[A Case of Metachronous Multiple Liver Metastases of AFP and PIVKA-â ¡ Producing Gastric Cancer, Responding to Transcatheter Arterial Chemoembolization].

We report a case of a 75-year-old man with a-fetoprotein(AFP)-producing gastric cancer accompanied by multiple large liver metastases. The patient underwent a total gastrectomy for gastric cancer(p-T3N3H0P0M0, fStage ⅢB). The patient then underwent chemotherapy(TS-1 80m g/day)following the radical operation. However, 5 months after the radical operation, he presented with multiple large liver tumors, which were subsequently biopsied. Based on immunohistochemical examination, the liver tumors were negative for AFP protein, but were similar to hepatoid adenocarcinoma, and no fibrosis was observed in the background liver. Therefore, we diagnosed the tumors as liver metastases of AFP producing gastric cancer and metachronous liver metastasis. The patient underwent transcatheter arterial chemoembolization(TACE). TACE decreased the AFP and PIVKA-Ⅱ levels and reduced the multiple huge liver metastases. Due to the increase in AFP and the multiple liver metastases, despite intensive hepatic infusion chemotherapy, he died 5 months after admission.

Early-stage T1b adenocarcinoma arising in the remnant cystic duct after laparoscopic cholecystectomy: a case report and literature review.

BACKGROUND: The cystic duct has been included in the staging classification scheme for gallbladder cancer since the 2010 publication of the AJCC Cancer Staging Manual (7th edition). To our knowledge, only seven other cases of adenocarcinoma arising in the remnant cystic duct following cholecystectomy have been reported in the English-language literature, and none has been reported as primary early-stage T1b remnant cystic duct cancer (CDC). We report, herein, a case of primary adenocarcinoma arising in the remnant cystic duct in a patient with history of laparoscopic cholecystectomy for gallstone disease. CASE PRESENTATION: An 81-year-old female presented with abdominal pain. Her medical history included a laparoscopic cholecystectomy for cholecystolithiasis two years prior. Jaundice was observed; imaging studies suggested that this was caused by choledocholithiasis. Blood chemistry findings showed severe liver dysfunction. Endoscopic retrograde cholangiography revealed haemobilia from the common bile duct with no evidence of choledocholithiasis. A bile sample showed Papanicolaou class IV cytology. As the extent of tumour spread was undetermined by abdominal ultrasonography and endoscopic ultrasonography, peroral cholangioscopy (POCS) was performed, which revealed tiny papillary lesions within the confluence of cystic duct, and fine granular lesions in the centre of bile ducts, signifying early-stage remnant CDC. Extrahepatic bile duct resection with regional lymphadenectomy was done. Histopathological findings revealed a 42-mm tubular adenocarcinoma originating from the remnant cystic duct with the considerable shallow spread across the extrahepatic bile ducts. It invaded the fibromuscular layer, with no lymphovascular or perineural invasion, no lymph node metastasis (13 nodes examined), and uninvolved surgical resection margin (R0 resection), and was staged as pT1bN0M0, Stage I. CONCLUSIONS: Primary early-stage T1b remnant CDC is an uncommon condition for which early diagnosis is challenging; if intraoperatively recognized, it can complicate surgery. Our experience of this case and an overview of the English literature suggest that POCS is an efficient tool to diagnosis this tumour and assess its spread along the extrahepatic bile ducts.

[A Case of Melena Caused by Peritoneal Dissemination, Treated with Interventional Radiology].

We reported a case of melena caused by perineal dissemination and treated with radiologic intervention. The patient was a 67-year-old woman, who underwent a partial duodenectomy for duodenal(4th portion)cancer in 2013. The pathological examination revealed that the tumor was tub2>por2 adenocarcinoma, SE, n+(10/20), M0. The patient received 2 courses of cisplatin(CDDP)plus S-1 and 8 courses of S-1 monotherapy. About 2 years postoperatively, the patient was hospitalized due to unauthorized bleeding. Metrorrhagia was diagnosed as intrapelvic dissemination based on abdominal computed tomography in April 2016. The patient underwent sigmoid colostomy because she developed bowel obstruction. Postoperatively, the patient received 6 courses of capecitabine plus oxaliplatin(CapeOX)plus bevacizumab. Three months later, a reduction in the recurrent lesion was observed. However, after 6 months, the patient was again hospitalized due to melena. Her condition improved after receivinga blood transfusion and infusinga hemostat. In order to control the hemorrhage, radiation therapy of 50 Gy/25 fractions to the intrapelvic dissemination was conducted. Bleedingcould not be controlled by conservative treatment with blood transfusion. Therefore, radiologic intervention was performed for melena caused by peritoneal dissemination. Neither rebleedingnor symptoms of possible ischemic complications were observed after the intervention until she died 3 months later.

[A Case of Angiosarcoma of the Breast Following Breast-Conserving Surgery with Radiotherapy for Breast Cancer].

We report a case of angiosarcoma of the breast following breast-conserving surgerywith radiotherapyfor breast cancer. The patient was 82-year-old woman, developed induration and eruption in the bilateral breast more than 8 years after the initial operation for breast cancer. The induration was diagnosed as angiosarcoma based on skin-biopsyand vacuum-assisted biopsy. The patient received simple mastectomy, and has been become recurrent condition about one month after simple mastectomy. We operated partial excision for recurrence tumor. She is still alive after rearly 1 year of past operation. There are no established therapies for angiosarcoma of the breast following breast-conserving surgerywith radiotherapyfor breast cancer. Although radiotherapy-induced sarcoma is rare, earlydetection of the tumor in the irradiation area is important, as radiotherapyis often performed for the breast cancer patients. This interesting case of angiosarcoma of the breast after breast-conserving surgeryfor breast cancer is reported.

[A Case of Pancreatic Metastasis of Renal Cell Carcinoma].

A 69-year-old woman underwent right nephrectomy for the treatment of renal cell carcinoma. Nine years later, a 2 cm, solitary tumor was detected in the pancreas tail using computed tomography, and the patient underwent distal pancreatectomy and splenectomy. The pathological diagnosis was metastasis of renal cell carcinoma. A year later, a new tumor was confirmed in the pancreas head on a follow-upCT scan. Nine years after the resection of the pancreatic metastasis, the pancreas head tumor had increased in size. It was determined to be renal cell carcinoma metastasis, but the patient remains alive and well 20 years after the initial resection.

[Usefulness of Palliative Gastrojejunal Bypass Surgery].

OBJECTIVES: The aim of this study was to evaluate the usefulness of gastrojejunal bypass surgery performed in patients presenting with upper gastrointestinal tract obstruction due to unresectable advanced cancer. SUBJECTS AND METHODS: The subjects were 21 patients who underwent gastrojejunal bypass surgery at our division between 2010 and 2014 for symptom palliation. We retrospectively evaluated the operative outcomes, whether chemotherapy was administered, the oral ingestion period, and survival time. RESULTS: The median postoperative day of starting oral ingestion was 6 (range: 2-42), and the median period from decreased oral ingestion to death was 4 (range: 0-26) days. Twelve patients (57%) were discharged. Postoperative chemotherapy was prescribed to all the 9 patients who desired treatment. The median duration of oral digestion time was 61 days, and the median overall survival time was 92 days. CONCLUSION: Gastrojejunal bypass surgery is found to have the potential to not only make relatively long-term oral ingestion possible, but also broaden available treatment options, such as home care or chemotherapy, thereby contributing to improved quality of life.

Serum metabolomics reveals γ-glutamyl dipeptides as biomarkers for discrimination among different forms of liver disease.

BACKGROUND & AIMS: We applied a metabolome profiling approach to serum samples obtained from patients with different liver diseases, to discover noninvasive and reliable biomarkers for rapid-screening diagnosis of liver diseases. METHODS: Using capillary electrophoresis and liquid chromatography mass spectrometry, we analyzed low molecular weight metabolites in a total of 248 serum samples obtained from patients with nine types of liver disease and healthy controls. RESULTS: We found that γ-glutamyl dipeptides, which were biosynthesized through a reaction with γ-glutamylcysteine synthetase, were indicative of the production of reduced glutathione, and that measurement of their levels could distinguish among different liver diseases. Multiple logistic regression models facilitated the discrimination between specific and other liver diseases and yielded high areas under receiver-operating characteristic curves. The area under the curve values in training and independent validation data were 0.952 and 0.967 in healthy controls, 0.817 and 0.849 in drug-induced liver injury, 0.754 and 0.763 in asymptomatic hepatitis B virus infection, 0.820 and 0.762 in chronic hepatitis B, 0.972 and 0.895 in hepatitis C with persistently normal alanine transaminase, 0.917 and 0.707 in chronic hepatitis C, 0.803 and 0.993 in cirrhosis type C, and 0.762 and 0.803 in hepatocellular carcinoma, respectively. Several γ-glutamyl dipeptides also manifested potential for differentiating between nonalcoholic steatohepatitis and simple steatosis. CONCLUSIONS: γ-Glutamyl dipeptides are novel biomarkers for liver diseases, and varying levels of individual or groups of these peptides have the power to discriminate among different forms of hepatic disease.

Laparoscopic surgery for urachal remnants in pubescent children: a case series.

BACKGROUND: Various techniques are applied in laparoscopic surgery for the treatment of urachal remnants, which are less invasive and associated with lower morbidity. We herein report a case series in which we treated urachal remnants and medial umbilical ligaments using a laparoscopic approach. CASE PRESENTATION: From 2015 to 2019, seven patients (male, n = 5; female, n = 2) with a urachal remnant were treated by laparoscopic surgery in our institute. Five boys and two girls with a median age of 11 years (range 10-15 years) were enrolled in this series. The clinical results of laparoscopic treatment, the perioperative records, and the pathologic results were evaluated. The operation was performed with the use of three ports and an EZ access® (Hakko Medical, Nagano, Japan), which is a silicon cap for the wound retractor (Lap Protector®, Hakko Medical, Nagano, Japan). The removal of the urachal remnant and medial umbilical ligaments was completed with a median operative time of 92 min (range 69-128). The median hospital stay after surgery was 4 days (range 2-5). No patients developed intra-postoperative complications or recurrence. CONCLUSIONS: Although our data are preliminary, complete laparoscopic removal of symptomatic urachal remnants and medial umbilical ligaments was a safe and effective minimally invasive approach, with better cosmetic outcomes.

[A case of multiple liver metastases of colon cancer with PyNPase-positive successfully treated with 5'-DFUR].

A 75-year-old man was diagnosed with transverse colon cancer. We therefore performed a transverse colectomy. Diagnosis of multiple liver metastases was made by intraoperative palpation, core needle biopsy and postoperative abdominal CT scan. 5'-deoxy-5-fluorouridine (5'-DFUR) 800 mg/day was administered orally after the surgery. After 2 months of administration, an abdominal CT scan showed the metastatic lesions of liver were reduced. After 8 months, an abdominal CT scan showed no evidence of liver metastases. Pyrimidine nucleoside phosphorylase (PyNPase), an enzyme that converts 5'-DFUR to 5-FU, has an important role in the expression of the anti-tumor activity of 5'-DFUR. Primary specimens of this case were regarded as PyNPase-positive. We think that administration of 5'-DFUR may be a useful treatment for advanced colon cancer that is PyNPase-positive.