ß-Catenin-activated inflammatory hepatocellular adenoma with pigmentation and atypical features: a case report.

Hepatocellular adenomas are rare diseases, defined as benign liver neoplasms composed of cells with hepatocellular differentiation. Differential diagnosis of hepatocellular adenoma from other lesions, including focal nodular hyperplasia and hepatocellular carcinoma, is crucial to determine treatment strategy. We describe a case of ß-catenin-activated inflammatory hepatocellular adenoma with malignant transformation. A 50-year-old man with a suspected liver tumor, based on abdominal ultrasonography findings, was referred to our hospital. Contrast-enhanced computed tomography and magnetic resonance imaging revealed a liver tumor in S2 which was enhanced in the arterial phase to the delayed phase. Based on diagnostic imaging findings, hepatocellular adenoma or focal nodular hyperplasia was suspected. We considered the possibility of malignant potential because of the enlargement of the lesion. Thus, we performed a laparoscopic hepatectomy. Histological examination showed pigment deposition in the hepatocytes, which was determined to be lipofuscin. Mild nuclear swelling and atypia in the tumor area indicated nodular growth. Based on the histological and immunohistochemical findings, the diagnosis was ꞵ-catenin-activated inflammatory hepatocellular adenoma with atypical features. The imaging features of hepatocellular adenoma and focal nodular hyperplasia are similar, but if the tumor tends to grow, surgical treatment should be performed because of the possibility of malignant hepatocellular adenoma.

[A Case of Stage â £ Gastric Cancer Treated with Conversion Surgery after Chemotherapy].

A case is a female of 61-year-old. She visited her local doctor with a chief complaint of frequent burping. She was hospitalized for gastric cancer with pyloric stenosis. Although open gastrectomy was planned the gastric cancer was unresectable due to pancreatic invasion and peritoneal dissemination. Cytology with abdominal lavage was CY0. She underwent gastrojejunostomy. She was treated by 19 courses of chemotherapy with SOX therapy for 2 years. The tumor reduced, and she underwent distal gastrectomy as conversion surgery. Pathological findings were por2>muc>tub2>tub1, ypT2(ypMP), INF c, int, Ly1a, V0, pPM0, pDM0, pN0(0/43), ypStage ⅠB, R0, Grade 2b. Adjuvant chemotherapy(S-1 and docetaxel)was administered after conversion surgery. She is alive without recurrence for 1 year and 6 months after gastrectomy. We report a case of Stage Ⅳ gastric cancer treated with conversion surgery after chemotherapy.

[Three Cases of Conversion Surgery for Unresectable Advanced Gallbladder Cancer with Distant Metastasis Treated with Gemcitabine plus CDDP].

All three patients were female, one in her 50s, and the other two in their 60s. The one in her 50s had liver metastasis and the other two had unresectable advanced cholecystic carcinomas with peritoneal dissemination. All three received 8-12 courses of gemcitabine plus CDDP(GC). After GC, all three were deemed to be candidates for R0 resection and underwent resection of two central liver segments. In addition, the second patient required an extrahepatic cholangiectomy; an extended cholecystectomy, plus an extrahepatic cholangiectomy, plus a complete omental resection; and the third needed an extended cholecystectomy, plus an extrahepatic cholangiectomy with a partial transverse colon resection, plus a partial duodenectomy. The pathologic response to chemotherapy was moderate in the patient with liver metastases, mild in the one who underwent the omental resection, and moderate in the patient who had the partial resection of the digestive tract. All three patients continued with postoperative chemotherapy. The patient with liver metastases and the one with the partial gastrointestinal tract resection have survived without recurrence for 52 months and 43 months, respectively, after the initial treatment. The patient with the omental resection has survived 44 months after the initial treatment with recurrent peritoneal dissemination and is continuing chemotherapy as an outpatient. Although further study is needed to accumulate more cases, the results suggest the usefulness of multidisciplinary treatment including conversion surgery in cases such as these.

Conversion surgery following gemcitabine plus cisplatin therapy for initially unresectable gallbladder cancer with peritoneal carcinomatosis: a case report.

BACKGROUND: Conversion surgery, which is defined as chemotherapy or chemoradiotherapy followed by radical surgery, may improve survival of patients with initially unresectable advanced biliary tract cancer, including gallbladder cancer. However, there are few reports on conversion surgery for advanced gallbladder cancer. CASE PRESENTATION: A 69-year-old woman was referred to our hospital with initially unresectable gallbladder cancer with peritoneal carcinomatosis. She underwent gemcitabine plus cisplatin therapy for 9 months. Extended cholecystectomy, resection of the extrahepatic bile duct with regional lymph node dissection, and total omentectomy were then performed as conversion surgery. The patient has survived without recurrence for 19 months postoperatively (31 months after the initial diagnosis) while continuing chemotherapy. CONCLUSIONS: This case suggests that conversion surgery for advanced gallbladder cancer is effective and may be curative for locally advanced disease and distant metastasis such as peritoneal carcinomatosis.

[Gallbladder Cancer with Multiple Liver Metastases Completely Responding to Gemcitabile plus Cisplatin Chemotherapy-A Case Report].

A 59-year-old man was diagnosed with cholecystolithiasis and cholecystitis and underwent cholecystectomy. The pathological findings were moderately differentiated adenocarcinoma(pT2)in the gallbladder fundus. Sixteen days after surgery, he visited our hospital due to jaundice. Abdominal enhanced CT and EOB-MRI revealed multiple liver metastases and lymph node metastases in the hepatoduodenal ligament that we deemed to be unresectable. A metallic stent was inserted for bile duct obstruction, and he underwent chemotherapy with gemcitabine plus cisplatin(GC). After 12 courses of GC, the metastatic lesions disappeared, and the patient showed complete response. FDG-PET/CT showed FDG uptake in the hepatoduodenal ligament and we subsequently decided to perform surgery. He underwent resection of the extrahepatic bile duct and regional lymphadenectomy. The pathological findings revealed no residual carcinomas in the bile duct or lymph nodes. We are continuing chemotherapy at present, and the patient is alive with no signs of recurrence at 1 year and 3 months following the diagnosis of multiple liver metastases.

[A Case of Liver Recurrence of Choriocarcinoma and AFP-Producing Carcinoma of the Stomach Showing a Complete Histological Response after Chemotherapy].

A 65-year-old man was hospitalized for gastric cancer. Abdominal computed tomography detected lower gastric cancer and invasion of the liver. Initial laboratory data showed high levels of serum AFP(2,688.6 ng/mL). He underwent distal gastrectomy with left lobectomy of the liver and cholecystectomy. Histology confirmed that the tumor consisted of 2 components: primary gastric choriocarcinoma and AFP-producing carcinoma. The pathological staging was pT4b(liver), N3aM0, Stage ⅢC. After surgery, AFP levels decreased to within the normal limits. Adjuvant chemotherapy(S-1)was administered for 1 year after the operation. Fourteen months later, PET-CT and EOB-MRI detected liver recurrence. He was treated with weekly paclitaxel(PTX)chemotherapy for the liver recurrence. After 12 courses, the tumor had disappeared. The patient was continuously treated with weekly PTX and is doing well without recurrence 24 months after the resection of the liver tumor. Co-existence of primary gastric choriocarcinoma and AFP-producing carcinoma is very rare. We report a case of liver recurrence of choriocarcinoma and AFP-producing carcinoma of the stomach showing a complete histological response after chemotherapy.

[A Case of Multiple Lymph Node Metastases Treated with Nivolumab after an Adrenalectomy for Solitary Adrenal Metastasis of Gastric Cancer after a Gastrectomy].

A 69-year-old man was hospitalized for gastric cancer. He underwent total gastrectomy with distal pancreatectomy, splenectomy, and cholecystectomy. Pathological staging was pT3N3aM0 and Stage ⅢB. Adjuvant chemotherapy(S-1)was administered postoperatively. Ten months later, left adrenal metastasis was detected on computed tomography(CT)scans. He was then treated with 4 courses of chemotherapy with SOX therapy and 2 courses of PTX plus RAM therapy for the left adrenal metastasis. However, the tumor size increased. He underwent adrenalectomy with left nephrectomy and partial resection of the transverse colon for the solitary adrenal metastasis. His pathological diagnosis was metastatic carcinoma of the left adrenal gland and lymph nodes, which invaded the left renal vein and originated from gastric carcinoma. Three months after the adrenalectomy, CT scans identified paraaortic, porta hepatis, and left supraclavicular lymph node metastases. The patient was continuously treated with nivolumab, for 20 courses, and is doing well with good PS. Adrenalectomy for solitary adrenal metastasis of gastric cancer very rarely occurs. We report a case of multiple lymph node metastases treated with nivolumab after an adrenalectomy for solitary adrenal metastasis of gastric cancer after a gastrectomy.

[Successful Treatment of Necrotizing Fasciitis Due to Ascending Colon Cancer-A Case Report].

A 70-year-old woman was brought to our hospital by ambulance because of severe groin pain on the right side. Computed tomography scan revealed a tumor in the ascending colon, intraperitoneal abscess spread to the subcutaneous tissues, and a large amount of pneumoderma. She was diagnosed with necrotizing fasciitis caused by penetration of ascending colon cancer and underwent lavage and drainage, right hemicolectomy, end ileostomy, and debridement of necrotic tissues on emergency. Postoperatively, she underwent debridement and irrigation at the bedside every day, but the necrotizing tissues spread. Debridement under general anesthesia was repeated on postoperative day 8. On postoperative day 20, negative pressure wound therapy(NPWT)was initiated to manage the exudates and wound condition, and healthy granulation tissues formed gradually. After 4 weeks, she underwent split-thickness skin graft implantation. The postoperative course was uneventful, and she was discharged from the hospital. She is currently on chemotherapy and has been alive for 1 year and 3 months after the first operation.

[A Case of Locally Advanced Pancreatic Cancer Successfully Resected after S-1 Therapy in an Elderly Patient].

We report a case of locally advanced pancreatic body cancer, accomplishing R0 resection following preoperative chemotherapy. An 80-year-old female patient was admitted to our hospital because of high CA19-9 levels.Based on computed tomography images, she was diagnosed with locally advanced cancer of the pancreatic body.We started S-1 chemotherapy (100mg/day, 2 weeks administration 1 week rest)because the tumor was suspected to have invaded the celiac trunk and the common hepatic artery.The tumor decreased in size, and the encasement of the celiac trunk and the common hepatic artery were released, following 6 months of chemotherapy.Subsequently, distal pancreatectomy with D2 lymph node dissection was performed.The patient was healthy and showed no signs of recurrence 5 years and 9 months after surgery.

[Evaluation of the Therapeutic Effect of Using Dual-Energy CT for Rectal Cancer after Neoadjuvant Chemotherapy].

It is difficult to know the effects of preoperative treatment on advanced rectal cancer even if using a variety of diagnostic imaging modalities. We report the efficacy of evaluating the therapeutic effect of using dual-energy CT(DECT)against rectal cancer after neoadjuvant chemotherapy(NAC). The subject sample consisted of1 1 patients who underwent rectal cancer surgery after NAC from September 2015 to January 2016. The pathological effective grade was higher if the after/before ratio ofcontrast enhancement on DECT was small(Grade 1a: 1.4, Grade 1b: 0.8, Grade 2: 0.4, Grade 3: 0.3). Therefore, a successful response rate occurred if blood flow was reduced after NAC. In this study, it was possible to predict the pathological response grade for rectal cancer via contrast enhancement using DECT.

[Laparoscopic Lateral Lymph Node Dissection for Rectal Cancer with Lateral Lymph Node Metastasis - A Case Report].

BACKGROUND: Lateral lymph node dissection(LLND)for locally advanced lower rectal cancer is the standard treatment procedure in Japan. We performed LLND with an extraperitoneal approach. Recently, we introduced laparoscopic surgery for locally advanced rectal cancer and laparoscopic LLND. We performed laparoscopic LLND in a patient havinglower rectal cancer with lateral lymph node metastasis that was detected via preoperative imaging. CASE PRESENTATION: The patient was a woman in her 50s who experienced melena and visited a physician. Colonoscopy revealed a tumor in the lower rectum and computed tomography showed lateral lymph node swelling and liver metastasis. The patient was referred to our institution and she was diagnosed with lower rectal cancer having lateral lymph node and synchronous liver metastases. We performed laparoscopic abdominoperineal resection and laparoscopic LLND. The operatingtime was 260 min, and the blood loss was 60g. CONCLUSION: The magnification of laparoscopy enables precision in the surgical operation of the narrow pelvis during lymph node dissection, allowingautonomic nerve preservation. Therefore, laparoscopic LLND is a helpful procedure in the treatment of locally advanced rectal cancer with a lateral lymph node metastasis.

[A Case of Laparoscopic Surgery for Rectal Cancer with Synchronous Lung Metastases after Chemotherapy].

A woman in her 70's presented with the predominant complaint of bloody stools. She was diagnosed with rectal cancer, and bilateral lymph node and pulmonary metastases were detected on computed tomography(CT). The patient was diagnosed with cT3N3M1a, cStage IV disease. After undergoing a colostomy, the patient was treated with S-1 plus oxaliplatin (SOX), and bevacizumab(Bev). A second CT scan obtained after completion of 7 courses of chemotherapy revealed that the lung metastases had significantly reduced or disappeared. Approximately 7 months after initial treatment, the patient underwent a laparoscopic Hartmann procedure to remove the tumor. The patient is currently under observation while being administered postoperative adjuvant chemotherapy as an outpatient in our department. There is currently no evidence of the safety of laparoscopic-assisted rectal cancer surgery for first-time Stage IV cases. However, when tumor regression has been achieved with chemotherapy, it may be an effective option.

[A Case of Pathological Complete Response after Neoadjuvant Chemotherapy(S-1 plus Oxaliplatin)and Laparoscopic Low Anterior Resection for Rectal Cancer].

We report a case of pathological complete response after neoadjuvant chemotherapy(NAC)(S-1 plus oxaliplatin)for rectal cancer. The patient was a 50-year-old man who had type 3 circumferential rectal cancer. An abdominal CT scan revealed locally advanced rectal cancer(cT3N2H0P0M0, cStage III b)with severe stenosis and oral-side intestinal dilatation. The patient was treated with NAC after loop-ileostomy. After 3 courses of chemotherapy, a CT scan revealed significant tumor reduction. Laparoscopic low anterior resection and bilateral lymph node dissection were performed 5 weeks after the last course of chemotherapy. The pathological diagnosis was a pathological complete response(no residual cancer cells). This case suggests that laparoscopic low anterior resection after NAC with S-1 plus oxaliplatin for locally advanced rectal cancer is a potentially effective procedure.

Vimentin expression of esophageal squamous cell carcinoma and its aggressive potential for lymph node metastasis.

Esophageal squamous cell carcinoma (ESCC) has been generally considered as one of the most aggressive cancers with poor prognosis. Vimentin is the major protein constituent of intermediate filaments in normal and neoplastic mesenchymal cells, and has been regarded as a marker of epithelial-mesenchymal transition (EMT). However, little is known about ESCC with vimentin expression as a marker of EMT. In this study, we analyzed vimentin expression in 129 cases of ESCC in order to elucidate whether vimentin expression is correlated with clinicopathological features and aggressive behavior of ESCC. Vimentin expression was identified in 96 of the 129 cases (74.4%). The cases with vimentin-positive carcinoma cells showed a significantly higher incidence of lymph node metastasis (P = 0.001). Carcinomas with vimentin expression were more advanced in terms of tumor status and lymphatic invasion (P = 0.001, P = 0.009, respectively), and associated with stronger stromal alpha-smooth muscle actin (alpha-SMA) expression (P < 0.001). Vimentin expression was also associated with distant metastasis, including distant node metastasis (P = 0.014). Vimentin expression in both primary and metastatic carcinomas was found in 68.6% (48/70) of the cases, while no vimentin expression in both primary and metastatic carcinomas comprised 92.3% of the cases (12/13) (P < 0.001). In conclusion, we demonstrated that vimentin expression in ESCC is an independent predictor of lymph node metastasis (multivariate analysis, P = 0.014, odds ratio: 3.314, 95% confidence interval: 1.276-8.605). In addition, vimentin expression was frequently retained in metastatic carcinoma of the lymph node.

[Predictive factors for histopathological liver injury in the patients who received preoperative systemic chemotherapy for colorectal liver metastases].

The operation for liver metastases from colorectal cancer is increasing due to a progress of chemotherapy. On the other hand, the live damage induced by chemotherapy affects on post operative course. We studied histopathological liver injury on the patients who received preoperative chemotherapy. Between January 2004 and May 2009, forty seven patients underwent hepatectomy for colorectal liver metastases after systemic chemotherapy, and the remnant liver was histopathologically investigated about sinusoidal dilatation and non-alcoholic steatohepatitis. As a result, chemotherapy including irinotecan or oxaliplatin was significantly associated with sinusoidal dilatation, and female gender or higher body mass index was correlated with non-alcoholic steatohepatitis. These results should be taken into consideration before liver resection in patients who have received preoperative chemotherapy.

Expression of syndecan-1 and E-cadherin is inversely correlated with poor patient's prognosis and recurrent status of extrahepatic bile duct carcinoma.

Extrahepatic bile duct carcinoma is one of the most extremely aggressive cancers with poor prognosis after curative resection. Syndecan-1 and E-cadherin are transmembrane glycoproteins, and have important roles in cell-cell adhesion and tumor progression. In this study, we examined 84 surgically resected cases of extrahepatic bile duct adenocarcinoma to clarify clinicopathological significance of syndecan-1/E-cadherin expression. Reduced expressions of syndecan-1 and Ecadherin were found in 69.0% (58/84) and 46.4% (39/84) of the bile duct carcinomas. Reduced syndecan-1 expression was correlated with lymphatic/venous/nervous invasion (P < 0.0001), and was associated with short overall survival (P = 0.0002). Reduced E-cadherin expression was correlated with lymphatic and nervous invasion (P = 0.008, P < 0.0001, respectively), and was associated with short overall survival (P = 0.0038). The results indicated that reduced syndecan-1/E-cadherin expression may be good indicators of recurrence and prognosis in extrahepatic bile duct carcinoma.

Resection of a locally advanced hilar tumor and the hepatic artery after stepwise hepatic arterial embolization: a case report.

We herein report a case of a hilar tumor with extensive invasion to the proper hepatic artery, which was successfully treated with a radical resection in a 57-year-old female patient after a stepwise hepatic arterial embolization. She underwent right colectomy and partial hepatectomy for advanced colon cancer two years ago and radiofrequency ablation therapy for a liver metastasis one year ago, respectively. A recurrent tumor was noted around the proper hepatic artery with invasion to the left hepatic duct and right hepatic artery 7 mo previously. We planned a radical resection for the patient 5 mo after the absence of tumor progression was confirmed while he was undergoing chemotherapy. To avoid surgery-related liver failure, we tried to promote the formation of collateral hepatic arteries after stepwise arterial embolization of the posterior and anterior hepatic arteries two weeks apart. Finally, the proper hepatic artery was occluded after formation of collateral flow from the inferior phrenic and superior mesenteric arteries was confirmed. One month later, a left hepatectomy with hepatic arterial resection was successfully performed without any major complications.

Intraoperative ultrasound as an educational guide for laparoscopic biliary surgery.

AIM: To analyze the efficacy of routine intraoperative ultrasound (IOUS) as a guide for understanding biliary tract anatomy, to avoid bile duct injury (BDI) after laparoscopic cholecystectomy (LC), as well as any burden during the learning period. METHODS: A retrospective analysis was performed using 644 consecutive patients who underwent LC from 1991 to 2006. An educational program with the use of IOUS as an operative guide has been used in 276 cases since 1998. RESULTS: IOUS was highly feasible even in patients with high-grade cholecystitis. No BDI was observed after the introduction of the educational program, despite 72% of operations being performed by inexperienced surgeons. Incidences of other morbidity, mortality, and late complications were comparable before and after the introduction of routine IOUS. However, the operation time was significantly extended after the educational program began (P < 0.001), and the grade of laparoscopic cholecystitis (P = 0.002), use of IOUS (P = 0.01), and the experience of the surgeons (P = 0.05) were significant factors for extending the length of operation. CONCLUSION: IOUS during LC was found to be a highly feasible modality, which provided accurate, real-time information about the biliary structures. The educational program using IOUS is expected to minimize the incidence of BDI following LC, especially when performed by less-skilled surgeons.