Clinicopathological variables and risk factors for lung recurrence after resection of pancreatic ductal adenocarcinoma.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) has a high recurrence rate even after curative resection. Lung recurrence may have better outcomes than other recurrences. However, its detailed clinicopathological features are unclear. We investigated the clinicopathological features and risk factors for lung recurrence after pancreatectomy for PDAC. METHODS: The study included 161 patients with potentially and borderline resectable PDAC who had undergone R0 or R1 pancreatectomy between January 2008 and December 2016. We retrospectively examined the prognosis and predictors for lung recurrence after curative resection. RESULTS: Seventeen patients (10.6%) had isolated lung recurrence. The median overall and recurrence-free survivals were 38.0 and 16.1 months, respectively. In multivariate analysis, para-aortic lymph node (PALN) metastasis (p = 0.006) and female sex (p = 0.027) were independent factors for lung recurrence. CONCLUSION: Lung recurrence had a better prognosis than other recurrences. PALN metastasis and female sex are independent risk factors for lung recurrence after curative resection for PDAC.

[A Case of Sigmoid Colon Cancer with Intussusception Prolapsing through the Anus].

A 76-year-old woman presented to the hospital with the colon prolapsing through the anus. The enhanced abdominal computed tomography(CT)showed intussusception of the sigmoid colon due to sigmoid colon cancer. It was difficult to reduce the intussusception, and we did not recognize the ileus and ischemic change of the colon. Therefore, we performed an elective surgery. Hartmann's procedure and lymph node dissection were performed 8 days after the hospitalization. The postoperative course was uneventful. We report a case of sigmoid colon cancer with intussusception prolapsing through the anus.

[A Patient with Ascending Jejunal Mesentery Metastasis of Pancreatic Cancer after a Subtotal Stomach-Preserving Pancreaticoduodenectomy].

A 73-year-old woman underwent a subtotal stomach-preserving pancreaticoduodenectomy, wedge resection of the portal vein, and partial resection of the transverse colon for pancreatic cancer at the age of 71. After 18 months, a computed tomography image showed an 8 mm tumor in the ascending jejunal mesentery. Six months later, the tumor grew to 20 mm and had an increased FDG uptake. The tumor was diagnosed as metastasis of pancreatic cancer to the ascending jejunal mesentery. Since no metastasis was found in the other organs, resection was performed. The pathological results showed adenocarcinoma with proximal lymph node metastasis. The patient was diagnosed with ascending jejunal mesentery metastasis of pancreatic cancer. The patient has remained healthy without recurrent disease 1 year 6 months after the resection. Ascending jejunal mesentery metastasis of pancreatic cancer is a type of distant metastasis. In the absence of metastasis to other organs, it is tolerable and radical resection is possible.

[A Case of Double Lung and Gastric Cancer Involving Para-Aortic Lymph Node Metastasis with Difficult Preoperative Diagnosis].

A man in his 60s was admitted to our hospital with anemia. An endoscopic examination revealed advanced gastric cancer. CT revealed peri-gastric and para-aortic lymphadenopathy, and a nodular shadow(20mm)in the lower lobe of the right lung. PET-CT revealed abnormal uptake in the para-aortic lymph node and stomach wall and the nodular shadow in the right lung. A bronchoscopy revealed pulmonary adenocarcinoma. From the above, he was diagnosed with gastric cancer(cT4a, cN2, cM1, cStage IV )and lung cancer(cT2a, cN0, cM0, cStage I B). Because of gastric bleeding, we decided to operate on the gastric cancer before the lung cancer. First, total gastrectomy, splenectomy, and cholecystectomy were performed and then dissection of lymph node No. 16was performed. Histopathological examination indicated that lymph node No. 16was common to lung cancer, so the final diagnosis was gastric cancer(pT4a, pN0, cM0, fStage II A)and lung cancer(cT2a, cN0, pM1, fStage IV ). In this case, lymphadenectomy of No. 16in the first and pathological diagnosis during surgery could help us avoid splenectomy and cholecystectomy, and could reduce invasion.

[A Patient with Multiple Pancreatic Metastases Undergoing Total Pancreatectomy 18 Years after Renal Cell Carcinoma Resection].

A 71-year-old woman underwent right nephrectomy for the treatment of clear cell renal cell carcinoma at the age of 53. After 15 years, surgical removal of a solitary tumor was performed in the right adrenal gland and thyroid gland; both were diagnosed as metastases of renal cell carcinoma. Eighteen years after the initial resection, computed tomography(CT) showed multiple hypervascular tumors spreading across the entire area of the pancreas. She was referred to our hospital, and endoscopic ultrasound-guided fine needle aspiration biopsy(EUS-FNA)revealed that they were metastases from the renal cell carcinoma. Total pancreatectomy and splenectomy were performed, and the patient remains alive and well with no evidence of recurrent disease 7 months after the pancreatectomy. Furthermore, her blood glucose level is well controlled with insulin therapy.

[Fourteen Cases of Low-Grade Appendiceal Mucinous Neoplasm].

Low-grade appendiceal mucinous neoplasm(LAMN)is a rare disease. In consideration of consistency with the 2010WHO Classification, LAMNwas classified in the Japanese Classification of Colorectal Carcinoma 8th edition. The present study involved 14 patients with LAMNover a 5-year period. The preoperative diagnosis was made as mucocele of the appendix in 9 cases. Operative interventions included ileocecal resection in 6 cases(laparoscopic; 3 cases)and appendectomy in 8 cases (laparoscopic; 6 cases). Histopathologically, there was no LNpositive case. While adjuvant therapies were not administered in all cases, all patients remain alive without recurrence. The treatment strategy for LAMNhas not been established. Therefore, an adequate surgical method with careful postoperative surveillance should be considered.

[A Case of Mucinous Adenocarcinoma of the Descending Colon with Extramural Progression].

A 63-year-old man was admitted to our hospital with a cough. Based on imaging studies, the patient was diagnosed with locally advanced descending colon cancer with extensive infiltration into peripheral organs by extramural progression. There was no distant metastasis. Therefore, he received left hemicolectomy with splenectomy, partial gastrectomy, and partial diaphragm resection. Histopathological examination showed a mucinous adenocarcinoma, pT4b, pN1, cM0, fStage III A. We report a rare case of extramural progression colon cancer with invasion of various organs and review 12 previous case reports.

[A Case of Synchronous Multi-Centric Invasive Ductal Carcinomas of the Pancreas].

A 69-year-old man with left upper abdominal pain visited our hospital. Abdominal CT revealed a hypovascular mass(66× 57mm)in the pancreatic tail. MRI revealed hemorrhage and cysts in the caudal lesion of the tumor. The tumor involved the posterior wallof the stomach. Based on a diagnosis of pancreatic tailcancer with gastric posterior wallinvasion, distalpancreatectomy and partialgastrectomy were performed. Histopathologicalexamination indicated 2 adjacent tumors through a capsule in the pancreas tail. These tumors were diagnosed as synchronous invasive ductal carcinomas of the pancreas, which were anaplastic and papillary carcinomas. We report a rare case of synchronous multi-centric invasive ductalcarcinomas of the pancreas.

[A Case of Mixed Adenoneuroendocrine Carcinoma(MANEC)of the Duodenum].

A 79-year-old man was admitted to our hospital because of a positive fecal occult blood test. Gastrointestinal endoscopy revealed a tumor in the duodenal bulb. Histologically, biopsy specimens indicated adenocarcinoma. The patient underwent distal gastrectomy. Histopathological examination showed a neuroendocrine carcinoma with an adenocarcinoma. According to the 2010WHO Classification of Tumours of the Digestive System, this case was diagnosed as mixed adenoneuroendocrine carcinoma(MANEC). There was no metastatic lesion in the resected lymph node. The patient has been followed up for 2 years without evidence of recurrence. We report a rare case of MANEC in the duodenum.

[Transnasal and transanal tube decompression versus self-expanding metallic stent as a bridge to surgery for obstructive colorectal cancer].

PURPOSE: The aim of this study was to compare the efficacy between the use of transnasal and transanal tube decompression and self-expanding metallic stents (SEMS) as a bridge to surgery for obstructive colorectal cancer. MATERIALS: Of a total of 42 patients with obstructive colorectal cancer, 29 were managed with transnasal or transanal tubes and 13 were managed by SEMS. RESULTS: The management duration to surgery in the stent group was longer than that in the tube group (18 vs 11 days; p<.05). More patients in the stent group could be discharged and take food or liquid normally. There was no difference in overall complications including anastomotic leakage, surgical side effects, or primary anastomosis. Perforation occurred in 2 patients in the tube group, while stent migration occurred in 1 patient in the stent group. There was no difference in complications between 2 groups. CONCLUSIONS: SEMS as a bridge to surgery for obstructive colorectal cancer could improve patients' quality of life during the preoperative period. Evaluations of the complications during decompression are needed for both methods.

[Therapeutic strategy for perforated colorectal cancer].

A total of 37 patients were surgically treated for a colorectal perforation between May 2006 and December 2013. The patients were divided into 2 groups: those with perforation due to colorectal cancer(colorectal cancer group, n=12) and those with perforation due to benign colorectal disease(non-colorectal cancer group, n=25). We examined the influence that onset near the perforation had on colorectal cancer clinical outcome. There was no significant difference in patient backgrounds between the two groups. In the colorectal cancer group, curative resections were performed in eight of the cases (67%), while there were 7 cases (58%) of regional lymph node dissection and all patients received a stoma without bowel anastomosis. In the colorectal cancer group, 1 patient (8%) died of a pulmonary embolism after surgery, whereas 2 patients (8.3%) in the non-colorectal cancer group died of sepsis after surgery. Nine of those patients (75%) received adjuvant chemotherapy. Four patients survived without recurrence. Prompt judgment of the disease severity and selection of optical surgical procedures including tumor resection and regional lymph node dissection is important for colorectal cancer perforation, and an adjuvant setting for the purpose of the long-term survival is necessary.

[Long-term survival of a patient with extrahepatic cholangiocarcinoma treated with adjuvant radiotherapy for positive ductal margins after surgical resection].

A 57-year-old man with abdominal discomfort visited our hospital. Abdominal computed tomography (CT) revealed no tumorous lesions. Endoscopic retrograde cholangiography (ERC) revealed a tumorous lesion in the middle bile duct. Peroral cholangioscopy-assisted biopsy was performed, and the lesion was diagnosed as a papillary adenocarcinoma. Extra bile duct resection and regional lymph node dissection were performed; however, residual carcinoma in situ was detected at the ductal margins by intraoperative frozen section analysis. Therefore, external radiation therapy at a dose 50.4 Gy/28 Fr was administered after the operation. No complication due to radiotherapy occurred. The patient remains alive and recurrence -free for more than 7 years after the operation. We report the long-term disease-free survival of a patient with extrahepatic cholangiocarcinoma who was treated with external radiation therapy for positive ductal margins after surgical resection.