[A Case of Primary Liver Cancer and Gastric Glomus Tumor Diagnosed Preoperatively and Treated with Liver Segmentectomy and Local Gastrectomy].

A man in his 70s was concurrently suspected of having a submucosal tumor(SMT)of the stomach and a liver tumor during a medical examination. Abdominal contrast-enhanced CT scan revealed S8 hepatocellular carcinoma(HCC)and an SMT of the stomach, which was strongly enhanced from the early to the later phase. Upper gastrointestinal endoscopy revealed a 20 mm SMT in the antrum of the stomach. Endoscopic ultrasonography showed a hyperechoic tumor in the fourth layer of the gastric wall. T2-weighted MRI showed a 25 mm SMT in the antrum of the stomach with a faint high signal intensity compared with that of the gastric wall. The patient was diagnosed with HCC and gastric glomus tumor, and a liver segmentectomy and a local gastrectomy were performed. Immunohistochemistry of the SMT revealed the expression of α-SMA but no expression of desmin, c-kit, CD34, or S-100. Therefore, a diagnosis of a Glomus tumor of the stomach was made. Gastric Glomus tumors are very rare; therefore, we have reviewed some citations and would like to discuss our case.

[A Case of Small Thymic Carcinoma with Pleural Dissemination Preoperatively Suspected as Pulmonary Metastasis from Rectal Cancer].

A case was 73-year-old man, who had history of laparoscopic high anterior resection surgery for rectal cancer, followed by adjuvant chemotherapy 2 years ago. Preoperative diagnosis was anterior mediastinal tumor, with multiple intrapulmonary nodules noted, though no increasing tendency. During adjuvant chemotherapy for colorectal cancer, the anterior mediastinal tumor showed some shrinkage, while that and 3 intrapulmonary nodules slowly increased in size after completion, thus rectal cancer pulmonary and mediastinal metastasis were suspected. Complete resection of the intrapulmonary nodules and anterior mediastinal tumor was considered feasible. Thoracoscopic observation revealed multiple small pleural seeding lesions and all speculated to be intrapulmonary metastases before surgery were also pleural lesions. Intraoperative rapid diagnostic findings of a biopsy section revealed possible colorectal cancer metastasis, though histological type was not revealed. Final histopathological diagnosis was pleural dissemination of thymic carcinoma. Lenvatinib was introduced 2 months later for thymic carcinoma with pleural dissemination. Two years after surgery, the anterior mediastinum primary tumor had slightly decreased and the pleural nodules also showed a shrinking tendency. In such cases of small tumor with increasing tendency and irregular margins, thymic carcinoma should be considered when planning treatment.

[A Case of Hypertrophic Pulmonary Osteoarthropathy Associated with Pulmonary Pleomorphic Carcinoma].

Hypertrophic pulmonary osteoarthropathy(HPO)is a tumor-associated syndrome that features the triad of clubbed fingers, periosteal bone growth in long bones, and arthritis, and is often associated with an adenocarcinoma or squamous cell carcinoma. This report presents details of a case of HPO associated with pleomorphic carcinoma, which was relieved by treatment. A 47-year-old woman was presented with a complaint of generalized arthralgia. A physical examination showed swollen joints in the body and clubbed fingers. Chest CT revealed a mass shadow in the left upper lobe and ultrasound- guided biopsy findings led to a diagnosis of non-small cell lung cancer. Furthermore, bone scintigraphy indicated symmetrical accumulation in bones and joints throughout the body. A right upper lobectomy was performed along with combined chest wall resection and mediastinal lymph node dissection with an open chest, and the presence of lung cancer complicated with HPO was indicated. Pathological examination results revealed a diagnosis of pleomorphic carcinoma(pT4N0M0, Stage ⅢA). Systemic arthralgia was resolved on the first postoperative day. One year after surgery, a solitary brain metastasis developed and was removed, with no recurrence at the time of writing. Joint symptoms related to HPO can be expected to improve with treatment of pulmonary lesions, thus aggressive procedures for diagnosis and treatment are desirable.

[Two Cases of Recurrent Colon Cancer with BRAF Mutation].

We report 2 cases of recurrent colon cancer with BRAF mutation. Case 1, a 75-year-old man, had rapid progress of multiple liver metastasis 5 months after curative resection, and died on 37 days after recurrence without induction of systemic therapy. Case 2, a 67-year-old man with diagnosis of peritoneal dissemination at 8 months after curative resection, received encorafenb and cetuximab (doublet-therapy) with certain effect, nevertheless advanced triplet-therapy with binimetinib was forced to pause due to severe skin disorders and he died on 123 days after recurrence. We considered that closed follow- up should be required after curatively resected colorectal cancers with BRAF mutation for early detection of recurrence, and prompt induction and evaluation of systemic treatment also should be required after unresectable recurrence including careful management with the attention to the features of doublet and triplet-therapy.

[Could Preoperative Conditions Be Preserved or Improved by the Support of Preoperative ONS Administration in Patients with Gastric Cancer?]

INTRODUCTION: In our hospital, we measure the body composition of patients undergoing gastrointestinal surgery. For patients who have a skeletal muscle mass(SMM)of less than 90% of the ideal, we provide them with guidance on having oral nutritional supplements(ONS)and self-exercise therapy. Therefore, we perform operations after taking measures on preserving/improving patient's preoperative conditions. This study was aimed to evaluate the effects on body weight, SMM, and fat mass(FM)in the patients scheduled for gastrectomy. PATIENTS AND METHODS: From January 2017 to December 2020, we retrospectively analyzed 64 gastric cancer patients whose body composition changes were measured at the time of initial diagnosis and immediately before surgery. The body composition was measured by a nutritionist using the BIA method, while the self-exercise therapy was instructed by a rehabilitation therapist. RESULTS: A total of 64 patients were divided into 2 groups: ONS group(36 patients)and Non-ONS group(28 patients). The median preoperative ONS administered to the ONS group was 15 packs. Body weight change showed a significant difference between the 2 groups(+0.73% and -0.91%[p<0.01]in the ONS group and Non-ONS group respectively). SMM change showed no significant difference between the 2 groups(+1.18% and +0.64%[p=0.19]in the ONS group and Non-ONS group respectively). Likewise, FM change showed no significant difference between the 2 groups(-1.08% and -3.50%[p=0.39]in the ONS group and Non-ONS group respectively). CONCLUSION: This study suggested that SMM and FM could be preserved, and body weight could be increased by the support of preoperative ONS administration even in patients with gastric cancer close to having sarcopenia.

[A Case of Rectal Neuroendocrine Tumor with a Major Axis of 10.7 mm with Lymph Node Metastasis].

The case is a 50-year-old woman. Colonoscopy performed by a local doctor for the purpose of stool occult blood positive revealed a 15 mm tumor in the lower rectum, biopsy showed chromogranin positive, synaptophysin positive, and Ki-67 index<1% showed a neuroendocrine tumor(NET), G1 was diagnosed and introduced. Colonoscopy revealed a smooth- surfaced circular hemispherical tumor with a lower edge 30 mm from the anal margin and 20 mm from the dentate line, and EUS showed 10.7×5.2 mm in layers 2 to 3. It was visualized as a well-defined hypoechoic tumor. Contrast-enhanced CT examination showed a 12×5 mm mass showing a contrast-enhancing effect, and no lymphadenopathy or distant metastasis was observed. Contrast-enhanced MRI showed no evidence of pelvic lymphadenopathy. Based on the above, it was diagnosed that NET, G1, and infiltration to the submucosa exceeding 10 mm. Although endoscopic resection as a diagnostic treatment was also an option, we determined surgical resection policy, therefore we performed laparoscopic rectal intersphincteric resection and upper D2 dissection. Histopathological findings showed a tumor of 11×8 mm infiltrating the submucosa( 5,000µm)with metastasis to the pararectal lymph nodes, and the diagnosis was T1b, N1, Ki-67 index 3%, Ly1, V1a, NET G2, pStage ⅢB. Her postoperative course was uneventful, and 6 months later, we performed her artificial anal closure. One year after the operation, there are frequent bowel movements but no fecal incontinence and she is alive without recurrence. For rectal NET with a tumor diameter of 10 mm or more, radical surgery with dissection is recommended because of the high risk of lymph node metastasis. In this case lymph node metastasis was observed surgical resection according to the above reason, but endoscopic resection was possible except that the preoperative size exceeded 10 mm to 0.7 mm and the distance from the anus was short, therefore it took some thought to decide the policy.

Effects of Daikenchuto on postoperative gastrointestinal motility in colorectal carcinoma patients with abdominal pain and distension: a prospective, randomized trial.

PURPOSE: To investigate the efficacy and safety of Daikenchuto (DKT) for colorectal cancer patients undergoing surgery with the potential risk of postoperative ileus (POI). METHODS: Colorectal cancer patients with abdominal pain and distention, scheduled for surgery, were randomly assigned to a DKT group or a control group. Patients assigned to the DKT group were given 15 g of DKT per day during the perioperative period. We then compared the perioperative gastrointestinal symptoms between the two groups. RESULTS: The aim for a sample size of 30 patients per group was not reached in time, so we conducted an analysis on 16 patients in each group. The visual Analogue Scale scores for abdominal pain and distention were similar in the two groups. The number of bowel movements per day on postoperative days (PODs) 1, 2, and 6 were significantly lower in the DKT group. The incidence of a sensation of incomplete bowel evacuation on PODs 3 and 28 was also significantly lower in the DKT group. There were no adverse events thought to be related to DKT. CONCLUSIONS: DKT could potentially inhibit diarrhea and reduce the number of bowel movements per day and the sensation of incomplete bowel evacuation after colorectal surgery. Thus, the perioperative use of DKT may be safe for colorectal cancer patients with abdominal pain and distention, who undergo surgery.

[A Case of Cytomegalovirus Reactivation after Chemoradiotherapy for Esophageal Cancer].

An 80-year-old man visited our hospital because of abdominal distension and epigastralgia. He was diagnosed esophageal cancer(Mt, SCC, T3N0M0, Stage Ⅱ). Because he was elderly, he received chemoradiotherapy(CRT)with S-1. At 54 Gy/27 Fr, he was admitted to the hospital because of cough exacerbation, fever, and food intake loss. A chest and abdominal CT showed a pneumonia pattern. First, antibiotics were started for suspected bacterial pneumonia. Nevertheless, elevation of inflammatory reactions and continuous fever were observed. As interstitial pneumonia was suspected, we started to administer an injection of prednisolone 60 mg. His respiratory symptoms were improved. However, we observed that disseminated erythema of the trunk spread throughout the body and liver enzymes further increased. As blood examination revealed elevated CMV-IgG antibody and C7-HRP positive, we diagnosed cytomegalovirus(CMV)reactivation. Administration of ganciclovir improved liver damage and disseminated erythema. He discharged our hospital while the steroid dose was reduced and valganciclovir continued administrating. The therapeutic effect of esophageal cancer was partial response(PR). We are following his symptoms and CT scan while adjusting the steroid dose. This is a rare case of CMV reactivation due to immunosuppression caused by steroids therapy during CRT against esophageal cancer. We should be aware of CMV infection during CRT and steroid therapy.

[Indication of Palliative Gastrojejunostomy for Unresectable Advanced Gastric Cancer with Obstruction from the View Point of Preoperative Inflammatory Biomarkers].

Palliative surgery for advanced gastric cancer with serious symptoms such as hemorrhage or obstruction may be meaningful in the point of improving quality of life(QOL). However, the meaning of palliative gastrojejunostomy for unresectable gastric cancer with obstruction is controversial. We retrospectively evaluated the effectiveness of gastrojejunostomy for unresectable gastric cancer with obstruction using preoperative inflammatory biomarkers. Blood lymphocyte monocyte ratio(LMR), neu- trophill ymphocyte ratio(NLR)and C-reactive protein/albumin ratio(CAR)were analyzed as inflammatory biomarkers in this study. The percentage of improvement in food intake, discharge from the hospitaland performance of chemotherapy were significantly higher in the patients without any preoperative inflammatory reaction compared to those with any inflammation. Moreover, the survival of the patients without any inflammatory change was significantly longer compared to those with any inflammation. In conclusion, preoperative status of inflammation may be a useful marker to predict the effect and outcome of palliative gastrojejunostomy for unresectable gastric cancer with obstruction. Especially when there is any inflammation, the surgical indication should be carefully judged.

[Three Cases of Advanced Gastric Cancer with Peritoneal Dissemination Successfully Treated with S-1 and Docetaxel Combination Chemotherapy].

Case 1: A 74-year-old man underwent total gastrectomy for gastric cancer, but peritoneal dissemination(P1c)was con- firmed intraoperatively in July 2011. Postoperatively, S-1/docetaxel(DTX)combination chemotherapy was administered; after 32 courses of treatment, S-1 was continued as monotherapy. However, in November 2013, CT scan showed a portal vein tumor. We modified the chemotherapy regimen, but he died 3 years and 7 months after the operation. Case 2: A 77-year-old man underwent distal gastrectomy for gastric cancer with peritoneal dissemination(P1b)in September 2013. He was treated with S-1/DTX/trastuzumab(Tmab)combination chemotherapy. After 5 courses of treatment, S-1was continued as monotherapy until October 2015. He has since survived without recurrence. Case 3: A 75-year-old woman was diagnosed with gastric cancer with peritoneal dissemination(P1c)by laparotomy in September 2014. She was treated with S-1/DTX combination chemotherapy. After 23 courses of treatment, chemotherapy was discontinued according to the patient's wish. She died 2 years and 6 months after the surgery. We suggest S-1/DTX combination chemotherapy as an option for advanced gastric cancer with peritoneal dissemination.

[Experience of Perioperative Status for Super Elderly Colorectal Patients in Our Facility].

We examined the perioperative situation according to estimation of physiologic ability and surgical stress(E-PASS)score of 35 colon cancer patients aged 85 years or older who underwent operation in our facility. The incidence of Grade 2 and Grade 3 complications according to Clavien-Dindo classifications increased with age. The preoperative risk score(PRS)also increased with age; however, the surgical stress score(SSS)did not. The comprehensive risk score(CRS)also increased with age. Because the PRS was already high in these elderly patients, since 2016, we implemented methods to lower the SSS to reduce patient risk, including decreasing the operative time and increasing the laparoscope rate. Compared to before these efforts, the SSS decreased, resulting in a reduced incidence of Grade 3 complications.

[A Difficult Case of Invagination of the Protruding Colon Cancer].

A 88-year-old female suffered of ileus due to advanced transverse colon cancer. Pneumonia was observed and nutrient condition was bad. Operation was found to be difficult because of the bad condition with complication on this present time. Self-expandable metallic stent(SEMS)was inserted to extend obstruction. But SEMS dropped out next day and SEMS, thicker than previous one, was reinserted. Main tumor was huge protruding tumor and the reason of ileus was invagination of the cancer. The fixation of SEMS was not so good, but the generalcondition was improved while a week after reinsertion of SEMS. Laparoscopic colon partial resection was performed safely. Bridge to surgery with SEMS for the case of invagination of protruding colon cancer was thought to be useful.

[A Case of Surgical Treatment of Pulmonary Metastasis from Gastric Cancer].

An 87-year-old woman was diagnosed with advanced gastric cancer and primary lung cancer in November 2012. She underwent distal gastrectomy for the gastric cancer in December 2012, and right upper wedge resection for the primary lung cancer in February 2013. After surgery, the patient received S-1 chemotherapy. However, she subsequently experienced adverse effects, and so S-1 chemotherapy was stopped. In February 2016, a computed tomographic scan of the chest showed a nodular shadow at S8 in the left lung. Because the nodular shadow gradually increased in size, we suspected that the diagnosis would be either primary lung cancer or metastatic lung cancer arising from gastric cancer. In July 2016, we performed left lower wedge resection. Histopathological examination of the resected specimen resulted in a diagnosis of metastatic lung cancer arising from gastric cancer. After pulmonary resection, the patient had no recurrent tumor. It is thought that surgery is an effective treatment for solitary pulmonary metastasis arising from gastric cancer.

[Liver Metastases from Pancreatic Neuroendocrine Tumor(P-NET)Treated with Surgery and Chemotherapy].

Pancreatic neuroendocrine tumor(P-NET)often involve liver metastases. We report a 52-year-old woman who underwent distal pancreatectomy for a pancreatic body tumor with a diameter of 8 cm. The pathological findings were P-NETG2 . After 1 year 6 months, a liver metastasis was detected. We performed partial hepatectomy. The pathological findings showed a Ki-67 index of 23%. After surgery, CPT-11 plus CDDP therapy and AMR therapy were administered. CONCLUSION: Multimodal therapies should be considered for P-NETliver metastases based on the Ki-67 index.

[A Case of Successful Treatment of Liver Metastases from Gastric Cancer with Chemotherapy].

A 69-year-old man was diagnosed with advanced gastric cancer accompanied by multiple liver metastases in April 2009. Because of worsening anemia due to bleeding from the primary tumor, we performed a distal gastrectomy. After gastrecto- my, he underwent S-1/CDDP combination chemotherapy. After 5 courses of chemotherapy, the size of the liver metastases was reduced. S-1/irinotecan combination chemotherapy was administered as second-line chemotherapy, but he developed grade 3 diarrhea, and the S-1/irinotecan combination chemotherapy was immediately stopped.Weekly paclitaxel chemother- apy was administered as third-line chemotherapy, and S-1/docetaxel combination chemotherapy was administered as fourth-line chemotherapy. After 11 courses of S-1/docetaxel combination chemotherapy, the liver metastases could not be detected by CT and PET-CT in October 2012, and it was concluded that a complete response(CR)had been obtained. He receive maintenance therapy with S-1 chemotherapy for 10 months. Now, he is alive without chemotherapy and has maintained a CR for 4 years 8 months after achieving a CR.

[Three Cases of Gastric Cancer with Rare Presentation of Oncologic Emergency].

We report 3 cases of gastric cancer with rare presentations of oncologic emergency. Case 1 involved cardiac tamponade caused by mediastinitis-induced pericarditis. Metastatic lymph nodes became enlarged after total gastrectomy and invaded the esophagojejunal anastomotic region. Then, a fistula to the mediastinum occurred, resulting in mediastinitis. The drainage was efficacious, but the patient died of cancer 1 month after admission. Case 2 involved cardiac tamponade caused by invasion of metastatic peritoneal tumor into the pericardium. The drainage was successful, but the patient died of cancer 2 weeks after drainage. Case 3 involved perforation of the stomach during the third course of chemotherapy. A total gastrectomy was urgently performed. Thereafter, chemotherapy was continued. However, the patient died of cancer 6 months later. These oncologic emergencies should be considered, although they are rare.

Multiple hepatic sclerosing hemangioma mimicking metastatic liver tumor successfully treated by laparoscopic surgery: Report of a case.

INTRODUCTION: Hepatic sclerosing hemangioma is a very rare benign tumor, characterized by fibrosis and hyalinization occurring in association with degeneration of a hepatic cavernous hemangioma. We report here a rare case of multiple hepatic sclerosing hemangioma mimicking metastatic liver tumor that was successfully treated using laparoscopic surgery. PRESENTATION OF CASE: A 67-year-old woman with multiple liver tumors underwent single-incision laparoscopic sigmoidectomy under a diagnosis of advanced sigmoid cancer with multiple liver metastases. Examination of surgical specimens of sigmoid colon revealed moderately differentiated adenocarcinoma invading the serosa, and no lymph node metastases. Serum levels of carcinoembryonic antigen and carbohydrate antigen 19-9 remained within normal limits throughout the course. Two months after sigmoidectomy, the patient underwent laparoscopic partial hepatectomy of S1 and S6 of the liver and cholecystectomy. Histopathological examination showed that the tumors mainly comprised hyalinized tissue and collagen fibers with sporadic vascular spaces on hematoxylin and eosin-stained sections, yielding a diagnosis of multiple hepatic sclerosing hemangioma. No evidence of recurrence has been seen as of 21 months postoperatively. DISCUSSION: Differentiating multiple sclerosing hemangiomas from metastatic liver tumors was quite difficult because the radiological findings were closely compatible with liver metastases. Laroscopic hepatectomy provided less blood loss, a shorter duration of hospitalization, and good cosmetic results. CONCLUSION: Sclerosing hemangioma should be included among the differential diagnoses of multiple liver tumors in patients with colorectal cancer. Laparoscopic hepatectomy is useful for diagnostic therapy for undiagnosed multiple liver tumors.

Cyclin-Dependent Kinase Activity Correlates with the Prognosis of Patients Who Have Gastrointestinal Stromal Tumors.

BACKGROUND: The estimation of recurrence risk remains a critical issue in relation to gastrointestinal stromal tumors (GISTs) treated with adjuvant therapy. The accuracy of the commonly used risk stratifications is not always adequate. METHODS: For this study, data were prospectively collected from 68 patients with GISTs who underwent R0 surgery between 2004 and 2009. The results from this analysis cohort were evaluated using the data obtained from an additional 40 patients in the validation cohort. Cyclin-dependent kinase 1 (CDK1)- and CDK2-specific activities were measured using a non-RI kinase assay system. RESULTS: The specific activities of CDK1 and CDK2, but not their expression, significantly correlated with recurrence. The specific activities of both CDK1 and CDK2 were independently correlated with mitosis and significantly correlated with recurrence-free survival (RFS). In the multivariate analysis, CDK2-specific activity (P = 0.0006), tumor size (P = 0.0347), and KIT deletion mutations (P = 0.0006) were significantly correlated with RFS in the analysis cohort. In the validation cohort, CDK2-specific activity (P = 0.0368) was identified as an independent prognostic factor for tumor recurrences with tumor location (P = 0.0442). CONCLUSION: The results suggest that the specific activities of CDK1 and CDK2 may reflect the proliferative activity of GISTs and that CDK2-specific activity is a good prognostic factor predicting recurrence after macroscopic complete resection of GISTs.

Single-incision laparoscopic totally extraperitoneal obturator hernia repair in a patient on antiplatelet therapy: a case report.

An 83-year-old woman who complained of right lower limb discomfort was diagnosed with a right obturator hernia by CT scan. On examination, she had a soft and flat abdomen without signs of peritoneal irritation. The Howship-Romberg sign was present. She had a history of vasospastic angina and paroxysmal supraventricular tachycardia, and took aspirin and dipyridamole until she was admitted to the hospital. Exploratory laparoscopy identified a spontaneously reduced small bowel from the right obturator canal, but there were no signs of ischemic and necrotic bowel. The patient underwent SILS for totally extraperitoneal obturator hernia repair without a dissection balloon. The patient recovered without perioperative complications such as hemorrhage and thrombotic episodes. She remains well, and CT scans showed no signs of obturator hernia recurrence at the 7-month follow-up.

[A Case of Successful Treatment of Metachronous Liver Metastasis from Gastric Cancer with Hepatectomy].

A 77-year-old man was found to have advanced gastric cancer and underwent total gastrectomy (pT4aN2H0P0M0, Stage ⅢB). Two years after gastrectomy, we found an elevated tumor marker level, and a liver metastasis appeared in segment 5 (20 mm in diameter). He was treated with S-1/CDDP combination chemotherapy. After 2 courses of chemotherapy, the tumor marker level kept rising and a CT scan detected a progressive tumor. S-1/irinotecan combination chemotherapy was administered as second-line chemotherapy. After 6 courses of chemotherapy, the size of the liver metastasis was reduced and the tumor marker level normalized. Because lymph node metastasis or peritoneal recurrence was observed, a partial resection of the liver (S5) was performed. After the operation, he was treated with S-1 chemotherapy again for 1 year and has had no recurrence.