[A Case of Breast Metaplastic Carcinoma and Distant Metastasis with Complete Response to Immunotherapy].

An 82-year-old woman visited our hospital complaining of a rapidly growing hemorrhagic mass with ulceration of the right breast. A CT scan revealed a circumscribed, lobulated mass of approximately 14 cm diameter, with coarse calcifications, which had invaded the skin and major pectoral muscle and with metastasis in the both lungs. She underwent a total mastectomy with major pectoral mastectomy. The pathological findings were spindle cell carcinoma admixed with chondroid metaplasia and an osteoid-like appearance; therefore, metaplastic breast cancer was diagnosed. Biweekly drip infusion of immune checkpoints inhibitor were administered as immunotherapy, which yielded a complete response of lung matastasis. Administration of monthly immune checkpoints inhibitor resulted in no recurrence for 3 years after the operation. Accumulation of further similar cases and development of a novel effective treatment are desired.

A rare case of metastatic solitary fibrous tumor of the pancreas manifesting as a cystic neoplasm: a case report.

BACKGROUND: Solitary fibrous tumor (SFT) is a rare mesenchymal tumor that typically arises from the pleura. Although it may appear in other organs, it rarely develops in the pancreas. We report herein a rare case of metastatic SFT of the pancreas originating from an intracranial tumor and subsequently identified as a cystic neoplasm of the pancreas. CASE PRESENTATION: A 58-year-old woman with a past medical history of brain tumor visited the hospital for further investigation of a cystic tumor in the pancreas tail. Abdominal imaging showed a heterogeneously enhancing mass that was initially suspected as a neuroendocrine neoplasm, solid pseudopapillary neoplasm, or mucinous cystic neoplasm of the pancreas. Distal pancreatectomy was performed without any intraoperative and postoperative complications. Pathological findings confirmed a diagnosis of malignant SFT of the pancreas with hyperproliferative potential. A histopathological review of her brain tumor revealed that the pancreatic tumor was derived from her brain lesion. The patient developed recurrent brain disease 4 years after the pancreatectomy, but no recurrence has been observed in the abdominal cavity. CONCLUSIONS: SFT should be considered in the differential diagnosis of untypical hypervascular pancreatic mass, particularly in patients with a history of an intrathoracic or intracranial mesenchymal tumor. Immunohistochemical analysis is crucial in detecting this tumor entity. Hyperproliferative status indicates a malignant disease and requires careful postoperative observation.

[A Case of Complete Response to Trastuzumab plus S-1 and Oxaliplatin for a HER2-Positive Recurrence of Gastric Cancer].

The patient was an 84-year-old male who underwent a total gastrectomy for advanced gastric carcinoma. He received S-1 chemotherapy, but his serum tumor marker(CEA, CA19-9)level increased 6 months post operation. Computed tomography suggested lymph node swelling ofthe portcaval space(No.12p), and we treated him with chemotherapy that consisted of4 courses of Tmab plus SOX(trastuzumab plus S-1 plus oxaliplatin). The abdominal CT scan that was performed after 3 courses ofchemotherapy and PET-CT that was performed after 4 courses of chemotherapy suggested that the metastatic lesion had disappeared. We therefore assumed that a complete response had been achieved by Tmab plus SOX chemotherapy. A combination ofS -1 and cisplatin(SP)has been the standard regimen for advanced gastric cancer, but the combination ofS -1 plus oxaliplatin was demonstrated to be non-inferior to SP. We report this case with a review of the literature, because the patient with HER2-positive recurrent gastric cancer achieved a complete response after Tmab plus SOX chemotherapy.

[A case of stage IV b pancreatic head cancer that was resected because of a good response to chemotherapy].

The prognosis of Stage IV b pancreatic cancer is extremely poor; the mean survival time is 2-4 months. However, new anticancer agents can improve the outcome of advanced pancreatic cancer. We present the case of a 50-year-old female patient with Stage IV b pancreatic head cancer with invasion to the superior mesenteric vein(SMV)and multiple liver metastases. The patient received S-1 as first-line chemotherapy. Three months later, a further CT scan showed reduction of the pancreatic tumor, disappearance of the liver metastases, and reduction in SMV invasion. Therefore, a subtotal stomach-preserving pancreatoduodenectomy with partial SMV resection was performed. Following surgery, the patient received S-1 chemotherapy again. However, lung metastasis appeared. Despite the initiation of gemcitabine(GEM)treatment, the patient developed metastases in other parts of the lung and the abdominal wall. She died 46 months after surgery, but it is noteworthy that the liver metastases were manageable. The combination of chemotherapy and surgery was effective in prolonging survival in this patient with Stage IV b pancreatic head cancer.

Novel surgical technique to prevent pancreatic fistula in distal pancreatectomy using a patch of the falciform ligament.

PURPOSE: Pancreatic fistula (PF) is a serious complication of pancreatectomy and many techniques and devices have been designed to prevent PF and abdominal bleeding after pancreatectomy. We report a modified technique using a patch of the falciform ligament to prevent PF formation after distal pancreatectomy (DP). METHOD: On completion of DP, the main pancreatic duct is sutured. The remnant pancreas is then closely patched and sutured vertically to the falciform ligament using 3-0 polypropylene suture. We compared the results of this method (group 1) with those of the simple method of covering the remnant pancreas with the falciform ligament (group 2). RESULTS: We performed this method in 14 patients undergoing DP. The rate of grade B or C PF in group 1 (7.1 %) was lower than that in group 2 (46 %). CONCLUSION: This is a simple and effective method of preventing PF fistula in DP.

Gallbladder bed pocket score as a preoperative measure for assessing the difficulty of laparoscopic cholecystectomy.

INTRODUCTION: Laparoscopic cholecystectomy (Lap-C) is a standard surgery for symptomatic gallbladder stones and acute or chronic cholecystitis. Resident surgeons often perform this operation early in their training, but they sometimes encounter difficulties for various technical reasons. Although encountering a gallbladder buried deep within the gallbladder bed is a common operative difficulty, literature on the subject scarcely exists. METHODS: Forty-two patients underwent Lap-C at our hospitals and were analyzed retrospectively. We defined the gallbladder bed pocket score (GBPS) as the maximum ratio between the height and width of the gallbladder bed measured based on multi-detector computed tomography (MDCT) images. GBPS and clinical factors were assessed in terms of their correlation with the time required for gallbladder dissection from the gallbladder bed. RESULTS: Of the 42 patients, 20 had histories of acute or chronic cholecystitis. The mean gallbladder dissection time was 14.9 min, and the mean GBPS was 0.43 in the coronal MDCT section and 0.56 in the sagittal section. The correlation coefficient between the GBPS and gallbladder dissection time was 0.40 (P = 0.01) in the coronal section and 0.38 (P = 0.02) in the sagittal section of the MDCT images. There was no statistically significant correlation between gallbladder dissection time and the surgeon's experience, patient's history of cholecystitis, gallstone size, or blood loss. However, GBPS > 0.4 predicted more difficult and prolonged dissection. CONCLUSION: GBPS is a useful tool for preoperatively predicting the time needed to dissect the gallbladder from the gallbladder bed during Lap-C. Cases with GBPS < 0.4 seem more suitable for resident surgeons who are performing gallbladder dissection early in their Lap-C training.

[A case of perforated gastric cancer in which resection for elimination was possible S-1/CDDP combined chemotherapy for peritonitis carcinomatosa].

The present patient was a 66-year-old male with sudden upper abdominal pain. The patient was diagnosed with perforated peritonitis at another hospital, and an emergency laparotomy was performed to confirm upper gastrointestinal tract perforation. A perforated lesion of approximately 1 cm in diameter was found on the anterior wall at the gastric upper body. The area surrounding the lesion was tumor-like. Malignancy was suspected; however, considering the patient's general status, greater omentum grafts were opted for. The patient was diagnosed with typeIII gastric cancer by gastroendoscopy postoperatively. A second surgery was performed after one month, but during laparotomy peritonitis carcinomatosa and metastastic nodules were found around the abdominal aorta. S-1/CDDP therapy was started on the 14th day after second surgery. After three courses of treatment, the tumor was found to have smoothened, wall consolidation was improved, and a third surgery was performed. During laparotomy, there were no other medical findings that raised suspicion of peritoneal dissemination or liver metastasis. It was concluded that radical surgery was possible, and distal gastrectomy(D2+a)was performed. Pathological examination revealed that poorly differentiated adenocarcinoma. The lower and muscle layers of the serous membrane and nodules around the abdominal aorta showed the disappearance of cancer cells. But the peritonitis carcinomatosa during second surgery had pathologically / changed the fibrosis tissue at the third surgery.

Relative adrenal insufficiency manifested with multiple organ dysfunction in a liver transplant patient.

Relative adrenal insufficiency is now a well-known clinical condition that occurs in critically ill patients particularly with septic complication. However, this pathology has long been unrecognized until recently in liver transplantation patients, for whom postoperative immunosuppressive therapies almost always comprise corticosteroids. We report an obvious case of relative adrenal insufficiency manifested by severe multiple organ dysfunction in a recipient after living donor liver transplantation (LDLT). A 38-year-old woman with multiple hepatocellular carcinoma developed refractory liver failure 2 months after the completion of the dual treatment; namely a cytoreductive right hepatectomy for bulky main tumors followed by 2 courses of percutaneous isolated hepatic perfusion for residual tumors in the remnant liver. She underwent a right-lobe LDLT, and postoperative immunosuppression was initiated with a low-dose tacrolimus monotherapy without corticosteroid because of a severe septic condition before transplantation. Postoperatively, she developed progressive hyperbilirubinemia, renal dysfunction, and coagulopathy. As the corticotropin stimulation test suggested the relative adrenal insufficiency, corticosteroid was commenced 40 days after LDLT. Thereafter, multiple organ dysfunction resolved dramatically and promptly. The patient is presently alive and well with completely normalized liver function 45 months after LDLT.

[Sustained complete remission with reductive surgery plus percutaneous isolated hepatic perfusion (PIHP) for bilobar multiple hepatocellular carcinoma with portal venous tumor thrombus--a case report].

For patients with multiple bilobar hepatocellular carcinoma (m-HCC) and/or advanced portal venous tumor thrombus (Vp3, 4), there has been no effective therapy, and the survival of more than 6 months was exceptional. Under these circumstances, we have developed a dual treatment (dual Tx) that combines reductive hepatectomy with percutaneous isolated hepatic perfusion (PIHP) for such patients. This dual Tx offers the high-rate of mid- and long-term survival in a subset of patients who had previously a dismal prognosis. Herein, we report a patient with Vp4 m-HCC who was successfully treated with dual Tx and survived for more than 2 years with a complete remission of hepatic tumors. A 53-year-old man had main tumors in the right lobe liver and multiple bilobar intrahepatic metastases (IM) with portal venous tumor thrombus reaching the portal trunk. He underwent an extended right hepatectomy with portal venous tumor thrombectomy, and subsequently PIHP twice in a 3-month period after reductive hepatectomy. After dual Tx, he had sustained complete remission for more than 2 years. He died because of obstruction of the superior vena cava by recurrent tumors in the mediastinum. His clinical course after treatment strongly indicates that the dual Tx should become a major treatment option for patients with Vp3, 4 m-HCC.

[A case of multiple hepatocellular carcinoma with rapidly progressing bilateral portal vein tumor thrombosis--a complete remission achieved with dual treatment of reductive surgery plus percutaneous isolated hepatic perfusion].

We herein report a case of multiple advanced hepatocellular carcinoma (HCC) with rapidly progressing portal vein tumor thrombosis (PVTT). All of the hepatic tumors have completely disappeared for more than two years by a dual treatment with reductive surgery plus percutaneous isolated hepatic perfusion (PIHP). A 55-year-old man was referred to our institution on June 30, 2003. The abdominal CT scan demonstrated multiple massive HCC in the entire liver with PVTT reaching the portal trunk (Vp4). Two weeks later, the PVTT rapidly progressed to the umbilical portion of the left portal vein, and to the confluence of the superior mesenteric vein and to the splenic vein. Thus, we semi electively performed an extended right hepatectomy together with thrombectomy of the PVTT. Subsequently, he underwent a repeated PIHP (1st; doxorubicin 90 mg/m2, 2nd doxorubicin 65 mg/m2). This treatment produced complete tumor clearance of all of the residual tumors in the left liver. In March 2005, he underwent partial pneumonectomy for a metastatic lung. This again resulted in normalization of serum AFP and PIVKA-II levels. Dual treatment is considered to be the strongest therapeutic modality for multiple advanced HCC with severe PVTT. In addition, a close follow-up is required because in such far advanced cases, metastatic lesions most likely recur in the liver but also in the distant organs.