Ibuprofen Would Be the First-Line Nonsteroidal Anti-inflammatory Drug for Polymyalgia Rheumatica: A Case Series of Five Patients.

The primary treatment of choice for polymyalgia rheumatica (PMR) is corticosteroids, which are better avoided for elderly patients susceptible to PMR. The cases of five patients cured with only a small dosage of 600 mg/day ibuprofen without steroids or methotrexate are reported. Their clinical features were compared with those of the 26 PMR patients who had steroids and/or methotrexate in addition to ibuprofen. PMR was diagnosed based on the 2015 EULAR/ACR criteria. They were all females aged 73-80. They all had no giant cell arteritis or autoantibodies. Nonsteroidal anti-inflammatory drugs (NSAIDs) other than ibuprofen had not worked in four cases; for the one, ibuprofen was the first NSAID. Their serum CRP levels were 1.57-12.8 mg/dL at ibuprofen introduction. Colchicine was co-administered in two patients. At the next visit three to seven days after ibuprofen introduction, they all showed a clear recovery with a CRP level decrease. Ibuprofen tapering was started within three months, and no relapse was until two to five years' follow-up. Comparison with the 26 patients who had additional steroid and/or methotrexate showed that the disease duration until ibuprofen introduction was statistically significantly shorter in the five patients (1.40±0.65 vs 3.28±2.98 months). Ibuprofen would be the first-line drug for PMR, and its earliest use would be beneficial.

Laparoscopic deroofing for a giant hepatic cyst with biliary communication: a case report.

Previous reports describing laparoscopic deroofing as a management modality for a hepatic cyst with biliary communication remain limited. We present the case of a 76-year-old woman who was monitored for 4 years for a giant hepatic cyst in the right lobe of the liver. She presented to our department with a chief complaint of abdominal distension. Moreover, imaging revealed a 24-cm giant hepatic cyst. During laparoscopic deroofing, minimal bile leakage from the intra-cyst wall was observed, which was laparoscopically closed with sutures. No bile leakage or cyst recurrence was observed 18 months postoperative. This highlights that laparoscopic surgery may be used in managing hepatic cysts with biliary communication. Intraoperative findings may reveal biliary communication, which requires careful observation of the cyst wall after deroofing.

[A Case Report of Rectal MiNEN Surgical Resection].

A 56-year-old man with diarrhea and bloody stools was found to have a type 2 tumor in the rectosigmoid region. A biopsy revealed well-differentiated tubular adenocarcinoma(tub1), and laparoscopic high anterior resection was performed. The final diagnosis was MiNEN(NEC:adenocarcinoma=6:4), RS, type 2, Ly0, V0, pT3(SS), pN0, M0, and pStage Ⅱa. He has been followed up without postoperative adjuvant chemotherapy and has been alive without recurrence for 1 year and 4 months after surgery. MiNEN is a rare disease, and most of them are mixed with NEC components or high- grade NET G3 and have a poor prognosis. We present an important case of rectal MiNEN.

[Long-Term Survival after Resection of Two Lung Metastases That Appeared Five Years after Pancreatic Cancer Surgery-A Case Report].

A woman in her 70s was diagnosed with cancer of pancreatic head. She underwent subtotal stomach-preserving pancreatoduodenectomy. Moderately differentiated adenocarcinoma, positive peripancreatic exfoliation surface, and R1 resection was diagnosed by histopathological examination. She underwent adjuvant chemotherapy(S-1), but 5 years and 6 months after the operation, a single nodule(16×9 mm)appeared on anterior segment of left lung. She underwent thoracoscopic left upper lobectomy on suspicion of primary lung cancer. Adenocarcinoma consistent with pancreatic cancer metastasis was diagnosed by histopathological examination. She didn't choose chemotherapy after second operation. 1 year and 1 month after the left pneumonectomy, a single nodule(11×10 mm)reappeared in lateral basal segment of right lung. Although it was difficult to diagnose whether it was primary or metastatic, she decided to undergo thoracoscopic partial lung resection. Histopathological examination revealed that the histology was similar to that of the previous lung lesion and was consistent with pancreatic cancer metastasis. After that, she also didn't choose chemotherapy. She has been alive for 7 years and 7 months after her first pancreatic cancer surgery without any new obvious recurrence.

[A Case Report of Appendiceal NET G1 Diagnosed by Histopathological Examination after Appendectomy for Acute Appendicitis].

A 36-year-old woman was diagnosed with acute appendicitis after a close examination of her abdominal pain and nausea. Laparoscopic appendectomy was performed, and pathological examination revealed a NET G1. They were localized lesions on the tips and body of the appendix, with no additional resection because the tumor size was less than 2 cm and no risk factors for recurrence and metastasis(vascular invasion, NET G2 or higher, or invasion of the mesentery). The patient was followed up with contrast-enhanced CT every 6 months and has been recurrence-free for 2 years postoperatively.

[Laparoscopic Resection of a Liver and Ovarian Metastasis of Transverse Colon Cancer-A Case Report].

A 60s woman was diagnosed to transverse colon cancer and she underwent laparoscopic right hemicolectomy. Localized peritoneal dissemination surrounding tumor was detected during surgery. She was administrated to chemotherapy due to a hepatic metastasis in S2/3 postoperatively. Subsequently, PET-CT revealed a left ovarian metastasis in addition to a liver metastasis during chemotherapy. Laparoscopic hepatic left lateral segmentectomy and bilateral adnexectomy was performed at 1 year and 9 months after the first surgery and histopathological examination showed a metastasis of transverse colon cancer. The growth of liver and lung metastases and peritoneal disseminations was detected at 6 months later after the second surgery and the patient is currently receiving palliative treatment. Previous literatures described that ovarian metastasis of colon cancer showed bilateral metastasis and resistance to chemotherapy frequently and ruptured in some cases. We should consider to resect bilateral ovary even if unilateral metastasis alone was detected by imaging examination.

[A Case Report of Pancreatic Tail Carcinoma with Positive Periotoneal Washing Cytology with Recurrence-Free Survival after Surgery and Chemotherapy].

A woman in her 70s underwent distal pancreatectomy(D2 dissection)for a pancreatic tail carcinoma after a close examination of the cause of her poorly controlled diabetes mellitus. Intraoperative rapid peritoneal washing cytology showed no malignant findings, but histopathological examination revealed Ptb, TS2, tub2, pT3, ly1, v3, ne3, mpd0, pS0, pRP1, pOO0, pPCM0, pDPM0, pN0, pM0, pCY1, pStage ⅡA, R0(Pancreatic Cancer Treatment Protocol 7th Edition). The patient was treated with S-1 therapy for 6 months postoperatively and is alive 1 year and 9 months without recurrence. The prognosis after resection of pancreatic cancer with positive peritoneal washing cytology is said to be worse than that of patients with negative, because of the high recurrence rate of peritoneal metastasis. We report a case of pancreatic tail carcinoma with positive peritoneal washing cytology with recurrence-free survival after surgery and chemotherapy.

[A Difficult Case of a Huge Cystic Gastrointestinal Stromal Tumor of the Stomach with CA125-Level Elevation].

A 67-year-old woman presented with abdominal distention. Computed tomography and magnetic resonance imaging revealed a huge tumor measuring >30 cm with solid and cystic regions. The serum level of CA125 was elevated. An exploratory laparotomy was performed by a gastroenterologist and a gynecologist for the purpose of diagnosis and tumor removal. During laparotomy, the ovary and uterus were found to be intact. The tumor was found to originate from the greater curvature of the stomach and invade the mesentery of the transverse colon. Histopathologically, tumor cells were positive on c-kit immunohistochemical staining. A high-risk gastrointestinal stromal tumor of the stomach was diagnosed according to the modified-Fletcher classification. Because cystic GIST is relatively rare and CA125 was elevated similar to that in Pseudo-Meigs syndrome, preoperative diagnosis was difficult in this case.

[Surgical Resection of Gastric MANEC-Two Case Reports].

Case 1 was a 78-year-old woman with a tumor in the stomach on preoperative CT of an inguinal hernia. The patient was diagnosed with advanced gastric cancer at posterior wall of fornix and underwent total gastrectomy and splenectomy. Postoperative pathological diagnosis was gastric mixed adenoneuroendocrine carcinoma(MANEC), T1b2, N1, M0, StageⅠB. She has been alive without recurrence for 3 years without postoperative adjuvant chemotherapy. Case 2 was a 78-year-old man who was admitted to the hospital with acute pancreatitis and had a thickened wall of the lesser curvature of the gastric antrum on CT. He was diagnosed with advanced gastric cancer and underwent distal gastrectomy and D2 dissection. Postoperative pathological diagnosis was gastric MANEC, T1b2, N1, M0, Stage ⅠB. Oral administration of S-1 was started as postoperative adjuvant chemotherapy, but he was very tired and ended in 1 course at his request. Computed tomography 6 months after the operation revealed multiple liver metastases, and he was transferred to best supportive care at his request. He died 1 year after surgery. We experienced 2 valuable cases of gastric MANEC.

[A Case of Pancreatic Body Cancer with Peritoneal Dissemination Followed Up for 15 Months without Recurrence].

A 72-year-old woman was admitted to the gastroenterology division of our hospital due to abdominal pain and vomiting. Dynamic contrast-enhanced CT showed a tumor at the body of the pancreas and main pancreatic duct dilation. She was diagnosed with carcinoma of the body of the pancreas via EUS-FNA. There was no vascular invasion or distant metastasis on preoperative imaging. She was introduced to the Gastrointestinal Surgery division where a mesenteric nodule was found at the time of the surgery. Intraoperative frozen section confirmed the diagnosis of occult peritoneal metastases. After consulting with her family, we completed the pancreatosplenectomy. On histopathological examination, this case was TS2, tub2, pT3, mpd0, S1, RP1, PV0, A0, PL0, OO0, N0, M1(PER), CY1, PCM0, DPM0, R1, stage Ⅳ. After the operation, we treated the patient with gemcitabine(GEM)plus nab-paclitaxel for 3 months(4 courses). She then developed side effects such as anorexia and tiredness. After discussing with the patient, chemotherapy was discontinued. The patient remains alive without recurrence 19 months after the operation. Patients with metastatic pancreatic adenocarcinoma have poor prognoses because they are no longer candidates for surgical therapy. We encountered a case of pancreatic body cancer with peritoneal dissemination, followed up for 15 months without recurrence.

[A Case of Synchronous Triple Cancer of the Stomach, Intrahepatic Bile Duct, and Prostate].

A 73-year-old man presented with the chief complaint of hematemesis(bloody vomiting). Upon examination, he was diagnosed as having gastric cancer with liver metastasis. He consulted our hospital for a second opinion. Gastrointestinal endoscopy showed a 50 mm early stomach cancer. Contrast-enhanced CT showed a progressive contrast-enhanced tumor in the S7 segment of the liver. FDG-PET/CT showed increased FDG uptake in the prostate. High PSA levels were also observed. He was diagnosed as having gastric cancer and prostate carcinoma. Intrahepatic cholangiocarcinoma and metastatic liver cancer were mentioned as differential diagnoses of the liver tumor. Hormonal therapy for prostate carcinoma failed to reduce the size of the liver tumor. PSA staining of the liver biopsy revealed negative results. As gastric cancer rarely metastasizes, metastatic liver cancer was unlikely. The patient was diagnosed as having intrahepatic cholangiocarcinoma. He underwent distal gastrectomy with hepatic posterior sectionectomy. The treatment strategy for multiple cancers depends on the primary lesion and the stage of cancer progression. Therefore, adequate evaluation is necessary before initiating treatment.

[A Case Report of a Patient Over 90 Years of Age with Liver Metastasis after Sigmoid Colectomy Controlled by a Combination Oral UFT/LV Chemotherapy Regimen].

A92 -year-old woman underwent laparoscopic sigmoid colectomy with D3 lymphadenectomy. Histological examination confirmed a pT3(SS), pN0, pM0, pStageⅡ tumor. Abdominal CT 6 months after surgery revealed liver metastasis close to the right branch of the portal vein in the S6 region of the liver. There were no indications for transcatheter arterial embolization, radiofrequency ablation, or hepatectomy. Although she had Grade 3 neutropenia, the patient received 15 courses of oral UFT/LV. Three courses of UFT/LV plus bevacizumab were also administered. She was judged to have achieved stable disease (SD); however, Grade 4 proteinuria was observed. After she was administered 2 courses of TAS-102, we shifted to best supportive care. She died of a sigmoid cancer 32 months after UFT/LV initiation. Careful adaptation of chemotherapy can be used to control a patient's condition during certain periods, even in patients with super-advanced age.

[A Case Report of Chylous Ascites after Laparoscopic Sigmoid Colectomy Treated with Conservative Therapy].

A man in his sixties with a medical history of diabetes and dyslipidemia was detected with a tumor with massive submucosal invasion on colonoscopy. He was diagnosed with sigmoid cancer and underwent laparoscopic sigmoid colectomy with D3 lymph node dissection. An electric surgical knife and an ultrasonically activated device was used to perform D3 lymph node dissection with preservation of the left colic artery(LCA)and division of the S1A and S2A. On postoperative day 4(POD4), 1 day after oral intake was started, chylous ascites began to develop. Owing to the small volume of ascites, oral feeding was continued, and chylous ascites was treated successfully with a low-fat diet. Chylous ascites immediately reduced on POD6, after which the drain was removed on POD7. He was discharged on POD9. Fasting and complete parenteral nutrition are not necessarily required in the treatment of chyle leakage after laparoscopic colorectal cancer surgery.

[A Case of Ruptured Gastrointestinal Stromal Tumor of the Stomach with Intraabdominal Bleeding].

A 50s man visited our hospital because of abdominal pain that initiated 1 day prior. An approximately 4.0×5.0×4.5c m tumor, which was in contact with the greater curvature of the gastric body, was detected on contrast-enhanced computed tomography. He was diagnosed with a ruptured gastrointestinal stromal tumor and underwent emergency surgery. During the operation, about 250mL of bloody ascites and a ruptured tumor measuring 6-7 cm in size was observed in the middle of the gastric body. Partial gastrectomy was performed. The histopathological diagnosis was GIST of the stomach. In the gene search, PDGFR-a mutation D842V was detected in exon 18. Therefore, he is undergoing a follow-up examination without postoperative adjuvant therapy even though he is classified as high-risk. Currently, the patient has survived for 8 months after surgery without recurrence. We should perform careful follow-up of the patient.

Anatomical variations of liver blood supply in patients with pancreaticobiliary maljunction.

PURPOSE: Pancreaticobiliary maljunction (PBM) arises from a developmental abnormality during the embryonic period; thus, these patients may have anatomical variations of the liver blood supply, including aberrant vessels and unusual locations. METHODS: We reviewed retrospectively the vascular anatomy of 52 patients with PBM, who were seen between 1998 and 2013. RESULTS: There were 11 male patients and 41 female patients. Sixteen patients had bile duct type (C-P type) PBM, 35 had pancreatic duct type (P-C type) PBM, and one had complex type PBM. Thirty-three patients had biliary dilatation. Nine (17.3 %) patients had an aberrant (replaced or accessory) hepatic artery and 2 (3.8 %) had an aberrant portal vein. Among 39 patients evaluated by contrast-enhanced computed tomography, 8 (20.5 %) had their right hepatic artery positioned on the ventral side of the common bile duct. The presence of aberrant hepatic vessels was not related to the type of confluence, biliary dilatation, type of Todani classification, or associated biliary malignancies. CONCLUSIONS: The incidence of the right hepatic artery being located on the ventral side of the common bile duct may be higher in patients with PBM than the naturally occurring incidence of about 10 % in the general Japanese population.

Preoperative bile replacement improves immune function for jaundiced patients treated with external biliary drainage.

BACKGROUND: Although preoperative biliary drainage in jaundiced patients is controversial, external biliary drainage (EBD) is beneficial for infection control in patients with biliary cancers. When EBD is performed, additional bile replacement (BR) has the benefit of improving impaired intestinal barrier function, but the detailed mechanism remains unknown. We examined the effect of bile replacement on immune functions over the duration of BR in jaundiced patients. METHODS: Fifteen patients were enrolled into this prospective study. BR was started soon after the total serum bilirubin concentration reached 5.0 mg/dl and was continued for 14 days. Drained bile was given two times orally (2 × 100 ml/day). Concanavalin A (Con A)- and phytohemagglutinin (PHA)-stimulated lymphocyte proliferation and serum diamine oxidase (DAO) activity were measured before starting and during BR. Twenty patients with EBD and no BR were analyzed as a control group. RESULTS: Serum liver enzymes, prothrombin time-international normalized ratio (PT-INR), and responses to Con A and PHA gradually improved over the 14 days of BR, but percentages of lymphocytes and DAO levels did not. PT-INR, and Con A and PHA responses did not improve during EBD in the control group. PT-INR significantly decreased in patients with a greater fraction of their drained bile replaced. CONCLUSIONS: Our results indicate that preoperative BR using as large a quantity of bile as possible is useful for improving blood coagulability and cellular immunity in patients with EBD.

Establishment of a novel cell line from intraductal papillary neoplasm of the bile duct.

BACKGROUND: Intraductal papillary neoplasm of the bile duct (IPNB) is a novel and increasingly-occurring disease. Its characteristics remain uncertain because of the lack of an in vitro culture system. We established and characterized a novel cell line from a human IPNB. MATERIALS AND METHODS: We obtained tumor tissue from a surgical specimen from a patient with IPNB. Cells were primary co-cultured with mouse stromal cells in serum-free medium. Tumor characteristics were compared among the primary IPNB, established cell line, and xenograft. RESULTS: We successfully established an IPNB cell line. We temporary termed this cell line Kobe Bile Duct Cancer (KBDC)-11. Xenograft formed a tumor which had ductal structures and mucus production as the primary tumor did. Overexpression of p53, MUC staining pattern, and CD133 expression were common among the primary IPNB, KBDC-11, and the xenograft. CONCLUSION: This novel cell line established from IPNB exhibited the same features as IPNB and might contribute to studies of IPNB and its process of malignant transformation.

Factors affecting survival after resection of intrahepatic cholangiocarcinoma.

PURPOSE: This study aimed at assessing the prognostic factors of resection of intrahepatic cholangiocarcinoma (IHCC), which remain unclear. METHODS: Among 70 patients with IHCC, who were admitted to our hospital between 1998 and 2011, 45 (64 %) underwent resection and 25 had unresectable tumors. Univariate and multivariate analyses were conducted retrospectively to assess the factors influencing survival of the patients who underwent resection. RESULTS: The median survival times of the patients who underwent resection versus those who did not were 16 months versus 9 months, respectively (P < 0.001). Multivariate analysis identified residual tumor status (relative risk 4.12, P = 0.04) and pathological differentiation (relative risk 5.55, P = 0.04) as independent factors predicting survival. Patients who underwent R1 resection had a significantly higher rate of local recurrence than those who underwent R0 resection (P = 0.008). With R0 resection, there were no significant differences in patterns and rates of recurrence between patients with narrow (≤ 5 mm) versus wide (>5 mm) surgical margins. CONCLUSIONS: R0/1 resection and a well-differentiated tumor were found to be independent prognostic factors for long-term survival after IHCC resection. If R0 resection was achieved, the width of the negative surgical margin did not affect the patterns and rates of recurrence.

Curative resection of hilar cholangiocarcinoma in a 25-year-old woman: report of a case.

A 25-year-old woman was referred to our hospital with persistent upper abdominal pain. Preoperative imaging studies revealed a hilar bile duct stricture with portal venous encasement, and the patient underwent curative resection involving extended left hepatectomy and segmental portal vein resection. The pathological findings demonstrated a well-differentiated tubular adenocarcinoma of the bile duct with regional lymph node metastasis (stage IIIB according to the UICC TNM classification), as well as the overexpression of p53 proteins and the K-ras gene mutation in tumor cells. The patient has shown no evidence of recurrence in the 10 months since the operation. Although there are several reports of relatively young adults with cholangiocarcinoma, the majority of such patients demonstrate either an anomalous arrangement of the pancreaticobiliary duct system or primary sclerosing cholangitis. The absence of any morphological abnormalities in this patient's biliary system implicates de novo carcinogenesis as the most likely cause of the cholangiocarcinoma.

[Re-resection for recurrent intrahepatic cholangiocarcinoma].

INTRODUCTION: The benefits of re-resection for recurrent intrahepatic cholangiocarcinoma (IHC) are unknown. PATIENTS AND METHODS: We evaluated the comparative efficacy of different treatment schema for recurrent IHC following curative resection. RESULTS: Among 46 patients, 26 underwent R0 resection, while 20 underwent R1 resection. There were 13 cases of recurrence in R1 patients (65%), and 19 in R0 patients (61%). Recurrent IHC cases were divided into 3 groups based on the treatment received after recurrence: re-resection (n=5), chemotherapy (n=13), and best supportive care (BSC) (n=8). Survival times were evaluated for each group; median survival times (MSTs) after recurrence were 26, 14, and 4 months for the re-resection, chemotherapy, and BSC groups, respectively (p=0.030). Next, we examined the patients who only had intrahepatic recurrence; MSTs after recurrence for re-resection, chemotherapy, and BSC groups were 26, 14, and 5 months, respectively (p=0.0018). CONCLUSION: In recurrent IHC, survival time improves with re-resection or chemotherapy, when compared to BSC. In patients with intrahepatic recurrence only, re-resection is especially effective in prolonging survival.