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A 39-year-old woman visited our hospital with complaints of nausea, vomiting, and lower abdominal pain for 2 weeks. Abdominal CT revealed thickening of the transverse colonic wall, dilated bowel, and a metastatic ischemic tumor in the liver (S7). We diagnosed her with obstructive colon cancer, clinical Stage Ⅳa(T, type 2, cT3, N0, M1a[liver]). At first, we placed a self-expanding metallic stent(SEMS)to decompress bowel obstructions. We planned a surgical resection of the primary tumor followed by partial resection of the liver. We performed a laparoscopic right hemicolectomy(D3)24 days after the stenting. Pathologically, we diagnosed her with BRAF-mutated colon cancer, pStage Ⅳa(pT4a, N1b[2/43], M1a[liver]). On completion of 4 courses of mFOLFOXIRI and bevacizumab, we confirmed a reduction of the S7 tumor but found a new tumor in S6. Since the tumors were potentially resectable, we performed partial liver resection(S6, S7)1 month later. A month following the hepatectomy, CT revealed a new tumor in S4. The patient has been receiving general chemotherapy (CapeOX and bevacizumab)without disease progression for 6 months. We experienced a challenging case of BRAF- mutated obstructive colon cancer with liver metastases.

We report 2 cases of neuroendocrine carcinoma(NEC)of colon and rectum with distant metastasis. The treatment of NEC with distant metastasis is based on the treatment of small cell lung cancer, but that is controversial because NEC is relatively rare. Case 1: A 75-year-old man who was admitted for anal pain. Physical examination showed the anal tumor and swelling inguinal lymph nodes. CT showed rectum tumor and multiple lymph node metastases to the pelvis and inguinal region. Colonoscopy showed a Type 3 tumor in the rectum. He was diagnosed with NEC based on biopsy and immunostaining. Colostomy was performed for pain relief and etoposide/cisplatin(EP)therapy was introduced. After 6 courses of the chemotherapy, CT showed progression of the tumor, then we made the shift to palliative treatment. Case 2: A 69-year-old man who was admitted for abdominal pain and back pain. CT showed transverse colon tumor with multiple metastases to the liver, lung, and lymph nodes. Colonoscopy showed a circumferential tumor in the transverse colon. He was diagnosed with NEC based on biopsy and immunostaining. He refused chemotherapy and died 2 months later.

A woman in her mid-50's presented to our hospital with jaundice, fatigue, and fever. Jaundice, elevated tumor markers, and lower bile duct stricture suggested malignancy, for which subtotal stomach-preserving pancreaticoduodenectomy was performed. The patient also had annular pancreas as the second part of the duodenum was surrounded by pancreatic parenchyma. The histopathological diagnosis was adenosquamous carcinoma of the duodenal papilla associated with annular pancreas. Adjuvant chemotherapy with TS-1 was administered for 1 year. Although para-aortic lymph node metastasis was detected radiographically 3 years 9 months after surgery, the recurrence remains under control and she is alive at 5 years 9 months after surgery due to multidisciplinary therapy.

We experienced a successful case in which the patient was treated with a combination of operation and transcatheter arterial chemoembolization for a hypervascular tumor of unknown primary origin in the liver; we report this case with a literature review. A 76-year-old man noticed an upper abdominal tumor and he visited our department for detailed examination. Enhanced CT scan showed multiple hypervascular tumors scattered across both lobes of the liver, and the pattern of contrast effect implied that the tumors were primary neuroendocrine tumors or endocrine metastases. Gastroscopy and colonoscopy showed no tumor in the intestine. TACE was performed mainly for the tumors in the right lobe. One month later, we performed left lateral segmentectomy and partial hepatectomy for segment 6. Histopathological findings showed that the tumors in the left lateral segment had neuroendocrine properties, and the tumor in segment 6 was necrosed. One year has passed since the surgery without recurrence of neuroendocrine tumors in the liver or other organs.

A 62-year-old man presented with complaints of acute abdominal pain. Abdominal enhanced CT showed free air in the abdominal cavity, a thickened stomach wall accompanied by deep ulcer, and enlarged lymph nodes around the stomach. Emergent surgery was conducted, and a perforation in the upper part of the stomach was found. Total gastrectomy was performed. On pathological examination, a mucosa-associated lymphoid tissue lymphoma was diagnosed. Histologic examination revealed the absence of Helicobacter pylori in the gastric mucosa. After the operation, adjuvant chemotherapy was not administered. However, he has been well for 11 months without any recurrence. Gastric MALT lymphoma with spontaneous perforation is considered extremely rare. A brief review of the literature is presented.

We report 2 successful cases treated with trans-catheter arterial embolization(TAE)for hemorrhagic shock due to pseudoaneurysm rupture at the primary tumor site in advanced colorectal cancer. Case 1: A 73-year-old female underwent Hartmann surgery at another hospital for rectal perforation and peritonitis. Six months later, she had a massive bloody stool and was transferred to our hospital. She was diagnosed with bleeding from advanced rectal cancer that remained following the first surgery. Contrast computed tomography(CT)showed that a branch of the superior rectal artery(SRA)developed an aneurysm at the primary tumor site, and TAE was performed to stop bleeding on hospital day 3. Case 2: A 79-year-old male with type 2 sigmoid colon cancer and simultaneous multiple liver metastases developed copious blood in the stool before primary tumor resection and was transferred to our hospital. Contrast CT showed that a branch of the SRA developed an aneurysm at the primary tumor site, and TAE was immediately performed to stop bleeding.

A 60-year-old male undergoing pelvic evisceration with D3 lymph node dissection for pR0 in 2006f or carcinoma of the rectum was diagnosed pathologically with moderately differentiated adenocarcinoma, fStage ⅡA(UICC pT3, pN0, M0). Follow-up CT revealed hypovascular liver tumors with intrahepatic bile duct dilation in the right lobe 8 years after the pelvic evisceration. We conducted right lobe hepatectomy. The resected specimens showed that the tumor extended predominantly along the right intrahepatic bile duct. Histological findings and an immunohistochemical examination of CK7, CK20, and CDX2 revealed metastasis of the rectum cancer. We finally diagnosed him with intrahepatic bile duct metastasis from rectal adenocarcinoma.

We report a rare case of a extrarenal retroperitoneal angiomyolipoma. A 64-year-old female visited our hospital because of an abdominal mass in her lower right abdomen. Enhanced CT scan revealed a 67×52mm tumor in lower right retroperitoneal space. MRI revealed adipose component in the tumor on T1 weighted images and T2 weighted images. Our preoperative diagnosis was retroperitoneal liposarcoma, and we performed retroperitoneal tumor resection. At operation the tumor was on the fossa iliaca, which was covered with capsule. It did not invade surrounding tissues. The resected tumor measured 90× 60×45 mm, and tiny hemorrhage was seen in the tumor. Histopathological findings showed that the tumor was composed of a mixture of adipose tissue, vessels, and smooth muscle. Immunohistochemistry demonstrated the tumor was stained with asmooth muscle actin(aSMA). We diagnosed the tumor as extrarenal retroperitoneal angiomyolipoma.

We report a case where resection was performed for pancreatic metastasis from renal cell carcinoma 21 years after nephrectomy. A 72-year-old man had undergone total gastrectomy with distal pancreatomy and splenectomy for gastric cancer, and right nephrectomy for primary renal cell carcinoma in 1993. Incidentally, a CT scan performed in 2014 revealed a tumor in the head of the pancreas. Enhanced MRI suggested that the tumor contained some fat tissue. The tumor in the pancreatic body had sharp margins; therefore, we performed subtotal pancreatectomy. The tumor was considered pancreatic metastasis from renal cell carcinoma. Pathological findings indicated clear-cell type carcinoma(G1-G2), which is very similar to renal cell carcinoma. We diagnosed pancreatic metastasis from renal cell carcinoma. The patient has remained well, with no recurrence 20 months after the pancreatectomy.

We report a case of multiple brain metastases from pancreatic cancer, which had responded remarkably to FOLFIRINOX. A 47-year-old man had hypovascular tumors, 25 mm on the body and 23 mm on the uncus of the pancreas; multiple liver metastases; and skin metastasis. A diagnosis of unresectable pancreatic cancer, cT4N3M1 (HEP, LYM, PUL, SKI), cStage Ⅳb was made. We chose FOLFIRINOX for treatment because of his young age and good performance status. After 6 courses, he showed decreasing tumor marker levels, an almost complete disappearance of the primary lesion, and reduced liver metastases. After 8 courses, abnormal behaviors were noted and we performed a head contrast-enhanced MRI, which revealed diffuse enhancement of the cerebral and cerebellar hemisphere. Multiple brain metastases from pancreatic cancer were diagnosed. We made the shift to palliative treatment, but his general condition was worsening and he died a month later, 7 months after the first diagnosis.

The patient was a 73-year-old woman with hematemesis, who was brought to our hospital by an ambulance. Emergency upper gastrointestinal endoscopy was performed, and a thickened wall and multiple ulcers were noted in the middle- lower region of the stomach body. The biopsy revealed gastric cancer (por), and the macroscopic depth of invasion was up to the subserosal layer. Multiple white granular protruding lesions were observed in the duodenal bulb and were diagnosed as follicular lymphoma by biopsy. As follicular lymphoma generally takes a long time to progress in many cases, the vital prognosis would be determined by the gastric cancer. Thus, total gastrectomy was performed for gastric cancer. For reconstruction, the double-tract method was used. Duodenal follicular lymphoma was continuously monitored by upper gastrointestinal endoscopy. Here, we describe the case of a patient with a complication of follicular lymphoma arising from duodenal and gastric cancer, which is very rare, and report this case along with a literature review.

We encountered a case of colorectal cancer with pelvic abscess treated with radical surgery following colostomy and chemotherapy. The patient was a man in his 60s with advanced rectal cancer. The tumor had expanded locally and formed an abscess. We evaluated the primary lesion as unresectable, and performed chemotherapy with 5-fluorouracil, Leucovorin, and oxaliplatin( mFOLFOX) plus bevacizumab after colostomy. After 13 courses of chemotherapy, the tumor shrank remarkably. We performed a low anterior resection followed by adjuvant chemotherapy with capecitabine. The patient has had no recurrence for 18 months after surgery.

The patient was a 43-year-old woman who visited our hospital with a primary complaint of intermittent abdominal pain. Upper gastrointestinal endoscopy revealed mild gastritis. The patient was treated with oral drugs, and the course was followed. Subsequently, the abdominal pain aggravated, and computed tomography (CT) was performed, in which right colic intussusception with a 4 cm cystic mass in the advanced portion was noted. Reduction by enema was attempted on the same day; however, a residual tumorous lesion was present in the ileocecal region. The patient was diagnosed with a cecal submucosal tumor with intussusception, and therefore, laparoscopic surgery was performed. Intussusception of the entire appendix in the ascending colon was noted, for which laparoscopic ileocecal resection was performed. In the excised specimen, a cystic lesion comprising the appendix filled with mucus was present. The postoperative recovery was favorable, and the patient was discharged on the seventh postoperative day. The lesion was histopathologically diagnosed as low-grade appendiceal mucinous neoplasm.

A 51-year-old male patient visited our hospital after a positive result for a stool test for occult blood. Subsequent lower gastrointestinal endoscopy showed a neoplastic lesion in the transverse colon, and abdominal computed tomography revealed a tumor in the tail of the pancreas. Since there was the possibility of multiple cancers with pancreatic cancer and transverse colon cancer, resection of pancreatic tail and transverse colectomy were performed. Histopathological findings: The pancreatic lesion was found to be a moderately differentiated tubular adenocarcinoma, and the lesion in the transverse colon was mainly located in the submucosal layer. In light of the principal lesion having the same histopathological characteristics as the pancreatic lesion, it was diagnosed as hematogenous metastasis of pancreatic cancer to transverse colon. Postoperative course: After 9 courses of 3-week administration of gemcitabine(GEM) and 1-week cessation, he developed hepatic metastasis. The treatment with GEM+S-1 was additionally repeated 7 times, but the patient was not responsive to the treatment, and died 1 year and 6 months after his first visit to our hospital.Surgery is not generally indicated in patients with pancreatic cancer with hematogenous metastasis. In this case, a comparatively long-term survival period was achieved after simultaneous resections.

We report the case of a patient with unresectable progressive advanced rectal cancer, who has been able to maintain a good quality of life because of combination therapy, including chemoradiotherapy. A 52-year-old woman was diagnosed with progressive locally advanced rectal cancer and invasion of the adnexa of the uterus and the left ureter. No distant metastasis was detected. Colostomy was performed, followed by chemoradiotherapy combined with S-1; then, mFOLFOX6 +bevacizumab (BV) therapy was administered. Aggravation of bilateral hydronephrosis was detected upon completion of 2 courses of treatment, and therefore, percutaneous nephrostomy of the right kidney was performed. After the patient underwent 20 courses of treatment, imaging showed a reduction in the size of the lesion, and the CEA level returned to normal. Later, remission was sustained by sLV5FU2+BV therapy and oral administration of S-1. As a result, we were able to remove the nephrostomy tube from the right kidney in February 2011. Four years after initiation of the treatment, the patient has shown no indication of recurrence.

Vaginal metastasis is extremely rare, as is metastatic colorectal cancer. A 78-year-old woman was diagnosed with rectal cancer and uterine fibroid. Low anterior resection and simple hysterectomy was performed and the final diagnosis was fStage IIIa. Adjuvant chemotherapy was not performed. One year after the surgery, she was referred to our hospital with the chief complaint of hematuria. A tumor was observed in the posterior wall of the vagina. We performed vaginal mucosal resection and the pathological diagnosis was metastasis of rectal cancer. One year and 5 months after the surgery, we performed left inguinal node dissection and the pathological diagnosis was metastasis of rectal cancer. The patient has remained disease-free for 3 years and 5 months without adjuvant chemotherapy after resection of the vaginal metastasis.

A 67-year-old man visited our hospital for further check-up of biliary tract disease since his two brothers suffered from biliary tract cancer. Abdominal CT scan revealed a wall thickning at the fundus of gallbladder and its vascularity was rich. Chronic cholecystitis was diagnosed, however, cancer was highly suspected. Cholecystectomy was performed and the frozen section of the gallbladder was compatible for cancer. Therefore, segment-4a and -5 liver resections with regeonal lymph node dissection were added. Although preoperative radiological findings were free of liver metastasis, the resected liver specimen included a nodule of 1 cm in segment-5. Extrahepatic bile duct was not resected because the stump of the cystic duct was free from cancer. The final pathological diagnosis according to the TNM classification was pT3N1M1, Stage IV. We considered the patient to be in the high-risk group of recurrence, adjuvant chemotherapy using both gemcitabine and S-1 was performed. S-1 (80 mg/body/day) was scheduled on day 1-14, and gemcitabine (1,000 mg/body) was scheduled on day 8, day 15. The treatment was continued for two years (a total of 28 courses) without experiencing advese events. The patient is cancer free by means of radiological and hematological studies. Gallbladder cancer with liver metastasis in segment-4a and/or -5 can be considered as "local" metastasis, which a liver resection and adjuvant therapy may lead to a good prognosis.

A 79-year-old woman was reffered to our hospital with the chief complaint of hematochezia. Type-2 tumor was found on anal canal by colonoscopy, and pathologic examination revealed a poorly differentiated squamous cell carcinoma. Computed tomography of the abdomen demonstrated obturatory node metastasis. The patient was diagnosed as having squamous cell carcinoma of the anal cana (l cStage III). After four months from chemoradiation (66 Gy/33 Fr plus S-1), the ulcer side was improved completely to epithelization, and abdominal CT scan showed a remarkable reduction of obturatory node metastasis. She was obtained a complete response. Now the patient is disease-free for ten months after chemoradiation.

A 69-year-old woman visited our emergency room because of sudden right lower quadrant abdominal pain. Abdominal CT revealed a ruptured tumor in the anterior segment of the liver. Emergency laparotomy was selected due to interventional radiology was not available. As the patient was in shock status with massive intraabdominal hemorrhage, ligation of the right hepatic artery and suturing of the tumor bleeding point was carried out. Given the patient's history and liver biopsy report, we concluded as hepatocellular carcinoma derived form NASH. Anterior resection of the liver was performed after the patient became stable. About one year later, tumor was detected in the lateral segment and was removed. The patient is free of disease for two and a half years after the initial operation. Carcinogenesis of the hepatocellular carcinoma within NASH is not well described. We herein report a case of ruptured hepatocellular carcinoma originated from NASH.

We report two cases of advanced pancreatic cancer whose prognoses are fairly good with surgery and chemotherapy. Case 1: A 71-year-old male patient was diagnosed as pancreatic head cancer by abdominal ultrasound. The tumor size was about 2 cm in diameter. Whipple's procedure and regional lymphadenectomy were conducted. Pathological diagnosis was pT3N2 with s0 and rp1. Gemcitabine (GEM) was administered in a routine fashion at out-patient clinic. He is free of disease after three years and eight months. Case 2: A 63-year-old male patient was diagnosed as pancreatic head cancer although the mass was not so clearly visible by CT. Pylorus preserving pancreaticoduodenectomy was performed with D2 lymph node dissection. Pathological report was pT3N1 with s0 and rp0. GEM was started six months after the operation but continued for only six months. After the non-treatment interval of six months, GEM was restarted due to the sudden elevation of CA19-9. Soon the number dropped but instead of reaching normal range, it began to increase again. S-1 was added to the regimen which gave a great response. He is well after three and a half years. CA19-9 was almost being normal. Both patients had cancer within the pancreas without an invasion to the surrounding tissue. GEM is a standard regimen for adjuvant chemotherapy. However, S-1 may contribute to the outcome when GEM becomes powerless.

The jejunostomy catheters were placed with needle catheter jejunostomy (NCJ) kits at the time of gastrectomy for the gastric cancer patients. When the oral intake of the post-operative patient is insufficient, home enteral nutrition (HEN) was introduced to the patient. Forty seven cases out of the 278 gatrectomy patients with jejunostomy were applied to HEN (400-1,200 kcal/day in the night). Twenty nine HEN gastric cancer cases received the chemotherapy in the outpatient clinic. The mean age was 71 years old, the number of total gastrectomy and distal gastrectomy were 21 and 8, respectively, and the number of Stage III and IV were 21 and 8, respectively. The chemotherapy for these 29 cases was continued for a long period unevenly in the outpatient clinic, even though the oral intake of the cases was insufficient. HEN is a good arm for keeping the chemotherapy secure and efficient in the outpatient clinic.

We report two cases of metastatic liver carcinoma with the treatment of radiofrequency ablation (RFA) and intraarterial chemotherapy. The 57-year-old man of Case 1 had resectable multiple liver metastases of rectal carcinoma in November 2007. He refused a liver resection, but accepted a low anterior resection of the rectum and RFA and intraarterial chemotherapy (5-FU 1,000 mg WHD). After this treatment, he had accepted systemic chemotherapy and found no liver recurrence within a year. The 66-year-old man of Case 2 had unresectable multiple liver metastases of locally-advanced esophageal carcinoma in July 2006. He had accepted radiochemotherapy (FP+65 Gy), and then RFA and intraarterial chemotherapy (5-FU 1,000 mg WHD). After this treatment, solitary brain metastasis and lymph node metastasis of mediastinum were found and treated, and now he has been alive with systemic chemotherapy.

We report an effective case of fifty-seven year-old female with unresectable pancreatic cancer. Its chief complaint of the case was epigastralgia in April 2007, and the diagnosis was locally-advanced cancer of pancreatic body (4 cm, Stage IVa) in June 2007. Laparotomy was performed, but the locally-advanced cancer was unresectable because of the invasion to the celiac trunk and superior mesenteric artery. Tumor biopsy and intra-operative radiotherapy (IORT, 12 MeV, 20 Gy) were only performed. The result of biopsy was moderately-differentiated adenocarcinoma. After laparoptomy, systemic chemotherapy (gemcitabine 1,000 mg/body) was performed once a week. After 4-set chemotherapy, her cancer pain was completely relieved and the tumor size was decreased to 25 mm on CT scan in October 2007. She has been treated as an outpatient.

We analyzed a recurrence pattern and prognosis of 42 gastric cancer cases with histological serosal exposure of cancer and without macroscopical residual cancer in the operation. These cases received adjuvant MTX-5-FU chemotherapy intraperitoneally. Twenty four patients showed a recurrence of gastric cancer. Twenty two patients died of recurrence, and two patients were still alive with recurrence. Seventeen patients (71%) developed peritoneal seeding, which means intraperitoneal chemotherapy made no influence to the pattern of recurrence of gastric cancer with serosal invasion. All of the recurred patients with Stage II and IIIA gastric cancer and about 60% of the recurred patients with Stage IIB and IV developed peritoneal metastasis. The prognosis of recurred 24 patients showed that 9 patients (38%) were kept alive for more than 3 years, and 5 patients (21%) were kept alive for more than 5 years. Intraperitoneal chemotherapy of MTX-5-FU did not touch the pattern of recurrence of gastric cancer with serosal invasion, but the analysis of the prognosis revealed a possibility of improvement of the prognosis.