Clinicopathologic study of stage I adenosquamous carcinoma of the lung.

OBJECTIVE: Adenosquamous carcinoma of the lung is a characteristic tumor that has both adenocarcinoma and squamous cell carcinoma components. Adenosquamous carcinoma is reported to have an aggressive clinical course, but its clinicopathological features and prognosis are unclear in the early stage. METHODS: Patients who underwent surgical resection for pathological stage I non-small cell lung cancer between April 2009 and December 2014 were retrospectively reviewed. Preoperative and postoperative data, histologic characteristics and outcomes of patients with adenosquamous carcinoma (n = 40) were compared to adenocarcinoma (n = 598) and squamous cell carcinoma (n = 131) patients. Factors affecting prognosis, particularly on recurrence, were assessed via Cox regression analyses. RESULTS: Patients with adenosquamous carcinoma had a worse prognosis than did patients with adenocarcinoma and squamous cell carcinoma in terms of 5 year overall (66.7%) and recurrence-free survival rates (44.9%), as well as a significantly higher recurrence rate (13/40 patients, 32.5%). Multivariable Cox regression analysis for recurrence-free survival rates revealed that the histology of adenosquamous carcinoma was an independent factor for recurrence (hazard ratio: 2.473, 95% confidence interval: 1.328-3.367; P = 0.0004). High serum carcinoembryonic antigen levels (hazard ratio: 5.962) and vascular invasion (hazard ratio: 4.899) were identified as risk factors for recurrence, and patients with adenosquamous carcinoma tended to have distant relapses, such as in the brain. CONCLUSIONS: Early-stage adenosquamous carcinoma of the lung is a histological type associated with severe prognosis and postoperative recurrence, often in distant sites, in approximately one-third of cases. High serum carcinoembryonic antigen levels and vascular invasion might be risk factors of recurrence.

Dual-energy Computed Tomography Iodine Map for Breast Cancer: Comparison With Dynamic Contrast-enhanced Magnetic Resonance Imaging.

BACKGROUND/AIM: The characteristics of different breast cancers imaged using dual-energy computed tomography (DECT) are unknown. Furthermore, the differences between DECT and magnetic resonance imaging (MRI) in the ability to assess tumor extent have not been clarified. Therefore, this study aimed to evaluate the effectiveness of DECT iodine maps compared to contrast-enhanced MRI in patients with operable breast cancer. PATIENTS AND METHODS: Clinicopathological data from 858 patients with breast cancer who underwent resection after DECT (100/140 kv) and MRI during 2012-2021 were collected. Tumoral iodine concentration (IC; max/Δ) was analyzed from iodine maps. Factors associated with the ability of iodine maps and MRI to predict tumor extent were analyzed with reference to resected specimens' pathological diagnosis. RESULTS: IC parameters varied according to the tumors' histological types and were correlated with the estrogen receptor, histological grade, and Ki-67 labeling index. In 86.2% of patients with invasive carcinoma with intraductal extension, images and resected specimen mapping were matched. Iodine maps were less accurate than MRI in identifying tumor borders in 9.8% and more accurate in 2.1% of patients. The discrepancies in assessing tumor borders between imaging modalities were associated with the tumor's IC parameters and mammary gland status. CONCLUSION: Differences in assessment between DECT and MRI in operable breast cancer are associated with IC parameters and background parenchymal enhancement. Therefore, evaluating tumor extent using DECT considering these characteristics appears to be a feasible approach.

[A Case of Advanced Esophageal Cancer with Esophago-Bronchial Fistula Closed by Pembrolizumab plus Chemotherapy Therapy].

We report a case of unresectable advanced esophageal cancer with an esophageal fistula that was treated with pembrolizumab plus CDDP plus 5-FU therapy and the fistula was closed. A 73-year-old male was diagnosed with cervical-upper thoracic esophageal cancer and esophago-bronchial fistula on CT and esophagogastroduodenoscopy. He underwent chemotherapy containing pembrolizumab. The fistula was closed after 4 cycles and oral intake became possible. Six months have passed since the first visit and chemotherapy is ongoing. The prognosis of esophago-bronchial fistula is extremely poor, and there is no established treatment, including fistula closure. Chemotherapy containing immune checkpoint inhibitors could considered to be expected not only for local control but also for long-term survival.

Laparoscopic repair of Morgagni hernia with extra-abdominal sutures and ileocecal resection for colon cancer: a case report.

Morgagni hernia is a rare form of diaphragmatic hernia. It is located at the anterior edge of the diaphragm and does not have an anterior rim. It is difficult to achieve a secure closure and maintain the tension of closure with laparoscopic surgery. We have performed laparoscopic resection of colorectal cancer and hernia repair simultaneously. An 89-year-old woman underwent laparoscopic hernia repair and ileocecal resection simultaneously. Regarding hernia repair, we considered that it would be difficult to use a mesh from the viewpoint of infection due to the colectomy. Therefore, we have done the extra-abdominal suture method. After laparoscopic ileocecal resection, a small incision was made in the epigastric region, and Morgagni hernia repair was performed with extra-abdominal sutures. She had no recurrence of either colon cancer or hernia for 22 months post-operatively. The extra-abdominal suture method can provide secure closure of the hernia orifice for Morgagni hernia.

Ischemic Necrosis of the Gastric Remnant Treated Successfully Using Total Remnant Gastrectomy.

Distal gastrectomy (DG) with lymph node dissection is considered as the standard treatment for gastric cancer. Ischemic necrosis of the gastric remnant is a rare but serious complication of DG that requires careful consideration for early diagnosis and treatment to lower the associated mortality rate. A 71-year-old male presented to our hospital with hyperglycemia and was evaluated for suspected diabetes. The patient's medical history was otherwise unremarkable. Computed tomography (CT) revealed a thickening of the stomach wall, with follow-up esophagogastroduodenoscopy revealing type 3 gastric cancer in the greater curvature of the antrum. Biopsy specimen confirmed a pathological diagnosis of mucinous adenocarcinoma, with a clinical diagnosis of cT3N0M0, cStageIIB. An open DG with Billroth I reconstruction was performed, without incident. On postoperative day 1, the patient developed a high fever, abdominal pain, and elevated white blood cell count (12,200/µL). On postoperative day 2, his C-reactive protein level increased to >30 mg/dL. CT revealed an edematous thickening of the stomach wall, with poor mucosal enhancement of the remnant stomach and thinning of the anastomosis wall, with air nearby. Emergency surgery was performed for suspected leakage. Intraoperative findings showed no evidence of leakage. Intraoperative endoscopy revealed a necrotic gastric remnant, and we performed a total remnant gastrectomy with Roux-en Y reconstruction. The patient was discharged in a stable condition, 25 days after the first surgery. Although ischemic necrosis of the gastric remnant is a rare complication, its possibility should be carefully considered after DG, for early diagnosis and treatment.

Thymic Mucoepidermoid Carcinoma: A Clinicopathologic and Molecular Study.

Thymic mucoepidermoid carcinoma (MEC) is a rare tumor, and its characteristics remain to be clarified. Here we investigated 20 cases of thymic MEC to systematically characterize its clinical, histopathologic, and molecular features. The median age of the patients was 56 years (range, 19 to 80 y), there was a slight male predilection (3:2), and 44% of the patients were asymptomatic at diagnosis. The median tumor size was 6.8 cm in diameter, 55% were pT1 tumors, and 50% were TNM stage I tumors. When 4 tumor grading systems for salivary MEC (Armed Forces Institutes of Pathology, Brandwein, modified Healey, and the Memorial Sloan-Kettering) were employed, low-grade, intermediate-grade, and high-grade tumors accounted for 35% to 70%, 5% to 25%, and 25% to 50%, respectively. Many histologic variants were noted, and 70% of the cases were classified as nonclassic variants. MAML2 rearrangement was detected in 56% of cases, and the fusion partner was CRTC1 in all cases. CRTC1-MAML2 fusion was associated with lower pT classification and lower TNM stage. The overall survival rate of all patients was 69% and 43% at 5 and 10 years, respectively. Worse overall survival was associated with higher pT stage, higher TNM stage, residual tumors, greater tumor size, high-grade tumor histology (Armed Forces Institutes of Pathology and Memorial Sloan-Kettering, but not the other 2), and with the absence of CRTC1-MAML2 fusion. Of note, none of the patients with CRTC1-MAML2 fusion-positive tumors died during the follow-up. In conclusion, the clinicopathologic and molecular findings of thymic MEC presented here are expected to contribute to the management of this rare tumor.

Pancreatic duct rupture associated with high-grade pancreatic intraepithelial neoplasia treated by radical resection: a case report.

We here report a case of pancreatic duct rupture associated with high-grade pancreatic intraepithelial neoplasia treated by radical resection. A 71-year-old man presented to our hospital because of abdominal bloating. Diagnoses of early-stage pancreatic body cancer with pancreatic duct rupture, pancreatic ascites, and formation of a pseudocyst were made on the basis of blood tests, multidetector dynamic computed tomography, endoscopic ultrasonography, magnetic resonance cholangiopancreatography, and endoscopic retrograde cholangiopancreatography. After achieving control of the ascites by placement of a pancreatic duct stent and aspiration of the pseudocyst, distal pancreatectomy with D2 lymph node dissection was performed. Intraoperative cytologic examination of the ascites was negative. The pathological diagnosis was high-grade pancreatic intraepithelial neoplasia in the pancreatic body. The branched pancreatic duct was occluded and dilated by acute inflammation around the pancreatic neoplasm, the inflammation being in the region of the dilated branched pancreatic duct and having caused its rupture. To the best of our knowledge, this is the first published report of pancreatic duct rupture associated with high-grade pancreatic intraepithelial neoplasia.

Clinical Behavior of Combined Versus Pure High-Grade Neuroendocrine Carcinoma.

BACKGROUND: The aim of this study was to investigate and compare the clinical behaviors of combined and pure high-grade neuroendocrine carcinoma (large-cell neuroendocrine carcinoma [LCNEC] and small-cell lung carcinoma [SCLC]). PATIENTS AND METHODS: Data of 132 patients who underwent complete resection for combined or pure high-grade neuroendocrine carcinoma (combined group, 67; pure group, 65) between January 2001 and December 2015 were retrospectively reviewed. The clinicopathological features were analyzed and compared, and the prognoses were assessed by performing the Kaplan-Meier method and Cox regression analysis. RESULTS: The combined and pure groups had nearly equivalent clinicopathological characteristics, specifically, older males with smoking history, almost the same percentage of pleural/lymphatic/vascular invasion, and nearly the same recurrence rates and relapse patterns. The combined group had prognosis equivalent to that of the pure group (5-year overall survival [OS] rates: 61.8% vs. 52.2%, respectively; P = .82 and 5-year recurrence-free survival [RFS] rates: 42.4% vs. 43.9%, respectively; P = .96), and this trend was identified in sub-analyses only for patients with LCNEC, SCLC, and the same pathological stage. Multivariable Cox regression analysis in patients with high-grade neuroendocrine carcinoma revealed that vascular invasion and pathological stage were independent prognostic factors for OS; more importantly, combined and pure histologies were proven to have nearly equivalent associations with prognosis (hazard ratio, 0.96; 95% confidence interval, 0.22to 1.66; P = .96). RESULTS: Combined high-grade neuroendocrine carcinoma had clinical behavior equivalent to those of pure high-grade neuroendocrine carcinoma, with similar clinicopathological characteristics.

How to do it: endovascular stent and ligament resection during pancreaticoduodenectomy for coeliac axis stenosis in median arcuate ligament syndrome.

To decrease complications associated with the treatment of coeliac axis (CA) stenosis due to median arcuate ligament (MAL) syndrome in pancreaticoduodenectomy, we performed combined preoperative endovascular stenting and intraoperative MAL resection. This technique can secure the CA blood flow to the hepatic artery before surgery in one stage and prevent CA restenosis and stent dislocation because there is no extrinsic compression of the CA after MAL resection.

[A Case of Primary Small Cell Carcinoma in the Breast with Neoadjuvant Chemotherapy That Were Difficult to Select Chemotherapy].

Primary small cell carcinoma in the breast is a rare and aggressive tumor, and a standard treatment strategy has not been established. Herein, we report a 35-year-old woman with primary small cell carcinoma in the breast. She had an 8 cm diameter tumor in the right breast. She was diagnosed with small cell carcinoma(cT3N1M0, cStage ⅢA)in the right breast, and neoadjuvant chemotherapy was planned. She received a combination chemotherapy of cisplatin(CDDP)and etoposide(VP- 16)based on the regimen for pulmonary small cell carcinoma; however, the disease showed progression. Therefore, 5-FU plus epirubicin plus cyclophosphamide(FEC)and weekly paclitaxel(PTX)chemotherapy based on a regimen for breast cancer were administered, and the tumor was partially reduced in size. Modified radical mastectomy followed by radiotherapy and hormonal therapy was performed. Ten months after the surgery, multiple liver and bone metastases occurred, and the patient died the following month. Further studies in other such patients are needed.

Successful surgical management of non-perforating acute appendicitis with septic disseminated intravascular coagulation: A case report and review of the literature.

INTRODUCTION: Perforating appendicitis and abscess-forming appendicitis may cause septic disseminated intravascular coagulation (DIC). However, non-perforating acute appendicitis with septic DIC is extremely rare. PRESENTATION OF CASE: A 67-year-old man was referred to our hospital one day after starting oral antibiotic treatment for acute appendicitis. Physical examination revealed only slight spontaneous abdominal pain without tenderness and peritoneal irritation. Contrast-enhanced computed tomography demonstrated an enlarged appendix (10 mm in diameter) without fecalith, ascites, intraperitoneal free air, and abscess. There was no evidence of perforating appendicitis. Laboratory analysis revealed septic DIC. The patient was diagnosed with non-perforating acute appendicitis with septic DIC. The patient was distressed regarding whether he should be treated conservatively with an antibiotics-first strategy or undergo an appendectomy. Ultimately, a laparoscopic appendectomy was performed. Histopathological examination showed non-perforating gangrenous appendicitis. He required DIC therapy for 2 days postoperatively. He was discharged on postoperative day 9, and remained in good health 1 month after surgery. DISCUSSION: There is no absolute index of conversion to surgery with an antibiotics-first strategy of appendicitis treatment. Judging the limit of conservative treatment and determining the best moment to perform surgery is a critically important matter for patients with acute appendicitis. CONCLUSIONS: The incidence of conservative treatment preceding an antibiotics-first strategy for acute appendicitis is increasing. However, it is thought that appendectomy should be performed when acute appendicitis is complicated with septic DIC, even if it is a non-perforating appendicitis in which improvement with conservative treatment is anticipated.

Laparoscopic excision of a retroperitoneal schwannoma: A case report.

Schwannomas are tumors originating from the Schwann cells of the peripheral nerve sheath. Only 1%-3% of schwannomas reportedly occur in the pelvis. In a 67-year-old man, a pelvic mass that was 52 mm in diameter was incidentally diagnosed during a preoperative CT evaluation for prostate cancer. Preoperative 3-D reconstruction CT showed that the feeding artery to the tumor originated from the internal iliac artery and the drainage vein from the internal iliac vein. Each vessel could be isolated, clipped, and cut with minimal bleeding. The tumor was easily dissected from adjacent structures and was completely resected via laparoscopic surgery. Histopathology and immunohistochemistry of the excised specimen revealed a benign schwannoma. Using 3-D reconstruction to recognize a tumor's positional relation with the supplying vessels is important for avoiding complications during laparoscopic resection in the narrow pelvis. Laparoscopic resection is safe, feasible, and effective for retroperitoneal schwannoma.

Appendiceal neurofibroma with low-grade appendiceal mucinous neoplasm in neurofibromatosis type 1 patient: A case report.

INTRODUCTION: Neurofibromas are a characteristic of the autosomal dominant disorder Neurofibromatosis type 1 (NF1), also known as von Recklinghausen's disease. Appendiceal neurofibromas are extremely rare, and low-grade appendiceal mucinous neoplasms (LAMNs) have not previously been reported in NF1. PRESENTATION OF CASE: A 62-year-old man with NF1 was scheduled for elective surgical treatment of an asymptomatic, enlarged and diffusely thickened appendix that remained after curative antimicrobial treatment of acute appendicitis. Laboratory analysis revealed all normal. Colonoscopy showed thickened appendiceal mucosa projecting into the cecum. A sample of the mucosa was found to be pathologically benign. The patient was preoperatively diagnosed with treated acute appendicitis with chronic appendiceal inflammation versus appendiceal neoplasms. Laparoscopic cecectomy was performed. Multiple neurofibromas were observed in the muscle layer, submucosa, and mucosa of the appendix on histopathological examination. Immunohistochemical examination showed positive staining for S-100. Pathologically, the patient was diagnosed with appendiceal neurofibroma consistent with NF1 with LAMNs. His postoperative course was unremarkable. He was discharged on post-operative day 3 and remained in good health 7 month after surgery. CONCLUSIONS: Appendiceal neurofibromas are often preoperatively diagnosed as appendicitis. Appendiceal neurofibromas should be considered in patients with NF1 who are suspected of having appendicitis.

Intestinal obstruction caused by low-grade appendiceal mucinous neoplasm: A case report and review of the literature.

INTRODUCTION: Intestinal obstructions due to appendiceal pathology are rare. Obstructions caused by low-grade appendiceal mucinous neoplasms (LAMNs) are rarer still. PRESENTATION OF CASE: A 79-year-old woman was referred to our hospital for mechanical small intestinal obstruction. The patient had undergone prior left oophorectomy via a lower abdominal incision. Physical examination revealed abdominal distension and slight tenderness. Laboratory analysis was unremarkable. Contrast enhanced computed tomography (CT) demonstrated dilation of an obstructed small intestinal loop without evidence of strangulation. There appeared to be a low density mass measuring 3.0 × 1.5 cm with a potential twist in the mesentery near the transition point in the small intestine. The patient was diagnosed with mechanical small intestinal obstruction and was treated conservatively with nasogastric tube decompression for one week. After no clinical improvement, we elected to surgically explore her. Intraoperative findings revealed that the ileum was compressed by the appendix, which had a cystic mass on its tip. There was no evidence of intestinal ischemia. Laparotomy appendectomy alone was performed. Pathology revealed a LAMN measuring 3.0 × 1.5 cm. She remains disease-free with 18 months of postoperative follow-up. DISCUSSION: Intestinal obstruction due to external compression by an appendiceal mass is rare, and is often difficult to preoperatively diagnose with CT. CONCLUSIONS: The etiology of small intestinal obstruction with a transition point in the right lower quadrant of abdomen includes an appendiceal mass on the broad differential for this common problem.

A rare case of retroperitoneal hemolymphangioma.

INTRODUCTION: Hemolymphangioma, a rare vascular developmental condition, is characterized by malformed venous and lymphatic components in various proportions. Herein, we report a case of a retroperitoneal cystic tumor in an adult patient. PRESENTATION OF CASE: A 68-year-old man presented to our hospital with complaints of abdominal pain and vomiting. His abdomen was distended with upper tenderness but without rebound tenderness. Computed tomography (CT) scanning demonstrated a retroperitoneal cystic tumor at the dorsal part of the pancreatic head. Thus, a diagnosis of liposarcoma or lymphoma was made. The patient was scheduled for surgery after his general condition became stable. Intraoperatively, the cystic tumor was found to have originated from the retroperitoneal space. The tumor was in contact with the pancreatic head, abdominal aorta, and inferior vena cava. There was no invasion into the surrounding tissue. The cystic tumor was resected completely. Histopathological examination revealed that the resected retroperitoneal cystic tumor was a hemolymphangioma. The patient had no recurrence during the 12-month follow-up. DISCUSSION: Hemolymphangioma is a rare benign tumor, and its accurate diagnosis before surgery is still difficult. Disease presentation may vary from simple well-defined cystic lesions to aggressive ill-defined lesions, mimicking malignancy. Complete excision provides the best results with a low recurrence rate. CONCLUSION: Further research is needed on the preoperative radiological diagnosis of such tumors and on how to determine tumor resectability in such cases.

Pancreatobiliary fistula associated with intraductal papillary mucinous carcinoma accompanying obstructive jaundice: A case report.

INTRODUCTION: Intraductal papillary mucinous neoplasms (IPMNs) occasionally involve formation of fistulas with other adjacent organs. Pancreatobiliary fistulas associated with IPMNs are rare, but affected patients often develop obstructive jaundice and cholangitis. PRESENTATION OF CASE: A 79-year-old man was referred to our hospital for evaluation of abnormal biliary enzymes. Contrast-enhanced computed tomography and endoscopic retrograde cholangiopancreatography demonstrated multiple cystic lesions with septa in the pancreatic head and fistulas between the cystic lesions and common bile duct. The clinical diagnosis was pancreatobiliary fistula associated with a mixed-type IPMN and accompanying obstructive jaundice. The patient underwent subtotal stomach-preserving pancreaticoduodenectomy. The resected specimen showed fistulas between the cystic lesions and common bile duct. Histopathological examination showed that the main and branch ducts of the pancreatic head were dilated and filled with mucus. The epithelia of the pancreatic ducts revealed papillary proliferation and an invasive adenocarcinoma arising from an intraductal neoplasm. Immunohistochemistry examination showed CDX2- and MUC2-positive reactions. The final diagnosis was an intraductal papillary mucinous carcinoma of the intestinal-type. The patient remained disease-free for 9 months postoperatively. DISCUSSION: The causes of death in patients who have pancreatobiliary fistulas associated with IPMNs without resection are cholangitis or hepatic insufficiency. Nonoperative treatment is limited for cases with obstructive jaundice. It is necessary to prevent obstructive jaundice and cholangitis due to a large quantity of mucinous material. CONCLUSIONS: Surgical resection should be considered, if possible, in patients with pancreatobiliary fistulas associated with IPMNs. A better prognosis is expected with prevention of obstructive jaundice or cholangitis.

Gastrointestinal stromal tumor of the esophagus: current issues of diagnosis, surgery and drug therapy.

Gastrointestinal stromal tumors (GISTs) often arise in the stomach and small intestine, while esophageal GISTs are rare. Due to their rarity, clinicopathological data on esophageal GISTs are extremely limited, and this results in a lack of clear recommendations concerning optimal surgical management for esophageal GISTs. It is difficult to distinguish esophageal GIST from leiomyoma, the most frequent esophageal mesenchymal tumor, prior to resection, because the two types of tumors appear similar on computed tomography (CT), endoscopic ultrasound (EUS), and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET). Fine-needle aspiration biopsy (FNAB) under EUS enables definitive diagnosis, but it is often avoided because scarring could make enucleation more difficult and increase the risk of tumor dissemination by capsule destruction. Esophageal segmental and wedge resections are not usually performed due to the anatomical peculiarity of the esophagus, and the surgical options are limited to the highly invasive esophagectomy or the much less invasive surgical tumor enucleation. The decision as to which surgical procedure should be performed for esophageal GISTs is still under debate. Tumor enucleation may be permitted for smaller tumors, and esophagectomy may be recommended for larger GISTs or high-risk tumors with a high mitotic rate. The purpose of neoadjuvant imatinib administration is downsizing of the GIST to reduce the extent of resection and to reduce the risk of intraoperative complications, including tumor rupture. The efficacy of neoadjuvant/adjuvant imatinib therapy for esophageal GISTs is poorly understood, because the reports are limited to case reports or case series with small numbers. More clinicopathological data and clinical trials for esophageal GIST are expected.

Reassessment of Right Middle Lobe Lung Cancer: Comparison of Segments 4 and 5 Tumors.

BACKGROUND: The purpose of this study was to elucidate the clinical behavior of right middle lobe lung cancer, with focus on the tumor location. METHODS: We reviewed retrospectively 711 patients who underwent lobectomy or bilobectomy for clinical stage I non-small cell lung cancer (upper lobe, 346; middle lobe, 82; lower lobe, 283). Factors affecting survival were assessed by log rank tests and Cox regression analyses. RESULTS: The prognosis of patients with segment 5 tumors (n = 39) was significantly worse than that of patients with segment 4 tumors (n = 43; 5-year overall survival rates, 69.8% versus 87.6%, p = 0.040; and 5-year recurrence-free survival rates, 58.4% versus 73.0%, p = 0.029). Segment 5 tumors were an independent factor for poor prognosis in multivariable Cox regression analysis, and tended to cause more pathologic mediastinal lymph node metastases than segment 4 tumors (12.8% versus 2.3%, p = 0.097). Compared with tumors in the other lobes, patients with segment 4 tumors demonstrated no significant difference in prognosis; however, patients with segment 5 tumors demonstrated a significantly and outstandingly worse prognosis than patients with other lobe tumors (5-year overall survival rates, 69.8% versus 82.2%, p = 0.020; and 5-year recurrence-free survival rates, 58.4% versus 71.4%, p = 0.0071). CONCLUSIONS: Patients with segment 5 tumors had a worse prognosis than patients with segment 4 and other lobe tumors. We speculate that is because segment 5 tumors cause more metastases to the mediastinal lymph nodes. Tumor location was an important prognostic factor for patients with right middle lobe lung cancer.

Invasive micropapillary carcinoma component is an independent prognosticator of poorer survival in Stage III colorectal cancer patients.

BACKGROUND: Invasive micropapillary carcinoma (IMPC) is an aggressive variant of adenocarcinoma found in several organs. Recent studies showed that IMPC in colorectal cancer leads to poorer prognosis than conventional colorectal cancer; however, the influence of IMPC on outcomes remains unclear. The present study aimed to identify the clinicopathological characteristics of colorectal cancers with IMPCs, and to evaluate the prognostic significance of IMPCs per se. METHODS: We retrospectively analyzed data from 837 patients with colorectal cancer who underwent surgical treatment. We compared the clinicopathological characteristics and survival outcomes of colorectal cancer patients with IMPCs to those without. RESULTS: Among 837 patients, 130 (16%) had an IMPC component, including 0 (0%) of 18, 9 (4.2%) of 215, 34 (13%) of 254, 59 (24%) of 249 and 28 (27%) of 101 patients with TNM Stages 0, I, II, III and IV, respectively. The 3-year disease-free survival (DFS) rates were significantly worse for Stage III patients with IMPC than for those without (55.3% vs. 78.7% respectively, P < 0.001), but not in patients with other stages. Multivariate analyses of patients with Stage III colorectal cancer found IMPC to be associated with significantly worse DFS (P = 0.026), as were high CEA levels, tumor budding and TNM staging. IMPC was only significantly associated with tumor invasion (P = 0.045) and venous invasion (P = 0.045) in Stage III tumors. CONCLUSIONS: Identifying IMPC components in Stage III colorectal cancer is crucial, as their presence is significantly associated with poorer survival.

Mixed adenoneuroendocrine carcinoma of the distal bile duct: A case report.

INTRODUCTION: Mixed adenoneuroendocrine carcinomas (MANECs) of the distal bile duct are extremely rare, and only a few cases have been reported in the English literature. PRESENTATION OF CASE: An 82-year-old man was referred to our hospital for increasing biliary enzymes. Abdominal computed tomography (CT) showed enlargement of the intrahepatic bile ducts and stenosis of the distal bile duct. Endoscopic retrograde cholangiopancreatography showed stenosis of the distal bile duct and a high-density signal at the same site on diffusion weighted imaging. PET-CT showed increased FDG accumulation (SUVmax: 4.5) at the distal bile duct stenosis. Biopsy specimens obtained by endoscopic ultrasonography-guided fine-needle aspiration revealed adenocarcinoma. The patient was diagnosed with adenocarcinoma of the distal bile duct and underwent subtotal stomach-preserving pancreaticoduodenectomy with regional lymph node dissection. The resected distal bile duct tumor was 18×14×12mm in diameter. Hematoxylin and eosin staining revealed a composite carcinoma with adenocarcinoma and non-adenocarcinoma elements. The non-adenocarcinoma component stained positive for synaptophysin and chromogranin A. The Ki-67 labeling index was 37%. The non-adenocarcinoma component was therefore diagnosed as a neuroendocrine carcinoma. The two composite carcinoma was diagnosed as MANEC of the distal bile duct. The patient was treated with surgery alone and he remained disease-free for 7 months after the surgery. DISCUSSION: The treatment of MANECs of the bile duct remains controversial and the prognosis is poor. CONCLUSIONS: There is no standard treatment for MANECs of the bile duct. Larger studies are required to establish standard treatment regimens.