Gastrointestinal stromal tumor of the small bowel complicated by torsion: A case report.

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors that originate from the gastrointestinal tract wall. Approximately 20-30 % of GISTs originate from the small intestine. GISTs of the small intestine generally present with a palpable mass, distention, and abdominal pain and may exhibit acute abdomen at the onset. Herein, we describe a rare case of a pedunculated GIST of the small intestine complicated by torsion. PRESENTATION OF CASE: A 69-year-old woman presented with lower abdominal pain. Abdominal contrast-enhanced computed tomography showed a 73 × 62 × 57-mm3 tumor in the pelvic cavity with enhanced margins and reduced contrast. It was presumed that the tumor had caused hemorrhagic infarction. Emergency laparotomy was performed, and the pedunculated tumor was found to be twisted 360° clockwise at the pedicle with hemorrhage and necrosis due to torsion. We performed partial resection of the small intestine including the tumor. Histopathological examination revealed tightly arranged spindle-shaped cells with hemorrhage, congestion, and inflammatory cell infiltration. Immunohistochemical staining showed positivity for CD34, CD117, and DOG1. CONCLUSIONS: Torsion of a pedunculated small intestine GIST, although very rare, requires emergency surgery and should be recognized as a cause of acute abdomen in patients with GIST. Immediate surgery is mandatory if torsion of a small intestinal GIST is suspected because the GIST or intestine may become necrotic owing to hemorrhagic infarction.

Primary spindle cell tumor originating from the liver that was difficult to diagnose.

BACKGROUND: It has been reported that hepatocellular carcinoma (HCC) with spindle cell tumor accounts for 1.8% of all HCCs, but spindle cell tumors that do not show an obvious conventional HCC are extremely rare. In this report, we describe a case of resection of a primary spindle cell tumor of the liver that was difficult to diagnose. CASE PRESENTATION: A 75-year-old man presented with fever and right chest pain. He was suspected of a giant primary diaphragmatic tumor of extrahepatic origin by imaging studies. The preoperative differential diagnosis included benign masses such as myxoid sarcoma and schwannoma, and we planned a diaphragmatic resection. Intraoperatively, however, dissection of the tumor from the liver was not possible, requiring an extended right posterior segmentectomy with combined resection of the diaphragm. The patient had a good postoperative course and 1 year has passed since the surgery with no recurrence. The pathology showed that the mass was located just below the hepatic capsule/parenchymal region and was adherent to the diaphragm, but there was no continuity. The morphology suggested a low-grade mesenchymal tumor such as a solitary fibrous tumor and perivascular epithelioid cell tumor, but immunostaining was negative, making the diagnosis difficult. Although some areas of high proliferative activity were observed, finally, the diagnosis of primary spindle cell tumor of the liver with smooth muscle differentiation was made based on the positive results of muscle markers such as αSMA, desmin, and h-caldesmon. CONCLUSIONS: Spindle cell tumor arising from the liver is so rare that preoperative and pathological diagnosis is often difficult to reach. Although further studies are needed to elucidate and better understand this uncommon clinical entity, we consider that complete resection is necessary for the above case, which may contribute to long-term survival.

Management of Pancreatolithiasis: A Nationwide Survey in Japan.

OBJECTIVES: The aim of this study was to assess prevailing treatment of pancreatolithiasis in Japan. METHODS: We surveyed clinical data from 1834 patients (1479 men and 355 women) at 125 hospitals. RESULTS: Extracorporeal shock-wave lithotripsy (ESWL) was performed alone in 103 patients (5.6%), ESWL plus an endoscopic procedure in 446 (24.3%), endoscopic treatment alone in 261 (14.2%), and surgery in 167 (9.1%). Other treatments were given to 358 (19.5%), whereas 499 (27.2%) received no treatment. Symptoms were relieved in 85.7% after ESWL, 80.8% after endoscopic treatment alone, and 92.8% after surgery. Early complication rates within 3 months after ESWL, endoscopic treatment alone, and surgery were 8%, 4.5%, and 27.1%, respectively. Late complications after ESWL, endoscopic procedures alone, and surgery were 1.7%, 2.5%, and 8.2%, respectively. Symptom relief but also early and late complications were greater after surgery than after ESWL and endoscopic treatment. Among 417 patients undergoing ESWL, 61 (14.6%) required surgery, as did 32 (16%) of 200 patients treated endoscopically. Surgery was required less frequently following initial operative treatment (11/164 patients [6.7%]). Nonsurgical initial treatments were chosen more frequently. CONCLUSIONS: First-line treatment of pancreatolithiasis should be ESWL with or without endoscopy because of minimal invasiveness and fewer complications.

Treatment of metastatic refractory colorectal cancer following regorafenib failure.

At present, there is no set strategy for the treatment of patients with colorectal cancer subsequent to the failure of standard treatment, other than the use of regorafenib (RGR) and TAS-102. The best order in which to use these drugs, and their safety and efficacy in combination with other drugs, are currently under investigation. It has been reported that RGR has a resensitizing effect on tumors that have previously failed to respond to anticancer drugs; this makes it a promising salvage therapy for colorectal cancer. The present report describes the results of a retrospective study on 17 patients with metastatic colorectal cancer who received RGR treatment following the failure of standard therapy. Following RGR failure, 71% of the patients were fit for further anticancer treatment, and these patients survived longer than those who did not receive further treatment. Furthermore, this intervention did not shorten the period of best supportive care. As a considerable number patients were fit for further anticancer therapy after RGR treatment, which resulted in prolonged survival without shortening the period of best supportive care, it may be beneficial for future research to focus on finding the optimal time at which to switch from RGR to further anticancer therapy.

Curative resection by splenectomy for solitary splenic metastasis from early gastric cancer: a case report and literature review.

BACKGROUND: Solitary metastasis of a malignancy to the spleen is rare, particularly for gastric cancer. Only a few case reports have documented isolated splenic metastasis from early gastric cancer. We describe a case of splenic metastasis from early gastric cancer. CASE PRESENTATION: A 60-year-old man underwent a distal gastrectomy for early gastric cancer. It infiltrated the submucosa with pathological nodal involvement (pT1bN2M0, stage IIB). One year after the gastrectomy, an abdominal computed tomography scan showed a low-density lesion, 17 mm in diameter, at the upper pole of the spleen. Positron emission tomography/computed tomography showed focal accumulation of fluorine-18 fluorodeoxyglucose in the spleen without extrasplenic tumor dissemination or metastasis. We diagnosed splenic metastasis of gastric cancer, and performed a splenectomy. Histological examination confirmed moderately differentiated tubular adenocarcinoma and poorly differentiated adenocarcinoma (solid type) that was consistent with the features of the primary gastric cancer. The splenic tumor was pathologically and immunohistochemically diagnosed as a metastasis from the gastric carcinoma. More than 18 months after the splenectomy, the patient has had no evidence of recurrent gastric cancer. CONCLUSION: When solitary metastasis to the spleen is suspected during the postoperative follow-up of a patient with gastric cancer, a splenectomy is a potentially effective treatment.

[A case of advanced signet ring cell carcinoma of the appendix that responded to S-1 and docetaxel].

A 68-year-old man was admitted to our hospital after testing positive in a fecal occult blood test. He was subsequently diagnosed with advanced signet ring cell carcinoma of the appendix with disseminated peritoneal disease and ascites. Weekly chemotherapy with S-1 was commenced, and after three courses, the tumor shrunk in size and the ascites decreased. Two more courses were administered;however, disease progression was noted because of increasing ascites. The chemotherapy regimen was changed to weekly docetaxel, and after two courses, further tumor shrinkage and a decrease in ascites were noted. The disease course of this patient suggests that S-1 and docetaxel were effective against signet ring cell carcinoma of the appendix. Here we report this case and discuss the relevant literature.

[A case of advanced gastric cancer with esophageal invasion treated by neoadjuvant S-1/CDDP chemotherapy].

A 75-year-old man was found, by endoscopic examination, to have type 2 advanced gastric adenocarcinoma with esophageal invasion in the cardia. Endoscopy and other modalities revealed observable esophageal invasion. To minimize surgical intervention, we treated him with S-1 and cisplatin as neoadjuvant therapy. Treatment was as follows: S-1(80mg/m2)was administered orally for 3 weeks followed by 2 weeks of rest, and cisplatin(60mg/m2)was administered by intravenous drip on day 8. Two courses of treatment resulted in marked shrinkage of the primary lesion and improvement of the esophageal invasion. Total gastrectomy with splenectomy, and D2 lymph node dissection were performed with an adequately long proximal margin, without thoracotomy. Pathological efficacy was Grade 2. At present, 1 year after the operation, the patient presents no evidence of a recurrence. We concluded that through neoadjuvant chemotherapy for advanced gastric cancer with esophageal invasion, thoracotomy could be avoided, thereby reducing risks associated with surgery.

Cardiophrenic angle lymph node metastasis from a fallopian primary tumor.

Isolated cardiophrenic angle node metastases are relatively rare, as are primary fallopian tube carcinomas. We describe a case of a cardiophrenic angle node metastasis from such a tumor, with no peritoneal involvement. A 52-year-old woman, who had been previously diagnosed with fallopian tube carcinoma, was referred with a right cardiophrenic angle mass. A thoracoscopic resection was performed. The pathological diagnosis was lymph node metastasis from the primary lesion.

[Successful withdrawal from disseminated intravascular coagulation caused by disseminated carcinomatosis of bone marrow originated from gastric cancer treated by sequential therapy consisting of MTX and 5-FU and palliative radiotherapy].

A 5 8-year-old man with severe back pain caused by multiple vertebral metastases developed disseminated intravascular coagulation(DIC). We adopted palliative radiotherapy(8 Gy/1 day)for palliation of his back pain as initial treatment. Afterwards, we started sequential chemotherapy consisting of methotrexate(MTX)and 5-fluorouracil(5-FU). After two courses, DIC was resolved, and the patient was discharged in fair condition after five more courses of MTX and 5-FU therapy.

[An effective case of gemcitabine therapy with post-operative peritoneal recurrence of intrahepatic cholangiocarcinoma].

The patient was a 53-year-old man who had undergone left hepatectomy due to intrahepatic cholangiocarcinoma in August 2007. Pathologically, the tumor was diagnosed as a cholangiocellular carcinoma (T2, N0, M0, Stage II). Ascites appeared about one year after surgery and control was difficult using diuretics. Since abdominal CT revealed peritoneal recurrence with massive ascites, we conducted chemotherapy using gemcitabine (GEM) in September 2008. In the outpatient setting, GEM at a dose of 1, 000 mg/body was administered once a week with a 1-week rest as 1 course. The response was assessed as a complete response (CR) because abdominal CT after 7 courses of chemotherapy showed the disappearance of both ascites and the peritoneal nodules. An adverse effect for GEM was grade 3 anemia, but we could continue the chemotherapy until September 2009. At present, CR has been observed, and one year and three months have passed since the peritoneal reccurrence.

Changes in blood flow and function of the liver after right portal vein embolization.

HYPOTHESIS: Abrupt occlusion of hemihepatic portal vein induced by preoperative portal vein embolization (PVE) may result in drastic alterations in blood flow and functional mass of the liver. DESIGN: Prospective study investigating the outcome of an intervention (PVE). SETTING: University tertiary-care referral center. PATIENTS: Thirteen patients who underwent PVE before extended right hepatectomy. MAIN OUTCOME MEASURES: The functional plasma flow and functional mass of the liver as well as the volumes of the left and right lobes were assessed before and after PVE. The functional plasma flow and functional mass of the liver were estimated by measuring the hepatic clearances of sorbitol (a high-extraction drug) and antipyrine (a low-extraction drug), respectively. The liver lobar volumes were measured by computed tomography. RESULTS: Hepatic plasma clearance of sorbitol (mean +/- SD; before PVE, 632.9 +/- 142.9 mL/min; day 14, 620.2 +/- 138.3 mL/min; not significant by 1-way repeated analysis of variance) and that of antipyrine (before PVE, 27.3 +/- 12.0 mL/min; day 14, 27.9 +/- 13.6 mL/min; P =.85, by paired t test) were stable after PVE. Fourteen days after PVE, the non-PVE-treated lobe was enlarged (mean +/- SD, 137% +/- 30%) and the PVE-treated lobe was atrophic (mean +/- SD, 87% +/- 15%); however, the total liver volume did not change significantly. CONCLUSIONS: The functional mass and plasma flow of the entire liver were stable after PVE despite the drastic change in the lobar distribution of the portal blood flow, whereas the non-PVE-treated lobe increased significantly in size. Our findings suggest that PVE leads to an increase in both the volume and the functional capacity of the non-PVE-treated lobe.