[A Case of Hepatocellular Carcinoma Evaluated as Complete Response by Combined Lenvatinib and Radiofrequency Ablation Therapy].

We report a case of hepatocellular carcinoma evaluated as complete response by combined lenvatinib and radiofrequency ablation therapy. A 74-year-old man visited our hospital because medical examination abdominal ultrasonography revealed a liver tumor. Abdominal MRI and CT showed a 3.3 cm tumor on the right hepatic vein in segment 7 of the liver, and hepatocellular carcinoma was diagnosed. Lenvatinib was administrated for 6 months, and laparoscopy-assisted radiofrequency ablation was performed as additional treatment. After 1 month, dynamic CT showed the disappearance of intratumoral arterial lesion enhancement and low density lesion area. The therapeutic effect was evaluated as a complete response.

Laparoscopic anatomical liver resection using indocyanine green fluorescence imaging.

BACKGROUND: Anatomical liver resections guided by a demarcation line after portal staining or inflow clamping of the target area have been established as essential methods for curative treatment of hepatocellular carcinoma (HCC) and have subsequently been applied to other malignancies. However, laparoscopic anatomical liver resection (LALR) procedures are very difficult to reproduce, and the confirmation of demarcation of the hepatic segment on a monitor is also challenging. Recently, indocyanine green (ICG) fluorescence imaging has been used to identify hepatic tumors and segmental boundaries during hepatectomy. Herein, we describe LALR using ICG fluorescence imaging. METHODS: Three patients underwent pure LALR using ICG fluorescence imaging at our institute. One patient underwent anatomical partial liver resection for HCC, another underwent segmentectomy 3 for metastatic liver cancer, and the third underwent right anterior sectionectomy for HCC. To visualize hepatic perfusion and the demarcation line by negative staining using an optical imaging system, 2.5 mg ICG was injected intravenously during surgery following clamping or closure of the proximal Glissonean pedicles. RESULTS: For all three cases, ICG fluorescent imaging clearly delineated the demarcation lines and allowed identification of intersegmental planes to some extent because the tumor-bearing hepatic region became non-fluorescing parenchyma during parenchymal transection. This allowed surgeons to recognize the direction and guide the transection of the liver parenchyma when performing LALR. CONCLUSION: LALR using ICG fluorescence imaging is a feasible procedure for resection of the tumor-bearing hepatic region and facilitates visualization of the demarcation line and identification of the boundaries of the hepatic sections.

Case of resected multiple hepatocellular adenomas in a young man with severe obesity.

BACKGROUND: Hepatocellular adenoma (HCA) is a rare liver tumor that has the potential for rupture and malignant transformation. Here, we report a case of multiple hepatocellular adenomas (HCAs) that were treated by surgical resection. CASE PRESENTATION: An 18-year-old man was admitted to our hospital with proteinuria. His height was 176.5 cm, weight was 126 kg, and body mass index was 40 kg/m2. A liver tumor was incidentally found on abdominal ultrasonography. Contrast-enhanced computed tomography and gadoxetic acid-enhanced magnetic resonance imaging revealed three hepatic tumors that were 68 mm, 16 mm, and 9 mm in segments 3/4, 8, and 1, respectively. A percutaneous needle biopsy of the largest tumor was performed, the diagnosis of unclassified type HCA was made, and laparoscopic partial liver resection was performed of all three. The postoperative course was uneventful, and the patient was discharged 12 days later. An immunohistochemical examination revealed positivity for serum amyloid A protein, no decrease in fatty acid-binding protein, and negativity for ß-catenin, glutamine synthetase, and cytokeratin 7. Therefore, these tumors were diagnosed as inflammatory type HCAs. CONCLUSIONS: We reported an extremely rare case of multiple resected HCAs in a young, obese Japanese man. Our findings suggest that HCA should be considered in the differential diagnosis of liver tumor in obese patients. Further studies that consider clinical and molecular risk factors are required to establish individualized treatment plans for HCA in obese patients.

Laparoscopic transabdominal preperitoneal approach for giant inguinal hernias.

BACKGROUND: Many surgical techniques have been developed to treat inguinal hernia. In recent years, the laparoscopic transabdominal preperitoneal (TAPP) approach has been widely performed to repair inguinal hernia. Giant inguinal hernia (GIH) is an extremely rare disease that is a challenge for general surgeons. GIH appears when patients neglect the treatment for many years and it is defined as an inguinal hernia that extends below the midpoint of inner thigh in standing position. According to previous publications, the Lichtenstein tension-free hernioplasty is recommended to repair GIH. In this article, we describe consecutive four cases of GIH repaired via the TAPP approach. METHODS: From April 2015 to March 2017, 200 patients underwent hernioplasty against inguinal hernia at our hospital. Inguinal hernias were treated via the TAPP approach in principle. We performed hernioplasty via the TAPP approach in all 4 patients (2%) who met the definition of Type 1 GIH. Demographic information, maximum diameter of hernia sac, hernia orifice size, and surgical data were obtained. RESULTS: The mean operative time was 135 min. No intraoperative complications were encountered. All patients could walk from postoperative day 1 and were discharged home early, but they all had scrotal seromas. Three patients did not need puncture or drainage, but one of them required puncture. All seromas disappeared within 6 months. There was no recurrence in the 8- to 24-month follow-up. CONCLUSION: The TAPP approach is a feasible, safe therapeutic option that may reduce wound size and pain following surgical treatment of Type 1 GIH.

A resected case of gallbladder metastasis with symptoms of acute cholecystitis in multiple metastatic ductal carcinoma of the breast.

Gallbladder metastasis from breast cancer, especially from ductal carcinoma, is rare. Herein, we report a rare case of gallbladder metastasis from ductal carcinoma of the breast that was diagnosed after laparoscopic cholecystectomy (LC) for acute cholecystitis. A 78-year-old woman presented with right upper abdominal tenderness and positive Murphy's sign during chemotherapy for advanced multiple metastases of the breast cancer. Abdominal ultrasonography and computed tomography showed a slightly thickened gallbladder wall and two calculi. After a diagnosis of acute calculous cholecystitis was established, LC was performed. Pathological examination revealed poorly differentiated adenocarcinoma infiltrating the submucosal and subserosal layer over the entire gallbladder, and a lymph node metastasis in the gallbladder neck. Immunohistochemical examination revealed that the tumor cells tested positive for estrogen receptor and negative for progesterone receptor, which was consistent with primary breast cancer. The patient was uneventfully discharged without abdominal pain 7 days later. Although she subsequently underwent several chemotherapies, she died 16 months later. In conclusion, gallbladder metastasis should be considered in patients with multiple metastatic breast cancer who present with signs or symptoms of cholecystitis. Moreover, LC should be considered to relieve the symptoms of cholecystitis for improved prognosis, even in a patient with multiple metastases.

Omental abscess due to a spilled gallstone after laparoscopic cholecystectomy.

Omental abscess due to a spilled gallstone is extremely rare after laparoscopic cholecystectomy. Herein, we report a 68-year-old man who presented with left upper abdominal pain after laparoscopic cholecystectomy for gangrenous cholecystitis. Seven months prior to admission, gallbladder perforation with spillage of pigment gallstones and bile occurred during laparoscopic cholecystectomy. The spilled gallstones were retrieved through vigorous peritoneal lavage. Abdominal computed tomography showed a 3 × 2.5 cm intra-abdominal heterogeneous mass, suspected to be an omental abscess, and ascites around the spleen. Exploratory laparoscopy revealed an inflammatory mass within the greater omentum. Laparoscopic partial omentectomy and abscess drainage were performed, and a small black pigment gallstone was unexpectedly found in the whitish abscess fluid. Abscess fluid culture results were positive for extended-spectrum ß-lactamase-producing Escherichia coli and Streptococcus salivarius, which were previously detected in the gangrenous gallbladder abscess. The histopathological diagnosis was abscess in the greater omentum. Postoperative course was uneventful, and the patient was discharged 13 days later. In conclusion, we report a successful case of laparoscopic management of an omental abscess due to a spilled gallstone after LC. It is important to attempt to retrieve spilled gallstones during LC because they may occasionally result in serious complications.

[A case of erythema multiforme induced by regorafenib therapy for metastatic colon cancer].

A 47-year-old woman underwent colectomy for advanced colon cancer and thereafter received regorafenib therapy as fourth-line chemotherapy. On treatment day 12, the patient developed erythema multiforme (EM) induced by the regorafenib therapy. Immediately after regorafenib was withdrawn, the patient was treated with oral bepotastine and steroid ointment, which relieved the EM without progressing to Stevens-Johnson syndrome (SJS). Regorafenib is used for third- or fourth-line chemotherapy. Progression of regorafenib-induced EM to SJS may cause critical dysfunction among patients. Before administering regorafenib therapy, the patient should be made aware of this potential adverse effect and be advised to withdraw the treatment and visit the hospital immediately if symptoms of EM are observed.

[Pathological complete response in a large gastric GIST that became resectable after neoadjuvant chemotherapy with imatinib mesylate].

We report a case of a large gastric gastrointestinal stromal tumor (GIST), which became resectable and achieved pathological complete response after neoadjuvant chemotherapy with imatinib mesylate. A 59-year-old man presented with left hypochondrial pain. Abdominal computed tomography (CT) revealed gastric GIST invading the spleen and the diaphragm. Administration of imatinib mesylate was initiated as neoadjuvant chemotherapy. Six months after neoadjuvant chemotherapy with imatinib mesylate, abdominal CT revealed a reduction in tumor size. We judged the tumor resectable and performed partial gastrectomy and splenectomy. Histologically, number of myofibroblasts increased, but no viable tumor cells were observed. Pathological complete response was obtained.

[Successful chemoradiation therapy for local control of rectal cancer with multiple bone metastases--a case report].

A 78-year-old man was admitted to our institute with the symptom of melena. The patient was diagnosed as having advanced rectal cancer (T4N2M1) with multiple bone metastases. Chemoradiation therapy was chosen for the local control because our proposal of colostomy was rejected. Concurrent chemoradiation therapy [46 Gy/23 Fr+tegafur/uraci (l UFT 400 mg/m2)/calcium folinate (Leucovorin: LV 75 mg/body)] resulted in a good partial response and the patient became asymptomatic. UFT/LV were administrated and most of the bone metastases were diminished. After 3 years of disease remission with good quality of life, local tumor recurred with the symptoms of melena and bowel obstruction. Colostomy and additional radiotherapy were performed for the palliation. He died after 4 years from the initial treatment. In advanced rectal cancer with distant metastases, chemoradiation therapy for local control plus systemic chemotherapy could be an alternative to improve quality of life.

Adenocarcinoma arising in a tubular duplication of the jejunum.

To our knowledge, only five cases of malignant changes in small-bowel duplication have been reported previously in the English-language literature, and these were found only in ileal duplications. We describe a unique case of adenocarcinoma arising in a tubular duplication of the jejunum; this is the oldest patients in whom malignant tumor of alimentary tract duplication has been reported. A 73-year-old man was admitted to our hospital because of lower abdominal pain. Computed tomography (CT) and ultrasonography showed two abdominal masses; one, about 5 cm in size, was observed in the upper abdomen, the superior mesenteric artery (SMA) and the other, which was a well-demarcated heterogeneous mass, was revealed in the lower abdomen. Laparotomy revealed the mass in the upper abdomen involved the SMA and transverse colon, while the mass in the lower abdomen was of white globular form, ping-pong ball size, in the jejunal serosa approximately 40 cm on the anal side from Treiz's ligament. Transverse colostomy and a partial jejunectomy were performed, and the tumor was resected. Histologically, the diagnosis was adenocarcinoma arising in a tubular duplication of the jejunum. The patient died of necrosis and perforation of the intestine due to obstruction of the SMA 7 months after the surgery. Autopsy revealed that the upper abdominal mass consisted of metastatic foci associated with the lymph node of the SMA.

[A case of hydronephrosis associated with appendiceal abscess].

An appendiceal abscess was complicated with right hydronephrosis in a 76-year-old woman who complained of general fatigue and fever. Ultrasonography demonstrated right hydronephrosis, and retrograde pyelography confirmed the hydronephrosis and showed ureteral stenosis. Computed tomography scan revealed a low-density area measuring 38 x 35 mm in size, anterior to the right ureter. Ureteroscopy and the biopsy of the mucosa was carried out, but malignant cells were not found. An exploratory laparotomy was performed. The mass had developed from the cecum and involved the ureter, requiring ileocecal excision, left partial ureterectomy and ureteric substitution with a Boari's flap. The histological diagnosis was an appendiceal abscess. The postoperative course was uneventful.