Primary hepatic neuroendocrine carcinoma diagnosed by needle biopsy: a case report.

BACKGROUND: Primary hepatic neuroendocrine carcinomas (NECs) are extremely rare. The rate of recurrence after resection is extremely high, and the prognosis is poor. It is debatable whether chemotherapy or surgical resection is the optimal initial treatment for primary hepatic NECs. Therefore, selecting an appropriate therapeutic approach for patients with primary hepatic NECs remains clinically challenging. We present a case of primary hepatic NEC in a patient who developed recurrence after undergoing surgical resection. CASE PRESENTATION: A 78-year-old man with bone metastases of prostate cancer was referred to our department because of a solitary 66-mm tumor in the left lateral segment of the liver, which was detected on annual follow-up by computed tomography after prostate resection. A biopsy and preoperative diagnostic workup identified the lesion as a primary hepatic neuroendocrine carcinoma; therefore, left lateral segmentectomy was performed. Immunohistochemically, the tumor was positive for chromogranin A, synaptophysin, and CD 56, and the Ki-67 index was 40%. This neuroendocrine carcinoma was classified as a large cell type. Adjuvant chemotherapy with carboplatin + etoposide was initially administered a month after surgery. However, lymph node recurrence occurred 4 months after surgery, and the patient died of systemic metastases 15 months after surgical resection. CONCLUSIONS: Due to the lack of availability of abundant quantities of relevant, high-quality data, there is no standard therapy for primary hepatic NECs. Selecting the most appropriate treatment for patients depending on several factors, such as the stage and differentiation of a tumor and a patient's performance status and clinical course, is consequently preferred. More cases need to be studied to establish the best treatment strategy for primary hepatic NEC.

Differential diagnosis and laparoscopic resection of an adrenal pseudocyst: A case report.

BACKGROUND: Adrenal pseudocysts are infrequent entities and definite preoperative diagnosis is difficult. We present a case of left adrenal pseudocyst, which was intraoperatively identified as having an adrenal origin and was resected using a laparoscopic approach. PRESENTATION OF CASE: A 41-year-old female was referred to our hospital for examination and treatment of a cystic lesion in the pancreatic tail. Preoperative diagnostic imaging studies showed a cystic lesion with intramural nodular structure, measuring 39 mm in the largest diameter and located between the pancreatic tail and the left adrenal gland. However, the origin of the cystic lesion remained unclear, and a definite preoperative diagnosis was not established. The cystic lesion was intraoperatively identified as having an adrenal origin after the division of the loose connective tissue layer around the lesion under the laparoscopic magnified view. Laparoscopic left adrenalectomy was performed as radical treatment and the histopathological diagnosis confirmed the presence of an adrenal pseudocyst. DISCUSSION: We could not ascertain the origin of the cystic lesion from the left adrenal gland and establish a definite diagnosis based on the findings of the preoperative diagnostic imaging modalities. Laparoscopic surgery could be more advantageous than the conventional open approach as not only a minimally invasive treatment option but also as an intraoperative diagnostic tool for cystic lesions in the pancreatic tail. CONCLUSION: This case report suggests that laparoscopic surgery could be clinically useful as not only a minimally invasive treatment but also an intraoperative diagnostic tool for cystic lesions in the pancreatic tail region.

Solitary pancreatic metastasis of gastric cancer with synchronous pancreatic ductal carcinoma: A case report.

BACKGROUND: There have been a few reports on solitary pancreatic metastases of gastric cancer. We present a case of solitary pancreatic metastasis of gastric cancer with synchronous primary pancreatic ductal carcinoma. PRESENTATION OF CASE: An 86-year-old man who had undergone total gastrectomy two and half years prior presented with a poorly enhanced tumor in the pancreatic body. We diagnosed pancreatic ductal carcinoma and performed distal pancreatosplenectomy. Histopathologically, the tumor comprised poorly differentiated adenocarcinoma cells mixed with moderately differentiated tubular adenocarcinoma cells that were compatible with metastasis of gastric cancer. There was also invasive ductal carcinoma of the pancreas. The postoperative course was uneventful. Six months after surgery, computed tomography revealed peritoneal dissemination, and he died of recurrence 10 months after surgery. CONCLUSION: Pancreatic metastasis of gastric cancer with synchronous primary pancreatic cancer can occur and should be considered in the differential diagnosis.

[Multicentral Questionnaire Results for Consciousness of Medical Personnel on Chemotherapy for Gastric and Colorectal Cancer].

When a medical provider(medical personnel)becomes a medical receiver(patient), does the consciousness about chemotherapy change ? If yes, what is the main reason ? In this study, we conducted a questionnaire on the consciousness of doctors and pharmacologists engaged in chemotherapy for gastric and/or colorectal cancer. The number of questionnaires collected was 83 and 92 for gastric and colorectal cancer, respectively. In adjuvant chemotherapy, 5%and 4%do not want to receive any chemotherapy for gastric and colorectal cancer if they are patients. The main reasons are binding hours, side effects, and no wish for life extension. About 11%and 9%change their consciousness regarding chemotherapy according to whether they are care providers or receivers. The main reasons are medical perspective and their sense of duty. In chemotherapy for advanced cancer, 6% and 5% of gastric and colorectal cancer patients, do not want to receive any chemotherapy. The main reasons are low expectations for being cured, binding hours, and no wish for life extension. Further, 21%and 14%wish to have limited chemotherapy. As regards consciousness on chemotherapy, 26% and 18% reported changes according to whether they are providers or receivers. The main reasons are medical perspective and their sense of duty. As for the purpose of chemotherapy for advanced gastric and colorectal cancer, 96% and 43% answered prolonging life and relief, respectively. The proportion of persons who answered complete cure is statistically higher in colorectal(32%)than in gastric cancer(18%). The most common answer for an adverse event they want to avoid if they are patients is peripheral neuropathy. These results clearly demonstrate that a considerable proportion of medical personnel hold a negative attitude against or are reluctant to receiving chemotherapy, especially for advanced gastric and colorectal cancer. It is of great importance to make use of these results in clinical practice.

Rectovaginal fistula after low anterior resection for rectal cancer healed by nonoperative treatment.

BACKGROUND: Rectovaginal fistula (RVF) is a serious complication after colorectal anastomosis using a double-stapling technique. RVF following this procedure has been considered to be refractory to conservative treatment. CASE PRESENTATION: A 75-year-old woman who underwent laparoscopy-assisted low anterior resection for early rectal cancer developed RVF on the 12th postoperative day. Conservative treatment was chosen and was successful. She was discharged from the hospital after 3 weeks with a normal oral diet. Colonoscopy on the 50th postoperative day showed that the RVF was closed. CONCLUSION: Conservative treatment may be effective for RVF after colorectal anastomosis using a double-stapling technique when there is no evidence of defecation through the vagina.

[A case report of anorectal malignant melanoma showing a complete response after DTIC/ACNU/VCR therapy].

We report herein the case of a 64-year-old male who presented with hematochezia. The patient was diagnosed with malignant melanoma of the anorectum using colonoscopy. Preoperative studies revealed no distant metastases, and he underwent Miles operation. Pathological exams revealed that the tumor had invaded the submucosa with lymphatic and venous invasion. Cancer cells were found in regional lymph nodes. Post-operative CT scan demonstrated multiple metastases in the liver, and he received two courses of combined chemotherapy, DAV regimen (dacarbazine: DTIC 100 mg iv days 1-5, nimustine hydrochloride: ACNU 100 mg iv day 1, vincristine sulfate: VCR 1 mg iv day 1), leading to a complete response. However, malignant melanoma cells were found in hernia contents at the operation for left inguinal hernia, which led to a diagnosis of recurrent malignant melanoma. The patient has subsequently been well without any sign of recurrence including liver metastases. To our knowledge, this is the first report of a complete response in a patient with multiple liver metastases of anorectal malignant melanoma after DAV regimen.

Collision tumor of primary malignant lymphoma and adenocarcinoma in the colon: report of a case.

This report presents the case of a 62-year-old man with a collision tumor of primary malignant lymphoma and adenocarcinoma in the cecum. All regional mesenteric lymph nodes that were removed surgically were found to be occupied by lymphoma cells and no lymph nodes contained any cancer cells, although the primary carcinomas did exhibit lymphatic invasion. Malignant lymphoma was also seen in the duodenum. Systemic chemotherapy was administered for the malignant lymphoma, and a complete response was thus obtained. However, just after chemotherapy multiple liver metastases of adenocarcinoma emerged, and chemotherapy against adenocarcinoma was therefore continued. The occurrence of synchronous lymphoma and adenocarcinoma of the colorectum is rare. Furthermore, collisions of these different entities are also extremely unusual; so far only five such case reports have been published. The accurate clinical determination of the dominant tumor and a close follow-up is required for proper treatment in these cases.

[Significance of CEA to predict the effect of chemotherapy with bevacizumab].

PURPOSE: Since chemotherapy with bevacizumab has become available for advanced colorectal cancer, its effectiveness has been reported. Generally, the RECIST guideline has been adopted to determine antitumor effects, however, several problems exist with the image analysis. The purpose of this study was to evaluate the significance of CEA to predict the effect of chemotherapy with bevacizumab. SUBJECTS AND METHODS: Twenty-five patients with advanced colorectal cancer were given chemotherapy with bevacizumab since August 2007. Among them, 18 patients were evaluated for the antitumor effect according to the RECIST guideline and were enrolled in this study. The relation of CEA and antitumor effects, and the change of CEA in every patient were analyzed retrospectively. RESULTS: Patients consisted of 16 men and 2 women, with a mean age of 64. 2 (49-78) years. Chemotherapy with bevacizumab was given for 7 cases with metachronous recurrences after curative operations (6 cases with liver and/or lung metastasis and 1 case with pelvic recurrence), and for 11 cases with synchronous liver and/or lung metastasis. First-line chemotherapy was given to 16 cases and second-line to 2 cases. The overall response rate was 55. 6%, and the response rate in 16 cases given bevacizumab as first-line was 56. 3%. The response rate in 3 cases whose CEA was within the normal range before chemotherapy was 100%. However, the response rate in 15 cases whose CEA was over the normal range was 46. 7%. Furthermore, 6 cases among 7 whose CEA was over 100 ng/mL had 5 months or less during which CEA could be kept under control with a mean period of 3. 0 months. On the contrary, 6 cases among 8 whose CEA was under 100 ng/mL had 5 months or more of CEA-controlled periods with a mean period of 8. 4 months. CONCLUSION: In chemotherapy with bevacizumab, the response rate in patients with normal CEA was higher than that in patients with high CEA. Patients with a CEA level of 100 ng/mL or more had a short CEA-controlled period, suggesting the effect of chemotherapy was small in those patients. There is a possibility that CEA might be clinically useful as a biomarker to predict treatment efficacy in chemotherapy with bevacizumab.

Isolated abdominal wound recurrence after lymph-node dissection for appendiceal adenocarcinoma.

A 47-year-old man with acute abdominal pain in the right lower quadrant underwent an appendectomy via McBurney's incision. Postoperative histology revealed a moderately differentiated adenocarcinoma in the appendix that invaded the submucosa along with lymphatic involvement. Forty-three days later, an ileocecal resection with radical lymph node dissection was performed through a midline incision. Three of the 30 resected lymph nodes were found to have adenocarcinoma metastasis. Five years later, an isolated abdominal wall recurrence occurred within the wound scar of the midline incision. A complete excision of the tumor and the invaded portion of the ileum was performed. To date, the patient has been well, with no evidence of recurrence for 5 years since the resection. The mechanism of abdominal wound recurrence is considered the leakage of carcinoma cells from transected lymph vessels during lymph node dissection, followed by the implantation of these cells into the abdominal wound.

Massive postoperative polyuria following total gastrectomy for gastric cancer.

Massive postoperative polyuria is rare, except in neurosurgery patients. Here we report excessive polyuria in a 59-year-old woman following total gastrectomy for advanced gastric cancer. The etiology of the patient's polyuria was unknown. Urine output was measured hourly and replaced with Ringer's lactate solution at 80% of measured volume. The rate of urine output during 9 postoperative days ranged from 900 to 2700 ml.h(-1). Several administrations of an antidiuretic hormone (ADH) analogue were ineffective in reducing urine output, suggesting a possible relationship of the massive polyuria to nephrogenic diabetes insipidus. Following oral administration of a thiazide diuretic, known to exert an antidiuretic action in nephrogenic diabetes insipidus, urine output was dramatically reduced. We conclude that this case of massive polyuria probably resulted from postoperative nephrogenic diabetes insipidus.

Occult breast cancer presenting as axillary metastases.

We report the case of a 52-year-old woman with occult breast cancer who presented with a hard metastatic nodule in the left axilla. Although histology identified a metastatic adenocarcinoma in the lymph nodes, numerous tests failed to detect the primary tumor. Immunohistochemistry showed that the resected lymph node was positive for both estrogen and progesterone receptors, suggesting the breast as the site of the primary tumor. Left modified radical mastectomy was performed. Pathology revealed an invasive ductal carcinoma (1.5x1 mm in size) with extensive lymphatic involvement, which strongly expressed both vascular endothelial growth factor-C (VEGF-C) and VEGF-D.