[A Case Report of Conversion Surgery for Pancreatic Ductal Adenocarcinoma with Liver Metastasis after Chemotherapy]

Pancreatic ductal carcinoma is one of the leading causes of cancer deaths in Japan. However, with remarkable progress in chemotherapy, studies have reported successful resection of initially unresectable pancreatic adenocarcinoma after chemotherapy. We report a case of curative surgery of pancreatic ductal adenocarcinoma with liver metastasis after chemotherapy. A 66-year-old man presenting with jaundice and weight loss was admitted to our hospital for an evaluation of pancreatic lesions. Computed tomography revealed a hypoattenuating mass in the head of the pancreas. We diagnosed this cancer as cT4(SMA>1/2)N1M0, cStage Ⅲand performed chemoradiotherapy for this locally advanced pancreatic cancer. Because of the appearance of liver metastasis, we treated this patient with GEM plus nab-PTX chemotherapy. There were no serious adverse events. After 3 therapy courses, the existing liver metastasis disappeared, and no new metastases were noted. Therefore, radical subtotal stomach-preserving pancreatoduodenectomy was performed. The tumor was diagnosed as moderately differentiated adenocarcinoma, ypT1a ypN0 ypM0, ypStage ⅠA, R0.

[A Case of Leiomyosarcoma of the Sigmoidal Mesocolon]

Leiomyosarcoma of the mesocolon is a very rare disease. Previously, there was no recommendation for chemotherapy or radiotherapy for leiomyosarcoma of the mesocolon, and only surgical resection reportedly offers a chance for cure. However, the reported cases of leiomyosarcoma of the mesocolon were not distinguished from those of gastrointestinal stromal tumor (GIST), which is the same mesenchymal tumor; thus, there is a possibility that they include cases that should be diagnosed as GIST. We report a case of leiomyosarcoma of the sigmoidal mesocolon.

[A Case of Curative Surgery after Infection Control Surgery for Peritonitis Due to Perforation of Rectal Cancer]

A 70s man was admitted to another hospital with a complaint of abdominal pain, and was diagnosed with a gastrointestinal perforation based on the presence of free air in the abdominal cavity on computed tomography. The patient was transferred to our hospital in shock and underwent emergency surgery. Operative findings showed a perforation of the rectosigmoid colon and rectal cancer at the anal side of the perforation site. As his general condition was unstable due to septic shock, only the segments of the colon including the perforation site and rectal cancer were resected for source control. The abdominal wall was kept open, and intraperitoneal contamination was managed with an open management method using negative pressure wound therapy. Systemictreatments for septicshoc k were performed in the intensive care unit with a vasopressor and polymyxin-B hemoperfusion. The general condition became stable with intensive care by postoperative day 3. We performed additional lymph node dissection and one-step rectal sigmoidoscopic anastomosis on postoperative day 4. The pathological results confirmed pT4aN1M0, pStage Ⅲa disease. Although the course was complicated by postoperative pneumonia, the patient was discharged on postoperative day 28. We experienced a case in which curative resection with radical lymph node dissection and one-step anastomosis were performed after infection and source control with open abdomen management.

[Sustained Complete Response of Hepatocellular Carcinoma with Multiple Intrahepatic Metastases following the Discontinuation of Sorafenib]

Sorafenib is an oral multi-targeted tyrosine kinase inhibitor used in cases of unresectable advanced HCC that significantly improves progression-free and overall survival. Complete response(CR)is uncommon; however, if major or complete radiological response are obtained, the issue of the discontinuation of sorafenib remains unresolved. The present study reported a case of a 75-year-old man with non-hepatitis B and C virus-related cirrhosis and multiple recurrent HCCs followingresection. In December 2010, a CT scan revealed multiple intrahepatic recurrence after TACE. Laboratory testingshowed Child-Pugh class A cirrhosis and an alpha-fetoprotein level of over 20,000 ng/mL. Sorafenib(800mg/day)was started in December 2010. The subsequent dynamic CT performed at the 6th month of therapy showed a partial response accordingto RECIST criteria and a complete response accordingto mRECIST. The AFP had decreased to within normal levels. In May 2012, the sorafenib dose was reduced(200 mgtwice daily)due to side effects(skin reaction). In December 2013, treatment was stopped after confirmation of a CR associated with shrinkage of the HCC. The patient maintained this remission until June 2018, more than 54 months after the discontinuation of sorafenib therapy. The adverse events of sorafenib were reversible. Further reportingof similar cases should help in the design of treatment strategies after CR to sorafenib therapy.

[A Resected Case of Tumorigenic Pancreatic Endocrine Cell Hyperplasia]

A 51-year-old man with a gallstone was found to have a tumor in the tail of the pancreas during preoperative examination. We performed EUS-FNA and a pancreatic neuroendocrine tumor was suspected.Therefore, laparoscopic distal pancreatectomy and cholecystectomy were performed.Pathological examination and immunohistochemistry showed that the pancreatic endocrine cells were uniformly increased and were composed of normal Langerhans islets.Therefore, the patient was diagnosed with pancreatic endocrine cell hyperplasia.Typical pancreatic endocrine cell hyperplasia does not form a tumor and is asymptomatic.However, some cases are symptomatic; therefore, when hypoglycemia or pancreatic hormone elevation are found without a clear cause, it should be distinguished.Because pancreatic tumors are difficult to diagnose definitely by imaging inspection alone, needle biopsy is necessary.However, neuroendocrine tumor and neuroendocrine cell hyperplasia are difficult to differentiate by biopsy.

Long-term outcomes of surgical resection of lung metastases from colorectal cancer

655

Background: The lungs are one of the most frequent sites of metastases from colorectal cancer(CRC). Surgical resection has been widely performed on patients with pulmonary metastases from CRC with favorable outcomes. Surgical treatment is considered an effective option, but the surgical indications of lung resection have institutional bias. In our hospital, we aggressively perform surgery for lung metastases when the primary tumor and other metastases are controlled and all lung metastases are resectable. In this study, the aim is to investigate the long-term outcomes of resections of lung metastases from CRC in our institute. Methods: Between April 2009 and November 2017, patients who underwent lung resections for metastases from CRC with curative intent in our hospital were investigated retrospectively. Kaplan-Meier survival curves, log-rank tests, chi-squared test and T-test were used to analyze the survival rates and the factors predicting recurrence. Results: Sixty-seven patients underwent lung resection of metastases from CRC. The median follow-up period was 25.3 (6-60) months. Five-year disease free survival was 33.6 % and 5-year overall survival was 63.9%. Because of pulmonary recurrence, second surgery was performed in 16 patients and a third surgery in three patients. 5-year overall survival rate after first lung resection in patients who underwent repeated lung resection was 49.2%. There was no significant difference between the number of patients with pulmonary recurrence and those with no recurrence after lung resection (p = 0.38). Twenty-one patients had experienced prior liver resection; the 5-year overall survival rate after lung resection in these patients was 57.9 %. Factors predicting recurrence were vascular invasion (v ≥ 2) of primary tumor (p = 0.02), pre-operative serum CEA (p = 0.03) and CA-19-9 (p = 0.04). Conclusions: The outcome of lung resection of metastases from CRC in our hospital was satisfactory. Aggressive lung resection for cases even after liver resection and repeated pulmonary recurrence may improve long-term outcomes.Vascular invasion of primary tumor and the pre-operative serum CEA and CA 19-9 level can be predictive markers for recurrence.

[A Case of Strangulating Intestinal Obstruction Caused by Coiling of Low-Grade Appendiceal Mucinous Neoplasm to Terminal Ileum]

The patient was a 67-year-old female without a history of surgery. She presented with an abdominal pain and vomiting, and was rushed to our hospital. The abdominal pain was severe, but no peritoneal irritation sign was observed. Abdominal CT scan revealed a strangulating intestinal obstruction and accumulation of ascitic fluid. Emergency surgery was performed for diagnosis and treatment. The intraoperative finding showed serous ascitic fluid and strangulating intestinal obstruction caused by appendiceal tumor coiling around the terminal ileum, which had become ischemic with thinning of its wall. Ileocecal resection with removal of lymph nodes(D3)was performed. The postoperative course was uneventful, and the patient was discharged 13 days after the surgery. Pathological examination of the appendiceal tumor revealed a low-grade appendiceal mucinous neoplasm(LAMN)with no metastasis to the lymph nodes. We had a rare case of strangulating intestinal obstruction caused by coiling of LAMN to the terminal ileum.

78 Evaluation of the genomic estimated breeding value of carcass traits in blastocyst-stage embryos derived from Japanese Black cattle

Genomic selection based on a high-throughput microarray for genotyping single nucleotide polymorphism (SNP) is expected to accelerate genetic improvement in cattle. Recently, a genomic evaluation system for carcass traits, such as carcass weight and marbling score, is being established in Japanese Black cattle. To further increase genetic improvement efficiency in this breed, establishing a genomic evaluation system for pre-implantation embryos before embryo transfer (ET) is required. Here, we examined the correlation between genomic estimated breeding value (GEBV) of carcass traits calculated from embryonic (blastocyst) biopsy cells and from a corresponding calf produced by ET (Experiment 1); we also evaluated the pregnancy rate following ET of GEBV-evaluated blastocysts (GEBV blastocysts) preserved by vitrification (Experiment 2). In total, 16 Japanese Black dams and cryopreserved semen from 6 Japanese Black sires were used for producing in vivo blastocysts (Day 7-8). In Experiment 1, four blastocysts (IETS code 1) were divided into biopsy cells (15-20 cells) and biopsied embryos using a micromanipulator equipped with a micro blade. Biopsy cells were processed for DNA extraction and whole-genome amplification. Freshly biopsied embryos were transferred to recipient cows, and DNA was extracted from the blood or ear cells of the resulting 4 calves. Then SNP genotyping was performed using Illumina bovine LD BeadChip (Illumina, San Diego, CA, USA). The GEBV of 6 carcass traits (carcass weight, ribeye area, rib thickness, subcutaneous fat thickness, estimated yield percent, and marbling score) were calculated using phenotypic and genotypic data from 4,311 Japanese Black steers, and these were compared between biopsy cells and the corresponding calf. In Experiment 2, 134 blastocysts (IETS code 1 and 2) in total were biopsied (10-20 cells), and the biopsied embryos were vitrified by the cryotop method. Biopsy cells were processed for SNP genotyping as in Experiment 1, and the samples in which the call rate was more than 85% were used for GEBV calculation. Based on GEBV records, 24 vitrified GEBV blastocysts were warmed, cultured for 3 to 5h, and 22 GEBV blastocysts that survived (re-expanded) post-culture were transferred to recipient cows. Pregnancy in these cows was diagnosed using ultrasonography during Day 55 to 60 of gestation. In Experiment 1, the SNP call rates of the biopsy cells and corresponding calf were 98.5 to 99.3% and 99.7 to 99.8%, respectively. The GEBV of 6 carcass traits from biopsy cells and from the corresponding calf had almost the same values. In Experiment 2, the SNP call rates of the biopsy cells were ranged from 26.1 to 99.3%. The GEBV of 6 carcass traits varied among full-sib embryos. The pregnancy rate following ET of vitrified GEBV blastocysts was 40.9% (9/22). These results suggest the possible application of a genomic evaluation system for carcass traits at the blastocyst stage in Japanese Black cattle. Further large-scale assessment of pregnancy rates following ET of cryopreserved GEBV blastocysts is required for practical application of the evaluation system.

[A Case of Disease Control Achieved with TACE Using Cisplatin for Liver-Limited Metastases of Colorectal Cancer]

A 54-year-old woman with unresectable multiple liver-limited metastases of rectal cancer was treated with cisplatin-based transcatheter arterial chemoembolization(TACE). Before initiating TACE, we performed abdominoperineal resection for advanced rectal cancer, resection of the bilateral ovaries for metastasis, liver resection for metastasis, and oxaliplatin/irinote- can/anti-EGFR chemotherapy for the unresectable liver metastases. For the liver-limited metastases that did not respond to systemic chemotherapy, we successfully controlled the disease in 26 months with TACE every 4 or 5months. A combination of 50mg cisplatin and 4 mL lipiodol was injected into the liver through the left or middle hepatic artery with a microcatheter via the femoral artery. The hepatic arteries were mildly embolized with Embosphere. Immediately after TACE, non-contrastenhanced CT was performed to confirm the distribution of the cisplatin powder and embolization. Tumor response was assessed by enhanced CT 3 months after the treatment. We report a case of liver metastasis of colorectal cancer successfully controlled with cisplatin-based TACE over 2 years.

[Resection for Peritoneal Dissemination of Colorectal Cancer]

We reported the outcome of colorectal peritoneal dissemination resection. Eleven patients who underwent R0 resection for colorectal peritoneal dissemination from January 2009 to December 2017 were examined in our hospital. The median observation period was 23 months, the 3-year overall survival rate was 72.8%, and the 3-year relapse free survival rate was 22.7%. Thus, surgical resection might be useful for peritoneal dissemination.

[A Case of an Elderly Patient with Unresectable HER2-Positive Gastric Cancer Successfully Treated by Chemotherapy Combined with Trastuzumab over a Long Period]

An 82-year-old man was diagnosed with advanced gastric cancer(tub2, HER2-positive), and the clinical findings were T3N3M1(LYM), Stage Ⅳ. We started chemotherapy with capecitabine, cisplatin, and trastuzumab. After the first course, the dose of capecitabine was reduced and cisplatin was discontinued due to Grade 3 neutropenia. After 4 courses, the remarkable shrinking of the primary tumor and metastatic lymph nodes enabled us to assess the possibility of radical resection, but the patient and his family declined it because of his advanced age. Thereafter, we continued the chemotherapy with capecitabine and trastuzumab for 75 courses. Until multiple lung, liver, and lymph node metastasis occurred after 77 courses, he was adequately managed and maintained good performance status(PS)over a long period of about 53 months.

[A Case of Successful Drainage for Mediastinitis during Chemotherapy for Unresectable Advanced Esophageal Cancer]

A 78-year-old man complained of dysphagia. Gastrointestinal endoscopy showed a Type 2 tumor in the lower esophagus and a Type 0-Ⅱa lesion in the posterior wall of the upper gastric body. An enhanced CT scan showed several swollen abdominal and cervical lymph nodes as well as bilateral lung multiple nodules, suggesting distant metastasis. We diagnosed the patient with double cancers consisting of an unresectable advanced esophageal squamous cell carcinoma with multiple lymph nodes and lung metastases(Lt, cT3N4M1, cStage Ⅳb)and early gastric cancer(U, post, cType 0-Ⅱa, cT1N0M0, cStageⅠ). On day 4 of the first course of chemotherapy(docetaxel plus cisplatin plus 5-FU: DCF), a high fever was observed. A chest CT scan revealed suspected mediastinitis and right pyothorax due to perforation by the esophageal cancer. Thoracoscopic mediastinal drainage was immediately performed. CT-guided abscess drainage was added for a residual abscess in the right thoracic cavity on day 10 after drainage surgery. The patient's general condition improved, and he was discharged on 24th postoperative day. The patient was able to reinstitute and continue DCF therapy until disease progression.

[A Case of Gastric Schwannoma with Regional Lymphadenopathy]

Schwannomas are rarely observed in the gastrointestinal tract. A 63-year-old man was referred to our hospital with gastric submucosal tumor with central ulceration by upper gastrointestinal endoscopy. Biopsy was performed, but pathological diagnosis was not obtained. A contrast-enhanced computed tomography scan of the abdomen revealed a round mass in the lower part of the stomach and regional lymphadenopathies. A distal gastrectomy with dissection of the regional lymph nodes (D2)was performed. The submucosal tumor measuring 67×49mm was resected. Histopathological examination revealed spindle-shaped cells arranged in palisades. The specimen was positive for S-100 protein, but negative for desmin, SMA, c-kit, and CD34. No tumor cells were found in the resected enlarged lymph nodes, indicating reactive lymphadenopathies. Based on these findings, the tumor was identified as a benign gastric schwannoma. Our patient shows no recurrence at 6 month follow-up.

[Treatment Outcomes of Gemcitabine and Cisplatin Combination Therapy for Unresectable and Recurrent Biliary Tract Cancer]

Gemcitabine and cisplatin combination therapy(GC therapy)is now considered a highly effective regimen for patients with unresectable and metastatic biliary tract cancer. We performed GC therapy for 18 patients between January 2014 and April 2018. The median age of the patients was 67.5 years, and 13 patients were men. Fifteen patients had a performance status (PS)score of 0, and 3 patients had a PS score of 1. Nine patients had distal cholangiocarcinoma, 3 had intrahepatic cholangiocarcinoma, 3 had duodenum papilla cancer, and 3 had gallbladder cancer. Fourteen patients showed recurrence after the radical resection, and 9 had liver metastasis. Sixteen patients had over Grade 3 hematological or non-hematological toxicities. The most-common adverse event was neutropenia. None of the patients had Grade 5 adverse events. The response rate was 11.1%, and the disease-control ratio was 66.7%. GC therapy was effective for patients with unresectable and recurrent biliary tract cancer. However, it is necessary to examine the eligibility of patients before treatment.

[Staging by TNM Classification of Two Cases of Advanced Appendiceal Carcinoma]

We report 2 cases of resected appendiceal carcinomas. Case 1: A 67-year-old woman. At surgery, multiple mucoid foci were observed in the peritoneal cavity. Laparoscopic right hemicolectomy(R2)was performed. The pathologic findings were a mixture of well-differentiated adenocarcinoma and well-differentiated mucinous carcinoma, grade 1, pStage ⅣA (pT2N0M1bG1). Six months after surgery, she is undergoing adjuvant chemotherapy at an outpatient clinic. Case 2: A 48- year-old woman. At surgery, invasion into the terminal ileum was observed. A laparoscopic right hemicolectomy resection (R0)was performed. The pathological diagnosis was Stage Ⅱ(pT4bN0M0). She has been followed-upat an outpatient clinic. Discussion: Case 1 had a relatively good prognosis if only well-differentiated mucinous carcinoma was seeded; however, because of the co-existence of well-differentiated adenocarcinoma, postoperative chemotherapy was performed. Case 2 was diagnosed with invasive mucinous carcinoma(grade 2), but because there was no dissemination or lymph node metastasis, follow-upfor Stage Ⅱ disease without adjuvant therapy was considered appropriate. Staging based on TNM classification appendiceal carcinoma cases is desirable for the prediction of prognosis and determination of the appropriate treatment strategy.

[Tracheo-Bronchial Airway Stenting for Airway Stenosis Due to Inoperable Advanced Esophageal Cancers]

BACKGROUND

Airway invasion due to inoperable advanced esophageal cancers can sometimes cause serious complications includingairway stenosis and fistula, and compromise patients' QOL. We retrospectively evaluated the effect of tracheobronchial airway stentingfor airway stenosis due to inoperable advanced esophageal cancers.

METHODS

Between 2010 and 2017, 9 patients with airway stenosis due to inoperable advanced esophageal cancers were treated by placement of a tracheo- bronchial airway stent.

RESULTS

Eight patients were treated with self-expandable metallic stents and only 1 patient was treated with a Dumon Y stent. In all cases, tracheo-bronchial airway stents were successfully placed without major complications. Four patients received post-stentingtreatment and 5 patients could be discharged from the hospital. The median survival time after stent placement was 2.8 months.

CONCLUSIONS

Tracheo-bronchial airway stentingwas a safe and effective treatment for improvingpatients ' QOL.

[A Case of Laparoscopic Rectal Amputation Performed for Anal Gland Mucinous Carcinoma with Pagetoid Spread]

A 69-year-old man was admitted for the growing anal tumor and referred to our hospital. The tumor was about 40mm in size, and by biopsy, he was diagnosed the adenocarcinoma. Based on this diagnosis, abdominoperinealresection and edge resection were performed. Histopathologicalfindings showed mucinous carcinoma originating from analgl and with pagetoid spread. Postoperative chemotherapy was not performed, but 1 year 6 months after the surgery, inguinall ymph node recurrence was found, and lymph node dissection was performed. One year after the operation, recurrence was not found.

[A Case of Laparoscopy Assisted Ileocecal Resection for Large Appendiceal Mucinous Adenocarcinoma]

Appendiceal mucinous adenocarcinoma accompanied by cysts ruptures by surgical operation and leakage of mucus into the peritoneal cavity results in deterioration of prognosis.We report a case where the appendix mucinous adenocarcinoma was safely excised by laparoscopically preceding vascular treatment, lymph node dissection and intestinal dissection.The case was a woman in her forty-age suffering from the right lower quadrant and fever; no improvement was observed even when antibiotics were administered.A cystic lesion with a maximum diameter of 75mm was found on the right side of the pelvis with CT, and numerous lymph adenopathy was observed along the iliac artery.Preoperative diagnosis was diagnosed as appendiceal mucinous adenocarcinoma suspected and laparoscopic resection of the cecum was performed with the above procedure without breaking the cyst.Pathological diagnosis was findings of appendicular mucinous adenocarcinoma.She was discharged on the 7th postoperative day after surgery, 6 months after surgery without relapse survival.In order to resect a cystic tumor by laparoscopic surgery, it is considered to be useful to take care to prevent the forceps from touching the tumor, and perform a procedure that precedes vascular dissection and intestinal dissection.

Laparoscopic resection followed by decompression with a drainage tube for obstructive colorectal cancer

844

Background: Obstructive colorectal cancer is an oncological emergency that requires emergency treatment. In Japan, laparoscopic resection after decompression with metallic-stent placement is becoming mainstream as a bridge to surgery (BTS). However, there are reports of worse prognoses due to stent placement, and the European Gastroenterology Society of Endoscopy guidelines do not recommend BTS. In our department, since 2011 the first choice of the treatment has been laparoscopic resection after decompression with a trans-anal or trans-nasal drainage tube. STo investigate the safety and short- and long-term results of laparoscopic resection after decompression with a drainage tube. Methods: Eighty-one cases of obstructive colorectal cancer that underwent surgery at our hospital from 2011 to 2016 were investigated with regards to the short- and long-term outcomes of treatment strategies for obstructive colorectal cancer. Results: The median age was 72 years old (39-94). The ratio of male to female was 46:29. The success rate of decompression was 86.7% (66 cases). Stages II, III and IV were involved in 25, 28 and 28 cases, respectively. The causes of the emergency operations were an inability to insert both the ileus tube and the stent (9.3%, 7 cases), and perforation (2.7%, 2 cases) when the trans-anal ileus tube was inserted. In the cases in which decompression was possible, the laparoscopic operation rate was 89.4% (56 cases) and the primary resection rate was 90.9% (59 cases). The median surgical time was 194 minutes (27-325), the median blood loss was 10 g (0-660 g),The median postoperative hospital stay was 14 days (5-147 days). The rate of anastomotic leak was 4.5%. There were no deaths within 30 and 90 days after surgery. The relapse free survival rate in Stage II and III were 72% and 67.9%, respectively. The median months of overall survival in Stage II, III and IV were 60.4, 56.3 and 18.7, respectively. Conclusions: A treatment strategy with laparoscopic resection followed by decompression with a drainage tube was performed feasibly and safely. At this time, the effects of a stent on oncological prognosis is unclear, and this strategy could be an effective treatment for obstructive colorectal cancer.

[A Case of Rectal Cancer with Multiple Endocrine Neoplasia Type 2]

A 63-year-old man with multiple endocrine neoplasia type 2(MEN2)was admitted to the hospital because of positive fecal occult blood tests. Colonoscopy revealed a 50mm type 2 tumor at the rectum, which was diagnosed as an adenocarcinoma based on histology. Since there was no apparent distant metastasis, laparoscopy-assisted low anterior resection with regional lymph node dissection was performed. The final diagnosis was pT3, pN0, pM0, pStage II . Almost all patients with MEN2 have RET mutations, and they are resistant to EGFR inhibitors. Those who have thyroid cancer with RET mutations are often given a RET kinase inhibitor. In this case, if the patient develops recurrent rectal cancer, it warrants checking for RET mutations and using a multi-kinase inhibitor.

[A Case of Ascending Colon Cancer with Lynch Syndrome Who Underwent XELOX Adjuvant Chemotherapy]

Lynch syndrome is an inherited syndrome with the development of the colorectal and various other cancers. Lynch syndrome is caused by mutations in the mismatch repair genes. A 33 year-old male underwent XELOX adjuvant chemotherapy for ascending colon cancer with Lynch syndrome. Although efficacy of 5-FU is not demonstrated in Lynch syndrome, MOSAIC trial had suggested a benefit from FOLFOX compared with 5-FU in patients who have colorectal cancer with Lynch syndrome. Oxaliplatin-based adjuvant chemotherapy can be a therapeutic option for colorectal cancer in lynch syndrome patients.

[A Case of Stage IV Metaplastic Breast Cancer in Which Primary Tumor Was Removed after Treatment with Anti-HER2 Systemic Therapy]

The patient was a 58-year-oldpostmenopausal woman. Vacuum assistedbiopsy of the left breast tumor revealedinvasive ductal carcinoma. Immunohistochemical examination was negative for estrogen receptor(ER), negative for progesterone receptor(PgR), andshowedan HER2 score of 3+. FDG-PET/CT revealedmultiple metastases to the left supracravicular and axillary lymph nodes and lungs. She was diagnosed with HER2-positive T3N3M1, Stage IV breast cancer. A 2-year regimen of chemotherapy with trastuzumab andvinorelbine achieveda complete response with regardto the metastatic sites; however, the size of the primary tumor increasedd espite the chemotherapy, andsurgical resection of the left breast with axillary lymph node dissection was performed for local control. Pathological examination of the surgical specimen revealed metaplastic carcinoma with sarcoma component surrounded by non-invasive ductal carcinoma. No component of invasive ductal carcinoma was found. Immunohistochemically, metaplastic carcinoma was negative for ER, negative for PgR, andrevealedan HER2 score of 0. There was discordance of HER2 status between pre- andpost -chemotherapy. The patient receivedno further chemotherapy following surgery andhas been without disease progression for 6 years. We suggest there is heterogeneity, that is, the metastatic sites andthe partial primary tumor were HER2-positive invasive ductal carcinoma and the remainder of the primary tumor was triple negative metaplastic carcinoma. As a result, the patient was able to discontinue chemotherapy with higher quality of life.

[A Case of Recurrent Colon Cancer Successfully Treated with Capecitabine plus Bevacizumab]

A 76-year-old woman had undergone a laparoscopic low anterior resection for rectal cancer. After 12 months, CT showed 2 tumors measuring 25mm in diameter in the pelvis and hydronephrosis. The patient was treated with CapeOX plus bevacizumab( Bmab). After 3 courses of chemotherapy, the size of the tumors was remarkably reduced. After 6 courses, the chemotherapy was withdrawn because of cystitis. Anaphylactic shock occurred after the 7th course after resumption of treatment. After 42 days, the chemotherapy(Cape plus Bmab)was resumed. The patient is recurrence free 13 months after achieving a complete response(CR).

[A Case of Pararectal Epidermoid Cyst Removed by Sacral Approach]

A 30-year-old woman was admittedto the hospital because of fecal occult bloodpositivity . Endoscopic colonoscopy indicated pressure on the right side of the rectum from the wall. Abdominal contrast CT and pelvic MRI revealed a cystic lesion with a maximum diameter of 5 cm on the pre-coccyx andthe right side of rectum. There was no continuity between the tumor andthe uterus/ovary. We diagnoseda pararectal tumor andremovedit via a sacral approach. The cyst was diagnosed as an epidermoid cyst. She was discharged on the 5th postoperative day. We could resect the tumor completely, because we chose an appropriate approach, considering the position, developmental direction, and size of the tumor.

[A Case of Sigmoid Colon Cancer with Distant Metastasis Successfully Treated with First-Line Cetuximab Monotherapy]

The patient was a 59-year-old woman with progressive sigmoid colon cancer with multiple metastasis(T3N2M1b[P2, H3, PUL2]Stage IV ). As the RAS gene in the patient was wild-type, we administered cetuximab monotherapy every week. One month after chemotherapy initiation, the tumor marker levels declined and the tumor size reduced. Patient's general condition was improved and mFOLFOX6 therapy was then continued in addition to cetuximab. As a side effect, acne-like rash is only grade 1 to 2, and there are no other serious side effects. Cetuximab monotherapy may contribute to the treatment of poor PS patients.

[The Treatment Outcomes of FOLFIRINOX for Unresectable and Recurrent Pancreatic Cancer]

FOLFIRINOX is now considered to be a highly effective regimen for patients with metastatic pancreatic cancer. We administered FOLFIRINOX therapy in 18 patients between October 2014 and April 2017 as follows: 2-hour infusion of L-OHP at a dose of 85mg/m2, 2-hour infusion of LV at a dose of 200 mg/m2, infusion of CPT-11 for over 90 minutes at a dose of 150 mg/m2, followed by continuous infusion of 5-FU over 46 hours at a dose of 2,400mg/m2. The median age of the patients was 66.5 years. There were 15 patients with performance status(PS)0, and 3 with PS 1. Two patients were Stage III and 16 patients were Stage IV . More than half of the patients had over Grade 3 hematological or non-hematological toxicities. The most common adverse event was neutropenia. Two patients had Grade 5 adverse events: severe cholangitis occurred in the patient with a biliary stent and overwhelmingpost -splenectomy infection occurred in the patient who underwent distal pancreatectomy. The response rate was 11.1%, and the disease control rate was 77.8%. FOLFIRINOX was effective in the patients with unresectable and recurrent pancreatic cancer. However, it is necessary to examine the eligibility of the patients.

[A Case of Resection of Obstructive Colon Cancer Associated with Aspiration Pneumonia, Under Combined Epidural-Spinal Anesthesia]

An 89-year-old woman was admitted to our hospital with vomiting, abdominal distension, and anorexia.A CT scan revealed an enhanced thickening lesion on the wall of the ascending colon, and intestinal expansion from the small intestine to the caecum.On colon fibroscopy, a round tumor was observed adjacent to the oral side of the hepatic flexure even though the end of the microscope could not progress toward the deeper regions.As the obstructive colon cancer was complicated by the presence of aspiration pneumonia, surgery could not be performed under general anesthesia.We initiated curative therapy for aspiration pneumonia right at the onset.Subsequently, due to lack of improvement in the patient's general condition, we conducted a right hemicolectomy under combined epidural-spinal anesthesia.

[A Case of a Two-Stage Hepatectomy for Irresectable Colorectal Cancer Liver Metastases]

A 60-year-oldman was diagnosedwith ascending colon cancer with multiple bilobar metastases. He then received7 courses of tegafur-gimeracil-oteracil andoxaliplatin (SOX)plus panitumumab as downstaging chemotherapy. This treatment significantly reducedthe size of the metastatic tumor, andwe subsequently triedto perform a curative resection. A twostage hepatectomy was plannedto avoidthe risk of hepatic failure from small future liver remnant. First, the anterior segmentectomy andthe left portal vein ligation were performed. Then, a curative resection consisting of a left lobectomy andextend - edright hemicolectomy were performed2 0 days after the first surgery. No recurrence was observed1 5 months after the operation. Two-stage hepatectomy as well as a combination of induction chemotherapy and portal vein ligation may have contributedto the improvedprognosis of the initially unresectable multiple bilobar liver metastases.

[Evaluation of the Occurrence of Surgical Site Infection(SSI)after Hepatectomy in Elderly Patients with Hepatocellular Carcinoma(HCC)]

The aim of this study was to evaluate the rate of surgical site infection(SSI)after hepatectomy in elderly patients with hepatocellular carcinoma(HCC). From June 2010 through December 2016, 276 cases of hepatectomy for HCC were performed in our hospital, and 39 cases included patients aged>80 years. The rate of SSI in the elderly group compared to the non-elderly group was 15.38%(6/39 cases)vs 7.73%(p=0.0855). The Child-Pugh classification(A/B/C)in the SSI group (n=6)vs in the non-SSI group(n=33)was 6/0/0 vs 32/1/0(p=0.5605), the liver damage classification(A/B/C)was 4/ 2/0 vs 25/8/0(p=0.6467), BMI was 23.3 kg/m / 2 vs 22.8 kg/m2(p=0.6544), PNI was 43.1 vs 46.2(p=0.3804), the operation time was 348.5 minutes vs 315.1 minutes(p=0.4478), blood loss was a small amount vs 401.5mL(p=0.0143), and the hospital stay after the operation was 27.5 days vs 10.0 days(p=0.0401), respectively. Hepatectomy for elderly patients was safe and feasible, and the only significant risk factor for SSI in elderly HCC patients was intraoperative blood loss.

[A Case of Metachronous Resection for Advanced Esophageal Cancer with Pheochromocytoma]

A 66-year-old man reporting chest stenosis was examined. Upper gastrointestinal endoscopy showed type 2 esophageal cancer. An enhanced CT scan showed several swollen lymph nodes in the lesser curvature of the esophagus. We diagnosed the patient as having advanced esophageal cancer with multiple lymph node metastases(cT3N2M0, Stage III ). After 2 courses of chemotherapy(DCF), a significant reduction was observed in the esophageal tumor; however, the tumor at the lesser curvature was almost unchanged. MIBG scintigraphy showed high uptake in the left adrenal gland. In addition, urinary adrenaline was elevated. Therefore, we diagnosed the patient with pheochromocytoma. Metachronous surgery was performed. First, left adrenalectomy was performed. After we confirmed stability of blood pressure, esophagectomy was performed. The patient is alive without recurrence for 7 months after these operations.

[Adjuvant Chemotherapy for Hemophilia B - A Case Report]

A 80s-year-old man with hemophilia B underwent operation for rectal cancer.Metastasis of the lymph nodes was revealed, so he was treated with adjuvant chemotherapy involving capecitabine and oxaliplatin(CapeOX).For safety, we measured tissue factor IX before every course of chemotherapy, and he completed 8 courses safely.

[Splenic Artery Left Common Iliac Artery Bypass for Hepatocellular Carcinoma with Celiac Artery Compression Syndrome - A Case Report]

Celiac artery compression syndrome(CACS)is a rare disorder characterized by postprandial intestinal angina caused by insufficient blood supply to the gastrointestinal organs. In this syndrome, the root of the celiac artery is compressed and narrowed by the median arcuate ligament of the diaphragm during expiration, sometimes causing difficulties in trans-arterial intervention. We report here a case that trans-hepatic arterial intervention was able to performed by splenic bypass. A 74- year-old man with multiple hepatocellular carcinoma(HCC)was performed the angiography, and diagnosed as CACS due to celiac artery root obstruction. The median arcuate ligament was incised in order to introduce trans-arterial intervention, but sufficient resumption of blood flow in the root of celiac artery could not be obtained, so bypass surgery was added from left common iliac artery to splenic artery with grafted right saphenous vein. One month later, trans hepatic arterial intervention is performed via graft, and treatment of HCC is ongoing. Splenic artery left common iliac artery bypass surgery was also considered to be an option for cases in which the resurgence of the blood flow in the root of the celiac artery was not obtained even in the median arcuate ligament dissection for CACS.

[A Case Report of Post-Radiochemotherapy Perineum Abscess Concurrent with Recurrence of Vaginal Cancer for Which Total Pelvic Exenteration Was Performed]

We report a case of a woman who was suffering from post-radiochemotherapy perineum abscess concurrent with the recurrence of vaginal cancer for which total pelvic exenteration was performed. A 66-year-oldwoman presentedat our hospital with irregular genital bleeding in November 2014. A series of examinations showedthat she was suffering from vaginal cancer(cT2N0M0, cStage II ). A radiochemotherapy regimen(external irradiation 45 Gy/25 Fr, CDDP 40mg/m2, 5 course)was commencedin January 2015. In the meantime, MRI revealedsome therapeutic effect, but in October 2015, MRI indicated the enlargement of the primary tumor(PD). The chemotherapy regimen was alteredanda regimen of paclitaxel plus nedaplatin was commenced in November 2015 andw as continueduntil April 2016. MRI was performedin March 2016 to distinguish the therapeutic response between PR and CR. In May 2016, the patient complainedof an increasedfrequency of melena. Colonoscopy was performedto reveal Grade 3 radiation enteritis, andargon plasma coagulation was requiredto stop bleeding. In June 2016, MRI was performedandrevealedCR. In July 2016, however, the radiation enteritis led to rectovaginal fistula, for which we performed transverse colostomy. Thereafter, the necrotic tissue gradually expanded into the perineum area to involve the urethra. Recurrence of the cancer was suspected; therefore, we decided to perform total pelvic exenteration in December 2016. Pathological examination of the surgical specimen indicated the recurrence of the vaginal cancer. We report this rare case andd iscuss the usefulness of total pelvic exenteration for the recurrence of vaginal cancer.

[Laparoscopic Pancreatectomy for Pancreatic Neuroendocrine Tumor - A Single Institution Experience]

BACKGROUND

Pancreatic neuroendocrine tumor(P-NET)is relatively rare and often has less aggressive biological behavior. P-NET was re-designated by the WHO in 2010 and 2017. Laparoscopic surgery is minimally invasive but has technical difficulties such as limitation of movement and laparoscopic view. The purpose of this study is to evaluate the efficacy of laparoscopic pancreatectomy(LPT)for P-NET.

METHODS

Between January 2012 and June 2017, 6 patients underwent LPT for P-NET at Kansai Rosai Hospital. Five patients who received open pancreatectomy(OPT)for P-NET and 41 patients who received laparoscopic distal pancreatectomy(LDP)for cystic tumor(CyT)or invasive ductal carcinoma(IDC)were included for comparison.

RESULTS

All patients who underwent LPT for P-NET were NET G1 in WHO Classification 2017 and Stage I in UICC TNM 2016. No significant differences were noted between LPT and OPT groups with respect to patient age or gender. Operation time was 421.5 versus 423.5 minutes(ns), blood loss was 121.7 versus 1,918.3mL(ns), hospital stay was 20.5 versus 58.0 days(ns)for LPT and OPT respectively. In LDP, there were no significant differences between PNEN, CyT, and IDC groups with respect to patient age, gender, operation time, blood loss and hospital stay. All patients who underwent LPT for P-NET alive without recurrence. The average observation period was 58.4 months.

CONCLUSIONS

Laparoscopic pancreatectomy is safe and effective approach to the management of pancreatic neuroendocrine neoplasm.

Fetal goitrous hypothyroidism treated by intra-amniotic levothyroxine administration: case report and review of the literature

BACKGROUND

Fetal goitrous hypothyroidism is mainly caused by maternal treatment of Graves' disease. Fetal goiter sometimes compresses the trachea and esophagus and may cause polyhydramnios, preterm labor, complications of labor and delivery, and neonatal respiratory disorder.

CASE PRESENTATION

We report a case of fetal goitrous hypothyroidism in which the mother had Graves' disease, which was treated with propylthiouracil. Intra-amniotic levothyroxine (L-T4) administration was performed, and the fetal goiter decreased in size. A female infant was delivered without goiter and complications. Thyroid function was within the normal range.

CONCLUSIONS

Previous reports on fetal goitrous hypothyroidism that was treated with intra-amniotic L-T4 showed that patients who had intra-amniotic L-T4 administration were likely to have a good outcome compared with patients who did not have L-T4. Thyroid function of the mother and fetus should be carefully monitored and treated appropriately.

[A Case of Neuroendocrine Tumor of the Ileum Manifesting as Fecal Occult Blood]

A 42-year-old woman was admitted to our hospital because of a positive fecal occult blood test. Colonoscopy examination revealed an elevated lesion measuring 25mm in diameter at the terminal ileum. A histological diagnosis of neuroendocrine tumor(NET)was made based on biopsy specimens taken from the lesion. Since no apparent distant metastasis other than the ileocolic lymph nodes was noted, laparoscopy-assisted ileocecal resection with regional lymph node dissection was performed. In the resected material, NET(G2)limited to the subserosa layer was present. The NET tested positive for synaptophysin, chromogranin A, and CD56. Metastases in the paraileal lymph nodes was detected. NET metastasis to the ileum is frequent, even if the tumor is small in diameter; therefore, it is necessary to resect the tumor entirely and to dissect the regional lymph nodes.

[Nab-Paclitaxel plus Gemcitabine Hydrochloride in Patients with Metastatic or Recurrent Pancreatic Cancer - A Single Institution Experience]

BACKGROUND

Pancreatic adenocarcinoma is one of the leading causes of cancer deaths in Japan.Albumin -bound paclitaxel (nab-paclitaxel)plus gemcitabine hydrochloride(GEM)combination chemotherapy provided significant improvements in the overall and progression-free survival in a phase III trial in Europe and America and a phase II trial in Japan.As a result, this combination therapy was approved for use in Japan.

METHODS

We evaluated the efficacy of nab-paclitaxel plus GEM with metastatic or recurrent pancreatic cancer.Between December 2014 and March 2016, 11 patients received nab-paclitaxel plus GEM as follows: nab-paclitaxel(125mg/m2 of body-surface area)followed by GEM(1,000mg/m2)on days 1, 8, and 15 every 4 weeks.The treatment was continued until disease progression, unacceptable adverse events, discontinuation as decided by the investigators, or patient refusal.

RESULTS

The mean age was 65.6 years(range, 48-75 years), and 8 out of 11 patients were men.Ten patients had an Eastern Cooperative Oncology Group(ECOG)performance status(PS)of 0.Ten patients had metastatic disease.Only 4 patients had no prior therapy.The mean duration of treatment was 10.2 weeks(range, 2-41 weeks).The relative dose intensities of nab-paclitaxel and GEM were 90.6%(66.7-100%)and 87.5%(62.9-100%), respectively.The major Grade 3 or 4 hematological toxicities were leucopenia(54.5%), neutropenia(36.4%), anemia (27.3%), and thrombocytopenia(18.2%).The major grade 2 or 3 non-hematological toxicities were fatigue(45.6%), skin rash(27.3%), peripheral sensory neuropathy(9.1%), anorexia(9.1%), and stomatitis(9.1%).There were no treatmentrelated deaths.Interstitial lung disease was not observed.The 6 month progression-free and overall survival rate were 25.7% and 66.7%, respectively. The disease control rate was 90.9%(complete response, n=0; partial response, n=1; stable disease, n=9; progressive disease, n=1).

CONCLUSIONS

Nab-paclitaxel plus GEM is well tolerated and associated with efficacy and improved survival outcomes.Nab -paclitaxel plus GEM can be the standard treatment for patients with metastatic pancreatic adenocarcinoma.

[A Case of Malignant Anorectal Melanoma with Laparoscopic Abdominoperineal Resection]

A 69-year-old man with anemia underwent colonoscopy. Colonoscopy showed a black tumor, 2 cm from the anal verge. The biopsy specimen revealed malignant melanoma, which was preoperatively diagnosed as T1(SM), N0, M0, Stage I . We performed laparoscopic abdominoperineal resection. The tissue type and diagnosis were malignant melanoma, pT1b(10 mm), pN0, pM0, ly0, v0, pDM0, pPM0, pRM0, pStage I b, according to the Colon Cancer Handling Terms, 8th edition). The patient did not receive adjuvant chemotherapy. However, he survived postoperatively for 9 months, with no sign of recurrence.

[A Case of Local Recurrence after Conserving Therapy for Occult Breast Cancer with Immediate Breast Reconstruction]

We report the case of a 70-year-oldwoman with local recurrence of occult breast cancer after conserving therapy. Breast cancer metastasis to an axillary lymph node was suspected when she was 62-years-old. Even with mammography, ultrasound sonography, positron emission tomography/computedtomography, andmagnetic resonance imaging, the primary disease lesion could not be identified. She underwent axillary dissection, and received 5 years of endocrine therapy. Eight years after surgery, a new ipsilateral breast tumor was detectedusing ultrasoundsonography andvacuum assistedbiopsy, confirmedas invasive carcinoma. This time the patient had no distant metastases; therefore, she was diagnosed with local recurrence, and mastectomy with immediate breast reconstruction was performed. Breast conserving surgery aims to reduce the psychological burden on the patient but must be closely followed-up in case of local recurrence. Any incidences of local recurrence can also be treatedusing breast reconstruction surgery.

[Laparoscopic Liver Resection for Elderly Patients with HCC]

Laparoscopic surgery is less invasive and has better cosmetic results. Laparoscopic liver resection(LLR)was covered by health insurance in April 2010, and has increasingly been performed in many hospitals, and also in cases of elderly patients. We report the results of laparoscopic liver resection for hepatocellular carcinoma(HCC)in patients ≥80 years old. From June 2010 through March 2016, 237 cases of laparoscopic hepatectomy for HCC were performed in our hospital, and 35 of 237 cases were patients ≥80 years old(the elderly group). The operation time in the elderly vs the non-elderly group was 321 minutes vs 340.9 minutes(p=0.4676), the blood loss was 447.2mL vs 331.5mL(p=0.6691), and the hospital stay after the operation was 18 days vs 16 days(p=0.6347). The 3 year disease free survival rate for stage I was 66.7% vs 58.6%(p= 0.1849), for stage II was 35.6% vs 31.8%(p=0.7538), for stage III was 33.3% vs 49.5%(p=0.8683), and for stage IV was 100% vs 32.4%(p=0.3452). Laparoscopic hepatectomy for HCC can be performed safely, even for patients ≥80 years old. Further studies are necessary to confirm the benefits of laparoscopic liver resection for elderly patients compared with the non-elderly.

[Pancreatic Cancer with Liver Metastasis Treated with Radical Surgery after Chemotherapy]

Pancreatic ductal carcinoma is a highly aggressive cancer, and chemotherapy is the standard therapy for pancreatic adenocarcinoma. We report curative resection for a case of pancreatic cancer with liver metastasis after chemotherapy. A 67-yearold woman presented with vomiting and weight loss, and was admitted to our hospital for an evaluation of pancreatic lesions. Computed tomography revealed a hypoattenuating tumor in the head of the pancreas. We would usually perform pancreatoduodenectomy based on a diagnosis of cStage III . However, this case was inoperable because we found 4 liver metastases during surgery, which we resected. Sixteen days after surgery, we administered FOLFIRINOX chemotherapy. The grade 2 toxicities were nausea, anorexia, diarrhea, and fatigue, but serious adverse events did not occur. After 7 courses of chemotherapy, no new metastases were noted. Therefore, radical subtotal stomach-preserving pancreatoduodenectomy was performed. The patient has survived without any recurrence for more than 17 months after hepatectomy.

[Multidisciplinary Treatment for High-Risk GIST of the Stomach]

A 59-year-old man underwent total gastrectomy(with D2 dissection)and cholecystectomy for gastric cancer and a submucosal tumor of the stomach. The specimen was immunohistochemically positive for c-kit, the Ki-67 label index was 10%, and the mitotic count was 20/HPF. Finally, the patient was diagnosed with high-risk gastrointestinal stromal cancer with normal type gastric cancer. After discharge from hospital, we started administration of TS-1 as adjuvant therapy for the gastric cancer. As multiple recurrences of the GIST in the abdomen developed, the patient underwent 3 radical local resections. Mutational analysis revealed a PDGFRA mutation in exon 18, which causes resistance to both imatinib and sunitinib. As he was refractory to imatinib, the patient received regorafenib. After a while, it caused liver failure, which required 7 rounds of plasmapheresis. The patient died from multiple organ failure resulting from multiple recurrences 4 years after the first surgery.

[A Case of Pure Squamous Cell Carcinoma of the Breast in an Elderly Woman Diagnosed by Cytology]

A n 85-year-old woman presented with a mass in the left breast. A3 7mm lobulated mass including enhancement of a cyst of 37mm was detected by sonography. An axillary lymph node had increased to 16 mm. Atypical cells dyed by light green and orange G were identified by fine needle aspiration and cytology. She was diagnosed with left breast cancer(cT2N1M0, Stage II B), histologically suspected to be squamous cell carcinoma. She underwent a left-breast-conserving surgery and axillary lymph node dissection. On pathology, a cyst of 34×30mm was noted. The tumor grew from inside the cyst to the surround- ing tissue and it had a trend for keratinocytes. Lymph node metastases affected 1/11. By immunostaining, the tumor was found to be ER(+), PgR(-), HER2(-), CK5/6(+), p40(+), mammaglobin(-), and GCDFP15(-). There was no component of ductal carcinoma. She received radiotherapy to the left breast and tamoxifen as an adjuvant therapy. Squamous cell carcinoma of the breast is rare. We encountered a case of pure squamous cell carcinoma of the breast in an elderly woman. We report this case with a discussion of the relevant literature.

[Multiple Metachronal Liver Metastases from a Rectal Neuroendocrine Tumor Controlled by Repeated Transcatheter Arterial Chemoembolization]

A 60-year-old woman was diagnosed with a rectal neuroendocrine tumor(NET)with SM invasion.We performed laparoscopic low anterior resection with D3 lymph node dissection.Pathological findings were rectal NET, G1, pSM(9,000 mm), ly0, v0, pN0, PM0, DM0, pR0, pStage I .Four years and 6 months later, contrast enhanced abdominal computed tomography (CECT)and contrast enhanced magnetic resonance imaging revealed multiple liver metastases.The tumors were unresectable because they were bilobar; therefore, we performed transcatheter arterial chemoembolizaion(TACE).One month later, CECT showed the lesions had shrunk.The metastases were well controlled via repeated TACE.For unresectable liver metastases from rectal NET, TACE can be an effective treatment.

[A Case of Successful Multidisciplinary Therapy for Advanced Esophagogastric Junction Cancer with Multiple Lymph Node Metastase]

A 64-year-old man reporting dysphagia was examined. Upper gastrointestinal endoscopy showed a type 3 cancer at the esophagogastric junction. Enhanced CT scan showed several swollen mediastinal and abdominal lymph nodes. We diagnosed the patient with advanced adenocarcinoma of the esophagogastric junction with multiple lymph node metastases(Siewert type II , cT3N2M1[LYM], Stage IV ). After 5 courses of chemotherapy(S-1 plus cisplatin), a significant reduction was observed in the size of the tumor and lymph nodes. Therefore, we performed conversion surgery. The patient underwent esophagectomy and mediastinal lymph node dissection using a right thoracotomy approach. He has survived without recurrence in the 10 months since this radical surgery.

[A Case of a Patient with Metastatic Rectal-Uterine Cancer from the Ascending Colon Who Underwent NOSE]

An 80-year-old woman had undergone a right hemicolectomy for ascending colon cancer 9 months prior to the current presentation. CT and PET-CT showed a solitary tumor measuring 55mm in diameter at the uterus and rectum. Three 5mm ports and two 12mm two ports were placed. The sigmoid colon was mobilized using a medial approach as usual in laparoscopic surgery. The rectum and uterus were mobilized and were resected. We inserted the End-catchTM in from the vagina and removed the specimen. The patient had no abdominal pain and was discharged from the hospital 9 days after the operation.

[A Case of Schwannoma Originating from the Sciatic Nerve]

A 75-year-old man was admitted with abdominal pain and taken to our hospital. CT and MRI showed a tumor measuring 60mm in diameter in the pelvic cavity. Based on the imaging findings, we suspected a schwannoma and decided to perform surgery. As the tumor was found to be benign in intraoperative frozen section diagnosis, the tumor was enucleated. Histopathological findings showed no nuclear atypia, and the patient was diagnosed with a schwannoma. He complained of paresthesia in his right leg after surgery, and underwent walking training. Six months after surgery, no recurrence was found.