 1, 90 × 85 mm, pAI (seminal grand), pN3, sH0, sP0, cM0: fStage IIIb. The nephrotic syndrome was evidently improved with no urinary excretion of albumin at forty-postoperative day. The perioperative management allowed a surgical resection to be undertaken that led the clinical curability in rectal cancer as well as nephrotic syndrome.

Small multicentric pancreatic carcinoma usefully diagnosed by positron emission tomography.

Pancreatic carcinoma has a poor prognosis, and early detection is essential for potentially curative resection. Despite a wide array of diagnostic tools, pre-operative detection of small pancreatic carcinomas is difficult. We report a case of pancreatic carcinoma that was bicentric and small. The head mass was diagnosed by computed tomography (CT), while the tail mass, which was suspected but indeterminate on CT, was diagnosed by positron emission tomography (PET). Thus, total pancreatectomy was performed. The PET results prevented our patient from undergoing tail mass biopsy, multiple surgeries and non-curative operation.