[A Case of Early Gastric Cancer That Coexisted with Multiple Submucosal Heterotopic Gastric Glands].

We report a case of surgical resection of an early gastric cancer that coexisted with multiple submucosal heterotopic gastric glands.A man in the 80's referred to our department because of an increased level of CEA.He had undergone hepatectomy for heterochronous liver metastasis of colon cancer.Gastrointestinal endoscopy revealed an early gastric cancer that coexisted with multiple submucosal gastric glands.He underwent segmental gastrectomy for gastric cancer.He exhibited no symptoms at the time of discharge.He has had no recurrence of gastric cancer 6 months after the surgery.We should appropriately care for synchronous or heterochronous gastric cancer in the remnant stomach if total gastrectomy is not performed in cases of therapy for gastric cancer with multiple submucosal heterotopic gastric glands.

[Hepatocellular Carcinoma with Bile Duct Thrombosis - A Case Report].

Hepatocellular carcinoma(HCC)is not commonly observed with bile duct thrombosis.Here, we report a case of HCC with bile thrombi that extended to the liver hilum.The patient was a 61-year-old man who visited us due to untreated type B hepatitis.He underwent screening with a CT scan that revealed LDA on the right posterior lobe of his liver with infiltration of the bile duct.Generally, bile resection and reconstruction should be considered for curative resection for bile thrombi; however, we attempted to conserve the common bile duct to preserve the options of percutaneous therapy in case of tumor recurrence.We performed right lobectomy of the liver.The bile duct thrombus was extracted without bile duct resection or reconstruction.The patient is alive 6 months after the surgery without any development.

[Gallbladder Carcinoma That Occurred 50 Years after Cholecystojejunostomy].

Creation of a cholecystojejunostomy has been recommended as one option in the palliation of biliary obstruction due to pancreatic carcinoma.However, it was a technique used for biliary drainage for acute cholecystitis a long time ago.We describe a patient who underwent a cholecystojejunostomy for acute cholecystitis 50 years prior to presentation, and then revealed a gallbladder carcinoma.

[A Case of Malignant Transformation of Intraductal Papillary Mucinous Neoplasm of the Pancreas Accompanied by Metachronous Triple Primary Cancer].

A 70's woman with a history of abdominal surgery for gastric cancer visited our hospital for the evaluation of bleeding during defecation.We diagnosed her with advanced rectal cancer and performed laparoscopic low anterior resection.As postoperative pathological staging was pT3N2M0, pStage III b, we included CapeOx therapy as adjuvant chemotherapy.One year and 4 months after the surgery, lung and liver metastases were revealed by CT and PET-CT scans.At the same time, dilatation of the main pancreatic duct(intraductal papillary mucinous neoplasm: IPMN)was detected.Thus, we first performed liver resection and then lung resection.After the surgery, new lung nodules and a mass lesion with IPMN with superior mesenteric venous invasion was found on CT scans.We then administered chemo-radiation therapy(CRT).After CRT, the lung and pancreatic lesions seemed to decrease slightly.Accidentally, a nodule on the cystic bladder was found, resected by transurethral resection of the bladder tumor(TUR-Bt), and diagnosed as a bladder cancer.Thirty months after the rectal surgery, she is continuing the S-1 chemotherapy with stable disease.

[A Case of Synchronous Double Cancers of the Liver and Pancreas Treated Using Pancreaticoduodenectomy and Liver Resection].

A 50-year-old woman had a 12mm liver tumor at segment 4 and was diagnosed with hemangioma. Two years later, the liver tumor had grown to 27mm in diameter, and a new pancreatic tumor was detected using CT examination. The pancreatic tumor was suspected of being pancreatic carcinoma, based on the results of endoscopic-ultrasound-guided fine-needlebiopsy( EUS-FNA)of the pancreas. The liver tumor was diagnosed as adenocarcinoma using liver biopsy. Because of its slow growth and the solitary liver tumor, synchronous pancreatic cancer and intrahepatic cancer were suspected. We therefore performed pancreaticoduodenectomy with portal vein resection and partial liver resection of segment 4. Upon histological analysis, carcinoma in situ was detected in the liver tumor and the patient was diagnosed with synchronous double cancers of the liver(cholangiocellular carcinoma)and pancreas(invasive ductal carcinoma). Our case indicated that it is very difficult to distinguish cholangiocellular carcinoma from metastatic liver tumor using diagnostic images. We should therefore consider the possibility of cholangiocellular carcinoma when a solitary tumor in the liver is detected at the same time as pancreatic cancer.

[Clinical Significance of Placing a PEG during Chemoradiotherapy for Advanced Esophageal Cancer].

BACKGROUND: Unresectable advanced esophageal cancer is often treated with chemotherapy or chemoradiotherapy(CRT). Nutritional disorders caused by dysphagia may lead to a poor prognosis. Placing a PEG before starting CRT for advanced esophageal cancer may maintain better nutritional status. PURPOSE: The purpose of this study is to evaluate the clinical significance of placing a PEG before starting CRT for advanced esophageal cancer. RESULTS: Fifty-one cases were evaluated, 22 PEG (+) and 29 PEG (-). The rate of a CRT was better in PEG (+) than PEG (-) cases (91% vs 79%). Infection around the PEG was the only type of complication, affecting 5%. CONCLUSION: PEG feeding during CRT is important in the development of effective treatments for unresectable advanced esophageal cancer.

[A case of synchronous sigmoid cancer and ureter cancer].

A 78-year-old-man visited a nearby doctor for treatment of hepatitis C and high blood pressure.He was diagnosed with right hydronephrosis by abdominal echography conducted in follow-up of hepatitis C treatment in November 2011; he was then introduced to our hospital for close inspection and medical treatment.We observed wall hyperplasia and narrowing of the lumen in the central sigmoid part by contrast-enhanced computed tomography (CT).The right ureter at the L4/5 level showed wall hyperplasia and a deep color, and the right ureter, renal pelvis, and calix were expanded on the head side. By examination for CF, we observed a type 2 lesion in the sigmoid colon, and a biopsy showed well-differentiated adenocarcinoma. Based upon these findings, he was diagnosed with synchronous sigmoid colon cancer (cT4aN0M0, cStage II) and ureter cancer (cT2N0M0, cStage II); we performed laparotomy sigmoidectomy(D3 dissection)and full extraction of the right kidney urinary tract (lymph node dissection in front of the vena cava, the latter outside and between the aorta and vena cava). The postoperative course was particularly uneventful, and the patient was discharged from the hospital on day 38 after the operation. More than 2 years after the surgery, the patient exhibits no sign of sigmoid colon cancer or ureter cancer recurrence.

[Occurrence of squamous cell lung carcinoma in the irradiated field after radiotherapy for breast cancer].

Radiotherapy for breast cancer reduces the incidence of disease recurrence and breast cancer mortality.However, it has also been associated with an increased risk of developing secondary cancers in exposed sites.Recently, we observed a 64-year-old woman who developed squamous cell lung carcinoma in the field irradiated with a total dose of 55 Gy after conservative breast surgery for left breast cancer 16 years previously.The patient underwent left upper lobectomy combined with chest wall resection.She had no recurrence of the breast cancer for 16 years.The secondary lung cancer tumor was of a different histological type than the primary breast cancer, and it appeared in the irradiated field.In conclusion, we regarded her lung cancer as a radiation-induced cancer, although it is difficult to clearly define radiation-induced cancer.In addition, the patient 's lung cancer may not only be a result of the late effect of irradiation, but might also be due to her smoking habit.

[A long-term survivor of a rectal carcinoid treated by use of repeat TACE for multiple intrahepatic recurrences after liver resection and MCT].

A woman between 50 and 60 years of age was diagnosed with a rectal carcinoid tumor and synchronal multiple liver metastases. We performed a transanal local resection of the rectal tumor, which was 10mm in diameter. During surgery, ultrasonography revealed 8 hypoechoic masses in the liver, and we performed a partial hepatectomy (S5/6, S8) and administered microwave coagulation therapy. Thirty-seven months after surgery, abdominal computed tomography revealed multiple low-density tumors in the bilateral lobe of the liver. We diagnosed these tumors as a recurrence of the liver metastases of the rectal carcinoid and performed trans-arterial chemo-embolization (TACE). After repeated TACE treatments, the liver metastases were controlled favorably. The patient is alive more than 50 months after diagnosis of the recurrent liver metastases. TACE appears to be effective for treating non-resectable multiple liver metastases of rectal carcinoids.

[Jejunostomy catheter feeding during postoperative chemotherapy for Stage IV gastric cancer].

Chemotherapy followed by surgery for Stage IV gastric cancer with passage obstruction poses a problem in terms of poor postoperative nutritional status. By maintaining an adequate postoperative nutrition status with jejunostomy catheter feeding, chemotherapy may possibly be continued. We treated 40 cases of Stage IV gastric cancer with passage obstruction from January 2008 to December 2011. In every case, jejunostomy catheter feeding tubes were placed during gastric cancer surgery. We performed 13 total gastrectomies, 20 distal gastrectomies, and 7 gastrojejunal bypass surgeries. Tube obstruction in 4 cases( 10%) and tube deviation in 1 case( 2.5%) occurred during the tube feeding period. Chemotherapy could be resumed in 37 cases( 92.5%), and the duration of chemotherapy was 330 days( range, 41-721). In cases of Stage IV gastric cancer, patients are obliged to start postoperative chemotherapy at an unstable period. By starting jejunal catheter feeding at an early stage after surgery, improved results could be expected in terms of shortening of the hospital stay or continuation of chemotherapy.

[A case of primary undifferentiated carcinoma of the duodenum].

We report a case of undifferentiated carcinoma of the duodenum. A 40-year-old man was referred to our hospital as he experienced upper abdominal pain that had persisted for half a year. Gastrointestinal endoscopy revealed a semicircular tumor in the duodenum. Enhanced computed tomography( CT) revealed that the tumor had not invaded the adjacent tissues, and lymph node metastases were not detected. Biopsy indicated a diagnosis of Group V cancer. Because the tumor was diagnosed as primary duodenal cancer, pancreatoduodenectomy and lymphadenectomy were performed. Histopathological examination revealed the presence of variant cells with irregular cores; we then diagnosed the tumor as undifferentiated cancer of the duodenum. No lymph node metastasis was detected microscopically. This patient has remained well without recurrence for 17 months since the operation. Undifferentiated carcinoma of the duodenum is rare, as only 9 cases have been reported in the Japanese literature.

[A case of neuroendocrine carcinoma of the duodenal papilla].

A 75-year-old man with a complaint of right hypochondrial pain consulted our hospital, and was diagnosed as having acute cholecystitis. We performed percutaneous transhepatic gallbladder drainage (PTGBD), and the cholecystitis resolved. However, obstructive jaundice occurred 2 weeks later. Thus, we performed an in-depth investigation and detected duodenal papilla cancer (cT3N1M0, Stage III). Pancreatoduodenectomy was performed. As postoperative histological diagnosis yielded positive and strongly positive immunostaining for synaptophysin and Ki-67, respectively, we diagnosed the patient as having neuroendocrine carcinoma (NEC) of the duodenal papilla. Three months after surgery, computed tomography (CT) scan showed multiple liver metastases and lymph node metastasis. Chemotherapy with carboplatin and etoposide was administered, but severe neutropenia developed, and therefore, the chemotherapy was discontinued. Subsequently, we decided on a policy of best supportive care (BSC). The patient died 11 months after surgery. NEC of the duodenal papilla is reported to be a rare and rapidly progressing disease and is associated with a very poor prognosis. Herein, we report a case of a patient in whom NEC of the duodenal papilla was resected.

[A surgical case of peritoneal dissemination metastasis of bile duct carcinoma after pancreaticoduodenectomy].

The patient was a 50-year-old woman who had undergone pancreaticoduodenectomy for bile duct carcinoma in April 2010. In August 2011, abdominal computed tomography (CT) revealed a solitary tumor (30×17 mm in diameter) behind the anastomosis of gastrojejunostomy. Gastrointestinal endoscopy revealed gastrojejunal ulceration (biopsy: Group V adenocarcinoma). Positron emission tomography (PET)-CT revealed a solitary tumor without any recurrence. We diagnosed the patient as having solitary recurrence of peritoneal dissemination of bile duct carcinoma. In September 2011, we performed resection of the peritoneal dissemination. The patient was discharged from the hospital 12 days after the operation and had a good postoperative course. Histologically, the tumor was diagnosed as peritoneal dissemination of bile duct carcinoma. Subsequently, the patient received postoperative chemotherapy. The patient remains alive with recurrence of peritoneal dissemination 37 months after pancreaticoduodenectomy and 20 months after resection of the peritoneal dissemination.

[A case with a lower rectal gastrointestinal stromal tumor undergoing sphincter-preserving laparoscopic resection after neoadjuvant imatinib therapy].

A man in his 30s visited our hospital after a local doctor diagnosed him with a rectal submucosal tumor. Colonoscopy and fine needle biopsy revealed a lower rectal gastrointestinal tumor (GIST). Pelvic MRI examination revealed apparent tumor invasion of the left levator ani muscle. Curative abdominoperineal resection( APR) of the tumor was required. Our strategy involved the initiation of neoadjuvant imatinib therapy to facilitate subsequent sphincter-preserving resection. Neoadjuvant chemotherapy for 11 months reduced the tumor size and permitted the R0 laparoscopic sphincter-preserving resection. He was discharged without any postoperative complications. The pathological findings revealed semi-curative effects and pR0 resection. Thus, neoadjuvant chemotherapy for advanced rectal GIST was a useful strategy for this function- preserving operation.

[Focal nodular hyperplasia that was difficult to differentiate from hepatocellular carcinoma].

A 59-year-old man had received medical treatment for alcoholic hepatopathy. He stopped drinking 3 years before visiting the hospital. On medical examination, the abdominal echo showed a hepatic mass lesion that was HBs-Ag (-) and HCV-Ab (-). Computed tomography (CT) revealed a tumor of more than 25 mm in diameter at S7 of the liver. Dynamic CT showed that it was stained in the early phase but washed out in the delay phase. Magnetic resonance imaging (MRI) showed high intensity staining of the tumor in both T1-and T2-weighted images, and it was also stained in the EOB Primovist MRI hepatobiliary phase. The findings from the images were not typical for hepatocellular carcinoma(HCC) or other benign tumors. We therefore performed an S7 partial hepatectomy. We diagnosed the tumor as focal nodular hyperplasia (FNH) by histology.

[A surgical case of solitary lymph node metastasis of hepatocellular carcinoma after nonsurgical treatment].

A 66-year-old man with multiple hepatocellular carcinomas(HCCs) underwent transcatheter arterial chemoembolization(TACE) twice and radiofrequency ablation(RFA) twice at another hospital in June 2009. In November 2010, abdominal computed tomography(CT) revealed a solitary lymph node metastasis( 23 mm in diameter) in the hepatoduodenal ligament, after which he was admitted to our hospital in December 2010. In February 2011, ethoxybenzyl diethylenetriamine pentaceric acid-enhanced magnetic resonance imaging (EOB-MRI) showed revealed a growing solitary lymph node metastasis(33 mm in diameter) and good control of the intrahepatic lesion. Positron emission tomography(PET)-CT confirmed the solitary lymph node metastasis without any other extrahepatic recurrence. We performed lymph node resection in March 2011 because of good control of the intrahepatic lesion and the lack of extrahepatic recurrence. He was discharged from our hospital 11 days after surgery with a good postoperative course. Histologically, the tumor was diagnosed as a lymph node metastasis of poorly differentiated HCC. Subsequent abdominal CT in January 2012 revealed multiple recurrent lesions, and he underwent TACE therapy in February 2012. Currently, the patient is alive 1 year 3 months after lymph node resection without any other extrahepatic recurrence.

[Laparoscopic reconstruction of jejunostomy catheter deviations in gastric and esophageal cancer patients who underwent jejunostomy].

Jejunostomy feeding is useful for maintaining nutrition in patients with gastric cancer and esophageal cancer. Special provisions must be made in cases of occlusion or dislocation of the jejunostomy catheter, and when the catheter is narrow and difficult to approach by endoscopy. Between 2007 and 2011, we encountered 69 cases of jejunostomy: 40 performed for gastric cancer and 29 for esophageal cancer. Catheter occlusion was seen in 7 cases and catheter dislocation in 9. Of these 16 cases, 14 could be recovered using interventional radiology (IVR), and the remaining 2 could not be because of fistel closure.

[Total pancreatectomy for pancreatic head cancer accompanied with multiple lesions].

Our patient was a 67-year-old man, with a chief complaint of brown urine. He subsequently underwent medical examination in June. Because the results of his blood examination revealed liver dysfunction, he was admitted to our hospital for further careful examination. An abdominal computed tomography(CT) scan showed the presence of a pancreas tumor, with a diameter of 2 cm, at the pancreas head, as well as common biliary duct dilatation and main pancreatic duct dilation from the head to the tail of the pancreas. The patient was diagnosed with pancreatic cancer[cT3( CH+, DU+), cN0, cM0, cStage III], with obstructive jaundice. After biliary drainage, we performed laparotomy in August. During the operation, other than the tumor on the pancreas head, identified at the preoperative diagnosis, we found 2 white nodules on the pancreas surface. One nodule was located at the body of the pancreas and the other, at its tail. On intraoperative pathological examination of the nodules, they were found to be invasive ductal carcinomas. On the basis of these findings, we suspected multiple cancers or overall pancreatic cancer; therefore, we performed total pancreatectomy, not pancreaticoduodenectomy (PD). We choose pancreatectomy over PD because it was impossible to confirm the cancerous area. Pathological examination of the resected specimen did not reveal any malignant lesion. Thus, if we had not performed pancreatectomy, assuming that the pancreas body or tail had no cancer lesion, based on the pathological examination result, the cancer would have persisted. Further, careful examination involving inspection and palpation is considered to be essential before resection of the pancreas tumor.

[A case of invasive ductal carcinoma of the pancreas originating from an intraductal papillary mucinous tumor that was initially misdiagnosed as a mucinous cystic tumor].

A 57-year-old woman was discovered to have a cystic tumor, 8 cm in diameter, at the pancreas tail, during routine screening with ultrasonography. The patient did not complain of tenderness, and no abdominal mass was palpable at physical examination. Enhanced computed tomography(CT) revealed that the tumor had mural nodules in the cyst wall, and we suspected it to be a malignant tumor that had occurred in the mucinous cystic neoplasm(MCN). Therefore, surgical resection was attempted, upon which the tumor was found to be hard and the surrounding tissue adhered widely to the stomach. We separated it carefully from the stomach and then performed a distal pancreatectomy. The cut surface revealed that the posterior wall of the cystic tumor was partly thickened, and microscopic examination revealed it to be invasive ductal carcinoma. No ovarian-like stroma was involved and some degree of dysplasia(PanIN 1-3) was found in the neighboring tissues. Therefore, we re-diagnosed it to be invasive ductal carcinoma of the pancreas derived from intraductal papillary mucinous tumor(IPMT), not from MCN. The patient received adjuvant chemotherapy, although 5 months later multiple lung metastases had appeared. The international consensus guidelines for management of IPMN and MCN of the pancreas suggest that they can usually be distinguished preoperatively, if there is a complete understanding of their clinical and imaging features. However, we sometimes find it difficult to distinguish the 2, because some IPMN or MCN cases have shared preoperative features. Herein, we report the case of invasive ductal carcinoma of the pancreas derived from IPMT that was originally misdiagnosed as a MCN.

[A case of anstomotic stricture after esophagectomy sufficiently treated by endoscopic triamcinolone injection therapy].

We report a case of 50-year-old man with refractory anastomotic stricture after esophagectomy, which was successfully treated with endoscopic triamcinolone injection therapy. He received a curative operation for advanced thoratic esophageal carcinoma (Mt, Type 3, cT3, cN1, MO, Stage III). Anastomotic leakage was occurred as post-operative adverse event, which recovered conservatively, and subsequently resulted in refractory anastomotic stricture. He had a recurrence of dysphagia despite of repeated bougienage and endoscopic balloon dilatation. Four years later, he received an intralesional triamcinolone injection in anastomotic stricture every four weeks. According to the 5 courses of treatment, anastomotic stricture was cured and there was no recurrence confirmed. Intralesional triamcinolone injection may be one of the promising options for the treatment of refractory anastomotic stricture after esophagectomy.