Pancreatic Adenosquamous Carcinoma Discovered Upon a Resection for Neck Tuberculous Lymphadenitis: A Case Report.

Cancer (including pancreatic cancer) can develop following a Mycobacterium tuberculosis infection within one year of tuberculosis infection. However, it is unclear whether tuberculosis infection increases the risk of developing adenosquamous carcinoma of the pancreas (ASCP), an extremely rare cancer with a poorer prognosis than pancreatic ductal adenocarcinoma (PDAC). Herein, we report a case of rapid growing ASCP discovered upon a resection for neck tuberculous lymphadenitis. The patient was a 57-year-old woman. An excisional biopsy of the swollen right neck lymph nodes revealed tuberculous lymphadenitis. One month after the biopsy, an abdominal computed tomography scan showed a 2.0 cm (diameter) ischemic tumor in the pancreatic tail. The tissue obtained using endoscopic ultrasonography-guided fine-needle aspiration led to the pathological diagnosis of ASCP. Two months after the biopsy, the tumor had grown to 3.5 cm (diameter), and invasion of the stomach and colon was suspected. Distal pancreatectomy, splenectomy, partial gastrectomy, and transverse colectomy were performed. The final diagnosis was ASCP (4.7 cm, pT3, pN0, cM0, and pStage IIA). Postoperative adjuvant combination chemotherapy combined with antituberculosis drugs was administered orally. We report the first case of rapidly growing adenosquamous carcinoma resected from the pancreas in association with tuberculous lymphadenitis. Additional evidence is needed to confirm that tuberculosis infection increases the risk of developing pancreatic adenosquamous cell carcinoma because its potential role in promoting squamous metaplasia is unclear.

[A Case of Sigmoid Colon Cancer with Horseshoe Kidney].

We reported a case of sigmoid colon cancer with horseshoe kidney. A 79-year-old man had lower abdominal pain and underwent colonoscopy. The results of colonoscopy revealed sigmoid cancer. Preoperative computed tomography revealed horseshoe kidney. He underwent radical laparoscopic surgery. The histopathological diagnosis was pStage Ⅱa(The 9th Edition). He has not recurred 22 months later after operation. Surgery for colorectal cancer with congenital anomalies of the urinary tract requires attention to intraoperative secondary injuries. Therefore, preoperative evaluation using 3D-CT is useful tool for safety. Operating the proper dissecting normal layer would make safe laparoscopic operation possible without unexpected injuries.

[A Case of Appendiceal Metastasis from Hilar Cholangiocarcinoma with Acute Perforated Appendicitis and Cholecystitis].

An 88-year-old woman had been diagnosed with hilar cholangiocarcinoma for 3 years since she received metallic stents for malignant biliary obstruction, and observed without any aggressive medical treatment. She was admitted to our hospital for further investigation of her abdominal pain. Abdominal CT showed an enlarged gallbladder, fluid collection in the right paracolic gutter, and swollen appendix. Laboratory tests showed high-grade inflammation. She was diagnosed with acute perforated appendicitis with acute cholecystitis. Laparoscopic cholecystectomy and appendectomy were performed. Perforation was confirmed intraoperatively in the appendix wall and accumulation of pus was found in the right paracolic gutter. There were no macroscopic findings of metastasis and peritoneal dissemination. Microscopic examination of the resected appendix showed adenocarcinoma cells positive for CK7 and negative for CK20 and CDX2, and were predominantly infiltrated from the muscular layer to the serosa of the appendix wall, with a diagnosis of appendiceal metastasis from hilar cholangiocarcinoma. Metastatic appendiceal carcinoma is rare, and appendiceal metastasis from hilar cholangiocarcinoma is extremely rare. Herein, we report a rare case of metastatic appendiceal carcinoma from hilar bile duct cancer with acute perforated appendicitis and cholecystitis along with findings of previous literature.

Development of an Eye-Tracking Image Manipulation System for Angiography: A Comparative Study.

RATIONALE AND OBJECTIVES: Appropriate image manipulation of angiographic image display systems during interventional radiology is performed by radiological technologists and/or nurses given instructions from radiologists. However, appropriate images might not be displayed because of communication errors. Therefore, we developed a manipulation system that uses an eye tracker. The study aimed to determine if an angiographic image display system can be manipulated as well by using an eye tracker as by using a mouse. MATERIALS AND METHODS: An angiographic image display system using an eye tracker to calculate the gaze position on the screen and state of fixation was developed. Fourteen radiological technologists participated in an observer study by manipulating 10 images for each of 5 typical cases frequently performed in angiography, such as renal tumor, cerebral aneurysm, liver tumor, uterine bleeding, and hypersplenism. We measured the time from the start to the end of manipulating a series of images required when using the eye tracker and the conventional mouse. In this study, the statistical processing was done using Excel and R and R studio. RESULTS: The average time required for all observers for completing all cases was significantly shorter when using the eye tracker than when using the mouse (10.4 ± 2.1 s and 16.9 ± 2.6 s, respectively; p< 0.001 by paired t test). CONCLUSION: Radiologists were able to manipulate an angiographic image display system directly by using the newly developed eye tracker system without touching contact devices, such as a mouse or angiography console. Therefore, communication error could be avoided.

[A Case of Completion Gastrectomy for Metachronous Gastric Cancer in the Remnant Stomach after Successful Treatment with ESD].

A 73-year-old man underwent distal gastrectomy, D2 lymphadenectomy, and Billroth Ⅰ reconstruction for Type 3 advanced cancer in the lower corpus lesser curvature in 20XX. After postoperative adjuvant chemotherapy, he self-detected a mass in the left breast. It was diagnosed as breast cancer. He underwent mastectomy and axillary lymphadenectomy 16 months after gastric cancer surgery. After postoperative adjuvant chemotherapy, gastric or breast cancer did not recur. However, periodic upper gastrointestinal endoscopy revealed an 8-mm 0-Ⅱa lesion in the anterior wall of the remnant middle stomach(Group 5)80 months after gastric cancer surgery. Endoscopic submucosal dissection(ESD)was performed, and radical resection was achieved. Periodic upper gastrointestinal endoscopy was performed thereafter; an ectopic 0-Ⅱa lesion was detected in the greater curvature of the remnant middle stomach(Group 5)21 months after ESD. Since this lesion suggested massive submucosal invasion, total resection of the remnant stomach and Roux-en-Y reconstruction were performed. The postoperative course has been favorable, and the patient has been alive without recurrence for 6 months postoperatively. A long period passes before intestinal juice reflux induces progression of a chronic inflammatory gastric mucosal lesion to cancer in the remnant stomach. Thus, long-term endoscopic follow-up may be necessary.

[A Case of Recurrent Gastric Cancer Successfully Treated by S-1 Chemotherapy].

We report a case of recurrent gastric cancer that was successfully treated by S-1 chemotherapy.An 81-year-old woman with advanced gastric cancer[L Less, Type 2, cT4a(SE), cN0H0P0M0, cStageⅡB]underwent distal gastrectomy.Abdominal CT performed 6 months after surgery revealed a low-density area in the liver.She was diagnosed with liver metastasis and started receiving S-1 chemotherapy.The liver metastasis achieved complete response, so S-1 chemotherapy was discontinued 12 months after recurrence.Abdominal CT performed 9 months after the discontinuation of S-1 chemotherapy revealed multiple low-density areas in the liver.She started receiving S-1 chemotherapy again, but S-1 chemotherapy was discontinued because of side effects after 2 courses.The patient died 24 months after receiving S-1 chemotherapy.

[A Case of Laparoscopic Gastric Local Resection for Dedifferentiated Gastric Liposarcoma].

A 73 year-old-woman visited our emergency department with a sudden stomach ache. A 7 cm tumor was found on the greater curvature side of the stomach by contrast-enhanced CT, and showed mosaic pattern when visualized with a contrast agent. An esophagogastroduodenoscopy showed normal mucosal gastric surface with compression findings by the gastric submucosal tumor, and therefore she was admitted to our department for surgery. Abdominal ultrasound revealed an uneven gastric submucosal tumor containing cystic components with a clear border, and gastric GIST was suspected due to its appearance, and therefore, laparoscopic gastric local resection was performed. The gastric tumor was located on the dorsal side of the greater curvature and adhered highly to the retroperitoneum and spleen. The omental incision was conducted first, and the adhesion around the tumor was carefully detached, following which wedge resection was performed using Endo-GIA®at the base of the tumor. The pathological findings of the resected specimens were mainly spindle-shaped tumor cells rich in polymorphism with a high degree of necrosis, and did not seem to be conclusively GIST; as such, various immunological tests were performed.c -kit(-), DOG-1(-), S-100 p(-), desmin(-), a-SMA(focal+), p16(+), MDM2(+), CDK4(+) results led to the diagnosis of dedifferentiated liposarcoma. The patient is currently being followed up with and is alive without recurrence 10 months after the operation.

[Analysis of Patients Who Received Nutritional Support and the Enhanced Recovery after Surgery(ERAS)Protocol after Esophagectomy].

BACKGROUND: Malnutrition is a frequently observed phenomenon in patients with esophageal cancer after esophagectomy. Nutritional support and the enhanced recovery after surgery(ERAS)protocol may prevent malnutrition. METHOD: Nine patients who underwent esophagectomy for esophageal cancer received perioperative management according to the ERAS protocol and enteral nutrition support(ELENTAL®or ENEVO®). We retrospectively evaluated the efficacy and safety of our perioperative management. RESULTS: The median day of first oral intake(water)was the second postoperative day. The median day of first oral intake(food)was the seventh postoperative day. The patients could consume more than one and a half bottle of enteral nutrition for a year after surgery. The prognostic nutritional index(PNI)was higher than 40, and the neutrophil-to-lymphocyte ratio(NLR)was lower than 3 for a year after surgery. CONCLUSIONS: Perioperative management according to the ERAS protocol and enteral nutrition support(ELENTAL®or ENEVO®)might be feasible and prevent malnutrition in patients after esophagectomy.

[A Case of Effective Palliative Care with CART for Refractory Ascites Associated with Cancerous Peritonitis of Gastric Cancer].

Refractory ascites associated with cancerous peritonitis causes abdominal tension and reduced oral intake. Frequent ascites drainage can cause rapid worsening ofa patient's general condition. Cell-free and concentrated ascites reinfusion therapy (CART)for refractory ascites was first covered in 1981, and the general conditions ofpatients and their symptoms could be improved after undergoing CART. Herein, we report a case of effective palliative care with CART for refractory ascites associated with cancerous peritonitis. A 66-year-old man was admitted to our hospital because ofabdominal distension. Computed tomography revealed the presence ofascites and gastric wall thickness; upper gastrointestinal endoscopy revealed an ulcerated lesion with raised margins on the body ofthe stomach. Biopsy ofthis lesion confirmed the diagnosis ofadenocarcinoma, and he was diagnosed with gastric cancer(M, Type 3, cT4a[SE], cN0, cH0, cP1, cM1, cStage IV). He underwent palliative care for ascites, followed by FLTAX regimen chemotherapy(5-fluorouracil[5-FU]and Leucovorin[LV]combined with weekly paclitaxel[PTX]). He received CART for 8 courses without complications, and his symptoms improved after receiving CART. He survived for about 18 months, and could ingest a normal diet for a long time. CART may be favorable in palliative care for massive ascites associated with cancerous peritonitis.

[A Case of Splenic Metastasis from Serous Surface Papillary Carcinoma of the Peritoneum Treated by Laparoscopic Splenectomy].

A 50-year-old woman with abdominal fullness, lower abdominal pain, elevated serum CA125, and ascites, underwent neoadjuvant chemotherapy with 6 courses of PTX/CBDCA followed by total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and intrapelvic peritoneal stripping based on a diagnosis of serous surface papillary carcinoma(SSPC) of the peritoneum. Complete response(CR)was shown after adjuvant chemotherapy with 3 courses of the same regimen. After 6 months, serum CA125 level re-increased and abdominal CT showed small low density areas in the patient's spleen and the perisplenic fat tissue. After the additional chemotherapy with 3 courses of PTX/CBDCA were performed based on a diagnosis of metastatic lesion from SSPC, anaphylactic shock occurred as the severe adverse event. The patient was given 9 more courses of the chemotherapy changed the regimen to PTX/CDDP. The splenic metastatic lesion had grown rapidly in the followed CT and then, laparoscopic splenectomy with peritoneal resection was performed based on a diagnosis of splenic metastasis from SSPC. The pathological examinations showed the tumor to be a splenic metastasis and peritoneal dissemination from SSPC. No recurrent lesion has been detected in the 9 months since removal of the splenic metastasis without adjuvant chemotherapy and the patient has survived for 4 years and 6 months since initial treatment.

[A Case of Advanced Esophageal Cancer Successfully Treated with Multidisciplinary Therapy].

We report a case of advanced esophageal cancer that was successfully treated using chemotherapy, operation, and chemoradiotherapy. A 66-year-old man with advanced esophageal cancer(Mt, O-Is, T4[N0.7-stomach], N2, M0, Stage III)was administered chemotherapy(docetaxel[DOC], cisplatin[CDDP], and 5-fluorouracil[5-FU]: DCF). As the esophageal tumor achieved complete clinical response after 2 courses of chemotherapy, lymph node dissection and proximal gastrectomy were performed for the residual tumor. Abdominal CT 3 months after surgery revealed lymph node swelling. He was diagnosed with lymph node metastasis and was administered chemoradiotherapy. After chemoradiotherapy, liver metastasis was revealed, and he underwent immune checkpoint inhibitor immunotherapy. Despite the administration of immune checkpoint inhibitors, the liver metastasis developed, so he was treated with S-1 chemotherapy. S-1 chemotherapy resulted in a favorable response, and almost all metastatic lesions decreased. The patient is alive 12 months after S-1 chemotherapy without any signs of tumor regrowth.

[The Surgical Experience for Bulky Serous Cystic Neoplasm of Pancreas].

A 74-year-old femalewas admitted to our hospital dueto thebulky abdominal tumor pointed out by ultrasonography of medical screening. Abdominal CT revealed the tumor, in a diameter 20 cm, replaced the total pancreas and compressed the surrounding organs and portal vein. We diagnosed as a pancreatic serous cystic neoplasm with a possibility of malignancy. The operative findings showed the tumor tightly adhered to stomach, duodenum, liver, transverse colon mesenterium, retroperitoneum and the surrounding main vessels. Total pancreatectomy, cholecystectomy, splenectomy and distal gastrectomy were performed. As a histopathological finding, thetumor surfacewas smooth and theinsidewas sponge-likeappe arancemixe d with microcystic and solid components. No malignant finding was observed. The patient was discharged without major complications on postoperative day 42, and remains alive with no recurrence for 9 months after surgery.

[Analysis of Patients Who Received Enteral Nutrition in the Course of Chemotherapy].

BACKGROUND: Chemotherapy-related adverse events can deteriorate the quality of life, as well as chemotherapy tolerance, for patients with gastric cancer. Nutritional support may prevent chemotherapy-related adverse events. METHODS: Five patients who received chemotherapy for advanced gastric cancer were prescribed enteral nutrition(Elental®or ENEVO®). We retrospectively evaluated the efficacy and safety of chemotherapy while receiving enteral nutrition. RESULTS: All patients consumed more than one bottle of enteral nutrition during chemotherapy. Median progression-free survival(PFS)and overall survival(OS)were 166 days(100-349)and 328 days(115-431), respectively. Major Grade 3 or 4 adverse events included neutropenia(0%), anemia(40%), and diarrhea(20%). The prognostic nutritional index(PNI)was higher than 40, and the neutrophil lymphocyte ratio(NLR)was lower than 3 over the course of chemotherapy. CONCLUSIONS: Nutritional support for gastric cancer patients receiving chemotherapy is feasible. There was a low incidence of chemotherapy-related hematological toxicity, with a relatively longer PFS in patients receiving enteral nutrition.

[A Case of Laparoscopic Transhiatal Esophagectomy for Esophageal Cancer after Chemoradiotherapy].

Patients with esophageal cancer often have various comorbidities, and these sometimes limit treatment choices. We report a case of esophageal cancer surgically treated using laparoscopic transhiatal esophagectomy after chemoradiotherapy in an elderly man with interstitial lung disease. A 77-year-old man who had undergone upper gastrointestinal endoscopic examination was admitted to our hospital with a diagnosis of esophageal cancer and interstitial lung disease. We diagnosed T4 esophageal cancer, and administered chemoradiotherapy. The chemoradiotherapy reduced the size of the tumor, but an esophageal stricture remained. A non-transthoracic approach was thought to be an appropriate choice for a patient at high risk for postoperative respiratory complications. Laparoscopic transhiatal esophagectomy was performed safely and successfully. In the postoperative course, temporary tracheotomy was necessary, but the tracheotomy tube was ultimately removed, after which he was able to consume food.

[Analysis of Short-Term Outcomes after Laparoscopy-Assisted Pylorus-Preserving Gastrectomy].

BACKGROUND: Pylorus-preserving gastrectomy(PPG)has long been used for the treatment of early gastric cancer, and its survival benefits, postoperative symptoms, and functional outcomes have already been reported in several studies. This study aimed to evaluate the short-term outcomes after LAPPG in our hospital. METHODS: Ten patients with early gastric cancer underwent LAPPG from 2013 to 2015 in our hospital. Their short-term outcomes after LAPPG were retrospectively analyzed. RESULTS: No intraoperative complications were observed, and no patient required conversion to open surgery or reoperation. At 1 year after the operation, the relative body weight(present/preoperative)of the patients was 94.8%, and the incidence of nausea, diarrhea, abdominal fullness, and vomiting was, each, 1 in 7. CONCLUSION: The short-term results show that LAPPG seems to be beneficial in terms of postoperative symptoms and functional outcomes.

[A Case of Large Rectal Villous Adenoma Associated with Tenesmus and Body Weight Loss].

The patient was a 78-year-old man who was hospitalized with a 1-month history of tenesmus and body weight loss. Blood tests revealed a mild increase in tumor markers(CEA 9.7 ng/mL)and an elevation of the inflammatory response. Colonoscopic examination disclosed a full circular lateral spreading tumor(LST)extending from the second Houston valve to the rectosigmoidal region with a more than 10 cm length. Since invasion to the SM layer was suspected, endoscopic resection was judged inapplicable and laparoscopic low anterior resection with D2 lymph node dissection was performed, along with covering ileostomy. The final pathology diagnosis was villous adenoma with carcinoma in adenoma, showing multiple villous structures categorized as high dysplasia. Postoperatively, he was free from tenesmus and his body weight increased. In addition, normalization of the tumor markers occurred.

[Analysis of 5-Fluorouracil and Leucovorin Combined with Weekly Paclitaxel in Advanced Gastric Cancer].

PURPOSE: Advanced gastric cancer patients with malignant ascites cannot tolerate S-1 plus cisplatin-containing therapy. The good toxicity profile of the FLTAX regimen(5-fluorouracil[5-FU]and Leucovorin[l-LV]combined with weekly paclitaxel) might make it a viable alternative treatment for these patients. We retrospectively evaluated the efficacy and safety of FLTAX in advanced gastric cancer patients. MATERIALS AND METHODS: Patients with advanced gastric cancer with malignant ascites were treated with 60mg/m2 paclitaxel, followed by 500 mg/m2 5-FU and 250 mg/m2 l-LV on days 1, 8, and 15. Treatment courses were repeated every 28 days. Patients were treated in our hospital from 2014 to 2016. RESULTS: Three advanced gastric cancer patients with malignant ascites received the FLTAX regimen. The median age was 66 years(range 58-66). The median number of treatment courses was 2(range 1-20). The median progression-free survival and overall survival were 55(95%CI 24-.)and 272(95%CI 108-.)days, respectively. Observed Grade 3-4 adverse events were as follows: hyponatremia(1), anorexia(1), upper gastrointestinal hemorrhage(1), and thromboembolic event(1). No treatment-related death occurred. CONCLUSION: FLTAX demonstrated an acceptable toxicity profile, and may be a good option for gastric cancer patients with malignant ascites.

A new approach for simple radioisotope cisternography examination in cerebrospinal fluid leakage detection.

OBJECTIVE: We developed a new quantitative interpretation technique of radioisotope cisternography (RIC) for the diagnosis of spontaneous cerebrospinal fluid hypovolemia (SCH). METHODS: RIC studies performed for suspected SCH were evaluated. (111)In-DTPA RIC images were taken at 0, 1, 3, 6, and 24-h after radioisotope injection following the current protocol. Regions of interest (ROI) were selected on 3-h images to include brain, spine, bladder or the whole body. The accumulative radioactivity counts were calculated for quantitative analysis. Final diagnoses of SCH were established based on the diagnostic criteria recently proposed by Schievink and colleagues. RESULTS: Thirty-five patients were focused on. Twenty-one (60.0%) patients were diagnosed as having SCH according to the Schievink criteria. On the 3-h images, direct cerebrospinal fluid leakage sign was detected in nine of 21 SCH patients (42.9%), as well as three patients with suspected iatrogenic leakage. Compared to non-SCH patients, SCH patients showed higher bladder accumulation at 3-h images (P = 0.0002), and higher brain clearance between the 6- and 24-h images (P < 0.0001). In particular, the 24-h brain clearance was more conclusive for the diagnosis than 24-h whole cistern clearance. The combination of direct sign and 24-h brain accumulation resulted in 100% of accuracy in the 32 patients in whom iatrogenic leakage was not observed. 1- and 6-h images did not provide any additional information in any patients. CONCLUSIONS: A new simple ROI setting method, in which only the 3-h whole body and 24-h brain images were necessary, was sufficient to diagnose SCH.

[A Case of Curatively Resected Locally Advanced Cancer of the Pancreatic Body Treated by Distal Pancreatectomy with En Bloc Celiac Axis Resection after Preoperative Intensive Treatment].

A 70-year-old woman with locally advanced pancreatic body cancer invading the celiac axis underwent 4 courses of preoperative chemotherapy consisting of gemcitabine(GEM)plus nab-paclitaxel(nab-PTX)on days 1, 8, and 15 every 4 weeks, followed by radiation therapy(CRT; 50.4Gy delivered in 28 daily fractions). The tumor size was greatly diminished and levels of all tumor markers were decreased. R0resection by distal pancreatectomy with en bloc celiac axis resection(DP-CAR)was performed. The histopathologic findings showed that the effect of CRT was grade 2b(Evans' classification), and the surgical margins were histologically clear. After the surgery, S-1 was administered continuously. The patient shows no signs of recurrence 1 year after surgery.

[A Case of Splenic-Hilum Lymph Node Recurrence after Spleen Preserving Total Gastrectomy for Gastric Cancer Following Neoadjuvant Chemotherapy].

A 69-year-old man was diagnosed with a large type 3, cT4bN2M0, cStage III c advanced gastric cancer located at the lesser curvature of the upper stomach. Neoadjuvant chemotherapy with S-1 plus CDDP was administered, and partial response was obtained after 2 courses. Subsequently, spleen preserving total gastrectomy with partial hepatectomy was performed. The final pathological diagnosis was UM, Less, yType 3, por1, ypT4b(SI liver), was ly2, v1, ypN2, M0, pStage III c, R0. Adjuvant chemotherapy with S-1 was administered; however, 5 months after the surgery, splenic-hilum lymph node recurrence was detected. Chemotherapy with CPT-11 plus CDDP was administered and a salvage operation was planned when the response to treatment was nonCR or nonPD. After 6 courses of chemotherapy, the treatment response was PR. Nine months after the first operation, spleno-pancreatic tail resection combined with partial hepatectomy was performed. The patient is currently disease-free without chemotherapy.