[A Case of Goblet Cell Adenocarcinoma Incidentally Diagnosed after Appendectomy That Required Additional Bowel Resection with Lymph Nodes Dissection].

A 54-year-old male presented to the clinic, complaining of dull lower abdominal pain that started a day ago. There was a tenderness on right lower quadrant on palpation and abdominal computed tomography(CT)showed that dilated appendix with a diameter of 12 mm. The patient was diagnosed with acute appendicitis and laparoscopic appendectomy was performed on the same day. The tip of the appendix was swollen and looked purple, gangrenous appendicitis findings were identified. However, histopathology detected GCA on resected appendix with positive surgical margin and additional tumor resection was indicated. Laparoscopic ileocecal resection with D3 lymph nodes dissection was performed 24 days after the first surgery. Resected specimen showed that the stump of the appendix was palpable as a mass in the orifice of the appendix and histopathology revealed the remnant of the appendiceal GCA. No lymph nodes tumor metastasis was identified. Chromogranin A and synaptophysin were positive and Ki-67 was approximately 50%. According to the guideline of neoadjuvant chemotherapy for colon cancer, oral 5-fluorouracil therapy was performed for half a year after the second surgery and the patient remains still healthy without recurrence 1 year after the surgery. Here, we experienced a rare case of GCA of the appendix that was detected incidentally after appendectomy for acute appendicitis.

[A Case of Monomorphic Epitheliotropic Intestinal T-Cell Lymphoma Causing Perforation of the Small Intestine].

Monomorphic epitheliotropic intestinal T-cell lymphoma(MEITL)is very rare and aggressive subtype of lymphoma with poor prognosis. A 60-year-old man complaining of abdominal pain was underwent partial resection of the jejunum for panperitonitis with a small intestinal perforation. The histopathological and immunohistochemical findings led to the diagnosis of MEITL. Postoperative course was uneventful. One month after the operation, the patient was scheduled for 6 courses of CHOP regimens. He presented with bowel obstruction twice during the 3 courses of CHOP. As the recurrence of MEITL could not be ruled out, diagnostic laparoscopy was performed. Laparoscopic findings revealed no recurrence and adhesive small bowel obstruction. The patient was followed closely without treatment after 6 courses of CHOP. The patient has been alive without recurrence 18 months after the resection. We reported a case of monomorphic epithelial intestinal T- cell lymphoma causing jejunal perforation.

[A Case of Type 4 Gastric Cancer with Peritoneal Dissemination Successfully Treated with Conversion Surgery after Intensive S-1 plus Oxaliplatin Chemotherapy].

S-1 plus oxaliplatin(SOX)chemotherapy is now widely used for the treatment of unresectable gastric cancer but there are few case reports about conversion surgery following SOX. Hereby, we report a case of type 4 gastric cancer with peritoneal dissemination successfully treated with conversion surgery after intensive SOX chemotherapy. A 69-year-old female was diagnosed of type 4 gastric cancer by upper endoscopy(por1, HER2 negative)and peritoneal disseminations were identified on left diaphragm and mesentery under direct vision. After 11 courses of SOX chemotherapy, CT revealed that primary tumor markedly decreased in size. Therefore, staging laparoscopy was performed and peritoneal disseminated lesions disappeared. Peritoneal cytology also turned negative. Subsequently, total gastrectomy and splenectomy were performed. Histology revealed that tumor was categorized as por2, ypT2N3M0, ypStage ⅢA, and Grade 2 in histological evaluation criteria. SOX was continued as an adjuvant chemotherapy for another 6 months and the patients remain healthy without recurrence. Unresectable gastric cancer with peritoneal dissemination can be successfully treated with conversion surgery following SOX chemotherapy and staging laparoscopy was useful to evaluate peritoneal dissemination. When conversion surgery is indicated for gastric cancer with peritoneal dissemination, downstaging should be confirmed by staging laparoscopy.

[A Case of Multiple Metachronous Metastases from Hepatocellular Carcinoma to Thoracic Spine and Right Adrenal Invading Right Kidney with Tumor Thrombus in the Inferior Vena Cava That Was Treated with Chemotherapy, Radiotherapy, Intravascular Therapy, and Surgery].

For extrahepatic recurrence after primary hepatocellular carcinoma resection, molecular targeted therapy is the first- choice and no consensus is reached on the indication of surgical resection of extrahepatic metastasis. However, when the extrahepatic lesion extends to vena cava, tumor thrombus can cause acute pulmonary embolism that can lead to fatal consequences. Here, we experienced a case of multiple metachronous metastases from hepatocellular carcinoma to thoracic spine and right adrenal invading right kidney with tumor thrombus in the inferior vena cava. Local radiation therapy to thoracic vertebra, molecular targeted therapy, and transcatheter arterial chemoembolization were performed but tumor thrombus still occluded vena cava. Therefore, to prevent pulmonary embolism and to bridge to immunotherapy, right adrenalectomy, right nephrectomy, thrombectomy and replacement of inferior vena cava were performed. The patient remains healthy 6 months after the surgery and still receiving immunochemotherapy.

[A Case of Solitary Right Adrenal Metastasis from Rectal Cancer].

An 86-year-old woman underwent laparoscopic high anterior resection for RS rectal cancer. Histological examination showed tub2-por, pT3, pN2a, Stage ⅢB disease. Given the age of the patient, adjuvant chemotherapy was not administered. Five months after the surgery, her carcinoembryonic antigen(CEA)level was elevated and a 42×25mm mass was detected in the right adrenalby computed tomography(CT). Metastasis from rectalcancer was suspected but no other lesions were detected by positron-emission tomography(PET)-CT. Nine months after the surgery, laparoscopic right adrenalectomy was performed. Histological examination revealed that the right adrenal tumor had moderately-differentiated adenocarcinoma very similar to the primary rectalcancer; therefore, the right adrenall esion was diagnosed as metastasis from the previous rectalcancer. The tumor marker levelreturned to normall evelafter the second surgery. The patient was discharged on the 8th post-operative day but declined adjuvant chemotherapy due to her age. Six months later, liver, lung, and peritoneal metastasis were identified by CT. We report this case of solitary adrenalmetastasis from rectalcancer resected by laparoscopic right adrenalectomy.

Surgical treatment of pulmonary metastasis from hepatocellular carcinoma.

BACKGROUND/AIMS: The lung is one of the most common sites of extrahepatic spread from hepatocellular carcinoma (HCC). The aim of this study was to evaluate the efficacy of surgical management in patients with pulmonary metastasis from HCC. METHODOLOGY: Fourteen patients with pulmonary metastases arising from HCC underwent surgery at the National Cancer Center Hospital between 1980 and 2001. The clinical and pathological data were analyzed retrospectively. RESULTS: Four patients were still alive and none of them had evidence of recurrent disease. Ten patients had died with recurrent HCC. The postoperative morbidity and mortality rates were low. The mean overall survival was 42.7 months (range, 8-87). The mean survival after initial thoracotomy was 21.6 months (range, 1-66). The 1-, 2-, and 5-year survival rates after metastasectomy were 71.4%, 44.6%, and 26.8%, respectively. CONCLUSIONS: Surgical treatment is appropriate option in selected patients for pulmonary metastasis arising from HCC, and might prolong survival.

Establishment of perineural invasion models and analysis of gene expression revealed an invariant chain (CD74) as a possible molecule involved in perineural invasion in pancreatic cancer.

PURPOSE: Perineural invasion causes frequent local recurrence even after resection and a poor prognosis for pancreatic cancer. We established perineural invasion models and analyzed the molecular mechanism of perineural invasion in pancreatic cancer. EXPERIMENTAL DESIGN: Seven pancreatic cancer cell lines with or without human peripheral nerves were s.c. implanted in nonobese diabetes/severe combined immunodeficient mice. We compared expression profiles among high and low perineural invasion cell lines by using an oligonucleotide microarray. We examined up-regulation of the invariant chain (CD74) in high perineural invasion cell lines in mRNA and protein levels and surgical cases immunohistochemically. RESULTS: Four of seven pancreatic cancer cell lines (CaPan1, CaPan2, CFPAC, and MPanc96) showed perineural invasion to s.c. transplanted human peripheral nerves. Moreover, CaPan1 and CaPan2 (high perineural invasion group) also resulted in a high frequency of perineural invasion to mouse s.c. peripheral nerves, whereas three pancreatic cancer cell lines HPAFII, AsPC1, and Panc1 (low perineural invasion group) did not show perineural invasion to either human or mouse nerves. We identified 37 up-regulated genes and 12 down-regulated genes in the high perineural invasion group compared with the low perineural invasion group. Among them, CD74 was up-regulated in the high perineural invasion group in mRNA and protein levels. Furthermore, immunohistochemical expression of CD74 in clinical cases revealed its significant overexpression in pancreatic cancer with perineural invasion (P < 0.008). CONCLUSIONS: This is the first report of perineural invasion models using human pancreatic cancer cell lines. In combination with gene expression profiling, it was indicated that CD74 could be a candidate molecule involved in perineural invasion. These models provide new approaches for study of perineural invasion in pancreatic cancer.

Nodular mucinosis of the breast: a case report with clinical and imaging findings.

We present a very rare case of nodular mucinosis of the breast. A 30-year-old woman noticed a right breast lump and consulted at our hospital because it gradually increased in size. On physical examination, the lump was 30 x 25 mm in size, and was located in the upper outer quadrant close to the nipple of the right breast. It was well-demarcated, mobile and hard. Ultrasonography (US) showed a clearly circumscribed, lobulated, and homogeneous hypoechoic lesion. Mammography (MMG) showed a round-lobular-shaped radiopaque mass without microcalcifications or spicula formation. Fine needle aspiration cytology (FNA) revealed no malignancy and mucin. Histologically, the excised tumor consisted of an abundant myxoid substance with scattered spindle cells without epithelial elements in the mucous lake. The mucinous substance stained positively with Alcian blue. Nodular mucinosis, simulating mucinous carcinoma or phyllodes tumor on clinical and imaging examinations, should be included in the differential diagnosis in cases of mucinous lesions occurring near the nipple in a young woman.