[A Case of Resected Combined Pancreatic Mixed Ductal Adenocarcinoma and Neuroendocrine Tumor].

A 63-year-old man was followed-up for diabetes mellitus. During follow-up, computed tomography(CT)showed dilatation of the main pancreatic duct in the tail of the pancreas. Abdominal enhanced CT revealed a 25 mm tumor in the body of the pancreas. Endoscopic ultrasound-fine needle aspiration(EUS-FNA)was performed, and the pathological diagnosis was adenocarcinoma. Therefore, based on the diagnosis of pancreatic body carcinoma, distal pancreatectomy with splenectomy was performed. The postoperative course was uneventful. Histological and immunohistochemical examination revealed that the tumor consisted of a ductal carcinoma and a neuroendocrine component. Therefore, combined pancreatic tumor (fT3N1M0, StageⅡB)was diagnosed. The patient subsequently received postoperative adjuvant chemotherapy(S-1 100mg/ day), and survived without recurrence 6 months after the operation. We report this case of combined pancreatic tumors with a review of the literature.

[A Case of Resected Metachronous Cholangiocarcinoma after Pancreaticoduodenectomy].

The patient was a 79-year-old woman, who had undergone pancreaticoduodenectomy(PD)for lower bile duct carcinoma in our hospital(pT3N0H0P0M0, fStage III ). Four years 6 months after the initial operation, abdominal CT revealed left bile duct expansion and hilar bile duct thickening. Therefore, based on the diagnosis of perihilar cholangiocarcinoma originating from the left hilar duct, we performed left lobectomy with caudate lobectomy and biliary tract reconstruction. The surgical specimen showed a tumor in the left hilar bile duct. Histopathological diagnosis of the tumor was a moderately differentiated adenocarcinoma(pT2aN0H0P0M0, fStage II ). Surgical margins were histologically negative. Since the tumor was located away from the anastomosed site of the cholangiojejunostomy, we determined that the tumor was not a recurrence but a metachronous cholangiocarcinoma. The postoperative course was uneventful. The patient survived without recurrence 2 years after the second operation. The possibility of heterochronic biliary carcinomas should be considered during follow-up evaluation. We report this case of metachronous cholangiocarcinoma that occurred 4 years 6 months after PD, with a review of the literature.

[A Case of an IgG4-Related Inflammatory Pseudotumor of the Liver Showing Enlargement That Was Difficult to Differentiate from Hepatic Cancer].

A 60-year-old man was admitted for a liver mass(S3), which rapidly increased in size during intraductal papillary mucinous neoplasm(IPMN)follow-up. Although EOB-MRIwas performed, the mass could not be accurately diagnosed as hepatic cancer. Thus, we performed a lateral segmentectomy. In the resected specimen, a solid tumor mass was clearly bound in segment 3 of the liver. Since histopathology revealed no malignant cells and many IgG4-positive cells, we confirmed the diagnosis as IgG4-related inflammatory pseudotumor of the liver. IgG4-related diseases occur in various organs in the body, and they are known to associate with autoimmune pancreatitis and sclerosing cholangitis, but an IgG4-related inflammatory pseudotumor of the liver is a rare disease. It is often difficult to distinguish from hepatic cancer and surgical resection is performed.

[A Case of Xanthogranulomatous Cholecystitis That Changed Over Time and Was Difficult to Distinguish from Advanced Gallbladder Cancer].

A 70-year-old man was referred because of suspected gallbladder cancer and gallstones. Contrast-enhanced CT, EOB-MRI and PET-CT could not completely rule out gallbladder cancer. The patient preferred follow-up without surgery. At 4 months after initial examination, the gallbladder wall thickening showed improvement, but appeared worse at 9 months after initial examination. Therefore, we decided to perform surgery. Since malignant findings were not observed on rapid intraoperative pathology, we performed a cholecystectomy and right hemicolectomy because of inflammation in the transverse colon. Pathological examination diagnosed xanthogranulomatous cholecystitis. The imaging appearance of xanthogranulomatous cholecystitis varies, and also changes over time, making it difficult to distinguish from advanced gallbladder cancer. We experienced a case of xanthogranulomatous cholecystitis that changed over time, and report this case with a review of the literature.

Usability of elective laparoscopic sigmoidectomy and feasibility of single-incision laparoscopic surgery for sigmoid volvulus: report of three cases.

A therapeutic guideline for sigmoid volvulus (SV) has not been established, and the most recommended surgical procedure for SV has not been determined. Our objective is to assess the usability of elective laparoscopic sigmoidectomy and the feasibility of single-incision laparoscopic surgery for SV following endoscopic reduction. SV typically affects the elderly and accounts for 1% to 7% of intestinal obstructions in Western countries. We report on 3 patients with SV who underwent elective laparoscopic sigmoidectomy following endoscopic reduction, and we first describe single-port surgery for SV. We discuss the 3 patients (a 79-year-old male, an 88-year-old female, and a 67-year-old female) with SV who underwent elective laparoscopic sigmoidectomy following endoscopic reduction. All 3 patients underwent laparoscopic sigmoidectomy, and 2 patients underwent single-port laparoscopic surgery without complications. Recurrence of volvulus was not seen during the course of 12 to 24 months. In experienced hands, elective laparoscopic sigmoidectomy after colonoscopic detorsion is a valuable alternative, and single-port surgery is also feasible.

[The Implications of Primary Tumor Resection during Recent Chemotherapy of Unresectable Colon Cancer].

Some patients with unresectable colorectal cancer can be treated by chemotherapy leaving the primary tumor unresected, but indications and implications of a later resection of the primary tumor (RPT) are often controversial. We investigated 5 patients whose primary tumors were resected during chemotherapy, either panitumumab or bevacizumab. The median age of these patients was 63 years and all were men. The unresectable disease was liver metastases in 4 patients and a primary tumor in 2 patients. A diverting stoma was constructed before initiation of chemotherapy in 2 patients. The median interval until RPT was 8.3 months and the reasons for resection were the appearance of obstructive symptoms in 3 patients and a desire for stoma closure in 2 patients. The size of the primary tumor had decreased until RPT in all patients. RPT was performed successfully in all patients, but 2 of the 3 operations that were initiated laparoscopically had to be converted to open surgery. Intensive chemotherapy was resumed in all patients and median survival after RPT was 19 months, including a patient whose liver metastasis was also resected later. RPT can relieve obstructive symptoms and close stomas. Because intensive chemotherapy is still possible and a lengthy survival can be expected after RPT, it should be considered not merely as a palliative option but also as a treatment strategy.

[Resected Focal Nodular Hyperplasia That Was Difficult to Differentiate from Hepatocellular Carcinoma--A Case Report].

We report a case of a 62-year-old woman with a growing liver tumor that was difficult to differentiate from hepatocellular carcinoma (HCC). Abdominal CT revealed a hypervascular tumor (36 mm in diameter) in segment 3 of the liver that showed early enhancement and which had grown from 30 mm to 36 mm over the previous year. A fatty liver and gallstones were also detected. Magnetic resonance imaging (MRI) showed high intensity staining of the tumor on both T1- and T2-weighted images, and EOB-MRI revealed a mass that showed high signal intensity in the hepatobiliary phase. The imaging findings were not typical for HCC; however, the possibility of malignancy could not be ruled out due to the enlargement of the mass. Therefore, in February 2015, we performed a laparoscopic left lateral segmentectomy with cholecystectomy. After a good postoperative course, the patient was discharged from the hospital 11 days after surgery. Histological assessment revealed the tumor was focal nodular hyperplasia (FNH).

[Adjuvant therapy with WT1 peptide-pulsed dendritic cell therapy in combination with TS-1 for pancreatic cancer with positive peritoneal cytology after curative operation].

A 66-year-old woman was diagnosed with pancreatic tail cancer, and she was referred to our hospital. Abdominal computed tomography(CT)revealed a tumor(2.5 cm in diameter)in the pancreatic tail, with invasion to the spleen and splenic vein. In February 2013, we performed distal pancreatectomy with splenectomy, left adrenal gland resection, and D2 lymph node dissection. Diagnostic peritoneal lavage cytology during surgery was positive; however, we performed curative resection because there were no signs of peritoneal dissemination and distant metastasis. The patient was discharged from the hospital 23 days after the operation, with good postoperative course. Histological diagnosis was pancreatic tail cancer, pT4N0H0P0M(-) fStage IVa. Subsequently, the patient received postoperative adjuvant chemotherapy(TS-1: 100mg/day, 4 courses)combined with Wilms'tumor 1(WT1)peptide-pulsed dendritic cell therapy. No serious adverse events occurred during the postoperative adjuvant therapy. The patient remains alive without recurrence 16 months after the operation.

Serum antibody titers against hepatitis C virus and postoperative intrahepatic recurrence of hepatocellular carcinoma.

BACKGROUND: Hepatocellular carcinoma (HCC) is the seventh most common cancer and the third leading cause of cancer deaths worldwide. Hepatitis C virus (HCV) infection is a major risk factor for HCC recurrence after curative resection. This study evaluated anti-HCV antibody (Ab) titer as a prognostic indicator of HCC recurrence after curative hepatic resection. METHODS: A total of 82 patients with HCC (anti-HCV Ab positive and hepatitis B surface antigen negative) who underwent curative hepatic resection were evaluated. Anti-HCV Ab titers were measured using a third-generation enzyme immunoassay, and patients were divided into high (n = 41) and low (n = 41) titer groups to compare their clinicopathological characteristics and disease-free survival. Univariate and multivariate analyses were conducted to identify risk factors for early or late recurrence. RESULTS: Multivariate analysis showed that anti-HCV Ab titer and vascular invasion were independent prognostic factors of disease-free survival [odds ratio (OR) 1.9, p = 0.03, and OR 1.8, p = 0.04, respectively]. Subgroup analysis identified only vascular invasion as an independent prognostic factor for early recurrences that were considered residual intrahepatic metastases. Subgroup analysis identified anti-HCV Ab titer and fibrosis grade as independent prognostic factors of late recurrences that were considered to be metachronous multicentric liver carcinogenesis (OR 4.8, p = 0.04, and OR 5.2, p = 0.03, respectively). DISCUSSION: Anti-HCV Ab titer is a predictive factor for HCC recurrence, especially the risk of late recurrence due to multicentric carcinogenesis. Prevention of liver carcinogenesis after hepatic resection for HCC might be appropriate for patients with high anti-HCV Ab titers.

Curative-intent stereotactic body radiation therapy for residual breast cancer liver metastasis after systemic chemotherapy.

Liver metastases from breast cancer are generally treated with systemic therapy such as chemotherapy or hormonotherapy. However, local treatment options such as resection, radiofrequency ablation (RFA), and radiotherapy can also be considered to treat oligometastases. We report the case of a 45-year-old female treated with stereotactic body radiotherapy (SBRT) after chemotherapy against a solitary liver metastasis from primary breast cancer. A liver metastasis with diameter of 35 mm developed 3.5 years after surgery for primary breast cancer in 2004. Fourteen courses of triweekly docetaxel treatments considerably decreased the metastatic lesion, but there still remained a tiny lesion radiographically. Chemotherapy was stopped because of the side-effects of docetaxel, and then SBRT was selected for additional treatment, aiming at complete cure of metastasis. X-ray irradiation (52.8 Gy/4 fractions) was applied to the remaining metastatic lesion, and magnetic resonance imaging (MRI) showed no evidence of residual tumor 4 months after irradiation. Neither regrowth nor recurrences have been found until now, 24 months after SBRT. SBRT for oligometastases of breast cancer may be one of the possible curative-intent options, being less invasive than surgical resection or RFA.

[A case of curatively resected advanced intrahepatic cholangiocellular carcinoma through effective response to neoadjuvant chemotherapy].

A 67-year-old-man came to our hospital for further evaluation of a liver tumor detected by abdominal ultrasonography at another hospital. Abdominal computed tomography showed a tumor (8 cm in diameter)in the left lobe of the liver, with invasion of the left and middle hepatic veins, and multiple lymph node metastases. Liver biopsy examination revealed intrahepatic cholangiocellular carcinoma (cStage IVB). Therefore, chemotherapy with gemcitabine(GEM)was administered. The hepatic tumor and multiple lymph nodes were reduced in size after eight courses of GEM chemotherapy. In May 2013, we performed an extended left hepatectomy with biliary tract reconstruction and extended lymph node dissection. The histological diagnosis was intrahepatic cholangiocellular carcinoma, pT3N0H0P0M (-), fStage III. The patient's postoperative recovery was good, and 1 month after surgery, the patient received 6 course of postoperative adjuvant GEM chemotherapy. No serious adverse events occurred during the postoperative adjuvant therapy period. The patient is alive without recurrence 14 months after surgery and 23 months after diagnosis.

[A case of curative resected pancreatic cancer coincident with a retroperitoneal abscess].

A 64-year-old man presented with a chief complaint of abdominal pain. An abdominal computed tomography (CT) scan showed a mass 30-mm in diameter at the splenic flexure, and we diagnosed a retroperitoneal abscess. Conservative therapy was successful, and the patient was discharged. However, 1 month later, he again experienced abdominal pain. To reassess the abscess, contrast-enhanced abdominal CT was performed. In addition to the retroperitoneal abscess, the CT scan showed an approximate 30-mm mass in the head of the pancreas with no contrast uptake. The abscess was also detected by endoscopic retrograde pancreatography. We suspected but could not confirm pancreatic cancer. Two months later, the patient developed obstructive jaundice. At this time, we diagnosed pancreatic cancer, and subtotal stomach-preserving pancreaticoduodenectomy was performed. The histopathologic diagnosis was pancreatic cancer, T4, N0, M0, Stage IVa. The postoperative course was favorable, and the patient received postoperative adjuvant chemotherapy. He remains alive without recurrence 15 months after surgery.

[HER2 testing for advanced recurrent gastric cancer in a general hospital].

The Japanese gastric cancer treatment guidelines(published as a web supplement for version 3)recommend the implementation of HER2 testing prior to the selection of chemotherapy. Since we had not yet implemented HER2 immunohistochemistry(IHC)methods for gastric cancer, we tried to compare the HER2 testing results from a reference laboratory(ref lab) and our hospital(in-house). The HER2 concordance rates were calculated between the results from in-house and ref lab using 26 cases(31 samples)which were from patients with advanced, metastatic unresectable, or Stage IV resectable gastric cancer. The HER2 expression(in-house/ref lab)was distributed as follows: negative/negative, 18 cases; negative/equivocal, 2 cases; negative/positive, 1 case;equivocal/equivocal, 2 cases; and positive/positive, 3 cases. The concordance rate was 88. 4%(23/26), and the mismatch rate was 11. 6%(3/26)between in-house and ref lab. Although IHC test results with in-house and ref lab had been generally consistent, it is still necessary to improve and standardize diagnostic accuracy in the near future.

[Efficacy of stereotactic radiotherapy for primary and metastatic liver cancer].

Twenty patients( 30 nodules) with metastatic liver cancer( MLC) and 10 cases with hepatocellular carcinoma( HCC) treated by stereotactic radiotherapy (SRT) were analyzed. SRT was administered at 48.0 or 52.8 Gy/4 Fr/1 wk. The response rate (RR) in MLC patients was 78%, and 11 patients survived longer than 1 year and 9 patients survived as long as 2 years. Clinical analysis suggests that the ideal indications for SRT in MLC are solitary nodules in patients without extrahepatic disease who have undergone systemic chemotherapy. Although RR of SRT for HCC was as high as 85%, intrahepatic recurrence was observed in all patients and 6 patients died within 1 year. Further analysis is needed to determine the indication for SRT in HCC patients.

[Stereotactic radiotherapy for metastatic liver cancer].

Twenty cases (27 therapeutic sites/30 nodules) of metastatic liver cancer treated with stereotactic radiotherapy (SRT)were analyzed. The original sites of cancer were colorectal(8 cases), breast(4 cases), stomach(3 cases), esophagus(2 cases), and other organs (3 cases). SRT was performed with 52.8 Gy·4 fr·-1·wk-1. The response rate was 78%, including complete response (CR) at 8 sites, partial response (PR) at 10 sites, stable disease (SD) at 2 sites, progressive disease(PD) at 3 sites, and not detected(ND) at 4 sites, thus demonstrating a potent local therapeutic effect. Ten patients survived for more than 1 year, 8 patients survived for 2 years, and 4 died before 6 months. Clinical analysis suggests that the ideal indications for SRT are patients with a solitary nodule and without extrahepatic disease who have undergone systemic chemotherapy.

[Effects of stereotactic radiotherapy targeting for recurrent gastric cancer].

We report the effects of stereotactic radiotherapy (SRT) targeting for distant solitary metastases from gastric cancer that were uncontrollable with chemotherapy. SRT(52.8 Gy per 4 fractions) was performed in 3 patients with liver metastasis and 1 patient with lung metastasis. Although SRT showed no effect in the patient with lung metastasis, complete remission from liver metastasis with cystic change was observed in all 3 patients. One patient died due to multiple liver metastasis, and the other 2 patients are alive 27 and 41 months after SRT without liver metastasis. Although pneumothorax and pleural effusion were recognized in 1 case, grade 3 or 4 adverse events were not recognized in all 4 cases. SRT showed excellent local therapeutic effects without serious complications, suggesting that this is an effective treatment for localized metastasis from gastric cancer.

[A case of paraaortic lymph node metastasis of gastric cancer resistant to chemotherapy successfully treated with chemoradiation therapy].

We report a case of recurrent gastric cancer with paraaortic lymph nodes (No.16LNs) that was effectively controlled with chemoradiation therapy. A 63-year-old man underwent distal gastrectomy, cholecystectomy, and D2 dissection in July 2004 for advanced gastric cancer in the lower third area that was diagnosed as moderately differentiated stage II adenocarcinoma [T1(SM), N2, H0, P0, CY0, M0]. He suffered from No.16LNs metastasis with serum CEA elevation in October 2007, and therefore, 4 courses of S-1, followed by 3 courses of CPT-11 as second-line treatment, 14 courses of docetaxel as third-line treatment, and 15 courses of paclitaxel+cisplatin as fourth-line chemotherapy, were administrated. Enlargement of No.16LNs with serum CEA elevation was observed in October 2010. Other metastases were not observed, and hence, chemoradiotherapy (CRT; S-1: 80 mg/body+total of 65 Gy per 26 Fr) for No.16LNs was performed. A partial response and reduction of serum CEA level were noted, and the patient is alive with no sign of progression 18 months after CRT. Grade 1 adverse events including anemia, fatigue, and anorexia were recognized. It is thought that chemoradiation therapy is an effective treatment for localized LN metastasis originating from gastric cancer resistant to chemotherapy.

[Complications associated with the placement of subcutaneous central venous access port devices: reasons for removal and complications observed].

OBJECTIVE: To clarify the complications associated with subcutaneous central venous access port devices, we investigated the patients who underwent placement of central venous access port devices in our hospital. METHODS: Overall, 171 cancer patients who underwent placement of subcutaneous central venous access port devices (119 for chemotherapy and 52 for home parenteral nutrition) between February 2006 and December 2011 and who were followed up for 1 month, were retrospectively analyzed in this study. Univariate analysis was performed on complications related to clinical factors, including age, gender, insertion sites, intended purposes, duration of catheterization, surgeons, catheter materials, and use of bevacizumab. RESULTS: The mean follow-up time was 213 days (range, 31-1,873), and 35 patients (20.5%) required the port device to be extracted due to complications, including infection in 24(14.0%), wound dehiscence at the port site in 2 (1.2%), obstruction of the catheter in 6 (3.5%), catheter-induced venous thrombosis in 1 (0.6%), and catheter fracture in 2(1.2%). No statistically significant differences were observed between the frequency of complications and age, gender, insertion sites, intended purposes, duration of catheterization, surgeons, catheter materials, or use of bevacizumab. CONCLUSION: The incidences of complications related to implantation and management of these devices are relatively high and early. Patients should be followed carefully by chest radiography at regular intervals.

[A case of advanced gastric cancer with splenic vein thrombus successfully treated with S-1 plus CPT-11 neoadjuvant chemotherapy].

A 63-year-old male admitted for hematemesis was diagnosed with type 3 advanced gastric cancer located in the upper and middle body of the stomach in an endoscopic examination. Abdominal computed tomography demonstrated lymph nodes metastasis and a splenic vein thrombus. Since curative resection was not deemed possible, we performed neoadjuvant chemotherapy using S-1 (120 mg, day 1-21) plus CPT-11 (135 mg, day 1 and 15) except for down-staging. After 4 courses of chemotherapy, gastric tumor and metastatic lymph nodes were reduced in size and the splenic vein thrombus was disappeared, and then total gastrectomy was performed (tub2, T2 (MP) N0 H0 M0 P0 CY0, Stage IB). S-1 medication was applied as adjuvant chemotherapy. Forty months passed from the operation, the patient remains alive with no signs of relapse.

[Complete remission of liver metastasis from gall bladder carcinoma after stereotactic radiotherapy-a case report].

A 75-year-old man was diagnosed as gall bladder carcinoma by postoperative histological examination following laparoscopic cholecystectomy. He underwent the second surgery of resection of liver bed and port sites with lymph node dissection. Isolated hepatic metastasis of 20 mm in diameter was found in S4/8 by MRI 18 months postoperatively, and stereotactic radiotherapy (52.8 Gy/4 Fr) was done for the metastatic lesion. The lesion could not be detected by CT 7 months after the radiotherapy, and thereafter no local recurrence has been observed for 24 months. However, lymph node metastasis of #9 was diagnosed 31 months postoperatively. Liniac radiotherapy (60 Gy/20 Fr)was performed and stable disease has been obtained for 9 months. The patient is alive at present of 43 months after surgery without any other site of the disease, and his quality of life is well maintained. Stereotactic radiotherapy showed an excellent local therapeutic effect without any serious complications, suggesting that this is a potent modality for isolated liver metastasis of gall bladder carcinoma.