Surgical management of primary undifferentiated pleomorphic sarcoma of the rectum: a case report and review of the literature.

BACKGROUND: Undifferentiated pleomorphic sarcoma (UPS) is a malignant soft tissue tumor that has been reclassified from malignant fibrous histiocytoma with the development of the pathological diagnosis. It principally occurs in the extremities but rarely occurs in the rectum. We herein report a rare case of UPS arising in the rectum. CASE PRESENTATION: A 85-year-old woman was referred to our hospital with a complaint of anal pain, which had persisted for several months. Computed tomography (CT) showed a 53 × 58 × 75 mm mass on the left side of the rectum. Colonoscopy revealed a submucosal elevation in the rectum without any exposure of the tumor to the surface. Contrast-enhanced CT and magnetic resonance imaging revealed an 80-mm mass that originated in the rectal muscular propria, and we suspected a gastrointestinal stromal tumor. No lymph node metastasis or distant metastasis was observed. We performed a laparoscopic Hartmann's operation. Intraoperatively, severe adhesion around the tumor caused tumor injury and right ureteral dissection. Thus, laparoscopic right ureteral anastomosis and ureteral stenting were additionally performed. The operation time was 6 h and 3 min, and the estimated blood loss was small. The patient was discharged without complications 25 days after surgery. A pathological examination showed that the tumor was composed of highly heterogeneous cells with no specific differentiation traits, leading to a diagnosis of UPS. Contrast-enhanced CT performed 2 months after surgery showed bilateral pelvic lymph node enlargement, which indicated recurrence. Considering the patient's age, we performed radiotherapy (50 Gy/25 Fr targeting the pelvic region). At present, 16 months have passed since the completion of radiotherapy. Contrast-enhanced CT shows that the recurrent lymph nodes have disappeared, and no new distant metastasis has been observed. CONCLUSIONS: We reported a case of UPS arising in the rectum. The surgical procedure and indication of preoperative therapy should be carefully selected because complete removal of the tumor is desirable in UPS.

[A case of primary mesenteric schwannoma with secondary ossification].

Schwannoma is a tumor that usually originates soft tissue peripheral nerves. Primary mesenteric schwannomas are rare, and furthermore, there are few reports of this with secondary ossification, which is extremely rare. Herein we report a case of primary mesenteric schwannoma with secondary ossification in a 46-year-old Japanese woman with recurrent postprandial abdominal pain and weight loss. Her vital signs were stable, and her blood test was almost normal except for a slight elevation of CA125. Computed tomography revealed a whirl sign indicative of superior mesenteric torsion. In contiguity with a constricted portion of the intestine, an approximately 70-mm, well-circumscribed tumor with calcifications, which was fed by the superior mesenteric artery was visible. On magnetic resonance imaging, the tumor appeared hypointense on T1-weighted images and inhomogeneous hyperintense on T2-weighted images. As a gastrointestinal mesenchymal tumor was suspected, we performed partial small intestinal resection including the tumor. Intraoperatively, the tumor was found to be incarcerated into a hernial orifice created by the adhesion of the sigmoid colon with the abdominal wall and uterus. Pathologically, the tumor had no continuity with the intestinal wall. It mainly consisted of hypocellular mucous, and spindle-shaped cells were sparsely distributed. Some areas were hypercellular with palisading arrangement cells. This was suggestive of an Antoni B>Antoni A type schwannoma. It also included secondary ossification and blood vessel assembly. The patient has had an uneventful postoperative course without recurrence for about 17 months. Primary mesenteric schwannoma is rare, and to our knowledge, only 20 cases including this case have been reported. Moreover, there has only been one report of primary mesenteric ossified schwannoma in 2018, and there has been no report in Japan so far. We report our experience with the successful treatment of primary mesenteric ossified schwannoma and review the literature.

[Elastofibroma Dorci;Report of a Case].

Elastofibroma is a relatively rare tumor that occurs commonly at the apex of scapula in elderly people. We report a case of elastofibroma of a female in her seventies. She visited our hospital with complaints of painful mass in her back, which was increasing in size. On the magnetic resonance imaging (MRI),the T1 and the T2-weighted images showed the same signal intensity as the muscle between the right scapula and the intercostal muscles. The internal fat component was cord-like, with high signal intensity. Based on the site of the tumor and characteristic findings on imaging, it was diagnosed as elastofibroma and resection was performed. Pathological findings revealed bundle-like proliferation of fibrous and spherical hyaline substances, together with collagen fibers. The hyaline substance stained in black on Elastica van Gieson staining and was confirmed to be elastic fiber. Thus, it was diagnosed as elastofibroma. The patient is on regular follow-up, with no recurrence after surgery.

Adjuvant chemotherapy for the perineural invasion of colorectal cancer.

BACKGROUND: To evaluate the association of perineural invasion (PNI) with outcomes in patients after colorectal resection of colorectal cancer (CRC) and to assess the effect of PNI on the response to adjuvant chemotherapy. PATIENTS AND METHODS: Data were retrospectively reviewed for 178 patients with consecutive stages I-III CRC who underwent curative surgery between January 1999 and December 2004. PNI data were examined, and the overall survival (OS) and disease-free survival rates were analyzed. RESULTS: PNI was detected in 36 of 178 patients (20%) and positively correlated with lymphatic invasion (P = 0.020), venous invasion (P = 0.037), and the incidence of metastasis or recurrence (P = 0.029). Five-year disease-free survival was 46% and 68% (P < 0.001) and the 5-y OS was 64% and 80% (P < 0.001) for patients with and without PNI, respectively. In stage III CRC, multiple regression analysis identified PNI as a strong negative prognostic factor of OS; among PNI-positive patients, median OS with adjuvant chemotherapy was almost twofold higher than that without adjuvant chemotherapy (6 versus 2.8 y; P = 0.017). CONCLUSIONS: PNI was a poor predictor of survival among patients with stage III CRC, and adjuvant chemotherapy may attenuate the adverse effects of PNI on survival.

Postoperative peripheral blood monocyte count correlates with postoperative bile leakage in patients with colorectal liver metastases after hepatic resection.

PURPOSE: Postoperative bile leakage is one of the most common complications after hepatic surgery. The relationship between the inflammatory response and postoperative bile leakage has not been fully investigated. Therefore, we retrospectively investigated the relation between postoperative peripheral blood monocyte count and bile leakage in patients with colorectal liver metastases (CRLM) after elective hepatic resection. METHODS: The study comprised 105 patients who had undergone hepatic resection for CRLM between January 2000 and March 2012. Perioperative risk factors pertinent to development of bile leakage were investigated using univariate and multivariate analyses. RESULTS: Bile leakage developed in 9 (8.6 %) of 105 patients. In multivariate analysis, intraoperative fresh frozen plasma (FFP) transfusion (p = 0.009) and lower monocyte count of the peripheral blood on postoperative day 1 (p = 0.038) were found as independent risk factors of bile leakage. CONCLUSIONS: Postoperative lower monocyte count and intraoperative FFP transfusion were associated with the development of postoperative bile leakage after elective hepatic resection in patients with CRLM.

Feasibility study of S-1 adjuvant chemotherapy in patients with colorectal cancer.

BACKGROUND: We evaluated the safety, efficacy, and compliance of 1-year treatment with S-1 in patients with stage II/III resectable colorectal cancer. METHODS: S-1 was administered orally in two divided doses daily. The dose was assigned according to body surface area (BSA) as follows: BSA <1.25 m(2), 80 mg/day; BSA ≥1.25 to <1.5 m(2), 100 mg/day; and BSA ≥1.5 m(2), 120 mg/day. S-1 was given for 28 consecutive days, followed by a 14-day rest. The study objects were the rate of completion of treatment as planned at 1 year, the ratio of the actually administered dose to the planned dose at 1 year, and the total number of days of treatment. RESULTS: At 1 year, the rate of completion of treatment as planned was 77.7 % (42/54 patients), and the ratio of the actually administered dose to the planned dose was 82.9 %. The mean and median total numbers of days of treatment were 209 and 252, respectively. Grade 3 or higher toxicity (watery eyes) occurred in only 1 patient. CONCLUSION: S-1 adjuvant chemotherapy had acceptable compliance, safety, and efficacy in patients with colorectal cancer. S-1 adjuvant chemotherapy is considered a possible standard treatment regimen for colorectal cancer.

Practice to extend indication of hepatic resection for colorectal liver metastasis.

BACKGROUND/AIMS: Recent reports have demonstrated that patients with limited extrahepatic disease and bilobar disease can benefit from aggressive surgical resection in combination with chemotherapy. Therefore, we extended indication of hepatic resection for colorectal liver metastasis (CRLM) since 2004. In this report, we retrospectively assessed changes in our therapeutic strategy for CRLM. METHODOLOGY: The subjects were 67 patients who underwent hepatic resection for CRLM between January 2000 and December 2008. Patients were classified into two groups; early period (2000-2003) and late period(2004-2008). We assessed prognostic factors and change in our hepatic resection policy on operative indication for CRLM in relation to therapeutic outcome. RESULTS: In multivariate analysis, more than 4 lymph node metastases (p=0.0277) and bilobar disease (p=0.0142) were significant predictors of disease- free survival, while significant predictor of overall survival were more than four lymph node metastases (p=0.0014) and bilobar disease (p=0.0392). Bilobar disease and presence of extrahepatic disease were significantly greater in late period. However, incidence of postoperative complications, disease-free and overall survivals in both periods were comparable. CONCLUSIONS: Practice to extend indication of hepatic resection for patients with advanced CRLM seems to increase the respectability rate without increasing morbidity and mortality, whenever a macroscopically curative resection with acceptable operative risk was thought possible.

Successful resection of port site recurrence of pancreatic ductal adenocarcinoma after laparoscopic distal pancreatectomy.

BACKGROUND: There are many reports of port site recurrence after laparoscopic surgery for various types of cancer. However, only two cases of port site recurrence after laparoscopic pancreatectomy have been reported to date. We herein report a case of port site recurrence after laparoscopic distal pancreatectomy. CASE PRESENTATION: A 73-year-old woman was diagnosed with pancreatic tail cancer and underwent laparoscopic distal pancreatectomy with splenectomy. Histopathological examination revealed pancreatic ductal carcinoma (pT1N0M0 pStage I). The patient was discharged on postoperative day 14 with no complications. However, 5 months after surgery, computed tomography showed a small tumor at the right abdominal wall. No distant metastasis had appeared after 7 months of follow-up. Under the diagnosis of port site recurrence without any other metastases, we resected this abdominal tumor. Histopathological examination showed port site recurrence of pancreatic ductal carcinoma. No recurrence was observed 15 months postoperatively. CONCLUSIONS: This is the report of successful resection of port site recurrence of pancreatic cancer.

A rare case of colorectal metastasis found 8 years and 10 months after gastrectomy for advanced gastric cancer: A case report and literature review.

Colorectal metastasis from gastric cancer is rare and may develop several years after gastric cancer surgery. Therefore, colonoscopic findings provide useful diagnostic information. The present report describes a case of gastric cancer colon metastasis diagnosed 8 years and 10 months after gastrectomy for advanced gastric cancer. A 64-year-old male patient underwent gastrectomy in December 2010 and received chemotherapy for 4 years and 10 months after the surgery. Subsequently, the patient was diagnosed as having colorectal cancer by computed tomography in February 2019. Colonoscopy revealed linitis plastica-like colon stenosis; however, biopsy pathology did not reveal any findings indicating malignancy. Right hemicolectomy was performed, and pathological examination revealed colon metastasis from gastric cancer. The patient received chemotherapy but died of peritoneal carcinomatosis 1 year and 8 months after the colectomy. According to literature, colorectal metastasis from gastric cancer is often attributed to hematogenous metastasis and often exhibits characteristic macroscopic features. Treatments, such as chemotherapy for gastric cancer and/or colorectal resection, are considered effective for gastric cancer colorectal metastasis.

Perioperative change in peripheral blood monocyte count may predict prognosis in patients with colorectal liver metastasis after hepatic resection.

BACKGROUND: Prognostic value of perioperative change in peripheral blood leukocyte subset count of cancer patients have not been fully investigated. Therefore, we retrospectively investigated the relation between perioperative change in peripheral blood monocyte count and disease-free as well as overall survival after hepatic resection for colorectal liver metastasis (CRLM). METHODS: The subjects were 64 patients who underwent hepatic resection for CRLM between January 2000 and December 2008. We retrospectively investigated the relation between perioperative change in peripheral blood monocyte count and disease-free as well as overall survival. RESULTS: In multivariate analysis, more than four lymph node metastases (P = 0.0298) and extrahepatic disease (P = 0.0423) were significant predictors of disease-free survival, while significant predictor of overall survival were more than four lymph node metastases (P = 0.0011), bilobar disease (P = 0.0024), and increase in perioperative monocyte less than twice (P = 0.0029). Morover, increase in perioperative monocyte of less than twice positively correlated with intraoperative blood transfusion. CONCLUSIONS: Perioperative change in peripheral blood monocyte count is an independent risk factor for overall survival after hepatic resection for CRLM, and may reflect immunosuppressive state.

Analysis of risk factors for surgical site infection and postoperative recurrence following inguinal and femoral hernia surgery in adults.

OBJECTIVE: We aimed to evaluate the causes of complications following surgery for inguinal and femoral hernia, using surgical site infection (SSI) and recurrence rate as indicators of outcomes to consider appropriate treatments. METHODS: We retrospectively assessed the medical histories of 1,098 patients with adult inguinal and femoral hernias who underwent herniorrhaphy between July 2010 and March 2019. Using SSI and recurrence rate as indicators of outcomes, we statistically assessed the influence of preoperative and operative conditions on surgical outcomes. RESULTS: The occurrence of postoperative SSI was significantly more frequent in patients who experienced a long surgical duration, excessive blood loss, and incarceration; underwent emergency surgery and bowel resection; and in whom no mesh sheet insertion was performed. There was no correlation between mesh use and SSI in cases that did not require emergency incarceration repair. For cases involving hernia incarceration, the use of a mesh sheet was avoided to prevent potential infection, which could explain the high incidence of SSI in cases where mesh was not used. The hernia may have recurred due to technical issues during the procedure, as well as failure to ligate the hernia sac. CONCLUSIONS: Selecting the appropriate surgical method for hernia repair may reduce the incidence of SSI. If manual reduction of inguinal hernias is not possible, an appropriate surgical procedure should be determined based on laparoscopic findings in facilities where laparoscopic hernia surgeries are frequently performed. Moreover, in cases without infection and bowel resection, mesh use may be beneficial. Recurrence can be prevented by ligating the hernia sac during surgery and solving relevant technical problems.

Risk Factors Associated with the Development of Metastases in Patients with Gastroenteropancreatic Neuroendocrine Tumors: A Retrospective Analysis.

Neuroendocrine tumors develop from systemic endocrine and nerve cells, and their occurrence has increased recently. Since these tumors are heterogeneous, pathological classification has been based on the affected organ. In 2019, the World Health Organization introduced a change expected to influence neuroendocrine tumor research, as gastroenteropancreatic neuroendocrine tumors are now included within a unified classification. This retrospective study aimed to investigate the characteristics (e.g., lymph node metastases and all other metastases) of gastroenteropancreatic neuroendocrine tumors using this new classification in 50 cases. Tumor size, depth, MIB-1 index, lymphatic invasion, venous invasion, and neuroendocrine tumor grade were significantly correlated with lymph node metastasis and other metastases. The venous invasion was more strongly correlated with lymph node metastasis and all other types of metastases than with lymphatic invasion. Identification rates for lymphatic invasion were considered lower because of structural problems such as lymphatic vessels being much thinner than veins. However, venous invasion was considered effective in compensating for the low identification rate in cases of lymphatic invasion. In future research, a unified classification and standardized framework for assessment will be important when analyzing the characteristics of neuroendocrine tumors, and large-scale studies are required.

Catamenial pneumothorax with partial liver herniation due to diaphragmatic laceration: a case report and literature review.

BACKGROUND: Catamenial pneumothorax is generally uncommon, with an incidence of less than 3-6% in women with spontaneous pneumothorax. As few cases of catamenial pneumothorax with diaphragmatic defect and liver herniation have been reported, this case report may be useful for understanding the cause and treatment. This case highlights the importance of the approach for liver hernia in patients with catamenial pneumothorax and endometriosis. CASE PRESENTATION: We report a case of catamenial pneumothorax in a 43-year-old woman with diaphragmatic partial liver hernia who was treated with thoracoscopic surgery. She was diagnosed with a right pneumothorax at menstruation onset. Chest computed tomography showed a nodule protruding above the right diaphragm. We performed thoracoscopic surgery to treat the persistent air leak and biopsied the nodule on the right diaphragm. There were blueberry spots on the diaphragm; the nodule was found to be the herniated liver. The diaphragmatic defect was sutured. Histological examination of the tissue near the partial prolapsed liver revealed endometrial tissue. CONCLUSIONS: It is speculated that ectopic endometrial tissue in the diaphragm will periodically necrose to become a diaphragmatic tear, which is a pathway for air to enter the thoracic cavity and eventually a herniated liver. Thoracoscopic surgery should be considered in patients with catamenial pneumothorax when a diaphragmatic lesion is suspected.

Significance of Primary Malignant Tumors on the Outcome of Patients With Resected Gastrointestinal Stromal Tumors.

AIM: This study aimed to clarify the significance of primary malignant tumors for the outcome of resected gastrointestinal stromal tumors (GISTs). PATIENTS AND METHODS: The medical history, pathological findings and prognosis of 66 patients with GISTs resected at our institute between January 2003 and December 2018 were investigated retrospectively and compared statistically. RESULTS: Among 66 patients with GISTs, 24 (36%) had concomitant malignant tumors. In an average study period of 57 months, one patient died from GIST, seven from other malignant tumors, and one from another disease. Only coexistence of GIST and other malignant tumors was recognized as a prognostic factor. Increasing age was significantly correlated with other malignant tumor in combination with GIST. When comparing patients with GIST alone and GIST with other malignant tumors, the latter showed significantly poorer prognosis. CONCLUSION: Coexistence of other malignant tumors was commonly observed in patients with GIST, and was associated with poorer prognosis. This association should be carefully considered and monitored in patients with GISTs.

Ruptured visceral artery aneurysms in a patient of neurofibromatosis type 1 (NF-1) successfully treated by endovascular treatment.

BACKGROUND: Neurofibromatosis type 1 (NF-1) is an autosomal dominant disease and arteriovenous abnormalities are a well-recognized complication. There are several case reports of ruptured aneurysms; however, among them, reports of superior pancreaticoduodenal artery (PDA) and superior mesenteric artery (SMA) aneurysms are rare. We experienced the case of ruptured PDA and SMA aneurysms in a patient of neurofibromatosis type I successfully treated by endovascular treatment. CASE PRESENTATION: A 55-year-old woman with NF-1 came to our hospital with abdominal pain and vomiting. Enhanced abdominal computed tomography revealed a hematoma in the retroperitoneum and an aneurysm in the head of the pancreas. Angiography was performed, and a ruptured aneurysm was suspected the periphery of the PDA, and we embolized it using coils. However, on postoperative day 2, the hemoglobin level decreased, and a branch of the SMA was ruptured. She underwent embolization using coils again and discharged on postoperative day 27 without any further hemorrhage. CONCLUSIONS: To our knowledge, this is the first successfully treated case of ruptured SMA and PDA aneurysms in a patient with NF-1.

Clinicopathological features of perforated colorectal cancer.

UNLABELLED: The aim of this retrospective study was to determine clinicopathological factors pertinent to the prognosis of perforated colorectal cancer (PCRC). PATIENTS AND METHODS: A retrospective review of clinical records of 17 cases of emergency primary resection for PCRC (stage IIIa in 2, stage IIIb in 6 and stage IV in 9) was performed. RESULT: The 5-year survival rate was 31% (31% for stage III and 12% for stage IV). When compared with non-PCRC (533 cases) in stage III (78.8%) or stage IV (14.8%), the 5-year survival rate of stage III perforated colorectal cancer was clearly worse (p<0.01) than the non-perforated counterpart. For stage IV, however, the two groups had a similar prognosis. MST of the PCRC was 31 months for stage III and 12 months for stage IV. Approximately half of the recurrence pattern of stage III (75%), or stage IV (44%) PCRC was peritoneal carcinomatosis. As for the type of operations performed, Hartmann's procedure was the preferred technique (71%), for which mortality and morbidity rate were both low. CONCLUSION: Because of the high incidence of peritoneal carcinomatosis and low 5-year survival rate, stage III PCRC should be regarded as a stage IV disease, for which postoperative chemotherapy seems essential.

CA19-9 Concentration After First-line Chemotherapy Is Prognostic Predictor of Metastatic Colon Cancer.

BACKGROUND/AIM: To evaluate whether the serum levels of CEA or CA19-9 concentration is a useful predictor of survival in patients with metastatic colon cancer (mCC). PATIENTS AND METHODS: Between 2012 and 2015, 113 patients with mCC who underwent chemotherapy according to the Japanese Colorectal Cancer Treatment Guidelines at four Jikei University Hospitals were enrolled in this study. The two serum tumor makers, CEA and CA19-9 were measured before first-line chemotherapy and at four months thereafter. RESULTS: Serum CA19-9 concentration at four months after first-line chemotherapy (p=0.003, HR=3.761) and first-line chemotherapy including oxaliplatin (p=0.038, HR=0.312) were independent predictors of survival in patients with mCC. By excluding the transverse colon, only serum CA19-9 concentration at four months after first-line chemotherapy (p=0.005, HR=3.660) was identified as the predictor of survival. CONCLUSION: Serum CA19-9 concentration after first-line chemotherapy seems to be a useful predictor of survival in patients with mCC.

Reevaluation of Preoperative Chemoradiotherapy for Clinical T3 Lower Rectal Cancer: A Multicenter Collaborative Retrospective Clinical Study.

AIM: This study aimed to re-evaluate the usefulness of preoperative chemoradiotherapy for clinical T3 lower rectal cancers without lateral lymph node metastasis. PATIENTS AND METHODS: Between 2010 and 2014, 132 patients with clinical T3 lower rectal cancer without lateral lymph node metastasis, 80 years of age or younger, who underwent curative resection at four Jikei University Hospitals were enrolled into this retrospective study. Of these, 22 patients received chemoradiotherapy (CRT) before surgery, 16 patients received intensive chemotherapy after surgery without preoperative CRT, and 94 patients underwent neither preoperative CRT nor intensive chemotherapy after surgery including 47 patients with postoperative oral chemotherapy for pathological diagnosis of stage III. RESULTS: The 3-year disease-free survival (DFS) of the 22 patients who received preoperative CRT was 95.5%, whereas that of the 94 patients who received neither preoperative CRT nor intensive chemotherapy was 72.0% (p=0.024). However, there was no significant difference in 5-year DFS between the two groups. No significant difference was identified in DFS between the 22 patients who received preoperative CRT and the 16 patients who received intensive chemotherapy after surgery without preoperative CRT. CONCLUSION: Intensive chemotherapy after surgery seems to yield a similar prognosis to preoperative CRT in patients with clinical T3 lower rectal cancer without lateral lymph node metastasis.

Schwannoma of the Small Intestine.

Schwannomas of the gastrointestinal tract are rare. Herein, we report a case of schwannoma originating from the small intestine. A 78-year-old woman underwent medical follow-up after surgery for bladder cancer, and a mass in the upper part of the pelvis was revealed by abdominal CT. With the diagnosis of a submucosal tumor of the small intestine, she underwent partial intestinal resection. The submucosal tumor was pathologically composed of S100-positive spindle cells and diagnosed as schwannoma. We report this case of rare schwannoma of the small intestine and review the literature.

Arterial infusion chemotherapy in patient with repeated recurrent tumor of cecal cancer: report of a case.

PURPOSE: We report a patient with a repeated recurrent tumor after Right-hemicolectomy for advanced cecal cancer who was treated by intra-arterial infusions of 5-fluorouracil (5-FU). METHODS: A computed tomography scan revealed a pelvic mass involving the psoas major muscle and quadratos lumborum muscle, in contact with the widely projecting toward L2-S2. The fluorodeoxyglucose-positron emission tomography (FDG-PET) revealed an accumulation spot in the same place. This case was deemed in operable, and one-shot bolus of 5-FU was administered through the tumor feeding arteries: the left 3rd, 4th lumbar, and ilio -- lumbar arteries at a dosage of 250 mg/body from each artery. RESULTS: A partial regression of the tumor was observed by computed tomography. The serum level of carbohydrate antigen 19-9 returned normal in 8 months. During chemotherapy, the side effect and complications were tolerable, and she experienced only grade-1 nausea caused by 5-fluorouracil. CONCLUSION: A long-time, intra-arterial 5-fluorouracil infusion could control effectively and safely.