Primary pancreatic glomus tumor invading into the superior mesenteric vein: a case report.

BACKGROUND: Glomus tumors are subcutaneous tumors arising from glomus bodies, thermoregulatory components of the skin. These tumors could occur in visceral organs where glomus bodies are not normally present. Herein, we report a case of primary pancreatic glomus tumor with aggressive direct invasion into the superior mesenteric vein (SMV). To the best of our knowledge, this is the second case report of a glomus tumor arising in the pancreas. CASE PRESENTATION: A 46-year-old woman was referred to our hospital due to vomiting with epigastric and back pain. Dynamic-CT revealed a well-circumscribed hypervascular mass, measuring 37 mm in its maximal diameter involving the pancreatic head. Both CT and endoscopic ultrasonography (EUS) revealed direct invasion into the SMV and radiologically suspected tumor thrombus. Biopsy sample obtained by EUS-guided fine needle aspiration revealed proliferation of small cells, round-to-oval tumor cells with round nuclei and scant cytoplasm. A histological diagnosis of pancreatic neuroendocrine tumor, G1 was initially considered. Therefore, subtotal stomach-preserving pancreatoduodenectomy using Child-II reconstruction was subsequently performed. Her SMV was resected and reconstructed due to extensive tumor involvement. Subsequent histopathological analysis revealed solid tumor cells proliferation that comprised oval-shaped nuclei and scant cytoplasm around disorganized or slit-shaped vessels in hematoxylin-eosin-stained slides. Immunohistochemical analysis then demonstrated positive immunoreactivity for smooth muscle actin, vimentin, and CD34, but negative for chromogranin A, synaptophysin, CD56, and signal transducer and activator of transcription 6. Based on these histological findings of resected specimens, the lesion was subsequently diagnosed as a primary pancreatic glomus tumor harboring direct invasion into the SMV. Her postoperative course was uneventful and annual surveys for the following 4 years post-op detected no clinical signs of recurrence. CONCLUSIONS: We report a very rare case of glomus tumor of the pancreas accompanied by venous invasion. Curative surgical resection is the best treatment option for pancreatic glomus tumors. Although pancreatic glomus tumor is rare, it should be taken into consideration in the differential diagnosis of a pancreatic solid tumor with hypervascularity.

[A Case of Thymic Carcinoma of Postoperative Liver and Mediastinal Lymph Node Metastases Where Long-Term Survival Was Achieved through Multidisciplinary Treatment].

The patient was a 67-year-old man. At the age of 60, he underwent resection of thymic carcinoma with partial resection of the right upper lobe of the lung because of invasive thymic carcinoma. The pathological diagnosis was Masaoka stage Ⅲ squamous cell carcinoma. Follow-up examination 2 years after surgery showed metastases to the mediastinall ymph node and liver. After undergoing radiotherapy of 50 Gy to the mediastinal lymph node metastasis, partial hepatectomy was performed for metastatic liver cancer. Post-operation, he received 4 courses of combination therapy of carboplatin and paclitaxel. Five years post-hepatectomy, the patient developed liver metastasis again and underwent hepatectomy for local control. Postoperative recurrent cases of thymic carcinoma generally have poor prognosis. We describe a patient with thymic carcinoma of postoperative liver and mediastinal lymph node metastases who achieved long-term survival through multidisciplinary treatment.

[A Case Report of a Difficult to Diagnose, Extremely Well-Differentiated Stomach Adenocarcinoma Diagnosed by Biopsy].

A Japanese man in his 60s presented with complaints of epigastric pain and weight loss. A gastrointestinal endoscopy revealed multiple gastric ulcers and an irregular mound located on the wall of the lower gastric body along the greater curvature, which was suspected to be cancerous. A biopsy revealed that it was a Group 2 tumor even though the biopsy was repeated 4 times. He was referred to our hospital and 3 biopsies were performed. The final result classified the tumor as Group 4. The patient underwent surgery and the pathological examination revealed an extremely well-differentiated adenocarcinoma( EWDA). An EWDA is characterized by a well-formed mucinous gland with little or no nuclear atypia, which makes preoperative biopsy diagnosis difficult.

[Two-Stage Radical Resection of a Case of Colon Cancer with Abdominal Wall Invasion and Cholangiocarcinoma].

A woman in her 50s was admitted to our hospital with fever and lower abdominal swelling. Abdominal CT/MRI examinations revealed irregular thickening of the transverse colon wall, which was attached to a subcutaneous abscess. An abdominal wall mass, a patent urachus, and a tumor in the 5th segment of the liver were also noted. Colonoscopy revealed type 2 advanced transverse colon cancer. The solitary, sessile tumor was observed at the apex of the bladder under cystoscopy, suggesting the formation of the urachal carcinoma. Transcutaneous liver biopsy obtained from the liver tumor indicated adenocarcinoma, which was morphologically different from the existing transverse colon cancer. Right hemicolectomy with resection of the umbilicus, abdominal wall, urachus, and part of the bladder wall was performed. Diagnosis of the transverse colon cancer invading the abdominal wall and bladder was confirmed by histopathological examination. Hepatectomy was performed in the next surgery, and the tumor was histopathologically diagnosed as an intrahepatic cholangiocarcinoma. Both the transverse colon cancer and the intrahepatic cholangiocarcinoma were radically resected. Radical surgical diagnostic resection may be valuable in cases of multicentric cancers of unknown primary origin, if radical resection of each individual tumor is required.

[A Case of Esophageal Carcinoma with Large Intramural Metastasis to the Stomach].

We report a rare case of esophageal carcinoma with gastric wall metastasis. A 73-year-old man with dysphagia underwent endoscopy and upper GI series and chest-abdominal computed tomography, revealing esophageal carcinoma and gastric cancer, which was diagnosed as squamous cell carcinoma by biopsy. The esophageal carcinoma was located in the lower thoracic esophagus(Lt). Total gastrectomy was performed. The resected specimen showed a type 3 tumor measuring 7×7 cm in the anterior wall of the stomach. Pathologically, the depth of invasion of the stomach was SE. He died 3 months after the operation. Esophageal carcinoma with gastric intramural metastasis is very rare and has a dismal prognosis. We report a rare case of esophageal carcinoma with large intramural metastasis to the stomach.

A primary hepatic gastrinoma accompanied by hyperplasia of multi-nodular Brunner's glands.

BACKGROUND: Primary hepatic gastrinoma causing severe ulcerogenic syndrome is extremely rare. Herein, we report a case of primary hepatic gastrinoma accompanied by hyperplasia of multi-nodular Brunner's glands in a patient who instead, preoperatively, was suspected of having multiple duodenal gastrinomas and hepatic metastasis. CASE PRESENTATION: A 57-year-old woman consulted a clinic complaining of melena, intermittent abdominal pain, diarrhea, and vomiting which had persisted for about 3 years. Six months before her presentation, she underwent segmental resection of the jejunum for acute peritonitis due to the spontaneous jejunal perforation. A blood test revealed that her serum immunoreactive gastrin (IRG) level was 12,037 pg/mL. Subsequently, she was transferred to our hospital. On computed tomography (CT), a hypervascular tumor of 23 mm in the segment 5 (S5) region of the liver was visualized. A selective arterial secretagogue injection test (SASI test) was performed twice. The first SASI test revealed that the hepatic tumor was a gastrinoma, and there was no gastrinoma in the duodeno-pancreatic region. Additionally, somatostatin receptor scintigraphy only visualized the tumor in the liver. However, the second SASI test, which was performed during the administration of a proton pump inhibitor and a somatostatin analog (octreotide acetate), revealed that there may have been gastrinomas existing not only in the liver but also in the upper part of the duodenum or the head of the pancreas. Duodenal endoscopy revealed multiple submucosal tumors in the first and the second portion of the duodenum, although a pathological examination of biopsied specimens obtained from the duodenal lesions was negative for malignant cells. Multiple endocrine neoplasia type 1 (MEN1) was excluded from her family history, and serum levels of both intact parathyroid hormone (iPTH) and calcium were within normal ranges. An anterior segmentectomy of the liver and pancreas-preserving total duodenectomy were performed on September 9, 2013. Postoperatively, her serum immunoreactive gastrin level decreased to less than 50 pg/mL. Pathological study of the resected specimens revealed a gastrinoma in the liver, but no gastrinoma in the duodenum. Interestingly, the duodenal submucosal tumor-like lesions were hyperplastic Brunner's glands. Postoperatively, she has been well without recurrence of hypergastrinemia for 4 years. CONCLUSION: We report a case of primary hepatic gastrinoma in a patient who has been cured for 4 years postoperatively. The diagnosis was somewhat difficult due to the coexisting, multiple hyperplastic Brunner's glands of the duodenum mimicking the submucosal neuroendocrine tumors, which might have developed due to long-term hypergastrinemia.

[A Case of Unresectable Locally Advanced Pancreatic Cancer Resulted in R0 Surgery after Chemotherapy].

A 67-year-old man visited our hospital for jaundice. Abdominal dynamic CT showed the hypovascular tumor at the head of the pancreas that surrounded superior mesenteric artery(SMA)at an angle of 220 degree. No metastasis in lymph nodes and other organs was observed. We diagnosed the tumor unresectable locally advanced(UR-LA)pancreatic cancer. Chemotherapy was administered with gemcitabine and nab-paclitaxel(GEM+nab-PTX)and achieved partial response. Regression in size and in range around SMA to an angle of 150 was observed. We assessed it possible to resect the tumor curatively, and performed subtotal stomach preserving pancreaticoduodenectomy and dissection of the plexus around the SMA, resulted in R0 surgery. Adjuvant chemotherapy was administered, and no recurrence was observed up to present, more than a year. It is suggested that GEM+nab-PTX can be effective as the primary therapy against UR-LA pancreatic cancer.

[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.

[Recurrent Gastric Carcinoma(Endocrine Cell Type)Successfully Treated with Multidisciplinary Therapy - A Case Report].

A 62-year-old woman was diagnosed with carcinoma of the stomach at another hospital. Distal gastrectomy with D2 dissection was performed and she was referred to our hospital. Histopathological and immunopathological examinations showed the tumor to be composed of adenocarcinoma and neuroendocrine carcinoma. The patient was followed until 4 months after the operation when an abdominal computed tomographic(CT)scan showed a metastatic tumor at S2 and S5/6 of the liver. No other organ metastases were found, and a hepatectomy was performed. The primary tumor of the stomach consisted of adenocarcinoma and neuroendocrine carcinoma; however, the resected metastatic liver tumor consisted of only neuroendocrine carcinoma. Liver and lung metastases appeared 2 months after the operation, and we started chemotherapy with VP-16 and cisplatin. After 8 courses of treatment, the lung metastases showed a CR, and the liver metastasis was SD. She is alive without lung metastases 9 months after the hepatectomy.

[A Case of Rectal Cancer Successfully Treated with Surgery and Stereotactic Radiotherapy for Metachronous Lung Metastases].

A 64-year-old woman underwent polypectomy for a rectal polyp(Isp). Pathological findings were invasion of the submucosa( 3,500 mm diameter), and she underwent anterior resection for rectal cancer(RS, pT1b, pN0, cM0, Stage I )without adjuvant chemotherapy. Lung masses were found in her right(8mm)and left lung(7mm). The tumors enlarged during the 4 month follow-up period. We decided to perform left partial pneumonectomy. The tumor was diagnosed as a lung metastasis from colon cancer by pathology. Because the right tumor was located towards the center, performing right pneumonectomy would have been quite invasive and we feared occult metastases. We decided to apply SRT(50 Gy)to the right tumor. The tumor shrunk and became a scar after treatment. There were no complications such as radiation pneumonitis. The patient was in good health without any recurrence for 12 months after SRT. Surgical resection is an optimal method to control lung metastasis from colon cancer if the lesion is operable. However, in the case of a tumor centrally located, surgical resection may cause deterioration of lung function. There are also cases with contraindications for surgery due to co-morbidities. In addition, there is no consensus on observation periods to exclude occult metastases. SRT can be an effective treatment for lung metastases from colon cancer when there are bilateral lung metastases and no metastases outside the lungs.

[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 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.

[Hepatic Resection of Multiple Liver Metastases from Gastric Cancer after Molecular Targeted Chemotherapy(S-1 plus Cisplatin plus Trastuzumab)].

A 62-year-old man was diagnosed with gastric cancer and underwent distal gastrectomy, and D1+b lymph node dissection. He was diagnosed postoperatively with T1b (sm2) N0M0, StageⅠA gastric adenocarcinoma and did not receive any adjuvant chemotherapy after surgery. One year and 6 months after gastrectomy, blood analysis indicated high levels of carcinoembryonic antigen (CEA 262.1 ng/mL) while abdominal computed tomography (CT) revealed multiple liver tumors (S7: 15 mm, S7/8: 20 mm). The patient was diagnosed with metachronous multiple liver metastases from gastric cancer. Chemotherapy, combined with molecular targeted therapy (S-1 plus cisplatin [CDDP] plus trastuzumab), was administered because of overexpression of the human epidermal growth factor receptor 2 (HER2) protein in the primary tumor as assessed by immunohistochemistry, the CEA levels decreased immediately after 2 cycles of the chemotherapy, and the liver metastases shrank markedly with no evidence of new lesions on abdominal CT. However, after treatment, Grade 3 neutropenia and diarrhea were observed. Chemotherapy was suspended and hepatic resection was performed. After hepatic resection, the liver tumors were histologically evaluated as Grade 2 metastatic gastric adenocarcinoma, and the HER2 expression of remnant carcinoma cells was established. The patient has been in good health and remained free of recurrences in the 2 years and 3 months after the liver resection. Surgery with preoperative chemotherapy (S-1 plus CDDP plus trastuzumab) can be an effective treatment for liver metastasis from HER2-positive gastric cancer.

[Adult Case of Invagination Due to Small Intestinal Metastases of Malignant Melanoma].

An 84-year-old woman was diagnosed with malignant melanoma after resection of a nasal cavity tumor in February 2008. In April 2010, she underwent small bowel resection because of ileus due to small intestinal metastases. She was diagnosed with ileus again in October 2010. Computed tomography (CT) and 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) revealed invagination of the small intestine and small intestinal metastases. We performed a palliative small bowel resection. She had a good postoperative course and was discharged 2 weeks after surgery. Oral intake was possible for 6 months until her death.

[A Case of HER2-Positive Advanced Gastric Cancer with a Pathological Complete Response to Neoadjuvant Chemotherapy with S-1/CDDP/Trastuzumab].

A 61-year-old man was referred to our hospital because of epigastric pain. Upper gastrointestinal endoscopy revealed a type 2 tumor at the gastric antrum, which was diagnosed as gastric adenocarcinoma (tub1) by pathological examination and was HER2 positive 3+ by the IHC method. Abdominal computed tomography revealed multiple metastases to regional lymph nodes (LNs), including bulky nodes at No. 3, 6, and 11p stations. In particular, No. 6 LN was 43 mm in diameter and had invaded to the pancreas. The clinical stage was Ⅲc (T4aN3M0) and neoadjuvant chemotherapy was conducted using S-1/CDDP/trastuzumab. After 2 cycles of chemotherapy, a partial clinical response was obtained and distal gastrectomy with LN dissection (D2 plus No. 16 LN) was performed. The pathological specimens showed no residual cancer cells in the stomach and LNs (Grade 3: pCR). Adjuvant chemotherapy was not administered. The patient is alive 10 months after the surgery with no evidence of recurrence.

[A Case of Rectal Cancer Successfully Treated with Stereotactic Radiotherapy for Liver and Lung Metastases].

An 84-year-old patient underwent anterior resection for rectal cancer (RS, T4a, N2, M0, Stage Ⅲb), without adjuvant chemotherapy. Liver metastasis 30 mm in diameter was found in the S7/8 segment 2 years and 6 months after surgery, and segmentectomy of the liver was performed. One year after hepatectomy, lung metastasis 9 mm in diameter was detected in the right S1 lobe. The tumor enlarged after a 2-month follow-up period. We decided to apply stereotactic radiotherapy (50 Gy/10 Fr) to control the lesion. The tumor shrunk and became a scar after treatment. The patient was in good health without any recurrences 7 months after stereotactic radiotherapy. Surgical resection is an optimal method to control lung metastasis from colon cancer when operable; however, there are cases with no indication for surgery due to co-morbidities. Stereotactic radiotherapy can be an effective treatment for lung metastasis from colon cancer when surgery is contraindicated.

[A Case of Bladder Adenocarcinoma with Rectal Metastasis].

A 77 year-old man with asymptomatic microscopic hematuria underwent a cystoscopic examination, which identified a broad-based papillary tumor at the cervix of the bladder. Adenocarcinoma was detected in the biopsy specimen. MRI and CT examination showed a huge papillary tumor of the bladder invading the inner lobe of the prostate. In addition, the wall of the lower rectum exhibited thickening with enlargement of the regional lymph nodes. Endoscopy disclosed a hemi-circular rectal tumor and pathological examination revealed adenocarcinoma, the profile of which was similar to the bladder tumor. The levels of CEA and CA19-9 were 5.3 ng/mL and 39 U/mL, respectively. A differential diagnosis considering bladder cancer, rectal cancer, or both was necessary before planning a treatment strategy. Since both tumors were judged to be resectable, total pelvic exenteration was carried out. Through detailed postoperative pathological examinations, it was concluded that this tumor was of bladder origin and it invaded the prostate along with metastasis to the rectum. Adenocarcinoma of the bladder is extremely rare and exhibits aggressive behavior.

[A case report of the use of laparoscopic surgery to remove an adrenal tumor following resection of sigmoid colon cancer].

A 58-year-old woman underwent sigmoidectomy and partial cystectomy for sigmoid colon cancer following colostomy. The final staging of the tumor was T3, N1, tub2, M0, fStage IIIa. She received 6 courses of CapeOX (oxaliplatin 130mg/m², capecitabine 200mg/m²) as adjuvant chemotherapy, which was discontinued because of severe general fatigue. At the same time, an increase in the levels of serum carcinoembryonic antigen (CEA) was detected and abdominal computed tomography (CT) revealed an expanded adrenal mass. Since whole-body ¹8F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET/CT) showed no evidence of multiple organ metastases except for the right adrenal tumor, a solitary adrenal metastasis from sigmoid colon cancer was strongly suspected. Hence, colostomy closure and laparoscopic adrenalectomy were concurrently performed. Histological examination revealed non-functional adrenal adenoma. Therefore, laparoscopic surgery was a reasonable choice even in this complex case.

[A case of resected liver metastasis from rectal cancer with bile duct stricture after radiofrequency ablation].

The patient was a 66-year-old woman who had undergone low anterior resection for rectal cancer. Although she received adjuvant chemotherapy after the surgery, a 1.5 cm hepatic metastasis was observed in segments 4/8. Radiofrequency ablation ( RFA) was performed for the metastatic tumor. Approximately 1 month after RFA, a local recurrence was identified together with intrahepatic bile duct dilation in the right lobe of the liver. Extended right hepatic lobectomy and left intrahepatic cholangiojejunostomy were performed to remove the tumor. Histopathological examination of the resected specimen showed a liver metastasis from the rectal cancer with stricture of the bile duct although the bile duct was not involved in the tumor. This suggested that the bile duct stricture was caused by RFA and not by the recurrent tumor. Currently, the patient is alive with no recurrence 14 months after the surgery. This case suggests the importance of salvage surgery for recurrent tumors after RFA therapy, especially in the case of RFA-related complications in conjunction with the tumor.