[A Case of Subcutaneous Scrotal Metastasis from Primary Gastric Cancer].

Metastases to the subcutaneous scrotum are extremely rare. Here, we report a 78-year-old man who presented with pain to the scrotum and inguinal area. Two years ago, he underwent total gastrectomy for gastric cancer. The pain was attributed to increased scrotal wall thickness. Incisional biopsy of the thickened scrotal wall revealed diffused infiltration of the subcutaneous tissue by islands of scirrhous type malignant cells. Moreover, immunohistochemical studies showed that the tumor cells were positive for CK7, CK20, and CDX-2. These features suggested a metastatic adenocarcinoma of upper gastrointestinal origin. Although there were no visceral metastases, the tumor cells were too widely spread to be dissected curatively. Palliative chemotherapy with tegafur, gimeracil, and oteracil (S-1) was restarted, and local pain was subsequently ameliorated. Since scrotal metastasis is unlikely to occur it is difficult to diagnose. Therefore, in patients with groin discomfort or swelling and a history of gastric cancer, metastatic adenocarcinoma should be included in the differential diagnosis for early detection of a tumor.

[Conversion Surgery for Unresectable Advanced Gastric Cancer-A Case Report].

Unresectable advanced gastric cancer is associated with poor prognosis. In a few studies, long-term survival was achieved with conversion surgery in patients who responded to chemotherapy. Here, we have reported a case of unresectable advanced gastric cancer in which curative resection was achieved with conversion surgery. A 70-year-old man who was diagnosed with advanced gastric cancer with multiple liver metastases received S-1/cisplatin therapy(S-1 120 mg/kg of bodyweight[bw]plus cisplatin 90 mg/kg of bw)as primary therapy. Because of the adverse reactions, secondary treatment with irinotecan therapy(CPT-11 200 mg/kg of bw)was initiated, which led to clinical complete response. A local recurrence was observed 44 months later; hence, irinotecan therapy was reinitiated. Although the disease was stable for 30 months, disseminated nodules appeared; thus, immunotherapy(nivolumab 150 mg/kg of bw)was initiated as tertiary treatment for the progressive disease. Although the number of disseminated nodules decreased, frequent blood infusions were necessary for anemia. Distal gastrectomy was planned as palliative surgery. Since no noncurative factors were detected intraoperatively, we considered that curative resection could be achieved with pancreaticoduodenectomy and changed the procedure. The operative time was 6 hours 35 minutes, and there was a blood loss of 312 g. The pathological diagnosis was ypT2- N1M0P0M0, ypStage ⅡA. At 13 months postoperatively, the patient was alive without recurrence.

[A Case of Laparoscopic Local Resection of the Stomach for an Inflammatory Myofibroblastic Tumor].

A 52-year-old man underwent upper gastrointestinal endoscopy screening that identified a submucosal tumor in the gastric fornix, and a solid tumor with a maximum diameter of 35mm was suspected based on abdominal computed tomography. An endoscopic ultrasound-guided fine needle aspiration biopsy showed spindle-shaped cells with KIT, CD34, desmin, and S-100 all testing negative. Based on the diagnosis of a gastrointestinal stromal tumor, subtotal gastrectomy was performed laparoscopically. Postsurgical histopathological testing led to a diagnosis of a primary gastric inflammatory myofibroblastic tumor. The present case has been defined as one involving a tumor part way along the spectrum between benign and malignant, with local recurrence and distal metastasis. Reports indicate that recurrence occurs frequently in cases wherein sufficient margins are not obtained or wherein there is enucleation, and complete surgical resection is recommended. With laparoscopic surgery, because an enlarged field of view can be obtained, and depending on the lesion site, good exposure of the operative field is possible, the authors believe that this approach would be beneficial in terms of local control. Moreover, it has been reported that anaplastic lymphoma kinase(ALK), which is a tyrosine kinase receptor protein, tests positive in approximately 60% of cases. Reports have also indicated that distal metastasis occurs frequently in cases in which ALK tests negative, and watchful waiting of these cases at regular intervals should be carried out to the same extent as of cases involving malignant tumors.

Enhanced detection of lymphovascular invasion in small rectal neuroendocrine tumors using D2-40 and Elastica van Gieson immunohistochemical analysis.

Rectal neuroendocrine tumor (RNET) lymphovascular invasion (LVI) is regarded as an important predictor of nodal metastasis after endoscopic resection (ER). However, little is known about the frequency of immunohistochemical detection of LVI in RNETs. This study was performed to establish the actual detection of LVI rate in RNETs ≤10 mm and to evaluate associated clinical outcomes. We retrospectively reviewed the records for 98 consecutive patients treated by ER with a total of 102 RNETs ≤10 mm. Tissue sections were labeled with hematoxylin-eosin (HE) stain, the D2-40 monoclonal antibody to evaluate lymphatic invasion, and Elastica van Gieson (EVG) stain to detect venous invasion. LVI detection rate by HE versus immunohistochemical analysis was compared. Follow-up findings and clinical outcomes were also evaluated for 91 patients who were followed for ≥12 months. Lymphatic and venous invasion were detected using HE staining alone in 6.9% and 3.9% of patients, respectively, whereas they were detected using D2-40 and EVG staining in 20.6% and 47.1% of the patients, respectively. Thus, the LVI detection frequency using D2-40 and EVG staining (56.9%) was significantly higher than with HE (8.8%). Two out of seven patients who required additional surgery had regional lymph node metastases. However, among the 84 patients who were followed up without surgery, no distant metastases or recurrences were detected. Compared with HE staining, immunohistochemical analysis significantly increased the frequency of LVI detection in RNETs ≤10 mm. However, the clinical impact of LVIs detected using immunohistochemical analysis remains unclear. Clarification of the actual role of LVI using immunohistochemical analysis requires a patient long-term follow-up and outcomes.

[A Case of Multiple Liver Metastases and Peritoneal Dissemination after Resection of a Gastrointestinal Stromal Tumor of the Stomach Successfully Treated with Imatinib Mesylate].

A 71-year-old man was diagnosed with a gastric tumor approximately 50mm in diameter on computed tomography (CT). In January 2000, he underwent a proximal gastrectomy. Pathological examination showed 5 mitoses per 50 high-power fields, while immunohistochemical analysis showed positive staining for KIT. Accordingly, the tumor was diagnosed as an intermediate- risk malignant gastrointestinal stromal tumor (GIST) for which the patient was followed. In January 2002, an abdominal CT scan revealed multiple hepatic tumors and a lower abdominal tumor, and the patient was diagnosed with liver metastases and peritoneal disseminations from GIST. After informed consent was provided, chemotherapy with 400 mg/day imatinib was initiated. The patient demonstrated a partial response 2 months after treatment. At 12 years 8 months after the diagnosis of liver metastasis and peritoneal disseminations, the patient shows no sign of recurrence.

Delayed perforation of the sigmoid colon after endoscopic reduction of sigmoid volvulus.

Case: An 81-year-old woman was diagnosed with sigmoid volvulus. As there were no signs of peritoneal irritation, emergency endoscopic reduction was attempted and achieved successfully. Although she remained stable on the following day, she suddenly developed perforative pan-peritonitis 35 h after the procedure. Outcome: Emergency laparotomy revealed a 10-mm-diameter perforation at the anti-mesenteric wall of the top of the sigmoid loop, and sigmoid resection with Hartmann's procedure was carried out. Pathological examination revealed ischemic necrosis around the perforation site. She recovered well with intensive care, and was discharged 32 days later. Conclusion: Delayed sigmoid perforation after endoscopic reduction of sigmoid volvulus is a rare but important and life-threatening pitfall, and should always be considered by acute care physicians. To prevent this dangerous complication, evaluation of the viability of the entire sigmoid by direct vision and semi-emergency operation as soon as the patient's condition is optimized after endoscopic reduction may be essential.

[A successful case with TS-1+CDDP chemotherapy for recurrent gastric cancer].

A 64-year-old woman underwent cholecystectomy for treatment of cholecystolithiasis in January 2005. Pathological examination rendered a diagnosis of gallbladder carcinoma. Wedge resection of the liver and dissection of the lymph nodes was performed. No tumor cells in either the liver nodule or lymph nodes were found during pathological examination. At 4 years after surgery, paraaortic lymph node recurrence was confirmed by computed tomography (CT). Gemcitabine was administered once weekly for the first 3 weeks in a monthly cycle, but the tumor continued to increase in size. Gemcitabine was then switched to TS-1, after which it was changed to cisplatin because of continued tumor growth. After 35 courses of chemotherapy, CT showed the disappearance of the paraaortic lymph node, and the patient achieved a complete response. She is currently free of disease at 9 years after surgery.

[A case of recurrent gastric cancer successfully treated with TS-1+CDDP chemotherapy].

A 74-year-old woman underwent distal gastrectomy and D1+ α dissection for the treatment of gastric cancer (pT2a, pN2, H0, P0, M0, Stage IIIA) in February 2008. She was treated with adjuvant postoperative chemotherapy consisting of TS-1. However, 32 months after the operation, paraaortic lymph node recurrence was confirmed by computed tomography (CT). She was treated with combined TS-1 and cisplatin chemotherapy. After 14 courses, CT revealed that the paraaortic lymph node metastasis had disappeared, and a complete response was attained. The patient is currently disease-free, 6 years after the operation.

[Two cases of adult T-Cell leukemia/lymphoma with main lesion in stomach treated by VCAP-AMP-VECP regimen].

We report two cases of adult T-cell leukemia/lymphoma(ATLL)having their main lesions in the stomach. Case 1 was a 74-year-old man, complaining of left upper abdominal mass and pain. Upper gastrointestinal endoscopy revealed an ulcerous lesion in the stomach. Histological analysis and southern blotting for HTLV-1 pro-viral DNA led us to our diagnosis of ATLL. There were no apparent lesions in the bone marrow and other organs. He died of tumor lysis and multi-organ failure shortly after treatment with the VCAP-AMP-VECP regimen. Case 2 was a 68-year-old man complaining of abdominal bloating and pain. Upper gastrointestinal endoscopy disclosed an irregularity of the gastric mucosa. A biopsy sample was diagnosed pathohistologically as non-Hodgkin's lymphoma. We conducted total gastrectomy. Based on the results from the histological study and southern blotting for HTLV-1 p ro-viral DNA in the resected specimen, a diagnosis of ATLL was made. We treated him with a VCAP-AMP-VECP regimen, but multiple bone metastases and pathologic fracture occurred, proving that the disease was progressive. ATLL having a main lesion in the stomach is rare, and requires an accumulation of cases analyzed with careful diagnostic approach to establish a standard therapy for it.

A rare case of esophageal cancer (T2N0) with a solitary cerebellar metastasis.

A 72-year-old man with a history of distal gastrectomy was diagnosed with esophageal cancer (EC). A subtotal esophagectomy and the residual total gastrectomy were performed via a right-sided thoracotomy and laparotomy with D2 lymph node dissection followed by reconstruction with a retrosternal right colonic interposition. The pathological diagnosis was Mt, 65 mm, moderately differentiated squamous cell carcinoma, pT2, ly0, v2, pN0, sM0, pStage II. The patient suddenly developed neurological symptoms 10 days after the operation, and brain magnetic resonance imaging detected a single solid left cerebellar tumor. This tumor was completely excised, and pathological diagnosis confirmed the tumor as an EC metastasis. He received adjuvant chemotherapy with cisplatin + 5-fluorouracil. Seven months later, he developed multiple brain metastases; however, no evidence of local recurrence or other metastatic sites was found. He died 8 months after the surgery. Solitary cerebellar metastasis from EC in which the primary tumor is T2N0 is rare, and the mechanism of this metastatic pattern is of particular interest. Our case study suggests that even if the primary tumor is in the limited stage and other metastatic sites are not identified at presentation, it seems reasonable to perform preoperative imaging of the brain for all patients with EC.