Impact of Tumor Subclassifications for Identifying an Appropriate Surgical Strategy in Patients with Intrahepatic Cholangiocarcinoma.

BACKGROUND: Intrahepatic cholangiocarcinoma (ICC) is subclassified into small and large duct types. The impact of these subclassifications for identifying appropriate surgical strategies remains unclear. PATIENTS AND METHODS: This study included 118 patients with ICC who underwent liver resection. Based on the pathological examination results, the participants were divided into the small duct-type ICC group (n = 64) and large duct-type ICC group (n = 54). The clinicopathological features and postoperative outcomes were compared between the two groups to investigate the impact of subclassification for selecting appropriate surgical strategies. RESULTS: Ten patients in the small duct-type ICC group had synchronous or metachronous hepatocellular carcinoma. The large duct-type ICC group had higher proportions of patients who underwent major hepatectomy, extrahepatic bile duct resection, portal vein resection, and lymph node sampling or dissection than the small duct-type ICC group. The large duct-type ICC group had significantly higher incidences of lymph node metastasis/recurrence and pathological major vessel invasion than the other. The small duct-type ICC group exhibited significantly higher recurrence-free and overall survival rates than the large duct-type ICC group. Further, the large duct-type ICC group had a significantly higher incidence of lymph node metastasis/recurrence than the small duct-type ICC at the perihilar region group. CONCLUSIONS: Suitable surgical strategies may differ between the small and large duct-type ICCs. In patients with large duct-type ICCs, hepatectomy with lymph node dissection and/or biliary reconstruction should be considered, whereas hepatectomy without these advanced procedures can be suggested for patients with small duct-type ICCs.

[Surgical Technique for Mesorectal Division in the Robotic Anterior Resection for Rectal Cancer].

Since April 2018, robot-assisted rectal resection has been approved as an insurance medical treatment, and robot- assisted rectal resection is rapidly becoming widespread. Even in robot-assisted laparoscopic surgery, mesorectal division is difficult in a narrow pelvic cavity. At the beginning of the operation, Vessel Sealer ExtendTM(price 89,250 yen)was used, but as the procedure became stable, the mesorectal division was started with bipolar forceps and monopolar scissors. The purpose of this study was to investigate the mesorectal division time and postoperative complications associated with changes in the procedure. 36 patients who underwent robot-assisted anterior resection for rectal cancer by the same surgeon from January 2019 to December 2021. We compared mesorectal division time and postoperative complication. Median operation time were 267 minutes, median console time were 132 minutes. There were no complications such as intestinal obstruction or anastomotic leakage. There was no difference in mesorectal division time time between Vessel Sealer groups and Scissors groups(14 min 55 sec vs 16 min 5 sec). The mesorectal division with bipolar forceps and monopolar scissors could be performed without extending the operation time, and could be performed with cost-benefit and safely.

[Locally Advanced Pancreatic Cancer Treated with Two-Staged Pancreaticoduodenectomy after Laparoscopic Median Arcuate Ligament Section-A Case Report].

A 76-year-old male was diagnosed as locally advanced pancreatic cancer because abdominal CT scan revealed a pancreatic head tumor with involvement of the proper hepatic artery. Gemcitabine plus nab-paclitaxel was initiated, but was discontinued because interstitial pneumonia was occurred. The treatment was switched to S-1 therapy and achieved stable disease for 22 months. Therefore, conversion surgery was scheduled. Because stenosis of the celiac artery origin due to median arcuate ligament(MAL)compression and dilatation of pancreatoduodenal artery arcade were observed, laparoscopic MAL section was performed. The patient was discharged on postoperative day 5 without complications. Postoperative CT scan revealed no stenosis of the celiac artery origin and disappearance of dilatation of pancreatoduodenal artery arcade. On postoperative day 14, subtotal stomach-preserving pancreaticoduodenectomy(PD)with portal vein resection was performed. The patient was discharged on postoperative day 19 without complications. Two-staged PD after MAL section make possible to evaluate blood flow accurately and select an appropriate operative method. Laparoscopic MAL section is minimally invasive and may be useful for two-staged PD in patients with celiac axis stenosis.

[A Case of Robotic Surgery for Local and Peritoneal Recurrence of Colorectal Cancer].

A 35-year-old women with sigmoid cancer(pT4aN1aM0, pStage Ⅲb)underwent laparoscopic sigmoidectomy. She had 8 courses of CapeOX for adjuvant chemotherapy, but follow up CT scan 1 year after the operation detected intraabdominal nodules in anastomotic site and in left lower quadrant of abdomen. After 10 courses of IRIS plus bevacizumab, the both intraabdominal nodules decreased in size. Robot assisted laparoscopic lower anterior resection and laparoscopic disseminated nodule resection were performed. The patient had no postoperative complications and the postoperative course was good. She remains alive without recurrence at 6 months after the second operation.

[Prognostic Analysis of Colorectal Cancer Patients by the Controlling Nutritional Status(CONUT)Score].

We examined the controlling nutritional status(CONUT)score and the long-term prognosis of colorectal cancer surgery cases. We retrospectively examined the prognosis of colorectal cancer patients who underwent surgery between January 2013 and December 2015. We targeted 449 patients who were able to calculate the CONUT score. A total of 266 patients (59.2%)had normal nutritional status(1 or less)and 183 patients(40.8%)had mildly poor or worse nutritional status (2 or more). The CONUT score was calculated through preoperative blood tests. The relationship between the CONUT score and overall survival was examined in the low and high groups. Overall survival was significantly shorter in the high group but relapse-free survival did not differ significantly between the 2 groups. There was no difference in cancer-specific survival between the 2 groups, but the survival time due to death from other diseases was significantly shorter in the high group. The CONUT score obtained from preoperative blood sampling suggested that the overall survival time was short in the malnourished group, and that it could be used as an index of prognosis due to death from other diseases.

[A Case of Advanced Gastric Cancer-Recurrence of Skin Metastasis Nine Years after Surgery and Rectal Stenosis Due to Peritoneal Dissemination Ten Years Later].

A 70-year-old man previously underwent laparoscopic total gastrectomy for gastric cancer in 2010 and pathological diagnoses were pT4a, pN3, M0, pStage ⅢC. The postoperative adjuvant chemotherapy was interrupted due to nausea, but the patient had no apparent recurrence within 5 years after gastrectomy. In 2019, a swelling appeared from the left inguinal region to the scrotum, and MRI scan showed subcutaneous edematous changes in the same region. Biopsy showed adenocarcinoma and we diagnosed a recurrence of gastric cancer with skin metastasis. In November 2020, the patient complained of defecation disorder, and CT scan showed a circumferential wall thickening with contrast effect in the rectum. Although colonoscopy revealed rectal stenosis, biopsy specimen showed no malignant findings. We suspected rectal stenosis due to peritoneal dissemination of gastric cancer and performed a colostomy. Intraoperative findings showed that the rectal wall was remarkably thickened with serosal erythema. Adenocarcinoma cells were found from the cytology of ascites. The patient was treated with nab-paclitaxel plus ramucirumab, then treated with nivolumab after failure of first-line therapy.

[Hemorrhage of Peritoneal Dissemination of the Ascending Colon Cancer Successfully Controlled by Palliative Radiotherapy-A Case Report].

An 81-year-old man underwent laparoscopic right hemicolectomy for ascending colon cancer. The postoperative diagnosis was tub1>tub2, pT4apN1bM0, pStage Ⅲb, ascending colon cancer. At 1 year 4 months after operation, abdominal CT showed dissemination around anastomosis. The patient has been treated with first-line systematic chemotherapy(capecitabine, oxaliplatin and bevacizumab). Epigastralgia and grade 4 anemia were observed at 5 years 7 months after initiation of chemotherapy when he was treated with second-line chemotherapy(capecitabine, irinotecan and bevacizumab). As abdominal CT showed that the dissemination progressed rapidly in size 30 mm to 100 mm, we diagnosed tumor bleeding in the dissemination. Palliative radiotherapy(30 Gy/10 Fr)for the dissemination was performed. Hemostasis and tumor shrinkage were achieved, and epigastralgia improved after receiving the radiation therapy. The patient discharged our hospital on 31 days form admission. We believe that palliative radiotherapy is effective to recurrent colon cancer with tumor bleeding.

[A Case of Intra-Abdominal Desmoid Tumors Occuring Four Years after Open Radical Prostatectomy].

Desmoid tumor is one kind of fibromatosis, and much occurs the abdominal wall and outside the abdominal wall. Intra- abdominal desmoid tumor is rare at about 8%. We experienced a case of intra-abdominal desmoid tumors occurring 4 years after open radical prostatectomy with some literature review. A 72-year-old man had undergone open radical prostatectomy for prostate cancer. Four years after that resection, multiple intra-abdominal tumors measuring 56 mm in maximum diameter was identified on follow-up computed tomography, and he was referred to our department for management. We performed laparotomy and investigation of the biopsy. Immunohistochemistry of the resected specimen indicated the tumor cells were positive for vimentin and ß-catenin, and the diagnosis was desmoid. We performed partial resection of the small intestine and ileocecal resection. His postoperative course was uneventful and he was discharged on the 12th postoperative day. He has shown no sign of recurrence in the 4 months follow-up since surgery. In the past, an operation was the best treatment for intra-abdominal desmoid tumor. But it is reported that watchful waiting is also possible by the case which has no symptom and dysfunction in NCCN guidelines 2019. Further research is needed.

[Hyperammonemia with Disturbance of Consciousness during 5-FU plus Nedaplatin Therapy for Esophageal Cancer-A Case Report].

Hyperammonemia is a rare adverse event of 5-FU. Here, we report a case of hyperammonemia with disturbance of consciousness during 5-FU plus nedaplatin therapy for esophageal cancer and present a literature review. A 69-year-old man was diagnosed with cT2N2M0, cStage Ⅲ esophageal cancer. He was administered with DCF therapy as the first-line neoadjuvant chemotherapy. After the first course, he showed renal dysfunction. Therefore, as the second-line neoadjuvant chemotherapy, he was administered with 5-FU plus nedaplatin. He vomited on treatment day 5 and suddenly presented with disturbance of consciousness on treatment day 6. Blood tests showed hyperammonemia(114 µg/dL). He was treated with rehydration and branched-chain amino acid solutions, resulting in a gradual improvement of symptoms. Hyperammonemia has been reported in patients with colorectal cancer but rarely in patients with esophageal cancer. A case of hyperammonemia during the 5-FU plus nedaplatin therapy has never been reported in Japan. We should be aware that 5-FU may cause hyperammonemia and resultant disturbance of consciousness during chemotherapy with 5-FU.

[A Case of Obstructing Rectal Cancer with Obstructive Colitis Resected after Neoadjuvant Chemotherapy to Avoid Anastomotic Leakage].

A 61-year-old male was referred to our department after decompression of the transanal ileus tube due to a rectal cancer obstruction. Colonoscopy revealed a circumferential type 2 tumor, 4 cm from the anal verge. The tumor was diagnosed as rectal cancer tub1-2, Group 5 on biopsy analysis. Longitudinal ulcers descending to the sigmoid colon were present and obstructive colitis was suspected. Enhanced computed tomography showed wall thickness in the Ra, Rb rectum and swelling of the mesorectum lymph node, but distant metastases were not identified. We diagnosed the patient with Ra, Rb rectal cancer cT4aN1aM0, cStage Ⅲb. Because of the risk of anastomotic leakage with obstructive colitis, we planned neoadjuvant chemotherapy(SOX therapy)after laparoscopic transverse colostomy. After neoadjuvant chemotherapy, colonoscopy revealed improvements in the obstructive colitis. The tumor was reduced in size and the chemotherapy appeared effective. We performed laparoscopic rectal super low anterior resection with resection of the D3 lymph node. Histopathological examination revealed tub1, ypT3, ypN0, and the chemotherapeutic outcome was rated as Grade 1a. The final diagnosis was Ra, Rb rectal cancer with ypT3ypN0M0, ypStage Ⅱa.

[A Case of Disseminated Carcinomatosis of the Bone Marrow with Carcinoma of the Rectum Diagnosed by Disseminated Intravascular Coagulation].

A 77-year-old man with rectal cancer was admitted to our hospital. After neoadjuvant chemotherapy, laparoscopic abdominoperineal resection of rectum with D3 dissection was performed. The pathological diagnosis was poorly differentiated carcinoma, pT3, N1a, M0, pStage Ⅲa. Adjuvant chemotherapy was not performed. Fifteen months after operation, his chief complaint was fatigue. Thrombocytopenia and elevation of tumor maker was detected by blood test and disseminated intravascular coagulation(DIC)was suspected. He was admitted to our hospital and we started anti DIC therapy immediately. Bone scintigraphy revealed multiple bone metastases, then we diagnosed disseminated carcinomatosis of the bone marrow. He died 10 days after hospitalization. Disseminated carcinomatosis of the bone marrow with colon cancer is rare and prognosis is very poor. It is important to diagnose and start treatment as early as possible.

[Effective Palliative Radiation for Hemostasis of Recurrent Colon Cancer in the Lymph Node with Gastric Wall Invasion].

A 76-year-old man underwent laparoscopic left hemicolectomy D3(pStage Ⅱb)for sigmoid colon cancer in 2015. Later, partial transverse colectomy D2(pStage Ⅱb)was performed because transverse cancer was also detected. Recurrent peritoneal dissemination was found in 2018. In 2019, hematemesis/black stool, as well as prominent anemia(Hb 3.1 g/dL)and bleeding from recurrent gastric wall invasion of the lymph nodes on the lesser curvature side of the stomach, was observed. Although hemostasis was performed endoscopically, palliative irradiation(30 Gy in 10 fractions)was performed to control bleeding because the risk of rebleeding was high. After irradiation, endoscopy showed that the ulcer in the infiltrated area of the gastric wall had a tendency to improve. No bleeding or progression of anemia was observed, and oral intake became possible. However, the patient's general condition deteriorated, and he died 80 days after palliative irradiation. For palliative radiation therapy, alleviation of pain owing to bone metastasis, as well as alleviation of the narrowed airway and esophagus, is known. Palliative radiation therapy has recently been performed for symptom relief and prognosis extension against tumor bleeding. Palliative radiation therapy for controlling bleeding has limited hemostatic effect compared with surgical resection, and it takes some time before hemostasis is achieved, but it is less invasive and less adverse event and may be an effective treatment option.

[A Case in Which pCR Was Obtained by S-1 plus Oxaliplatin Therapy Administered as Neoadjuvant Chemotherapy for Advanced Gastric Cancer].

A 78-year-old man presented with anemia, with a hemoglobin level of 6.7 g/dL, during follow-up for angina pectoris and paroxysmal atrial fibrillation. Upper gastrointestinal endoscopy revealed type 2 advanced gastric cancer(por), and abdominal computed tomography(CT)showed multiple lymph node metastases. He was diagnosed with advanced gastric cancer, cStage Ⅲ(cT3N1M0). He received neoadjuvant chemotherapy in 3 courses of SOX(80mg/m / 2/day of S-1 on days 1-14 and 7 days of rest, and 100mg/m2 of oxaliplatin on day 1). Grade 1 thrombocytopenia was observed, but it resolved without any other major side effects. Upper gastrointestinal endoscopy revealed a marked reduction in the primary lesion, and abdominal CT showed a significant reduction in the metastatic lymph node. We performed laparoscopic distal gastrectomy(D2+No. 14v)for advanced gastric cancer ycT1N(+)M0, ycStage ⅡA. Histological assessment revealed no evidence of residual tumor cells in the primary tumor or lymph nodes, and the histologic response was classified as Grade 3, pathological complete response(pCR). We report a case in which pCR was obtained by SOX therapy administered as neoadjuvant chemotherapy for advanced gastric cancer.

[A Case of Metachronous Metastasis to the Pancreas from Ascending Colon Cancer after Subtotal Stomach-Preserving Pancreaticoduodenectomy(SSPPD)].

A67 -year-old man was diagnosed with ascending colon cancer and multiple liver metastases and underwent laparoscopic right hemicolectomy(D3 lymphadenectomy). Pathological examination indicated tubular adenocarcinoma(tub1, pT4apN2H2M1[HEP], pStage Ⅳ). After chemotherapy, he underwent hepatectomy. One year and 9 months after the first operation, obstructive jaundice appeared. Abdominal computed tomography revealed a tumor 2 cm in size in the head of the pancreas. After several detailed examinations, he was diagnosed with pancreatic metastasis of ascending colon cancer. After partial resection of the left lung metastasis, pancreaticoduodenectomy(SSPPD-Ⅱ A-1, D1 lymphadenectomy)and low anterior resection(LAR)for early rectal cancer were performed. The tumor was positive for CDX2(+), resulting in a diagnosis of pancreatic metastasis. There has been no indication of recurrence 8 months after the pancreatic surgery. Resectable pancreatic metastasis from colon cancer is rare, and there are no clear indications for resection. Some cases of long-term survival have been reported; however, further studies are needed in order to establish a consensus.

[A Case of Sister Mary Joseph's Nodule from Transverse Colon Cancer Effectively Treated with SOX plus Bevacizumab Chemotherapy].

A 47-year-old woman presented with a hard umbilical nodule that appeared red and was painful. A biopsy of the umbilical nodule revealed adenocarcinoma. As a result of general examinations, the patient was diagnosed with umbilical, hepatic, and ovarian metastases from transverse colon cancer. She was treated with S-1 and oxaliplatin(SOX)plus bevacizumab chemotherapy. After 4 courses of chemotherapy, CT revealed that the primary lesion and umbilical and hepatic metastases had reduced in size. We considered this to be a partial response and thus administered 4 additional courses of SOX plus bevacizumab chemotherapy. Finally, she remained well for 22 months and achieved relatively good prognosis. An umbilical metastasis from an internal malignancy is known as a Sister Mary Joseph's nodule, and it has very poor prognosis. Most studies show that the survival period from the time of diagnosis is within 1 year. However, our case suggests that novel anti-cancer drugs or molecular-targeted agents may improve survival.

[A Case of Sigmoid Colon Cancer It Was Found from Penetration of Sigmoid Diverticulum].

A 52-year-old woman presented with sudden left lower abdominal pain, fever, and vomiting. As the symptom got improved immediately she went home then. She consulted our hospital with chief complaint of the left lower abdominal mass. Abdominal computed tomography revealed sigmoid colon cancer with abscess. She was diagnosed with sigmoid colon cancer via colonoscopy. Sigmoidectomy including partial resection of the abdominal wall was performed(D3 lymphadenectomy). Surgical specimen showed penetration of diverticulum on mucous membrane of the lesion which had been thought of a abdominal wall permeation and a tumor of I sp type at anal side. Pathological examination showed diverticulitis with penetration and the tumor was tubular adenocarcinoma(tub1, pT1bpN0, pStage I ). We had doubted penetration of sigmoid colon cancer most, but the cause of penetration turned out to be diverticulitis. We experienced a case in which we could performed surgery of sigmoid colon cancer and penetration of diverticulum at the same time.

[A Retrospective Study of Preoperative Concurrent Chemoradiotherapy for Locally Advanced Resectable Rectal Cancer].

PURPOSE: To analyze chemoradiotherapy results for locally advanced rectal cancers at a single institution. METHODS: The study cohort comprised 12 patients with clinically diagnosed T3/4, NX, M0 adenocarcinomas of the rectum who received preoperative chemoradiotherapy. RESULT: Pathological complete response(pCR)were observed in 2/12(16.7%)patients and pathological downstaging in 5/12(41.7%)patients, with generally mild adverse events. CONCLUSION: Preoperative che- moradiotherapy for clinical T3/4, NX rectal cancers significantly reduces local recurrences and improves prognoses.

[A Case of Apocrine Carcinoma of the Breast].

A 76-year-old postmenopausal woman presented with a bloody attachment on the left nipple. She had a 3 cm-sized tumor in her left breast. Mammography showed a spiculated irregular mass. Ultrasonography showed a 38 mm, low echoic mass with an irregular border. Core needle biopsy examination indicated apocrine carcinoma of the breast, ER(-), PgR(-), and HER2(-). An overall examination showed no distant metastasis. We diagnosed her with apocrine carcinoma of the breast(T2N0M0, cStageⅡA). We performed total mastectomy with sentinel lymph node biopsy. The postoperative histopathological examination revealed apocrine carcinoma without lymph node metastasis. The patient recovered uneventfully and was discharged 8 days after the surgery. She has not experienced any recurrence for 1 year and 7 months after the surgery.

[Transanal Minimally Invasive Surgery for Rectal Neuroendocrine Tumor].

A 57-year-old woman was admitted to our hospital due to a suspected rectal tumor at previous doctor. Colonoscopy showed a submucosal tumor with 8mm yellowish protrusions and smooth surfaces in the rectum, 5 cm from the anal verge. Endoscopic ultrasonography showed the appearance of the internal portions of the tumor to be relatively uniform in low echoic imagery. The tumor was located in the second to third layer. Histopathological findings showed neuroendocrine tumor- G1. We performed transanal minimally invasive surgery with GelPOINT®Path. Under general anesthesia, complete fullthickness excision of the rectal lesion was performed. Primary closure was accomplished using a 3-0 braided absorbable suture. The operation duration was 24 min; blood loss was very little in this case. The patient recovered uneventfully and was discharged 2 days after the operation. There was no anorectal dysfunction and no local and distant recurrence during the postoperative follow-up of 1 year 3 months. Transanal minimally invasive surgery with GelPOINT®Path was an effective treatment for the safe removal of small rectal tumor indicated for local resection.

[A Case of Emergency Surgery for Intussusception Due to Cecal Cancer].

A 79-year-old woman was admitted to the hospital because of continuous right lower abdominal pain lasting for 1 day. There was tenderness with signs of peritoneal irritation at the right lower abdomen along with a palpable mass. With the diagnosis of intussusception of the ileocecal region by CT examination, an emergency surgery was performed under general anesthesia. By laparoscopic ileocecal resection with lymph node dissection, the ileocecal region was found invaginated into the transverse colon, although this was easily reduced by Hutchinson's procedure. The histological diagnosis of the tumor was highly differentiated adenocarcinoma in Stage Ⅲb. The postoperative course was uneventful and the patient remained in good health without any recurrence during a follow-up period of 12 months. When a patient has a sign of peritoneal irritation, such as in our case, and intestinal tract necrosis and perforation by intussusception cannot be excluded, it is necessary to perform an emergency surgery.