[A Case of Spindle Cell Tumor in the Gastric Mucosa Treated with Laparoscopic Local Gastrectomy].

The patient was a 43-year-old man. An upper gastrointestinal endoscopic examination revealed a gastric submucosal tumor(SMT)-like, elevated 8-mm lesion in the greater curvature of the upper body of the stomach. It was diagnosed as spindle cell tumor on the basis of biopsy findings, and a gastrointestinal stromal tumor(GIST)was suspected. Various immunohistochemical staining techniques were used; however, a definitive diagnosis could not be achieved. There was no evidence of distant metastasis even on thoracoabdominal computed tomography imaging; thus, the patient was referred to our department for definitive diagnosis and surgical treatment. Laparoscopic local gastrectomy with concomitant intraoperative gastroscopy was performed. Pathological examination of the resected specimen showed a type Ⅱc-like lesion with a maximum diameter of 6 mm in the mucosal layer along with spindle cell proliferation. Immunostaining was negative for c- kit, DOG1, CD34, S-100, SMA, WT-1, desmin(N), EMA, and keratin(pan)and positive for ß-catenin, Bcl-2, and vimentin; furthermore, low Ki-67(MIB-1)expression was detected. Therefore, GIST, solitary fibrous tumor, leiomyoma, leiomyosarcoma, desmoid tumor, spindle cell carcinoma, and synovial sarcoma were excluded, and an unclassifiable spindle cell tumor arising from the gastric mucosa was diagnosed. The patient has remained recurrence-free for 1 year and 8 months post-operatively and is currently under careful outpatient follow-up.

[A Case of Large Cell Neuroendocrine Carcinoma of the Ampulla of Vater].

An 80-year-old women admitted to our hospital with jaundice. Abdominal contrast-enhanced CT scan revealed an enhanced tumor, measuring 10 mm, at the duodenal ampulla. Upper endoscopy showed a submucosal tumor-like lesion at the duodenal ampulla. Immunohistochemical findings showed positive for chromogranin A and synaptophysin, and neuroendocrine carcinoma was diagnosed. Subtotal stomach-preserving pancreaticoduodenectomy with regional lymph node dissection was performed. The final diagnosis was large cell neuroendocrine carcinoma(LCNEC). Multiple metastases of liver, lung and bone were occurred 14 months after the surgery, and she died 21 months after the surgery. LCNEC of the duodenal ampulla is very rare, and its prognosis is poor.

[A Case of Omental Desmoid Tumor after a Small Bowel Resection for Gastrointestinal Stromal Tumor].

An intra-abdominaldesmoid tumor, especially omentaldesmoid tumor, is rare. Here, we report a case of omentaldesmoid tumor after a smallbowelresection for gastrointestinalstromaltumor (GIST). A 73-year-old man underwent a partial resection of smallbowelfor GIST. He received adjuvant therapy with imatinib due to high risk of recurrence. After 2.5 years of treatment, a follow-up CT showed a 15mm nodule in the omentum near the splenic flexure. We considered the possibility of recurrence and imatinib failure, and laparoscopic tumor resection was performed for differential diagnosis. Immunohistochemicalstaining showed negative for c-kit, CD34, desmin, and S100. However, it was diagnosed as desmoid tumor because of positive b-catenin. Intra-abdominal desmoid tumor should be a differential diagnosis for a new single lesion in patients with GIST.

[A Case of Stage IV Breast Cancer with Extensive Metastasis Successfully Treated with S-1 plus Anastrozole Therapy].

We report the case of a patient in which S-1 plus anastrozole was administered as first-line chemotherapy for Stage IV breast cancer with skin invasion, multiple lymph node metastasis, and lymphangitis carcinomatosis. A 77-year-old woman had a mass destroyed immediately outside the axilla with dry coughs. An 11mm unpalpable mass in the right breast and an axillary mass were confirmed to be scirrhous carcinoma(Luminal type B), respectively, by core needle biopsy. In one course, S- 1(100mg/day)therapy involves taking 2 courses of 14 days of administration and 7 days off the drug. Anastrozole(1mg/ day)was administered daily. After completion of one course, marked shrinkage of the axillary tumor and supraclavicular lymph node, and lightness of coughing was observed. The metastatic lymph nodes and pulmonary metastatic lesions reduced in size by over 30%, as revealed using CT. The adverse event was only grade 1 pigmentation and lacrimation. Ten months later, the self-destructed skin was completely scarred, and metastatic lesions had maintained their reduction in size. According to the results of the SELECT BC study, S-1 as primary chemotherapy for breast cancer is an evidence-based drug that can reduce the decrease in QOL, such as hair loss, and it can be positively selected.

[Long-Term Disease-Free Survival by Curative Resection in a Case of Remnant Gastric Cancer with Peritoneal Recurrence].

The patient was 69-year-old man. For the remnant gastric cancer, partial resection of the remnant stomach with combined resection of mesentery of transverse colon was performed. Pathological diagnosis was adenocarcinoma(tub2>tub1), M, B- 50-AJ, type 3, pT4b(mesentery of transverse colon), pN0, CY0. A CT scan of 6 months after the surgery showed a tumor on the left side abdomen and diagnosed as peritoneal recurrence. Chemotherapy consisted of 1 course of TS-1(100mg/body) plus cisplatin(70mg/body), 4 courses(2 weeks administration and 1 week break)of TS-1(100mg/body), 8 courses of docetaxel(80mg/body). Tumor shrinkage and internal necrosis were observed. Peritoneal tumor was resected 19 months after the first surgery, and partial resection of the invaded transverse colon and jejunum was performed. Pathological diagnosis was metastasis of remnant gastric cancer. After that, it is 61 months since the first surgery and 42 months from the recurrence surgery without relapse.

[A Case of Perforation Peritonitis with Multiple Duodenal and Intestinal Malignant Lymphomas].

Malignant lymphomas of the duodenum and small intestine are relatively rare, but are clinically important, as they may result in perforation peritonitis. Here, we report a case of perforation peritonitis caused by multiple duodenal and small intestinal malignant lymphomas. An 84-year-old man was diagnosed with malignant lymphoma of the duodenum. Although chemotherapy was planned, emergency surgery was performed to treat perforation peritonitis. Laparoscopic observation revealed that the perforation was not in the duodenum, but in the ileum. In addition, numerous lymphoma lesions were revealed throughout the small intestine. Partial resection of the small intestine including the perforation was performed. Primary gastrointestinal malignant lymphoma may exist over multiple digestive tracts and it is necessary to carefully diagnose and treat, even in emergency surgery.

[Two Cases of Colorectal Cancer with Tumor Thrombus in the Inferior Mesenteric Vein].

In colorectal cancer, progression with an intravenous tumor thrombus is very rare. Here, we report 2 cases of colorectal cancer which showed a tumor thrombus in the inferior mesenteric vein (IMV). Case 1: A 69-year-old woman was admitted for the treatment of advanced rectal cancer, and underwent a low anterior resection. Six months of post-operative therapy was carried out with mFOLFOX6, but a metachronous lung metastasis was detected and a lung partial resection was performed. Case 2: A 67-year-old man was admitted for the treatment of advanced sigmoid colon cancer with simultaneous liver metastasis, and underwent a laparoscopic high anterior resection. Four courses of mFOLFOX6+bevacizumab chemotherapy were carried out after surgery, and subsequently he underwent a partial hepatectomy. In both cases IMV tumor thrombus was suspected from abdominal contrast-enhanced computed tomography (CT). Tumor thrombus filling the lumen of the IMV was confirmed on histopathological examination. Colorectal cancer with IMV tumor thrombus is a form of advanced cancer with advanced vascular invasion, and there is a high risk of simultaneous or metachronous hematogenous metastasis. Combined modality therapy should therefore be given to improve the prognosis.

[Protein-losing gastroenteropathy in a case of colon cancer].

A 74-year-old man was admitted with primary complaints of appetite loss, abdominal swelling, and pedal edema. Laboratory data revealed the presence of anemia and hypoalbuminemia. Barium enema and colonofiberscopy demonstrated an advanced cancer in the transverse colon. Albumin scintigraphy revealed high uptake by the tumor in the transverse colon. Preoperative administration of albumin did not improve hypoalbuminemia. Serum protein and albumin levels improved immediately after resection of the tumor. Therefore, in the presence of hypoalbuminemia due to leakage from the tumor, it is important to operate promptly, without waiting to correct the hypoalbuminemia.

[A case of small bowel cancer with positive peritoneal cytology and five-year recurrence-free survival].

Small bowel cancer is frequently detected at an advanced stage and its prognosis is poor. We report on a patient with small bowel cancer with positive peritoneal cytology who survived for 5 years without recurrence after surgery.The case involved a 73-year-old woman who had undergone partial resection of the small intestine and lymphadenectomy for a small bowel tumor with obstruction. Pathological examination confirmed papillary adenocarcinoma with partial serosal invasion. Ascites cytology indicated a class V tumor. Adjuvant chemotherapy with TS-1 was administered for 20 months, and the patient has survived without evidence of disease for over 5 years.In this case, it is possible that TS-1 chemotherapy was effective for prevention against small bowel cancer recurrence.Furthermore , peritoneal cytology in patients with small bowel cancer should be evaluated as a predictor of prognosis.

[Two cases of chylous ascites after laparoscopic colorectal cancer surgery].

We report the cases of 2 patients in whom chylous ascites developed after laparoscopic colorectal cancer surgery. Case 1 involved a 64-year-old woman who underwent laparoscopic right hemicolectomy with D3 lymphadenectomy for transverse colon cancer. Chylous ascites occurred immediately after the resumption of oral food intake on postoperative day 3. The patient gradually recovered by undergoing immediate treatment and by consuming a low-fat diet. The drain was removed on postoperative day 8, and the patient experienced no adverse events thereafter. Case 2 involved an 80-year-old man who underwent laparoscopic high anterior resection with D2 lymphadenectomy for multiple sigmoid cancers. Chylous ascites occurred a day after the resumption of oral food intake on postoperative day 3; however, food intake was continued. Because of its small volume, the chylous ascites was easily drained on postoperative day 6. Most cases of chylous ascites after colorectal cancer surgery can be easily resolved. However, if involvement of a major lymph duct is suspected during surgery, it should be ligated or clipped.

[A case of esophageal cancer with a funnel chest].

Esophageal cancer is a disease that is difficult to manage before and after surgery and is associated with a high in-hospital mortality rate despite there being reports of improved outcomes after multidisciplinary treatment. Meanwhile, although funnel chest is generally a subclinical condition, patients with this deformity may sometimes present with cardiac failure and chest pain. We report a case of advanced esophageal cancer with a funnel chest deformity that was very difficult to reconstruct after thoracoscopy-assisted resection.

Ten-year protocol biopsy findings of renal allografts in the calcineurin inhibitor era.

Ten-year protocol biopsies were performed in 16 patients treated with calcineurin inhibitor (CNI) continuously. All kidney grafts were functioning well at the time of biopsy with the mean serum creatinine level of 1.6 +/- 0.8 mg/dL. The specimen of biopsy showed various degrees of tissue injury. According to the Banff grading, allograft glomerulopathy (cg) was observed in one case. Interstitial fibrosis (ci) and tubular atrophy (ct) were observed more frequently in 13 (81%) and 15 (93%) cases, respectively. Fibrous intimal thickening (cv) was seen in one (7%) case. Arteriolar hyaline thickening (ah) was seen in 14 (87%) cases. These findings were associated with chronic rejection in one case, recurrence of original disease in four (25%) cases, toxicity of CNI in 14 (87%) cases. Longer follow-up studies are needed to confirm whether CNI should be continued or not in the long-term period following kidney transplantation for better graft survival.

Management and outcome of living kidney grafts with multiple arteries.

PURPOSE: Kidney allografts with multiple renal arteries (MRAs) have been used with increasing frequency since the advent of laparoscopic live donor nephrectomy. To determine if MRA grafts affect the short- and long-term outcomes of grafts and patients, we analyzed 340 grafts procured by open nephrectomy. METHODS: We divided the graft recipients into five groups according to the methods used for vascular reconstruction. We compared patient and graft survival, serum creatinine levels, total (rewarm) ischemic times (TIT), incidence of acute tubular necrosis (ATN), need for antihypertensive drugs, incidence of acute rejection episodes, and vascular and urologic complications, between the MRA group and a control group of patients with single-artery renal grafts. RESULTS: In patients who underwent multiple anastomoses in situ, prolonged TIT resulted in an increased incidence of ATN, but there was no significant difference between the MRA groups and the control group (P = 0.45). The incidence of vascular complications was higher in the MRA groups (P < 0.01), but there were no significant differences in the other variables among the groups. CONCLUSION: Multiple renal artery grafts procured by open nephrectomy can be transplanted as successfully as those with single arteries, by using meticulous suturing techniques.

Living liver donation: preoperative assessment, anatomic considerations, and long-term outcome.

BACKGROUND: A major prerequisite for living donor liver transplantation (LDLT) as an acceptable treatment modality is thoughtful consideration of the donor. However, there has been no comprehensive audit of living liver donation focusing on issues such as donor selection, anatomic surveys, and long-term outcome. METHODS: Between June 1990 and January 2002 at our institution, 160 LDLTs were performed and 177 patients were referred for LDLT. For these patients, a total of 203 potential donors were screened. The process of donor selection, safety of donor hepatectomy, and postoperative morbidity were investigated. Additionally, an anonymous questionnaire was administered to 100 donors who had undergone LDLT more than 3 years previously. RESULTS: Thirty-eight (19%) of the 203 donor candidates were excluded. Precise estimation of the hepatic anatomy was indispensable for donor safety. None of the donors showed prolonged postoperative liver dysfunction nor developed complications requiring reoperation or readmission. There was no donor mortality. The responses to the questionnaire indicated that 95% of the living donors had not felt coerced to donate and that 5% were neutral about coercion pressure. There were no severe postoperative aftereffects, but minor problems were reported by 51% of the respondents. CONCLUSIONS: Our appraisal of the perioperative and long-term postoperative course of LDLT donors revealed that although most donors are satisfied after undergoing LDLT, there is a need for strict attention to the process of donor selection and long-term postoperative follow-up. The outcome of the present series seems to confirm the safety of donor hepatectomy.

Recent advance in living donor liver transplantation.

Living donor liver transplantation (LDLT)has been performed in more than 2000 cases around the world. This procedure is considered to have certain advantages over cadaveric liver transplantation, because detailed preoperative evaluation of the donor liver is possible and superior graft quality is available. The indication has recently been widened to include adult patients. The results of LDLT have been reported to be very good. In this article,several considerations on LDLT,including living donor selection and application to adult patients, are discussed. Between June 1990 and March 2001, 143 patients underwent LDLT at Shinshu University Hospital. During this period, 160 patients were determined to be candidates for liver transplantation in our institution, and 185 candidates were evaluated as potential donors for these patients. Thirty-eight of 185 donor candidates were excluded for reasons including liver dysfunction and withdrawal of consent. The recipients included 60 adults, 50 (83%) of whom are currently alive. Taking into account the worldwide shortage of cadaveric organ donation,the importance of LDLT will probably never diminish. This procedure should be established on the basis of profound consideration of donor safety as well as accumulated expertise of hepatobiliary surgery.