Duodenal tuberculosis with gastric outlet obstruction: a case report of successful diagnosis and treatment, with review of literature.

BACKGROUND: Duodenal tuberculosis (TB) is extremely rare, and its diagnosis is challenging owing to the lack of specific symptoms and radiological or endoscopic findings. When it leads to gastric outlet obstruction (GOO), diagnosing it accurately and providing appropriate treatment is crucial. However, this is often overlooked. CASE PRESENTATION: A 35-year-old man presented with abdominal pain, fullness, vomiting, and weight loss. Upper gastrointestinal endoscopy and radiography revealed nearly pinpoint stenosis with edematous and reddish mucosa in the D1/D2 portion of the duodenum. Computed tomography (CT) showed the duodenal wall thickening, luminal narrowing, multiple enlarged abdominal lymph nodes, and portal vein stenosis. Conventional mucosal biopsy during endoscopy revealed ulcer scars. We initially suspected stenosis due to peptic ulcers; however, chest CT revealed cavitary lesions in both lung apices, suggesting tuberculosis. Due to the suspicion of duodenal TB and the need to obtain deeper tissue samples, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed. The tissue sample showed caseating granulomas with multinucleated giant cells, and acid-fast bacilli were positive by Ziehl-Neelsen staining. The patient was diagnosed with duodenal TB and subsequent GOO. Because the patient had difficulty eating, surgical intervention was prioritized over antitubercular drugs, and laparoscopic gastrojejunostomy was performed. The patient started an oral diet on the 3rd postoperative day and began antitubercular treatment immediately after discharge on the 11th day. During the 6th month of treatment, endoscopic examination revealed residual duodenal stenosis; however, the bypass route functioned well, and the patient remained asymptomatic. CONCLUSIONS: An aggressive biopsy should be performed to diagnose duodenal TB. EUS-FNA has proven to be a useful tool in this regard. Both nutritional improvement and antitubercular treatment were achieved early and reliably by performing laparoscopic gastrojejunostomy for duodenal TB with GOO.

A new method to optimize resection area using a radiation treatment planning system and deformable image registration for breast-conserving surgery after neoadjuvant chemotherapy.

BACKGROUND: We devised a breast-conserving surgery (BCS) utilizing a new image-processing and projection technique using a radiation treatment planning system (RTPS) and deformable image registration (DIR) for patients with breast cancer after neoadjuvant chemotherapy (NAC). RTPSs and DIR are commonly used in planning radiation treatment. The purpose of this pilot study was to evaluate the feasibility of our procedure. PATIENTS AND METHODS: Twenty-six patients diagnosed with breast cancer underwent NAC and BCS between November 2014 and May 2020. Multidetector-row computed tomography was performed in the same position used for surgery before and after NAC. In the DIR, CT before NAC was fused to CT after NAC. The RTPS simulated the design of tumor excision, and excision area was projected onto the breast skin utilizing an irradiation device. RESULTS: In 26 patients with breast cancer after NAC, BCS was performed using the processing and projection technique of the RTPS with DIR. Only 1 of 26 patients showed carcinoma present in the surgical margins, and subsequently developed ipsilateral breast tumor recurrence. Mean excised volume was 33.5 cm3 (range, 12.8-62.8 cm3), and percent breast volume excised was 6.8% (range, 2.5-15.7%). CONCLUSIONS: This pilot study confirmed the simplicity and utility of our procedure for minimally invasive BCS in patients with breast cancer after NAC. We will keep evaluating the safety and efficacy of our procedure in more patients.

[Inflammatory Breast Cancer Treated with Multidisciplinary Treatment-A Report of Two Cases].

Case 1: A 77-year-old woman presented with redness and swelling with a peau d'orange appearance in the whole left breast. She was diagnosed with inflammatory breast cancer(T4dN1M0, stage ⅢB of the basal-like subtype). Four courses of FEC followed by 4 courses of docetaxel as the primary systemic therapy were effective. She underwent mastectomy and axillary dissection, and pathological examination revealed a partial response. She received radiation therapy after surgery. At present, 5 years after surgery, the patient is alive without recurrence. Case 2: A 46-year-old woman presented with redness and swelling with a peau d'orange appearance in the whole left breast and edema of the left arm. She was diagnosed with inflammatory breast cancer(T4dN3M1, stage Ⅳ of the HER2 subtype)with bone metastasis and cancerous pleurisy. After 4 courses of FEC as the primary systemic therapy, the breast tumor disappeared, but pleural effusion persisted. Subsequent chemotherapy with pertuzumab, trastuzumab, and docetaxel was effective, as computed tomography showed no lesions. She underwent mastectomy and axillary dissection, and pathological examination revealed a complete response. She received radiation therapy after surgery. At present, 2 years after surgery, the patient is alive without recurrence.

[Study of Phyllodes Tumor of the Breast in 44 Cases of Resection].

Phyllodes tumor is a rare interstitial and epithelial mixed tumor which constitutes 0.3-0.9% of all breast tumors. It is classified into benign, borderline malignant, and malignant. Differentiating this from fibroadenoma is difficult, however, when diagnosed, complete surgical resection is recommended. Patients and results: Forty-four patients who underwent surgery between April 2009 and April 2020 and were diagnosed with phyllodes tumors and the median observation period was 44 months. The average tumor diameter was 39.2 mm, and the surgical procedures performed were mastectomy in 3 cases, partial resection in 26 cases, and extirpation in 15 cases. The surgical margin was positive in 6 cases. Intra-breast recurrence occurred in 4 cases, of which the initial surgery in 3 cases was extirpation. The pathological diagnosis was malignant in 4 cases, malignant in 15 cases, and benign in 25 cases. Conclusion: In this study, intra-breast recurrence occurred in many cases treated by extirpation, and it was considered that the surgical technique for complete resection such as partial resection should be selected.

[A Case Report on Laparoscopic Duodenal Sleeve Resection of GIST at a Distal Portion from the Papilla Vater].

A 21-year-old woman was admitted for preshock due to severe anemia. A 5 cm gastrointestinal stromal tumor(GIST)at the jejunal flexure of her duodenum was diagnosed by enhanced CT examination. We performed a total laparoscopic pancreas- preserving duodenal sleeve resection with a 2 cm margin from the tumor. Functional end-to-end anastomosis was done with the patient lying in a right half lateral decubitus position in order to shift the weight of the tumor and duodenal mesentery to the right to prevent surgical capsule damage. We experienced one case(5.5%)of peritoneal(recurrent)GIST after laparoscopic gastrectomy. However, this is generally a safe and useful procedure for laparoscopic duodenal sleeve resection of duodenal GIST at a distal portion from the papilla Vater, when performed by a skilled team.

[Laparoscopic Hepatectomy of Metastases from Breast Cancer-A Case Report].

A 53-year-old woman, who had been operated with Bt plus Ax plus Ic for right breast cancer 2 years before, revealed an isolated hepatic metastasis at the S4 edge on follow-up computed tomography. The surgical approach is not recommended for distant metastases from breast cancer because of the lack of survival benefits according to the breast cancer guidelines. Nevertheless, the operation could be performed safely and easily for this patient owing to the location and size of the tumor. In addition, the case was a good indication for laparoscopic hepatectomy. We could perform the operation safely with a laparoscope, and the patient was discharged from the hospital on postoperative day 6. Hepatectomy is controversial for metastases from breast cancer. However, in select cases, hepatectomy with a laparoscope can be the therapeutic option as it can improve the survival of patients with hepatic metastases from breast cancer.

[A Case of Gastric Neuroendocrine Carcinoma with Rapidly Increasing Liver Metastasis].

The patient was a 72-year-old man. A gastrointestinal endoscopy was performed because of his anemia and revealed semicircular type 3 tumor in the lower body of the stomach. Biopsy was performed to diagnose adenocarcinoma. Computed tomography(CT)showed no distant metastasis, and the operation was performed 3 weeks after first visit. During operation multiple liver metastasis were recognized, and we performed distal gastrectomy and partial liver resection. The final diagnosis was neuroendocrine carcinoma(NEC). EOB-MRI after surgery revealed multiple liver metastases of 10-20 mm in size, similar to the intraoperative findings, and chemotherapy with cisplatin(CDDP)plus S-1 was started. A significant reduction was recognized after 3 courses of chemotherapy. Gastric NEC has a high proliferative capacity, and distant metastasis may become apparent in a short period of time. Although there is no clear guideline for chemotherapy, CDDP plus S-1 could be 1 treatment option.

[A New Projection-Marking Technique for Breast-Conserving Surgery Using a Radiation Treatment Planning System and Multi-Leaf Collimator in Patients with Breast Cancer-A Pilot Study].

In this study, a breast-conserving surgery(BCS)was performed involving the new image projection technique, using a radiation treatment planning system(RTPS)and a multi-leaf collimator(MLC), for patients with ductal carcinoma in situ (DCIS)and invasive ductal carcinoma(IDC)with ductal components. This study aimed to evaluate the feasibility of this procedure as a pilot study. From June 2014 to May 2017, 27 patients diagnosed with DCIS and IDC with ductal components underwent BCS. In the RTPS, the design of tumor resection was simulated, and the extent of resection was projected to the breast surface using the MLC. BCS was performed using this skin marking. Among 27 patients, 4(14.8%)had carcinoma in the surgical margins. As a pilot study, the simplicity and usefulness of this procedure was confirmed in BCS for patients with DCIS and IDC with ductal components. Further evaluation of its safety and efficacy will be conducted in more patients.

[A Case of Gastrointestinal Stromal Tumor Re-Resected Ten Years after the Resection of Its Recurrence].

The patient was a 75-year-old man who was diagnosed as having jejunal gastrointestinal stromal tumor(GIST)and underwent partial resection of the small intestine including the tumor 12 years ago. Two years after the first resection, recurrence was detected, and a second resection was performed. Ten years after the second resection following recurrence, he took imatinib, and computed tomography(CT)revealed abdominal and liver tumors. We was diagnosed as having GIST recurrence, and a third resection, which included an abdominal tumor resection and partial hepatectomy, was performed. The pathological findings were metastatic abdominal GIST and angiomyolipoma of the liver. The Japanese Clinical Practice Guidelines for GIST suggest a surgical indication only for local recurrence of GIST and resectable liver metastases. Recurrent GIST cannot be completely cured with antineoplastic drugs alone. Multidisciplinary treatment is necessary for long-term survival of patients with recurrent GIST.

[A Case of Transverse Colon Cancer with Liver Metastasis and Tumor Thrombosis of Portal Vein Effectively Treated with Chemotherapy].

The patient was a 70-year-old man. He was diagnosed with advanced transverse colon cancer. A computed tomography (CT)revealed liver metastasis and tumor thrombosis of portal vein. We started combination chemotherapy with capecita- bine/oxaliplatin(CapeOX). Perforation of the tumor was observed 5 days after CapeOX therapy was started. Treatment with abscess drainage and ileostmy, infection was controlled and general condition was improved. After 9 courses of CapeOX, we changed chemotherapy regimen to irinotecan/tegafur-gimeracil-oteracilpotassium (IRIS)due to strong side effects. In CT and FDG-PET examination after 8 courses of IRIS, the tumor of transverse colon, liver metastasis, and the tumor thrombosis of portalvein became unclear. A year and 6 months have passed since chemotherapy was started, recurrence was not observed. For the patients with unresectable colorectal cancer, it is necessary to consider multidisciplinary treatments including chemotherapy while considering the general condition of them.

[Four Cases of Occult Breast Cancer Treated with Breast Conserving Therapy after Neoadjuvant Chemotherapy].

We report 4 patients with occult breast cancer(OBC)who underwent breast conserving therapy(BCT)after neoadjuvant chemotherapy(NAC). All patients complained of axillary tumor and were diagnosed by core needle biopsy. Pathological examination of the axillary lymph nodes proved that 3 cases were adenocarcinomas and 1 case was squamous cell carcinoma, but imaging studies could not depict any primary lesions in the breast and other organs. Since distant metastasis was not observed, BCT with axillary lymph node dissection(ALND)was performed after NAC. All patients were undergoing whole breast irradiation. There were no residual cancer cells in the axillary lymph nodes in case 1 due to the treatment effect of NAC, but lymph node metastasis remained in other 3 cases. In the second case, she followed a rapid outcome, and pulmonary metastasis appeared in 7 months after surgery and died in 10 months. In the other 3 cases, there has not been found local and distant recurrence. Although OBC requires appropriate systemic treatment, present observation indicated that ALND with breast irradiation after NAC could be a useful option.

[A Case Report of Long-Term Survival after Excision for Needle Tract Implantation of Biopsy and Hepatectomy for Cholangiocarcinoma with Gall Bladder Hemorrhage].

A 77-year-old men with abdominal pain suffered from gall bladder hemorrhage and liver abcess was admitted for intensive care of severe acute cholangitis. He had hemobilia which was treated by the endoscopic retrograde bile duct drainage. After 2 months treatment with rest for purulent myelitis, he had neoplastic change of liver abcess diagnosed as intrahepatic bile duct cancer by percutaneous core needle biopsy. He underwent surgery as central bisegmentectomy and left the hospital at home 3 months later after rehabilitation for surgical site infection. He noticed growing mass on right chest 6 months later after hepatectomy and was diagnosed as needle tract implantation in chest wall by CT examination. Pathological exam revealed cholangiocarcinoma by radical excision. He have disease free for 5 years after second operation. Although percutaneous biopsy for hepatic tumor increases risks of needle tract implantation and dissemination, there is an advantage of radical resection for tract implantaion.

[A Case of Repeat Liver Resection after Laparoscopic Resection of a Synchronous Liver Metastasis of Colon Cancer].

A 44-year-old woman with subileus was diagnosed with advanced sigmoid colon cancer with a synchronous liver metasta- sis (segmanet 5/8). Laparoscopic anterior resection was performed, and histological diagnosis was sigmoid colon cancer, 55×40 mm, type 2, tub2>por2, pT3, ly2, v2, pN1, M1a, Stage Ⅳ (Japanese Classification of Colorectal Carcinoma, Eighth edition). Four courses of neoadjuvant chemotherapy (FOLFIRI plus panitumumab) shrank the liver metastasis. Laparoscopic partial liver resection was performed for 285 minutes, with 350 g of blood loss. The patient was discharged 9 days after the operation. Two courses of oral adjuvant chemotherapy (S-1) was performed but discontinued owing to side effects. Seven months after the surgery, computed tomography revealed 2 small liver metastasis (segment 8). Although the sizes were 35 and 5 mm, respectively, the larger mass was closed to the middle and right hepatic vein. Therefore, open hepatectomy was performed for 285 minutes, with 525 g of blood loss. The patient was discharged 9 days after the operation without complication. The patient had no recurrence for 1 year after the last surgery.

[Long-term survival following postoperative combined modality therapy for pancreatic cancer].

A 69-year-old woman with back pain underwent distal pancreatectomy with left adrenectomy for advanced pancreatic cancer pathologically diagnosed as poorly differentiated invasive ductal carcinoma with retroperitoneal and perineural invasion, pT3N0M0, Stage III. The patient received adjuvant chemotherapy with S-1 for 6 months. However, 3 years after surgery, computed tomography (CT) revealed para-aorticlymph node (LN) recurrence. Treatment with gemcitabine (GEM) was begun and continued for 3 years. Following progression of the LN recurrence 5 and half years after surgery, administration of radiotherapy reduced diarrhea and back pain. Supportive care combined with radio-frequency ablation(RFA)was provided for multiple liver metastasis 5 years 7 months after surgery. The patient died due to gastrointestinal hemorrhage 6 years after surgery. We report long-term postoperative survival of a patient with recurrent pancreatic cancer following combined modality therapy.

[A case of recurrent transverse colon cancer invading the pancreas and duodenum successfully treated with biliary and duodenal stenting].

We report a case of recurrent transverse colon cancer invading the pancreas and duodenum that was successfully treated with biliary and duodenal stenting. A 46-year-old man underwent ascending colostomy for the treatment of obstructive transverse colon cancer with hepatic metastasis. Chemotherapy achieved a partial response, but the levels of tumor markers later began to rise again. He then underwent right hemicolectomy and partial hepatectomy. Post-operative chemotherapy was administered, but the recurrent tumor caused obstructive jaundice and duodenal obstruction. These were successfully treated with biliary and duodenal stenting, and the patient was able to remain at home and maintain his quality of life.

[A case of rectal endocrine cell carcinoma treated by laparoscopic assisted intersphincteric resection after neoadjuvant chemotherapy].

A 51-year-old male patient visited our hospital with a complaint of anal dysfunction and anal pain. Colonoscopy revealed a lower rectal cancer just above the dentate line, and its biopsy showed endocrine cell carcinoma. Enhanced computed tomography( CT) showed pararectal and right inguinal lymph node metastasis. Leucovorin, 5-fluorouracil, and oxaliplatin (FOLFOX) therapy was initiated first; then, after K-RAS was found to be wild type, 6 courses of FOLFOX plus panitumumab were administered. After the chemotherapy, the main tumor and the lymph node swelling reduced evidently. Its effect was judged as a partial response (PR). Laparoscopic assisted intersphincteric resection, right inguinal lymph node dissection, and temporary ileostomy were performed. The pathology revealed endocrine cell carcinoma (MP, ly2, v2, n0, stage II). Its pathological effect was judged as Grade 1b. Five months after the surgery, the ileostomy was closed.

[A case of advanced breast cancer in which quality of life was improved by Mohs' paste and hormone therapy].

We report a case of breast cancer hemorrhage locally controlled with zinc chloride paste (Mohs' paste), which is usually applied as a fixative for 24 h before micrographic surgery of cutaneous neoplasms. A 73-year-old woman was suffering from continuous bleeding from an advanced right breast cancer; this bleeding stopped after 15 min by hemostatic treatment with Mohs' paste. Long-term hemostasis and decreased exudates were maintained by weekly treatment. Although radical operation and chemotherapy were recommended, she rejected both without hormone therapy. The tumor size has been locally controlled for 2 years. This rapid treatment with Mohs' paste is effective for controlling bleeding and breast tumor exudates without adverse events, and improves the patients' quality of life.

[A case of recurrent gastric cancer successfully treated by a combination of CPT-11 and CDDP as the third-line chemotherapy].

We report a case of recurrent gastric cancer successfully treated by a combination of CPT-11 and CDDP as the third- line chemotherapy. A 78-year-old man with advanced gastric cancer underwent a curative distal gastrectomy. Three years later, the tumor marker level began to rise and computed tomography (CT) revealed lymph node metastasis invading the pancreas resulting in pancreatic duct dilatation. S-1 treatment was initiated but was discontinued because of a systemic exanthem. Paclitaxel was administrated as secondary chemotherapy. But, after 2 courses, a further increase in the tumor marker level and portal vein invasion were observed. Combination therapy of CPT-11 and CDDP was administered as the third-line chemotherapy. After 3 courses, the tumor marker level normalized, tumor size decreased, and the invasion was eliminated. Third-line chemotherapy against recurrent gastric cancer should be considered if patient performance status (PS) is maintained.

[A case of mediastinal lymph node metastasis from rectal cancer successfully treated by carbon ion radiotherapy].

We report a case of mediastinal lymph node metastasis from rectal cancer successfully treated by carbon ion radiotherapy. A 65-year-old woman underwent sigmoid colostomy against unresectable rectal cancer. After chemoradiotherapy, primary rectal cancer became resectable and low anterior resection was performed. Curative local resection was done and chemoradiotherapeutic effect was grade 2. Chemotherapy after the operation wasn't effective enough and the size of the mediastinal lymph node increased. So she underwent carbon ion radiotherapy (52.8 Gy) which markedly decreased the lymph node size (-48%). Multi-modality therapy, such as radiation, chemotherapy, operation and carbon ion radiotherapy was applied. Successfully, locally advanced rectal cancer was resected and distant lymph node metastasis was controllable.

Percutaneous transhepatic ethanol ablation for postoperative bile leakage after a hepatectomy.

A 68-year-old male underwent a partial hepatectomy for hepatocellular carcinoma located in S5 close to the confluence of the anterior and posterior Glisson's sheath. Thereafter, bile leakage developed from the drain on postoperative day (POD) 2. Endoscopic nasobiliary drainage of the biliary tree and percutaneous drainage of the biloma proved ineffective, and the bile leakage continued at a constant volume of 40 mL per day. A fistulogram on POD 62 demonstrated an enhancement of the isolated bile duct. Ethanol injection into the isolated bile duct was attempted to ablate biliary epithelium but this was unsuccessful because it was impossible to insert the tube into the isolated bile duct. Ethanol was injected into the liver parenchyma surrounding the isolated bile duct via the percutaneous transhepatic approach under sonographic guidance on POD 78 in order to eliminate the production of bile juice by destroying both the biliary epithelium and liver parenchyma. The bile leakage decreased one day following the ethanol injection, although the patient experienced a prolonged fever for a week, and he was discharged on POD 100. This is the first report of ethanol injection into the liver parenchyma by a percutaneous transhepatic approach, instead of into the bile duct, to treat intractable bile leakage.