Giant esophageal liposarcoma with squamous cell carcinoma resected via the cervical approach: a case report

Background

Liposarcoma is one of the most common soft tissue sarcomas, but is extremely rarely found in the esophagus. There have been no reports of esophageal liposarcoma together with superficial carcinoma of the esophagus. Here, we report a patient who underwent complete resection of esophageal liposarcoma with carcinoma via a cervical approach.

Case presentation

A 66-year-old man was diagnosed with an esophageal tumor 11 years ago, but he left it untreated. He presented to our hospital with progressive dysphagia and appetite loss since the previous year. Esophagogastroduodenoscopy (EGD) showed a large pedunculated submucosal tumor (SMT) originating at the esophageal entrance, extending to the gastroesophageal junction. Additionally, there was a superficial carcinoma on the surface of the SMT, 30 cm from the incisor teeth. Three-dimensional computed tomography (3D-CT) showed a giant elongated intraluminal tumor extending downwards from the cervical esophagus. We diagnosed a giant esophageal polyp accompanied by a superficial carcinoma and performed tumor resection via a cervical approach. The excised specimen consisted of a 23.0 × 8.5 cm polypoid mass. The final diagnosis by histopathological and immunohistochemical examination was well-differentiated liposarcoma and esophageal squamous cell carcinoma. He was discharged on postoperative day 14 with drastic improvement in his swallowing ability.

Conclusion

We reported an extremely rare case of esophageal liposarcoma together with esophageal squamous cell carcinoma that was successfully resected through a small cervical incision.

[Clinical Outcome of Robot-Assisted Distal Pancreatectomy in Our Institutional Introduction]

We evaluated the clinical outcome and assessed the safety of robot-assisted distal pancreatectomy(RADP)of early 5 cases in our institutional introduction. We followed the guidelines for introduction of robot-assisted pancreatectomy proposed by Japanese Society of Endoscopic Surgery. Patients' characteristics were 2 men and 3 women, 45-79(median 52) years old, and 3 patients with neuroendocrine neoplasm, 1 with intraductal papillary neoplasm and 1 with mucinous cystic neoplasm. Spleen-preserving RADP was performed in 2 cases. Clinical outcomes of 5 cases underwent RADP were, operation time was 308-437(median 330)minutes, blood loss was 5-270(median 100)mL and none received transfusion. Postoperative pancreatic fistula and postoperative complication more than Grade Ⅲa(Clavien-Dindo classification)were none. Postoperative hospital stay was 7-11(median 8)days. RADP in our institution was safely introduced by following the proposal of guidelines.

Proper use of appendiceal stump closure methods for surgical site infection in laparoscopic appendectomy

INTRODUCTION

Although some studies have reported on the relationship between appendiceal stump closure methods and postoperative complications, there is no fixed method for this procedure. This study aimed to compare treatment outcomes of the existing procedures.

METHODS

We retrospectively analyzed the records of 200 patients who underwent urgent laparoscopic surgeries and investigated whether the difference in the appendiceal stump closure method was a risk factor for surgical site infection. The patients were divided into the Endoloop and endostapler groups, and 45 propensity score-matched patients were included. The treatment outcomes of the two groups were compared.

RESULTS

The patients with high body temperature showed significantly developed surgical site infection in multivariate analysis (P = .036). There was no significant difference in the appendix stump methods (Endoloop vs endostapler). Regarding postoperative complications, superficial and deep incisional surgical site infection, organ/space surgical site infection, ileus, and complications of Clavien-Dindo grade IIIa or higher; there was no significant difference between the endoloop and endostapler groups after propensity score matching (P = .725, 1.000, .645 and .557, respectively).

CONCLUSION

By properly using the Endoloop and endostapler according to the severity of inflammation, the Endoloop can be safely performed in many cases. Inexpensive Endoloop as an option for stump closure methods should positively impact medical costs.

Single-incision laparoscopic ileocolectomy for solitary cecal colon diverticulitis with calcified fecalith: a case report

The prevalence of colonic diverticular disease has been on the increase in Japan due to an increase in westernized diet and a rapidly aging population. However, solitary cecal diverticulum is rare and considered congenital in etiology. Solitary cecal diverticulitis with calcified fecaliths is even rarer. Herein, we report a case of cecal colon diverticulitis caused by a calcified fecalith in a 38-year-old woman treated with single-incision laparoscopic surgery. To the best of our knowledge, this report describes the first case of cecal colon diverticulitis caused by a calcified fecalith that was successfully treated with single-incision laparoscopic ileocolectomy.

[Laparoscopic Left Hemicolectomy-It Is Confirmed That the Accessory Middle Colonic Artery Branched from the Splenic Artery Showed by Preoperative 3D-CT]

There is a wide variety of vessel types in the transverse colon region. Among them, it is very rare that the accessory middle colonic artery(A-MCA)is branched from the splenic artery. We found a transverse colon cancer. The dominant vessel of the cancer was the A-MCA branched from the splenic artery. This vessel type was confirmed by preoperative 3D-CT. We performed a laparoscopic left hemicolectomy for the cancer. In this study, we report a case of safe laparoscopic surgery in which we separate the A-MCA branched from the splenic artery using the preoperative 3D-CT image.

Cutaneous metastasis of cecum cancer with MSI-high and BRAFV600E mutation: a case report

Background

Cutaneous metastases of colorectal cancer (CRC) are rare, occurring in 0.7% to 5% of cancer patients. Furthermore, the molecular subtypes of cutaneous metastasis of CRC are unclear. Here, we present a rare case of cutaneous metastasis of high-frequency microsatellite instability (MSI-high)/BRAFV600E-mutant cecum cancer.

Case presentation

A 77-year-old woman presented at the outpatient clinic with a subcutaneous mass on her left back. An excisional biopsy was performed and metastatic cutaneous adenocarcinoma was diagnosed. A computed tomography scan of the thorax and abdomen showed thickening of the cecum wall, the presence of pericolic lymph nodes, multiple masses in the liver, and a single nodule in the right lung. Right colectomy with D2 lymphadenectomy and functional end-to-end anastomosis was performed because of the almost-complete intestinal obstruction. The expression of KRAS wild type, BRAFV600E mutation, and MSI-high was detected in the cecum cancer using molecular pathological examination. She received chemotherapy with XELOX + BEV regimen (capecitabine + oxaliplatin + bevacizumab). After four administrations, a computed tomography scan showed reduction of distant metastases, which suggested partial response.

Conclusions

We encountered a rare case of cutaneous metastasis of MSI-high and BRAFV600E-mutant cecum cancer. In the future, it will be necessary to accumulate more cases to identify clinical features and more effective treatments for CRCs with cutaneous metastasis.

[Two Cases of Stevens-Johnson Syndrome after Nivolumab Therapy for Gastric Cancer]

Case 1: A 51-year-old man with advanced gastric cancer and peritoneal metastasis was referred to our hospital. He received fourth-line chemotherapy with nivolumab, but it became PD. Next, he received S-1 plus docetaxel therapy as fifth- line therapy. After 2 courses of S-1 plus docetaxel, erythema and blisters appeared on his limbs, with erosions of the oral mucosa and penis. We diagnosed Stevens-Johnson syndrome(SJS)based on the clinical and pathological findings. He received steroid treatment, but the cutaneous symptoms persisted; therefore, it was impossible to continue the chemotherapy because of the SJS. Case 2: A 75-year-old woman with recurrence of peritoneally disseminated gastric cancer received third-line chemotherapy with nivolumab. After 1 course of nivolumab, erythema appeared on her body and limbs, with erosion of the lips and oral mucosa. We diagnosed SJS based on the clinical findings. She received steroid treatment, but the cutaneous symptoms persisted; therefore, it was impossible to continue chemotherapy because of the SJS. It should be noted that the onset of serious irAEs, such as SJS, might make continuous chemotherapy difficult.

[Effect on Prognosis of Immune-Related Adverse Events after Nivolumab Treatment in Gastric Cancer]

BACKGROUND

The clinical efficacy of nivolumab has been shown as a third-line treatment for advanced gastric cancer; however, nivolumab sometimes causes immune-related adverse events(irAEs). We retrospectively examined the clinical features and influence on treatment in cases of irAEs after nivolumab treatment.

METHOD

We retrospectively examined 43 patients who received nivolumab treatment at our institution between October 2017 and December 2019.

RESULT

The incidence of irAEs was 23.2%(10/43), and Grade 3 or higher irAEs included interstitial pneumonia, hypoadrenalism, Stevens- Johnson syndrome(SJS), and type 1 diabetes. Three patients showed long-term disease control after irAE onset. Meanwhile, SJS prevented patients from continuing treatment for gastric cancer.

DISCUSSION

Nivolumab is effective in some patients with gastric cancer, while irAEs made subsequent treatment difficult. Trifluridine/tipiracil or irinotecan are also known to be effective as therapeutic drugs after third-line treatment for gastric cancer in addition to nivolumab; therefore, the choice of the third-line drug and management of irAEs owing to individual cases are considered desirable.

CONCLUSION

Long-term efficacy is expected with nivolumab, but it may be necessary to recognize that the onset of serious irAEs might make subsequent treatment difficult.

[Total Pelvic Exenteration and Perineal Reconstruction with a Gracilis Myocutaneous Flap for Local Recurrence of Rectal Cancer]

The case involved a female in her 70s. Six years prior, she had undergone an abdominoperineal rectal resection for rectal cancer. Local recurrence was observed during follow-up so preoperative chemoradiotherapy was performed to shrink the tumor, followed by a total pelvic exenteration, bilateral ureterocutaneous fistula, and perineal reconstruction with a gracilis myocutaneous flap. She was discharged from hospital 39 days following surgery with no major complications. We herein report on a case of a good postoperative course due to surgery including a total pelvic exenteration and perineal reconstruction with a gracilis myocutaneous flap for postoperative local recurrence.

[Outcome of Repeated Surgical Resections of Hepatic and Pulmonary Metastases from Colorectal Cancer]

Previous reports have demonstrated that repeated surgical resections of resectable hepatic and pulmonary metastases from colorectal cancer contribute to a better prognosis. We retrospectively assessed the outcomes of 19 patients with colorectal cancer who underwent repeated resections of hepatic and pulmonary metastases between February 2007 and February 2017. The median observation period was 69.9 months, and 26 liver and 27 lung resections were performed. The cumulative 5-year survival rates after resection of the last metastasis was 75.1% and the median disease-free survival after resection of the last metastasis was 34.7 months. Although 7 patients showed recurrence and 4 patients died, 7 patients exhibited long-term survival. Univariate analysis revealed that simultaneous liver and lung metastases were significantly predictor of poor prognosis(p=0.039). Progress of the patients in the present study were comparable to those in previous reports. Therefore, we propose that repeated surgical resection of hepatic and pulmonary metastasis from colorectal cancer could improve patient prognosis. Further studies should examine to identify more accurate prognostic factor with large series.

A rare case of enlarged gastric heterotopic pancreas with retention cysts: A case report and literature review

INTRODUCTION

Gastric heterotopic pancreas (HP) is usually asymptomatic and benign; however, it may become evident when it is complicated by pathological changes such as inflammation, bleeding, and malignant transformation.

PRESENTATION OF CASE

A 43-year old man was diagnosed with gastric HP 18 years prior suffered a haemorrhage from the enlarged gastric HP with multiple cystic lesions. Although endoscopic ultrasonography-guided fine needle aspiration showed no malignancy, he underwent a partial gastrectomy for diagnosis and treatment. Postoperative histological findings revealed ectopic pancreatic tissue with retained cysts that consisted of dilated pancreatic ducts without malignancy.

DISCUSSION

This is a first report of enlarged gastric HP due to the expansion of retained cysts. Gastric HP is rarely enlarged by pathological changes including inflammation, retention cysts, or malignant neoplasms.

CONCLUSION

Symptomatic enlarged gastric HP should be respected and further examined histologically to ensure diagnostic accuracy.

[Simultaneous Distal Gastrectomy, Distal Pancreatectomy, and Splenectomy Based on Remnant Gastric Blood-Flow Evaluation with Intraoperative ICG Fluorescence]

The splenic artery and vein are important to the remnant stomach after distal gastrectomy(DG). Hence, total gastrectomy is recommended when performing gastrectomy and distal pancreatectomy(DP)with splenectomy(S). In the present case, a man in his 70s was diagnosed with early gastric cancer. Abdominal CT detected a dilated main pancreatic duct. Chronic pancreatitis was suspected, but malignancy could not be completely ruled out. Thus, DG with Roux-en-Y reconstruction and DP with S were performed simultaneously. The remnant gastric blood flow was evaluated with intraoperative indocyanine green(ICG)fluorography and the blood flow was confirmed. Finally, the remnant stomach was preserved. The postoperative course was uneventful, except for the occurrence of anastomosis edema. This result suggests that ICG fluorescence is useful to evaluate remnant gastric blood flow and that it may be possible to perform DG and DP with S simultaneously depending on the case.

A multicenter prospective registration study on laparoscopic pancreatectomy in Japan: report on the assessment of 1,429 patients

BACKGROUND

Prospective studies are needed to understand the safety and feasibility of laparoscopic pancreatectomy. The aim of the present study was to describe laparoscopic pancreatectomy currently undertaken in Japan, using a prospective registration system.

METHODS

Patient characteristics and planned operations were registered preoperatively, and then the performed operation and outcomes were reported using an online system. Collected data were also compared between institutions based on their level of experience. This study was registered with UMIN000022836.

RESULTS

Available data were obtained from 1,429 patients at 100 Japanese institutions, including 1,197 laparoscopic distal pancreatectomies (LDPs) and 232 laparoscopic pancreatoduodenectomies (LPDs). The rates of completion for planned operations were 92% for LDP and 91% for LPD. Postoperative complication rates after LDP and LPD were 17% and 30%, and 90-day mortality rates were 0.3% and 0.4%, respectively. Shorter operation time, less blood loss, and lower incidence of pancreatic fistula were observed in institutions experienced in LDP. A higher rate of pure laparoscopic procedure and shorter operation time were noted in institutions experienced with LPD.

CONCLUSION

LDPs and LPDs are performed safely in Japan, especially in experienced institutions. Our data could support the next challenges in the field of laparoscopic pancreatectomy.

[Microsatellite Instability in Gastric Cancer]

INTRODUCTION

Pembrolizumab and nivolumab are anti-programmed death receptor-1(PD-1)antibodies. The use of pembrolizumab for unresectable or metastatic cancer with microsatellite instability-high(MSI-High)has been recently approved. However, there were few clinical reports on MSI in gastric cancer.

MATERIALS AND METHODS

We examined the clinicopathological features and MSI for 37 patients who underwent chemotherapy for unresectable gastric cancer in January 2019.

RESULTS

MSI-High was observed in 3 patients(8.1%). Among the MSI-High patients, there was a tendency towards older age, female sex, undifferentiated type, distal-located lesions and lymphatic vessel invasions, but the differences were not significant. Eleven patients underwent chemotherapy with nivolumab, 4 of them had partial response(PR). Three out of the 4 patients (75%)were MSI-High.

CONCLUSIONS

These results suggested that anti-PD-1 antibody could be effective as a secondary treatment for unresectable or metastatic gastric cancer among MSI-High patients.

[A Case of Gastric Cancer with Continued Progression-Free Survival Even after Total Gastrectomy and Nivolumab Therapy]

This is a first report of gastrectomy after nivolumab immunotherapy. We describe a case in an elderly woman with gastric cancer diagnosed with cT4bN3M1(LYM), cStage ⅣB disease. Although she was administered 2 courses of SOX chemotherapy as the primary treatment, she could not continue the treatment to due to bone marrowsuppression. The second-line treatment was weekly PTX therapy, but she experienced Grade 3 neutropenia and thrombocytopenia in the first course and could not continue treatment. Nivolumab as the next treatment was effective but was discontinued for suspected druginduced pneumonia. During that time, tumor hemorrhage occurred and we performed total gastrectomy. Postoperatively, nivolumab chemotherapy was resumed. There were no adverse events and the patient has had a continued partial response for 30 courses. Gastrectomy was necessary in this case, allowing observation of the pathological findings of this highly effective case.

[Analysis of Hepatectomy for Liver Metastasis from Gastric Cancer]

INTRODUCTION

The indication of hepatectomy for liver metastasis from gastric cancer has not been definitely established.

PATIENTS AND METHODS

Among 12 cases that were performed hepatectomy for liver metastasis from gastric cancer in our institute from 2008 to 2016, we analysed prognosis and the benefit of surgical resection.

RESULTS

The overall 5-year survival rates of all cases were 42.3%, and median survival time was 2 years. The overall survival rates of synchronous metastasis was 59.3%and of metachronous metastasis was 0%. Recurrence rate of all cases within 1 year was 75%. There was no long-term survivor for metachronous metastasis because of its early recurrence though it was solitary liver tumor.

CONCLUSION

We should carefully indicate surgical resection for liver metastasis from gastric cancer.

[A Rare Case of Abdominal Malignant Triton Tumor]

A 60-year-old woman presented at our hospital with abdominal pain and vomiting.Three abdominal tumors were detected, and she was referred to our department for surgery.She underwent an enterectomy including 2 of the tumors.The third tumor could not be resected because it had invaded the superior mesenteric artery(SMA)and superior mesenteric vein(SMV). Based on positive immunohistochemistry results for S-100 protein and desmin, nerve sheath differentiation with rhabdomyoblastic differentiation was confirmed, and she was diagnosed with a malignant triton tumor(MTT).She received postoperative chemotherapy with adriamycin and dacarbazine.However, she died 7 months after surgery, with multiple peritoneal metastases.MTT is a subtype of malignant peripheral nerve sheath tumor and is very rare.MTT has a poor prognosis with a high tendency of local recurrence and early metastasis.The most common treatment strategy is radical resection followed by postoperative chemoradiotherapy.When preoperative diagnosis is possible, radical resection with clear margins should be performed.

[A Case of Mixed Hepatocellular and Primary Hepatic Neuroendocrine Carcinomas with Remnant Liver Recurrence and Rapid Exacerbation]

The patient was a 77-year-old man with a 4.0 cm hepatictumor in hepaticsegment 4. Plain computed tomography(CT) showed the tumor with low density. On dynamicexamination, the tumor showed heterogeneous enhancement during the arterial phase. Magneticresonanc e imaging showed the tumor as a low intensity area in the hepatobiliary phase in hepatic segments 4, 6, and 8. A month later, CT showed an enlarged tumor in segment 4 measuring 7.0 cm. We diagnosed the tumor as primary liver cancer and suspected it to be hepatocellular carcinoma(HCC)preoperatively. We performed extended medial segmentectomy and partial hepatectomy of segment 6. The histopathological diagnosis was mixed HCC and primary hepatic neuroendocrine carcinoma(PHNEC). Three months after hepatectomy, the patient died of multiple intrahepatic recurrences. In most of the reported cases of mixed HCC and PHNEC, only the PHNEC component has been detected in the biopsy of the metastatic lesions. This fact might suggest that PHNEC has a higher proliferative activity and malignant potential than HCC. Standard treatment for mixed HCC and PHNEC is unclear; therefore, development of multidisciplinary treatment strategies combining surgical treatment and systemic chemotherapy is required.

[Clinical Outcome of Hepatectomy of Liver Metastasis of Duodenal Ampullary Cancer]

We evaluated the clinical outcome and assessed the indication of hepatectomy for liver metastasis of duodenal ampullary cancer. We analyzed 42 cases of duodenal ampullary cancer and 4 patients who underwent hepatectomy for liver metastasis. Eleven(50%)of 22 cases with recurrence of duodenal ampullary cancer had liver metastasis. Four cases were solitary and 7 cases were multiple. Four patients underwent hepatectomy didn't had other organ metastasis. Three of 4 cases with solitary liver metastases and one of 7 cases with multiple metastasis underwent hepatectomy. One of 3 cases of solitary liver metastasis died of lung and bone metastases without liver recurrence 2 years and 8 months after hepatectomy. Other 2 cases are long surviving without recurrence 8 years and 8 months and 4 years and 9 months after hepatectomy respectively. One case of multiple liver metastases died of early liver recurrence 10 months after hepatectomy. The indication of hepatectomy for liver metastasis was restrictive. However the prognosis of patients with solitary liver metastasis was relatively favorable. Therefore hepatectomy could be indicated for solitary liver metastasis of duodenal ampullary cancer.

[A Case of Anaplastic Carcinoma Spindle Cell Type of the Pancreas]

Anaplastic carcinoma spindle cell type is an extremely rare disease and its prognosis is very poor. We herein report a case of anaplastic carcinoma spindle cell type of the pancreas. A 50-year-old man complaining of epigastralgia was found to have a pancreatic body-tail tumor by abdominal US and CT studies. Abdominal CT showed an irregular poorly-enhanced 33mm tumor containing a cystic component. ERCP revealed the main pancreatic duct was cut off at the tumor. Cytology of the pancreatic fluids did not indicate malignancy. A pancreatic tumor with a cystic component similar to pancreatic neoplasms containing cystic degeneration or a mass-forming pancreatitis concomitant with pancreatic pseudocyst was suspected. Therefore, we performed distal pancreatectomy. Histological findings showed the center of the tumor was severely necrotized and oval or spindle dysplastic cells proliferated around the peripheral area. According to the immunohistological staining pattern, the patient was diagnosed as having anaplastic carcinoma spindle cell type. He was administered oral S-1 for 6 months and is now recurrence-free, surviving for 15 months after pancreatectomy. Reports of long-term survival cases that also demonstrated R0 resection should be indicated in the treatment of anaplastic carcinoma spindle cell type despite the poor prognosis.

[A Case of Duodenal Invasive Advanced Gastric Cancer in Which the Primary Tumor Achieved pCR, but Viable Cancer Cells Remained in Lymph Node No.13 after Neoadjuvant Chemotherapy]

A woman approximately 70-years-old with duodenal invasive advanced gastric cancer was referred to our hospital. Meta- stasis to lymph node(LN)No.13 was suspected based on FDG/PET-CT. For better curability, we selected neoadjuvant chemotherapy( NAC)with S-1 plus oxaliplatin(SOX therapy). After 3 courses of SOX, distal gastrectomy with D2(+No.13) lymphadenectomy was performed. Upon pathological evaluation, no viable cancer cells were found in the primary tumor, but viable cancer cells were identified in LN No.6 and 13. LN No.13 was defined as M1 according to the current Japanese classification of gastric carcinoma. On the other hand, the 2014 Japanese gastric cancer treatment guidelines(ver. 4)mentioned that D2(+No.13)lymphadenectomy may be an option in potentially curative gastrectomy for tumors invading the duodenum. This case suggests that No.13 lymphadenectomy is necessary as a curative operation for duodenal invasive advanced gastric cancer, even if the primary tumor has achieved pCR after NAC.

Sclerosing angiomatoid nodular transformation of the spleen presenting rapid growth after adrenalectomy: Report of a case

•

SANT displayed a rapid growth in size from 20 mm to 70 mm during 3 years after adrenalectomy.

•

Splenectomy was performed by hand assisted laparoscopic surgery (HALS).

•

Corticosteroids might be useful for treating SANT.

Introduction

Sclerosing angiomatoid nodular transformation (SANT) is a rare benign lesion with an unknown natural history and pathogenesis. So far fewer than 100 cases were documented, but detailed incidence and prevalence are unknown.

Presentation of case

We report a case of SANT of the spleen in a 37-year-old man that showed rapid growth after adrenalectomy for primary aldosteronism. Computed tomography showed a nodule in the spleen that increased in size from 2.0 cm to 7.0 cm during 3 years of observation.

Discussion

This case is reported because data regarding growth rates and natural history of these lesions are limited and few cases have been reported to show the rapid growth progression seen in this case.

Conclusion

Decreases in glucocorticoid concentrations following adrenalectomy may have contributed to the rapid growth of SANT of the spleen, because SANT is considered to be related to immunoglobulin G4-associated disease.

[A Case of Advanced Gastric Cancer with Para-Aortic Lymph Node Dissection after Neoadjuvant Chemotherapy]

The patient was a 49-year-old woman with advanced gastric cancer.CT and PET-CT revealed para-aortic lymph node metastases.She was diagnosed with Stage IV T4aN3M1(LYM)and underwent neoadjuvant chemotherapy with S-1 plus CDDP.After 3 courses, both the tumor and para-aortic lymph node metastases decreased in size.Because radical resection was considered possible, she underwent distal gastrectomy with D3(D2+No.1 6a2-b1)dissection and Roux-en-Y reconstruction. Histopathological findings revealed the cancer was Stage I B(yp T1b N1)with the disappearance of cancer cells in the para-aortic lymph nodes.She was discharged on POD 32.She underwent adjuvant chemotherapy with S-1 and was followed up for 3 years with no recurrence.Para -aortic lymph node metastases are factors predicting a poor outcome; however, when neoadjuvant chemotherapy is effective, long-term survival can be expected from gastrectomy with curative PAND.

[Two Cases of Locally Recurrent Rectal Cancer after Intersphincteric Resection That Were Controlled with a Combination of Chemoradiotherapy and Abdominoperineal Resection]

We report 2 cases of locally recurrent rectal cancer after intersphincteric resection(ISR)that were controlled with a combination of chemoradiotherapy and abdominoperineal resection(APR). In Case 1, we performed preoperative chemoradiotherapy( TS-1 plus RT 45 Gy)and APR for the local recurrence of ISR. On pathology, viable neoplastic cells were noted. In Case 2, we performed preoperative chemotherapy(Bmab plus mFOLFOX6)and APR for the local recurrence of ISR. On pathology, no viable neoplastic cells were noted. However, a local recurrence developed again 3 months later. Therefore, we performed chemoradiotherapy(TS-1 plus RT 53 Gy). The 2 patients survived without recurrence until now. Their pathology tissues and clinical courses showed that control of local recurrence with only chemoradiotherapy or surgical resection was likely to be difficult. We might be able to improve the prognosis of patients with a combination of chemoradiotherapy and surgical resection.

[A Case of Malignant Obstruction of the Colon Due to Peritoneal Dissemination of Gastric Carcinoma Treated with Colon Stenting and Colectomy after Chemotherapy]

A man in his 60s underwent gastrectomy to treat gastric carcinoma. Approximately 2.5 years after the surgery, he was admitted to the hospital because of abdominal pain. He was diagnosed with obstruction of the transverse colon due to a colon tumor. A stent was placed to treat the obstruction and avoid oncologic emergency. Biopsy results and imaging showed that the patient did not have colon cancer, but his previous gastric cancer had disseminated peritoneally. Chemotherapy was selected as treatment for recurrent gastric cancer. After chemotherapy, the patient underwent colectomy with removal of the stent. His postoperative course was good, and he was discharged from hospital without complications. The patient received additional chemotherapy. We encountered a case of colon obstruction due to peritoneal dissemination of gastric cancer that was successfully treated using a metallic colorectal stent. Colon stenting for malignant bowel obstruction is useful to avoid oncologic emergencies. However, there is no evidence at this time that long-term placement of a stent is safe. The decision to remove or retain the stent should be made upon carefully considering the condition of the patient and progression of the disease.

[Assessment of Endoscopic Resection and Partial Duodenectomy for Duodenal Mucosal Tumor]

INTRODUCTION

The risk of perforation following endoscopic resection is high. We analyzed the outcome of partial duodenectomy and discussed the therapeutic strategy for duodenal mucosal tumor(DMT).

PATIENTS AND METHODS

We analyzed 19 cases who have undergone endoscopic resection, and 11 cases who have undergone partial duodenectomy for DMT in our institute since 2007. We divided them into the first period(ESD actively indicated)and late period(ESD carefully indicated according to the alteration of indication of ESD for DMT in 2013)groups.

RESULTS

In the first period, all 17 cases initially underwent endoscopic resection and 4 cases were complicated by perforation. On the other hand, in the late period, 6 of 12 cases initially underwent endoscopic resection and 1 case was complicated by perforation. Emergent partial duodenectomy was performed with additional resection in the perforation cases. There were no complications associated with surgery, and all 29 cases achieved curative resection, based on the histology results.

CONCLUSION

We can safely indicate endoscopic resection for DMT with surgical back-up and cooperation with the endoscopic internal department.

[A Long-Surviving Case of Unresectable Gall Bladder Carcinoma Treated with Gemcitabine-Based Chemotherapy]

We report a 5-year surviving patient with unresectable gall bladder carcinoma treated with gemcitabine(GEM)-based chemotherapy. A 64-year-old man was diagnosed with unresectable gall bladder carcinoma with peritoneal dissemination based on laparotomy findings. Two months later, he started to receive GEM chemotherapy. Twelve months after surgery, the patient chose to suspend GEM treatment. One year and 10 months later, multiple lung metastases appeared and GEM was restarted in combination with UFT. Although the primary lesion and lung metastases gradually progressed, the patient maintained a good quality of life. After 3 years and 2 months, chemotherapy was changed to GEM plus S-1 because of progressive disease. Five years and 2 months after surgery, his condition was complicated by a secondary pneumothorax, and the patient received home oxygen therapy. Five years and 8 months after surgery he died of respiratory distress caused by the progression of lung metastases. Even in the case of unresectable advanced gall bladder carcinoma, effective chemotherapy could improve quality of life and prolong survival.

[Report of a Case of Long-Term Survival with Mulitidisciplinary Therapy for a Patient with Multiple Liver Metastases from Rectal Cancer]

Multidisciplinary therapy is necessary to prevent recurrence of advanced rectal cancer and advanced cancer with metastases. Here we report a case of long-term survival of a patient with advanced rectal cancer with multiple liver metastases. An 80's woman had previously undergone both Hartmann's operation and a partial hepatectomy for advanced rectal cancer with multiple liver metastases. A year after chemotherapy, a CT scan revealed multiple liver metastases. Thus, we performed partial liver resection. After another round of chemotherapy, a CT scan revealed lung metastases and local recurrence of the rectal cancer; therefore, we performed partial lung resection and a Miles operation. These procedures were conducted 4 years after her first operation. The following year, PET-CT revealed a mediastinum lymph node metastasis; consequently, we performed radiation therapy. New lung metastases and local recurrences of rectal cancer were identified after the radiation therapy; thus, we resumed the therapy, including a molecular targeting drug. Although the patient is in a tumor-bearing state, she is still alive 10 years after her first operation.

[A Case of Locally Advanced Pancreatic Cancer Showing R0 Resection after Resection of the Portal Vein Following Preoperative Chemoradiotherapy]

We report a case of pancreatic cancer showing R0 resection after resection of the portal vein(PV)following preoperative chemoradiotherapy. A 71-year-old woman was admitted to our hospital with back pain. We diagnosed the patient with pancreatic cancer using computed tomography scan and fine-needle aspiration biopsy. Because the tumor directly invaded the PV, we diagnosed it as a borderline resectable locally advanced pancreatic cancer. Radiation therapy(40 Gy/20 Fr)was administered with S-1 monotherapy(120 mg/body/day on days 1-5 and days 8-12). After the treatment, the main tumor was stable without distant metastasis. Therefore, we performed pancreaticoduodenectomy with resection of the PV. Pathological examination confirmed negative margin status. The patient was healthy and showed no sign of recurrence eight months after surgery.

Changes over time in milk test results following pancreatectomy

AIM: To investigate changes over time in, and effects of sealing technology on, milk test results following pancreatectomy.

METHODS: From April 2008 to October 2013, 66 pancreatic resections were performed at the Iwakuni Clinical Center. The milk test has been routinely conducted at the institute whenever possible during pancreatectomy. The milk test comprises the following procedure: A nasogastric tube is inserted until the third portion of the duodenum, followed by injection of 100 mL of milk through the tube. If a chyle leak is present, the patient tests positive in this milk test based on the observation of a white milky discharge. Positive milk test rates, leakage sites, and chylous ascites incidence were examined. LigaSure™ (LS; Covidien, Dublin, Ireland), a vessel-sealing device, is routinely used in pancreatectomy. Positive milk test rates before and after use of LS, as well as drain discharge volume at the 2^nd and 3^rd postoperative days, were compared retrospectively. Finally, positive milk test rates and chylous ascites incidence were compared with the results of a previous report.

RESULTS: Fifty-nine milk tests were conducted during pancreatectomy. The positive milk test rate for all pancreatectomy cases was 13.6% (8 of 59 cases). One case developed postoperative chylous ascites (2.1% among the pancreatoduedenectomy cases and 1.7% among all pancreatectomies). Positive rates by procedure were 12.8% for pancreatoduodenectomy and 22.2% for distal pancreatectomy. Positive rates by disease were 17.9% for pancreatic and 5.9% for biliary diseases. When comparing results from before and after use of LS, positive milk test rates in pancreatoduodenectomy were 13.0% before and 12.5% after, while those in distal pancreatectomy were 33.3% and 0%. Drainage volume tended to decrease when LS was used on the 3^rd postoperative day (volumes were 424 ± 303 mL before LS and 285 ± 185 mL after, P = 0.056). Both chylous ascites incidence and positive milk test rates decreased slightly compared with those rates from the previous study.

CONCLUSION: Positive milk test rates and chylous ascites incidence decreased over time. Sealing technology may thus play an important role in preventing postoperative chylous ascites.

Surgical Resection for Hepatocellular Carcinoma with Cardiac Cirrhosis after the Fontan Procedure

A 29-year-old woman who underwent the Fontan procedure at 10 years of age had an incidental finding of liver masses on abdominal ultrasonography. Subsequent gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid magnetic resonance imaging showed a 15 mm hypervascular mass with washout in the hepatobiliary phase in liver segment 4 (S4), and an 18 mm hypervascular mass without washout in the hepatobiliary phase in liver segment 2 (S2). The S2 liver mass was pathologically diagnosed to be a regenerative nodule by an ultrasound-guided needle biopsy, and the S4 liver mass was pathologically diagnosed as a poorly differentiated hepatocellular carcinoma after partial hepatectomy.

[Outcome of Pulmonary Metastasectomy for Hepatocellular Carcinoma]

Pulmonary metastasis of hepatocellular carcinoma (HCC) is considered a poor prognostic feature of the disease, and the utility of pulmonary resection is unclear. We evaluated clinical outcomes following pulmonary resection in 7 patients. All patients underwent video-assisted thoracic surgery (VATS). The median disease-free interval (DFI) was 14 (6-23) months. During pulmonary resection in 1 of the patients, intrahepatic recurrence was discovered and, 18 months later, this patient died of the recurrence. Of the remaining 6 patients, 2 patients developed intrahepatic recurrence and brain metastasis and died at 66 months and 10 months after pulmonary resection. Three patients are still alive and disease-free to date with a median follow-up duration of 42 (18-55) months. Of these 3 surviving patients, 2 patients had solitary pulmonary metastases and 1 patient had multiple bilateral pulmonary metastases; these patients underwent VATS once. The 7th patient underwent VATS 3 times for pulmonary metastasis and had no evidence of intrahepatic or extrahepatic recurrence. This patient died of an unrelated cause 15 months after the last pulmonary resection (47 months after the primary pulmonary resection). This study indicates that surgical resection of metachronous pulmonary metastases is associated with a favorable outcome in selected patients.

[Efficacy of Neoadjuvant Therapy for Borderline Resectable Pancreatic Cancer Involving the Superior Mesenteric Artery]

Multidisciplinary therapy is essential in the treatment of borderline resectable pancreatic cancer involving the superior mesenteric artery (BR-SMA). We analyzed the outcomes of multidisciplinary treatment for BR-SMA and evaluated the efficacy of neoadjuvant therapy (NAT). We reviewed the clinical courses of 10 patients with BR-SMA. Seven patients were treated with preoperative neoadjuvant therapy (NAT group), and 3 patients underwent radical pancreaticoduodenectomy first (SF group). In the NAT group, the rate of R0 was 7/7 (100%), the induction rate of postoperative adjuvant chemotherapy (AC) was 6/7 (86%), and the first recurrence sites were the lung in 4 patients, and the liver and peritoneum in one patient each, respectively. In the SF group, the rate of R0 was 2/3 (67%) because of a positive pathological dissecting peripancreatic margin in 1 case. The induction rate of AC was 3/3 (100%), and the first recurrence sites were the liver in 2 patients, the peritoneum in 1, and a local site in 1. The disease free survival of the NAT group (median survival time [MST] 19.3 months) was significantly better than that of the SF group (MST 5.7 months) (log rank test, p=0.002). The median overall survival of the NAT and SF groups was 51.6 months and 19.5 months, respectively (p=0.128). An R0 resection could be performed in all cases in the NAT group. The NAT extended disease-free survival. We conclude that NAT is recommended in the treatment of BR-SMA.

The Preventive Effect of Endovascular Treatment for Recurrent Hemorrhage in Patients with Spinal Cord Arteriovenous Malformations

BACKGROUND AND PURPOSE

Spinal cord AVMs represent rare and insufficiently studied pathologic entities. Embolization is thought to play an important role in the management of spinal cord AVMs. Factors for recurrent hemorrhage and the impact of endovascular treatment on prevention of recurrent hemorrhage remain to be confirmed. We aimed to assess recurrent hemorrhagic incidence of spinal cord AVMs and its prevention by endovascular treatment.

MATERIALS AND METHODS

We reviewed 80 patients with spinal cord AVMs by spinal cord angiography who had hemorrhage before the first endovascular treatment at New York University Medical Center, Beth Israel Medical Center, or Roosevelt Hospital in New York. We compared the baseline and radiologic characteristics of patients with and without recurrent hemorrhage by the log-rank test and the Cox proportional hazards model.

RESULTS

We observed recurrent hemorrhage in 35 (44%) patients (1/41 patients with endovascular treatment and 34/39 patients without endovascular treatment). The median length of total follow-up was 659 days (interquartile range, 129-2640 days), and the median length from first-to-recurrent hemorrhage was 369 days (interquartile range, 30-1596 days). The log-rank test revealed that endovascular treatment and venous thrombosis reduced recurrent hemorrhage, and associated aneurysm was related to recurrent hemorrhage. Even in multivariate analysis, the endovascular treatment reduced (hazard ratio, 0.027; P < .0001) and associated aneurysm increased (hazard ratio, 3.4; P = .044) the risk of recurrent hemorrhage.

CONCLUSIONS

Endovascular embolization is the first choice of treatment for spinal cord AVMs and is effective in preventing recurrent hemorrhage.

Pathology of embolic debris in carotid artery stenting

BACKGROUND

The relationship between magnetic resonance (MR) plaque imaging and the pathology of distal embolic debris is unknown. We aimed to evaluate the relationship between the pathology of embolic debris in the embolic filter during carotid artery stenting (CAS), MR plaque imaging, and new ischemic lesions on diffusion-weighted imaging (DWI).

METHOD

We prospectively reviewed the 36 patients who underwent CAS using a filter-type embolic protection device. Pathology of debris was categorized into thrombosis, inflammatory cells, elastic fiber, and calcification. We compared the clinical parameters, MR plaque imaging, and pathological characteristics of the embolic debris retained in the filter during CAS on univariate analysis.

RESULTS

Eleven patients had and 25 patients did not have new lesion on DWI. All of DWI-high lesions were identified in affected side middle cerebral artery territory. Embolic debris was microscopically confirmed in 28 patients (78%); thrombosis in 11 (31%), inflammatory cells in 13 (36%), elastic fiber in 12 (33%), and calcification in 9 (25%). Proportion of asymptomatic carotid stenosis, intra-operative bradycardia/hypotension, and inflammatory cells of debris were significantly higher in patients with new DWI-high lesions. There was no significant relationship between the pathological characteristics and MR plaque imaging of distal embolic debris.

CONCLUSIONS

Our study showed that new DWI-high lesions might be influenced by types of debris in the filter. The need for future studies specifically examine the association of pathology of debris and findings of MR plaque imaging with new DWI-high lesions during CAS is emphasized.

Risk factors for mortality in patients with non-traumatic pontine hemorrhage

OBJECTIVES

For patients with non-traumatic pontine hemorrhage (PH) who will survive, determining prognosis is vital for appropriate therapeutic planning in the acute stage. This study aimed to determine reliable prognostic factors of mortality in patients with PH.

MATERIALS AND METHODS

The cases of a total of 118 consecutive PH patients were reviewed. We compared clinical and radiological characteristics between patients who died and survivors by the log-rank test and performed multivariate analysis by the Cox proportional hazards model using variables that were marginally or significantly associated with PH-related death on the log-rank test (P < 0.20).

RESULTS

The median length of follow-up was 51 days (interquartile range: 7-742 days). Sixty-six patients (56%) died and 52 (44%) survived during follow-up period. Multivariate analysis showed that Glasgow Coma Scale score <9, hyperthermia (a core temperature of ≥39°C), maximum hematoma diameter more than 27 mm, and hematoma extension to midbrain and/or thalamus were significantly related to PH-related death. The Kaplan-Meier method showed that patients without these four factors had successively longer period at PH-related death (21 patients without factors: mean 2900 days; 97 patients with at least one of four factors: mean 820 days).

CONCLUSIONS

Promptly identifying PH patients who are most likely die is important. The decision to stop life support in patients with PH is difficult, but factors, which are shown in this study, may be used to determine the level of care.

Repeated resections for liver metastasis from primary adrenocortical carcinoma: A case report

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Adrenal cortical carcinoma (ACC) is rare, often recurring, and has a poor prognosis.

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Surgery remains the optimal treatment for ACC, due to chemotherapy’s ineffectiveness.

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Our patient developed 2 liver metastases after right adrenalectomy (1.5 and 4 years).

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Therefore, complete surgical resection should be considered in similar cases.

Introduction

Adrenal cortical carcinoma (ACC) is a very rare type of tumor that generally has a poor prognosis. Little has been reported on repeated liver resections with recurrent metastasis still confined to the liver. In this report, we describe a case of functioning ACC in a 65-year-old woman with 2 liver metastases of the ACC (at 1.5 and 4 years) after the right adrenalectomy.

Presentation of case

A 65-year-old woman was referred to our hospital based on a suspicion of hyperaldosteronism. Abdominal computed tomography revealed a lesion at the right adrenal gland; therefore, we performed right adrenalectomy and subsequently diagnosed the lesion as ACC. However, follow-up computed tomography at 1.5 and 4 years after the right adrenalectomy revealed liver metastasis of ACC; liver resection was performed for both metastases.

Discussion

Complete surgical resection is the established approach for the treatment of ACC. The prognosis of ACC is usually dismal, and recurrence rates of up to 85% have been reported. However, the appropriate treatment for recurrent ACC is not well established, and the effectiveness of other modalities, such as chemotherapy and radiotherapy, is not proven. Therefore, surgical resection may currently be the most appropriate treatment modality, as the patient achieved a disease-free interval of 2.5 years after the first liver resection.

Conclusion

In selected patients with recurrent or metastatic ACC, resection is likely to be associated with prolonged survival. However, a full cure is generally not achievable, and a multidisciplinary approach is likely needed to achieve long-term disease-free status and survival.

Arterial stiffness as a risk factor for cerebral aneurysm

OBJECTIVES

A low ankle-brachial index (ABI) is associated with increased mortality and risk of myocardial infarction and stroke in the general population. Arterial stiffness can be assessed non-invasively by the measurement of brachial-ankle pulse wave velocity (PWV), a simple and reproducible method. Because the importance of ABI and baPWV in the pathogenesis of cerebral aneurysms remains uncertain, we aimed to measure ABI and baPWV in patients with intracranial saccular and dissecting aneurysms to clarify whether these aneurysms are associated with arterial stiffness and atherosclerosis.

MATERIALS AND METHODS

We prospectively investigated 78 patients diagnosed with intracranial saccular (n = 66) and dissecting (n = 12) aneurysms. The control group consisted of an age- and gender-matched normal population. We compared the clinical characteristics in patients with intracranial saccular aneurysms and controls, those with intracranial dissecting aneurysms and controls, and those who had cerebral aneurysms with and without subarachnoid hemorrhage. We also compared ABI and baPWV among saccular aneurysm locations and evaluated the correlation between the number of saccular aneurysms and ABI and baPWV.

RESULTS

Multivariate logistic regression analysis shows that hypertension and higher baPWV (>1400 cm/s) are significantly associated with saccular aneurysms. Simple regression analysis revealed no correlation between the number of saccular aneurysms and ABI (r = -0.064, P = 0.611), and baPWV (r = 0.007, P = 0.956).

CONCLUSIONS

The baPWV was associated with intracranial saccular aneurysms even after adjustment of hypertension and smoking. Assessment of the baPWV may aid the evaluation of the intracranial saccular aneurysm and the development of strategies for screening patients with intracranial saccular aneurysms.

[A case of AFP-producing esophagogastric junction cancer with liver metastases with a good response to chemotherapy]

A 62-year-old man was diagnosed with esophagogastric junction cancer following esophagogastroduodenoscopy in response to hematemesis. Although liver metastasis was detected during surgery, a total gastrectomy and lower esophagus resection for local control was performed. Alpha-fetoprotein(AFP)-producing tumor with hepatoid adenocarcinoma was diagnosed on the basis of the pathological examination. Serum AFP levels remained high postoperatively and multiple liver metastases were detected on computed tomography imaging. After 6 courses of chemotherapy with S-1 and cisplatin (CDDP), a significant reduction in the size of the liver metastases and a decrease of serum AFP levels were achieved. Postoperative 2-year tumor control using S-1 single agent chemotherapy was obtained. AFP-producing esophagogastric junction cancer has a poor prognosis. This case raises the possibility that long-term survival can be obtained by combining surgery for local control with systemic chemotherapy.

[An examination of the utility of high-precise radiation therapies for the recurrence of postoperative esophageal cancer]

We analyzed 16 cases (23 therapeutic sites) of post-operative recurrence of esophageal cancers that were treated with high-precise radiation therapies.The recurrence sites were cervical lymph nodes (5 cases), superior mediastinal lymph nodes (5 cases), posterior mediastinal lymph nodes (3 cases), regional lymph nodes with anastomosis (2 cases), abdominal paraaortic lymph node (3 cases), and regions with hematogenous metastasis (5 cases: liver, lung, spleen, and dissemination to the diaphragm bottom).By recurrence number, 10 cases presented with a single lesion, and 6 cases had multiple lesions.The effect of the treatment was complete response (CR) in all cases, and 6 cases maintained CR.The median of the overall survival after radiotherapy was 562 (132-1,231) days.Analysis of the prognostic factors for the overall survival from a recurrence revealed that the metastatic number (single) (p=0.003), and the metastatic pattern(hematogenous metastasis) (p= 0.004), significantly improved prognosis.We conclude that radiotherapy is an option to extend prognosis in some recurrence cases.

[Gastric cancer with liver metastasis and peritoneal dissemination treated with conversion surgery to achieve r0 resection after capecitabine, cisplatin, and trastuzumab chemotherapy-a case report]

Herein, we present a case report suggesting the importance of conversion surgery and the effectiveness of adjuvant chemotherapy with trastuzumab. A 77-year-old woman was diagnosed with gastric cancer complicated by multiple liver metastases and peritoneal dissemination. Owing to a HER2 immunohistochemistry (IHC) tumor score of 3+, we initiated capecitabine plus cisplatin (CDDP) plus trastuzumab chemotherapy. Subsequently, the liver metastases and peritoneal dissemination were absent on computed tomography images, and no new metastatic lesions developed during chemotherapy. After 10 chemotherapy courses, the patient underwent distal gastrectomy and 2 partial liver resection procedures. The liver metastasis remained, and it received a score of 2+ on the HER2 IHC test. We have continued to administer postoperative capecitabine plus trastuzumab chemotherapy because no metastatic lesions have appeared.

[A case of intrahepatic cholangiocarcinoma with peritoneal dissemination treated successfully with surgical resection and adjuvant chemotherapy]

A 72-year-old woman was diagnosed with liver dysfunction during a medical examination. An abdominal computed tomography (CT) scan showed multiple nodules in the left lobe, anterior segment, andposterior segment of the liver, leading to a diagnosis of intrahepatic cholangiocarcinoma (ICC). Extended left lobectomy and partial hepatectomy in the anterior and posterior segment with lymph node dissection was performed. At the time of the operation, small nodules on the peritoneum near the stomach were resected; these nodules were diagnosed as peritoneal disseminations of ICC. The histopathological diagnosis was moderately differentiated tubular adenocarcinoma (T4N0M1, Stage IVB). Adjuvant chemotherapy with S-1 was administered for 18 months. Thirty months after the operation, multiple lung metastases were detected by using CT, and chemotherapy with gemcitabine was initiated. Thirty-six months after chemotherapy with gemcitabine, the patient is alive and at home despite her lung metastases, which grew slightly in size. Herein, we report a long-term survival case of ICC with peritoneal dissemination that was successfully treated with surgical resection and adjuvant chemotherapy.

[Three cases of surgical resection of peritoneal recurrence of hepatocellular carcinoma following hepatectomy]

Surgical treatment of peritoneal recurrence (PR) of hepatocellular carcinoma (HCC) is still controversial. We report herein 3 cases of PR treated by surgical resection. Firstly, a 55-year-old woman presented with recurrences in the peritoneum and mediastinal lymph nodes 12 months after hepatectomy for ruptured HCC. After the administration of sorafenib, the mediastinal lesions shrank and the PRs were resected. There has been no recurrence 20 months after PR resection. The second case was of a 56-year-old man with recurrences in the remnant liver and the peritoneum 41 months after hepatectomy for ruptured HCC. The remnant liver lesions were controlled by transcatheter arterial chemoembolization (TACE), and the PRs were resected twice. However, multiple bone and lung metastases developed and the patient died of HCC 73 months after peritoneal resection. In the third case, a 63-year-old man had recurrences in the remnant liver and the peritoneum 78 months after hepatectomy. Remnant liver lesions were controlled by radiofrequency ablation (RFA) and TACE, and PRs were resected. However, the hepatic lesions had progressed and he died 102 months after initial hepatectomy. Based on our observations, patients with PRs who have no other distant metastases and whose intrahepatic lesions are controllable and PRs are completely resectable may have relatively long-term survival. Surgical treatment of PR may also improve the quality of life and prognosis.

[Experiences of laparoscopic repeat hepatectomy for recurrent hepatic cancer after open hepatectomy]

We report 3 cases of recurrent hepatic cancer in patients who underwent laparoscopic repeat hepatectomy (LRH). Case 1: A 70-year-old female with ascending colon cancer and liver metastases underwent open right colectomy followed by open S5 resection. Seven months later, the patient experienced a recurrence in the lateral segment and underwent laparoscopy-assisted ( L-A) partial resection. The adhesiolysis around the left liver was performed through a 7-cm upper median incision. Partial resection of the lateral segment was performed by hand-assisted laparoscopic surgery (HALS) using a median incision. Case 2: A 63-year-old female with metachronous liver metastases from rectal cancer underwent open S4a and S5 resection. Nineteen months later, she experienced a recurrence in S4b and underwent an L-A S4b resection. Adhesiolysis around the previous hepatic transection was performed through a small upper median incision. Mobilization of the liver was performed by HALS. A hepatic transection of S4b was also performed in the upper median incision. Case 3: An 80-year-old female with hepatocellular carcinoma (HCC) recurrence in the lateral segment after open S4 resection underwent L-A lateral segmentectomy. An adhesiolysis, mobilization of the liver, and a hepatic transection were performed by HALS and hybrid technique as described in case 2. In a patient with a history of open hepatectomy, LRH may be extensively indicated by utilizing HALS or a hybrid procedure.

[A case of fixing an anastomotic site to the abdominal wall out of the abdominal cavity for a small intestinal perforation during chemotherapy]

A 53-year-old man presented with a continuous high fever and was diagnosed with diffuse large B-cell lymphoma with metastasis to the lung, spleen, and mesenterium. He was treated with cyclophosphamide and prednisolone followed by administration of cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP) chemotherapy 20 days later. Two days after initiation of CHOP therapy, the patient complained of severe abdominal pain. Perforative peritonitis was diagnosed using abdominal computed tomography. A perforation of the small intestine approximately 160 cm distal to the Treitz ligament was uncovered during emergency laparotomy. The risk of leakage was considered too high for anastomosis of the small intestine to be performed. Further, construction of an intestinal stoma could result in a high-output syndrome that could lead to difficulty in resuming chemotherapy. Based on these considerations, we fixed the anastomotic region to the abdominal wall using a technique similar to construction of an intestinal stoma. Post-operative anastomotic leakage did not occur. Nine days later, a perineal hernia was noted near the anastomotic site and a second operation was performed. The anastomotic site was placed back into the abdominal cavity during this operation. CHOP therapy was resumed 16 days after the first operation.

[A case of superficial primary malignant melanoma of the esophagus]

A 71-year-old man who was being followed-up for esophagus melanosis in the middle thoracic esophagus for 2 years was found to have a black semipedunculated tumor at the same site. Radical subtotal esophagectomy with 2-field lymph node dissection was performed. Histopathological examination indicated a malignant melanoma (pT1b [SM1], N0, Stage I). Adjuvant chemotherapy with DAC-tam (dacarbazine, nimustine, cisplatin, and tamoxifen) was administrated for a diagnosis of primary cutaneous malignant melanoma. After 2 courses of chemotherapy, no recurrence was observed for 10 months. Combined radical surgery with lymph node dissection and systemic chemotherapy is recommended for primary malignant melanoma of the esophagus with submucosal tumor invasion. This treatment is necessary because of the risk of high local recurrence and distant metastasis based on the malignant potential predicted by histopathological examination.