[Hemorrhagic Colon Cancer with Left Atrial Thrombus Formation after Anticoagulant Therapy Discontinuation-A Case Report].

The patient was a 72-year-old female. She had been taking rivaroxaban for chronic atrial fibrillation; however, she stopped taking it due to anemia and was hospitalized urgently. A contrast-enhanced computed tomography(CT)scan showed a 30 mm mass in the ascending colon, and a colonoscopy revealed ascending colon cancer(cT3, cN0, cM0, cStage Ⅱa). The tumor was hemorrhagic and was thought to have caused the anemia. On day 6 of hospitalization, another contrast- enhanced CT scan showed a poorly contrast-enhanced area in the left atrium, and transesophageal echocardiography revealed 2 left atrial thrombi(27 mm and 17 mm). Since early induction of anticoagulation therapy was considered, an emergency open right colectomy was performed to remove the cause of the bleeding. Intravenous heparin therapy was started the day after surgery and was switched to oral apixaban therapy on the fourth postoperative day. The postoperative course was good, and she was discharged home on the 17th postoperative day. This patient had conflicting clinical problems simultaneously; however, immediate decision-making and initiation of treatment were effective.

[A Case of Unresectable Pancreatic Cancer with Massive Cancerous Ascites Responsive to KM-CART].

A 79-year-old woman visited our hospital complaining of bloating. An abdominal enhanced CT scan revealed pancreatic body cancer with cancerous ascites and multiple liver metastases. We started gemcitabine(GEM)plus nab-paclitaxel chemotherapy. Chemotherapy was not continued because she was unable to take oral medication owing to increased cancerous ascites. We conducted modified KM-cell-free and concentrated ascites reinfusion therapy(KM-CART). Her symptoms improved, and she began having oral intake after KM-CART. Chemotherapy was then re-initiated. Seven months have now passed since we started chemotherapy, and we can continue chemotherapy while conducting KM-CART repeatedly. KM- CART is useful for treating unresectable pancreatic cancer with massive cancerous ascites in terms of continuing chemotherapy.

Successful omental flap coverage repair of a rectovaginal fistula after low anterior resection: a case report.

BACKGROUND: Rectovaginal fistula (RVF) is a troublesome and refractory complication after low anterior resection (LAR) for rectal cancer. An omental flap repair was performed for the RVF caused due to Crohn's disease and childbirth trauma. However, there are few cases of an omental flap repair for RVF after LAR. Herein, we present a successfully repaired case of RVF by omental flap coverage after LAR for rectal cancer. CASE PRESENTATION: A 50-year-old female patient with advanced rectal cancer underwent laparoscopic LAR with double-stapling technique anastomosis and achieved curative resection. She complained of a stool from the vagina and was diagnosed with RVF on the postoperative day (POD) 18. Conservative therapy was ineffective. We performed laparoscopic fistula resection and direct closure of the vagina and rectum, designed the omentum that could reach the pelvis, repaired RVF by omental flap coverage, and performed transverse colostomy on POD 25. She was discharged on initial POD 48. Seven months after the initial operation, colostomy closure was administered. There was no recurrence of RVF found 1 year after the initial operation. CONCLUSIONS: The patient achieved an omental flap coverage for RVF. We successfully performed the omental flap coverage repair in patients with RVF after the leakage of LAR. An omental flap may become an alternative treatment for muscle flap or an effective treatment for RVF.

Triple metachronous primary pancreatic and gallbladder cancer associated with pancreaticobiliary maljunction: a case report.

BACKGROUND: Metachronous pancreatic and gallbladder cancer is a rare condition and has a dismal prognosis. Herein, we present a patient with triple metachronous primary pancreatic and gallbladder cancer associated with pancreaticobiliary maljunction who achieved long-term survival after undergoing repeat curative surgery. CASE PRESENTATION: A 65-year-old female patient with advanced gallbladder cancer associated with pancreaticobiliary maljunction underwent extended cholecystectomy with extrahepatic bile duct resection. The pathological diagnosis was T3N0M0 stage III A papillary adenocarcinoma with hepatic invasion. During a monthly follow-up, a diffuse hypovascular 2.0 × 1.5-cm mass was detected in the pancreatic head 6.2 years after the initial surgery. Hence, the patient underwent pancreaticoduodenectomy. Histological examination revealed T3N0M0 stage IIA well-differentiated adenocarcinoma without lymph node metastases. Marked inflammatory reaction was observed in the non-cancerous lesions of the proximal pancreatic head parenchyma containing bile pigment within ductular lumens. After 12.5 years from the initial surgery, total pancreatectomy for a 4.0 × 3.0-cm mass in the remnant pancreas was performed. Histological examination revealed T3N1M0 stage IIB moderately differentiated adenocarcinoma with lymph node metastases. Hence, surgical curative resection was achieved. Based on the pathological findings, a definitive diagnosis of triple metachronous pancreatic and gallbladder cancer was made. The pathology suggests no precursor lesions such as pancreatic intraepithelial neoplasia (PanIN) and atypical flat lesions, but marked inflammations in the non-cancerous lesions, strengthening our hypothesis that chronic inflammation induced by the pancreaticobiliary maljunction is related to carcinogenesis of the pancreas. Despite further adjuvant chemotherapy, the patient's general condition worsened; however, she remained alive 15.2 years after the initial surgery while receiving the best supportive care. CONCLUSIONS: Repeat curative surgery for triple metachronous cancer was associated with a favorable prognosis. Both the biliary tract and the pancreas should be closely monitored during follow-up among patients with pancreaticobiliary maljunction, which can be managed with curative surgery.

A case of multiple metastatic gastric cancer with primary lesion vanished after administrating nivolumab, and the effect remains even after discontinuance of therapy.

Nivolumab is one of the immune checkpoint inhibitors available for chemotherapy-resistant gastric cancer. There have been few reports of confirmed prominent shrinkage of the primary tumor and some reports of prolonged antitumor effect after discontinuance of the drug, but it is not universal. A 67-year-old male was admitted to our hospital and diagnosed with metastatic gastric cancer that had spread to the bilateral lobe of the liver, distant lymph nodes, and peritoneum. He received five courses of S-1 plus oxaliplatin, followed by three courses of ramucirumab plus paclitaxel leading to disease progression. Then, the patient was administered nivolumab as third-line therapy. Tumor size was markedly reduced after three courses, esophagogastroduodenoscopy (EGD) revealed scar formation on the lower gastric corpus after seven courses, and biopsy specimen showed no malignancy. When a slight lower limb muscle weakness manifested, possibly an immune-related adverse event (irAE) after 15 courses, we stopped administration of nivolumab. The patient has survived for 26 months since his first visit, and elimination of the primary tumor and ascites with noted shrinkage of liver and lymph node metastases have followed for more than 10 months since discontinuance of nivolumab.

A long-term survival case of unresectable gastric cancer with multidisciplinary therapy including immunotherapy and abscopal effect.

The prognosis of unresectable gastric cancer remains poor. Multidisciplinary treatment of unresectable gastric cancer is, therefore, thought to be essential for improving patients' outcomes. Here, we report a successful case of multidisciplinary therapy for unresectable gastric cancer. The patient was a 69-year-old woman who was diagnosed with type 2 gastric cancer with remote lymph node metastases and peritoneal dissemination. Although shrinkage of the primary lesion and remote lymph nodes were observed following chemotherapy, we performed distal gastrectomy to deal with continuous bleeding from the primary lesion. Combination therapy with radiation and chemotherapy was effective for multiple metastases in both subclavian lymph nodes and metachronous multiple axillary lymph nodes. Nivolumab combined with radiation therapy also induced regression of remote lymph node metastases, peritoneal dissemination, and adrenal metastasis. Abscopal effects, i.e., shrinkage of the non-irradiated lesions, were also observed. Thus far, the patient has been able to maintain a good quality of life while receiving continued nivolumab therapy. Multidisciplinary therapy including immunotherapy and abscopal effect may improve the quality of life and contribute to long-term survival of patients with unresectable gastric cancer.