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A 91-year-old man had a history of cholecystectomy and choledochostomy for cholecystolithiasis and choledocholithiasis. Eleven years earlier, intrahepatic stones were found in the posterior bile duct, and he did not wish to undergo treatment. Over time, worsening of the intrahepatic stones and dilation of the intrahepatic bile duct were observed. At 91 years old, enhanced abdominal CT revealed wall thickening of the hilar bile duct, and MRCP showed stenosis of the hilar bile duct. Endoscopic retrograde cholangiography showed no contrast in the right intrahepatic bile duct and marked dilation of the left intrahepatic bile duct. Brush cytology confirmed adenocarcinoma, leading to a diagnosis of hilar cholangiocarcinoma. He underwent open right and caudal lobectomy with biliary reconstruction. Histopathological examination revealed a hilar cholangiocarcinoma, T3N1M0, Stage Ⅲc, mainly located at the confluence of the right and left hepatic ducts. This case suggests a potential association between hepatolithiasis and hilar cholangiocarcinoma, emphasizing the importance of regular imaging examinations for timely surgical resection. Early intervention, including liver resection, is recommended for the management of hepatolithiasis.

Laparoscopic pancreaticoduodenectomy has been covered by insurance since 2016 in Japan, and advance laparoscopic and robotic pancreaticoduodenectomy has been also covered by insurance since 2020 in Japan. It has been reported that laparoscopic pancreatectomy causes few postoperative adhesions in the abdominal cavity and that repeat laparoscopic surgery could be performed. However, in robotic pancreatectomy, there have been no such reports yet. We reported that even after robotic pancreaticoduodenectomy, there were few adhesions in the abdominal cavity, and we were able to perform the robotic distal pancreatectomy with preservation of the splenic artery and vein. This suggested that robotic surgery was an effective treatment method for repeat pancreatectomy, given its low invasiveness and minimal adhesion.

We report a case in which a patient with advanced gastric cancer with liver metastasis and bulky N showed marked tumor shrinkage with chemotherapy, and underwent conversion surgery. A 77-year-old male. Patient was referred to our department because of advanced gastric cancer. Upper gastrointestinal endoscopy revealed type 2 advanced cancer in the posterior wall of the gastric antrum. Abdominal CT showed thickening of the gastric wall in the same region and bulky lymph node enlargement and para-aortic lymphadenopathy behind the stomach. Staging laparoscopy showed the primary tumor and bulky lymph nodes forming a single mass, invading the pancreas, jejunum, and mesentery, and a solitary mass in the hepatic S3. Biopsy pathology revealed adenocarcinoma. We diagnosed the advanced gastric cancer cT4b(pancreas, jejunum), N2M1 (LYM, HEP), P0CY0, Stage ⅣB. After 2 courses of systemic chemotherapy FOLFOX/nivolumab, total gastrectomy, D2 node dissection, splenectomy pancreas tail resection, cholecystectomy, hepatic resection, partial transverse colon resection, partial jejunum resection, Roux-en-Y reconstruction. R0 resection was performed. The operative time was 620 minutes and blood loss was 1,025 mL. Pathologically, the patient was diagnosed with hepatoid adenocarcinoma, ypT4bN1M1(LYM, HEP), ypStage Ⅳ. The pathological efficacy evaluation was Grade 1a in the primary tumor. The patient has been recurrence-free for 9 months since the initial diagnosis.

A 73-year-old man underwent upper gastrointestinal endoscopy during a medical check-up that revealed a Type 2 lesion in the anterior wall of the gastric body. The biopsy confirmed tub2. A contrast-enhanced CT scan revealed focal wall thickening and lymphadenopathy in the gastric body. The patient was diagnosed with gastric cancer(M, ante, Type 2, T4aN1M0, Stage ⅢA). Laparotomy total gastrectomy D2 dissection and Roux-en-Y reconstruction were performed. Pathological results were tub1, int, INF b, ly0, v1, pT4aN0M0, pStage ⅡB. S-1(100 mg/day)was started as adjuvant chemotherapy but discontinued after 3 courses due to anorexia(Grade 2). Multiple pulmonary metastases(both lungs, 5)were confirmed by CT examination 9 months after the operation. A diagnosis of gastric cancer recurrence was made, and CapeOX plus nivolumab was started as first-line therapy. After 2 courses, lung metastases tended to shrink. The lesion developed a complete response(CR)after 3 months. After that, CapeOX plus nivolumab was continued, but peripheral neuropathy(Grade 2)was observed in the 15th course. With continued capecitabine monotherapy and nivolumab(impaired liver function [Grade 3]for irAE), despite the maintenance of CR, hepatic function increased repeatedly(Grade 3)and led to the discontinuation of chemotherapy upon patient's request. Currently, CR has been maintained for 5 years and 6 months after recurrence.

Introduction: Laparoscopic pancreaticoduodenectomy(LPD)has been covered by insurance since 2016 in Japan. Advance LPD and robotic pancreaticoduodenectomy(RPD)has been also covered by insurance since 2020 in Japan. The aim of this study was to analyze the perioperative results and outcomes of RPD and LPD for the elderly patients and to compare to the non-elderly patients., Patients and Method: Between July 2020 and April 2023, 67 patients underwent RPD and between May 2012 and February 2021, 63 patients underwent LPD at Kansai Rosai Hospital. Sixty-seven RPD and 62 LPD patients without extended resection were divided into 2 groups those who were over 75 years old(R/LPD E)(n=55)and under 74 years old(R/LPD non-E)(n=74). Control patients who received open pancreaticoduodenectomy(OPD)without extended resection between April 2010 and April 2023 were also divided into 2 groups those who were over 75 years old(OPD E)(n =60)and under 74 years old(OPD non-E)(n=78). The patient age was 79.0 and 60.5 years, the male to female ratio was 35/20 and 45/29, disease ratio(invasive ductal carcinoma or not)was 7/48 and 9/65 in R/LPD E and R/LPD non-E groups, respectively. The patient age was 79.0 and 79.5 years, the male to female ratio was 35/20 and 31/29, disease ratio (invasive ductal carcinoma or not)was 7/48 and 30/30(p<0.0001)in R/LPD E and OPD E groups, respectively. This study was approved by the Human Ethics Review Committee of Kansai Rosai Hospital(Certificate Number: 2001019)., Results: The average operation time was 644.6 and 675.2 minutes, an estimated blood loss was 220.8 and 134.4 g, postoperative pancreatic fistula(ISGPS 2016, [-]/BL/Grade B/C)was 24/18/13/0 and 28/25/21/0, delayed gastric emptying(ISGPS 2007, [-]/Grade A/B/C)was 48/0/4/3 and 61/2/6/5 and postoperative hospital stay was 27.9 and 25.9 and in R/LPD E and R/LPD non-E groups, respectively. No significant differences were noted between the groups, However, postoperative complication over Ⅲa Clavien-Dindo classification was 8(15.7%)and 3(4.4%)cases(p=0.0319)in R/LPD E and R/ LPD non-E groups. The average operation time was 644.6 and 492.1 minutes(p<0.0001), an estimated blood loss was 220.8 and 534.8 g(p=0.0004), postoperative pancreatic fistula(ISGPS 2016, [-]/BL/Grade B/C)was 24/18/13/0 and 27/8/24/1(p=0.0442), postoperative hospital stay was 27.9 and 42.0(p=0.0490)in R/LPD E and OPD E groups, respectively., Conclusion: The R/LPD was undergone in safety, even for the over 75 years old patients.

Para-aortic lymphadenectomy in gastric cancer surgery is a highly difficult surgical technique. In our hospital, we introduced robotic surgery in anticipation of the minimal invasiveness and advanced operability. We use a tunneling approach that progresses from the Treitz ligament to the peri-aorta. The transverse mesocolon is expanded with a tissue grasping clip, and the retroperitoneum is incised from the side of the Treitz ligament to approach the abdominal aorta and inferior vena cava. The No.16b1 and No.16a2 latero lymph nodes can be dissected with a good visual field. When it is judged that the visual field development of the No.16a2 inter-lymph nodes is poor, Kocher's operation is added. Since 2016, 18 patients have undergone para-aortic lymphadenectomy, 3 of whom underwent robotic surgery in our hospital. R0 resection was performed in all the cases, and 22.5 lymph nodes were dissected as No.16 lymph nodes(20.0 in all the cases included laparotomy). Although only a small number of patients were examined, robot-assisted para-aortic lymphadenectomy was considered safe.

Tumor mutation burden(TMB)-High is known to potentially elicit a favorable response to immune checkpoint inhibitors. In this report, we present a case of recurrent hilar cholangiocarcinoma with TMB-High, in which we performed comprehensive treatment including immune checkpoint inhibitor pembrolizumab. The patient was a 58-year-old male diagnosed with hilar cholangiocarcinoma who underwent extended right hepatectomy, caudate lobe resection, bile duct excision, and bile duct reconstruction. Postoperatively, peritoneal seeding recurrence and liver metastasis were observed, indicating TMB-High. Therefore, pembrolizumab therapy was administered. The tumor marker CA19-9 significantly decreased, and the peritoneal seeding and liver metastatic lesions disappeared on imaging. In this case, we experienced the use of pembrolizumab monotherapy for TMB-High recurrent bile duct cancer with early postoperative peritoneal seeding recurrence. Further accumulation of cases is needed, but pembrolizumab monotherapy holds promise as a treatment option for TMB-High bile duct cancer at the hepatic hilum.

A 41-year-old male, with a history of neurofibromatosis type 1(NF1)was referred for further evaluation of positive fecal occult blood test. Abdominal contrast-enhanced CT incidentally showed a mass lesion with early darkening in the small intestine. It was suspected to be a small intestinal arteriovenous malformation, and surgery was performed. The tumor in the small intestine was resected under laparoscopic assistance. The histopathological diagnosis was gastrointestinal stromal tumors associated with NF1, which are usually located in the small intestine and relatively favorable prognosis.

A 75-year-old female, at her initial presentation, the tumor occupied her entire right breast, with a foul-smelling exudate. A biopsy revealed ER-positive, HER2-negative breast cancer, and CT revealed multiple lung metastases. Paclitaxel and fulvestrant were administered sequentially, the bleeding from the right breast mass stopped and the mass flattened. But, as the tumor progressed, the right breast mass re-enlarged and began to re-bleed. Therefore, hemostatic treatment with Mohs paste was performed in parallel with tamoxifen. Hemostatic effect was observed for a while, but she gradually became refractory to Mohs paste, necessitating frequent blood transfusions. It was decided to discontinue systemic drug therapy and consider palliative treatment, and to perform radiation therapy in parallel with Mohs paste treatment for the purpose of local control. After radiation therapy, the bleeding has completely stopped and blood transfusion has not to be required for 6 months. Although systemic drug therapy has been discontinued at the patient's request, she is still alive. While systemic drug therapy was discontinued, we were able to confirm the pure local control effect of combination of radiation therapy and Mohs paste.

Background: In recent years, the number of colorectal cancer in Europe and the U. S. has been decreasing, but there are increasing reports on the trend of early-onset colorectal cancer(EOCRC), which is a rare population with no established knowledge on its characteristics., Subjects and Methods: Of 3,501 colorectal cancer cases treated at our hospital between April 2011 and December 2021, those aged 39 years and younger were included., Results: There were 32 EOCRC cases, 11 males/21 females. The histological type was tub in 31 cases and por in 1 case. Postoperative adjuvant chemotherapy was administered in 14 patients, and 12 completed the scheduled course. Twenty nine patients underwent R0 resection, of which 6 patients had recurrence and 5 patients died of primary disease. In summary, although EOCRC patients were in good general condition and had a high completion rate of adjuvant chemotherapy, the relapse rate was high, suggesting the need for aggressive adjuvant chemotherapy and careful postoperative surveillance.

Malignant tumor occurring in the inguinal region are relatively infrequent, and metastatic tumor is extremely rare. We report a case of inguinal hernial sac metastasis of cecal cancer resected with TAPP approach. The case is a 80's man. One year and 6 months after cecal cancer surgery, contrast-enhanced computer tomography(CT)examination revealed a solitary tumor in the right inguinal canal. We diagnosed inguinal hernia sac metastasis of cecal cancer and performed surgery. The mass in the hernia sac was resected with the TAPP approach. Histopathological findings were consistent with peritoneal metastasis directly to the inguinal hernia sac. The patient has been alive without 2 years after metastasectomy. It is necessary to treat patients with a history of malignant disease with keeping the possibility of inguinal hernia sac metastasis in mind.

We report a case of advanced gastric cancer with simultaneous liver metastasis in which long-term survival has been obtained by multimodal therapy. Case 75-year-old, male. Esophagogastroduodenoscopy revealed advanced type 2 cancer in the greater curvature of the angular incisure. Computed tomography showed a single 20 mm mass was found in liver S2. Histopathological findings indicated that differentiated adenocarcinoma(tub1, HER2 3+). Diagnosis was gastric cancer, cT4aN0M1HEP, Stage Ⅳ. Tumor shrinkage was obtained after 2 courses of capecitabine/cisplatin/trastuzumab. Laparoscopic distal gastrectomy and partial liver resection was performed. Histopathological findings indicated tub1, ypT4aN0M1HEP, ypStage Ⅳ, grade 1a. A single 10 mm recurrence was observed in liver S1/2 13 months after first surgery. After chemotherapy, rehepatic resection was performed. Three years have passed since the last hepatectomy, and the patient is currently undergoing recurrence-free follow-up.

Prognosis of pancreatic cancer is extremely poor due to recurrence in the early postoperative period. However, there are some reports that the prognosis for lung recurrence alone is relatively better than that of others. In this study, we report the cases of lung recurrence alone after radical resection of pancreatic cancer performed at our hospital. Among 255 cases of radical resection of pancreatic cancer performed at our hospital between July 2010 and August 2021, 6 cases in which the initial recurrence site of recurrence was lung alone were included in the study. The median age of the patients was 72 years (62-82), and there were 5 males and 1 female. Four patients had undergone pancreaticoduodenectomy and 2 patients underwent distal pancreatectomy. Four patients received adjuvant chemotherapy, 3 with S-1 and 1 with GEM. No patients underwent surgical resection for recurrence of lung metastasis, and all patients were treated with chemotherapy. The median time to recurrence was 351 days. As initial therapy after recurrence, 3 patients received GEM plus nab-PTX combination therapy and 3 patients received S-1. The median overall survival after recurrence was 1,979 days, and the 1-year and 3-year overall survival rates after recurrence were 100% and 100%, respectively. The prognosis of patients with recurrence of lung metastasis after surgery for pancreatic cancer at our hospital was similarly good as the previous reports.

The patient was a 48-year-old woman. At the time of consultation, a hard mass of 30 mm in size was palpated in area A of the right breast, and a firm mass of about 10 mm was seen in the umbilical region. Histological diagnosis of the breast mass was invasive ductal carcinoma. PET-CT scan showed accumulation in the right breast, as well as suspicion of umbilical metastasis and peritoneal dissemination, uterine mass, and left ovarian cancer. Since this is an atypical metastatic site for invasive ductal carcinoma of the breast, and the possibility of peritoneal dissemination due to gynecological cancer complications cannot be ruled out, resection of the umbilical mass and laparoscopy was performed. The review laparoscopy revealed no evidence of primary cancer in the uterine body or left ovary, and a white nodular lesion of suspected seeding in the peritoneum around the left ovary. The histology and immunostaining results of the umbilical mass and left peri-ovarian nodule both showed glandular luminal structures similar to those of the primary breast cancer, and the left peri-ovarian nodule was ER positive, GATA3 positive, and PAX8 negative, leading to the diagnosis of umbilical metastasis and peritoneal seeding derived from breast cancer. Umbilical metastasis is often referred to as Sister Mary Joseph's nodule in the case of visceral malignancies and is often associated with peritoneal dissemination and is often caused by invasive metastasis of peritoneal dissemination lesions on the dorsal side of the umbilical region. In this case, histological examination of the umbilical specimen showed no disseminated lesion on the peritoneal side, so it was not considered to be an invasive metastasis due to peritoneal dissemination.

We report a case of a 73-year-old man who underwent endoscopic mucosal resection (EMR) for early rectal cancer(i ntramucosal cancer)at other hospital 17 years ago. Ten years later, he underwent a total colonoscopy, which showed no recurrence of the tumor. Twelve years later, a mass with calcification was incidentally detected in front of the sacrum, which was diagnosed as a benign tumor at that time. Seventeen years later, he presented with constipation and diarrhea, and was detected of a sub-circumferential tumor in the rectum by a total colonoscopy. Biopsy revealed that the tumor was malignancy. CT showed a mass in the left lateral liver lobe. The mass was suspected of metastasis. Laparoscopic super lower anterior resection was performed for rectal cancer, and pathological examination showed that the tumor was pT4a, N3, M1(H), Stage Ⅳa. One month after surgery, laparoscopic hepatectomy was performed for liver metastasis. Six months after surgery, CT showed multiple lung metastases. He continues to undergo chemotherapy. Although this case was treated with EMR for intramucosal carcinoma, clinical history and pathological findings suggested local recurrence.

Background: Since a randomized phase Ⅲ trial conducted in the UK in 2009 showed the superiority of gemcitabine (GEM)plus cisplatin(CDDP)combination therapy over GEM monotherapy, GEM plus CDDP combination therapy has been first-line chemotherapy for unresectable biliary tract cancer., Methods: GEM plus CDDP combination therapy was administered to 29 patients with unresectable biliary tract cancer from 2016 to 2021., Results: The mean age was 71.9 years, male/ female 19/10. The target of chemotherapy was below, local progression was 3 cases, first distant metastasis 7 cases, metastatic recurrence 19 cases. The type of cancer was below, intrahepatic bile duct carcinoma was 8 cases, hepatic hilar bile duct carcinoma 6 cases, gallbladder carcinoma 5 cases, cystic duct carcinoma 1 case, distal bile duct carcinoma 6 cases, and papilla Vater's cancer 3 cases. The dosing period was 23.1 weeks(range 2-52 weeks). The relative dose intensities of GEM and CDDP were 73.7% and 75.1%. The adverse events were below, the hematological toxicities of Grade 3 or higher were neutropenia(65.5%), leukopenia(3.4%), and thrombocytopenia(10.3%). Non-hematological toxicities of Grade 2 or higher were fatigue(13.7%)and skin rash(6.9%). There was no interstitial pneumonia. The disease control rate was 66.7 %(complete response, n=0; partial response, n=6; stable disease, n=10; progressive disease, n=8)., Conclusion: GEM plus CDDP combination therapy was safe to perform and was an effective treatment for unresectable biliary tract cancer.

The patient was a 68-year-old woman without history of surgery. She presented with abdominal pain and leg edema. Ultrasound scan revealed hepatic masses. Colonoscopy and abdominal CT scan revealed unresectable rectal carcinoma with massive multiple liver metastases suspected of invasion of the inferior vena cava. After a transverse colon bi-pore colostomy, 10 courses of FOLFOX plus panitumumab therapy were administered, and the liver tumor was markedly reduced in size and determined to be PR by CT. Considering the possibility of unresectability due to the liver metastases re-growth, surgery was planned with liver-first approach(LFA). First, open resection of the right caudate lobe of the liver, combined resection of the IVC, combined resection of the diaphragm, partial hepatic S2 resection(2 sites), and cholecystectomy were performed, followed by laparoscopic anterior resection(D3)1 month later(R0). Postoperatively, the colostomy was closed after 8 courses of CapeOX(capecitabine alone from the middle of the course). Now the patient is alive and recurrence-free 4 years after the initial diagnosis. Conversion surgery with LFA after chemotherapy can be an effective treatment strategy for colorectal cancer with advanced liver metastases.

A 70s-year-old man visited the gastroenterologist with a complaint of bloody stool. Lower gastrointestinal endoscopy revealed a 50 mm type 0-Ⅰs+Ⅱa lesion in the center of the anterior wall of Rb in 4 cm from anal verge, and he was diagnosed with rectal cancer in cT1bcN0cM0, cStage Ⅰ. Endoscopic submucosal dissection was performed, but it was discontinued due to muscular traction, and was referred to our department at a later date for surgical purposes. Robot-assisted laparoscopic Hartmann's surgery(D2 dissection, sigmoid colon colostomy)was performed, and the pathological result was pT2pN0cM0, pStage Ⅰ with negative resection margins. Three months after the operation, a tumor was found on the left side of the stoma, and he visited us. Biopsy revealed the recurrence of skin metastasis of rectal cancer, and surgical procedure including colostomy and skin tumor resection, ileostomy, and colonic mucus fistula was performed. The patient was transferred to the hospital 3 months after the operation, but 2 months after the transfer, an increasing CEA was observed and CT revealed a local recurrence in the pelvis. Irradiation(45 Gy/15 times)was performed for the pain relief, but the general condition deteriorated thereafter and he died 8 months after the second operation.

Introduction: There are few reports of surgery which preserve the function of pancreas for benign or low malignant tumors. While we have introduced laparoscopic pancreaticoduodenectomy (LPD), we have also performed laparoscopic pancreas-sparing duodenectomy (LPSD). In the present study, we investigated surgical techniques and results of LPSD., Materials and Methods: Between October 2019 and January 2022, 3 patients were underwent LPSD. The procedure was performed after obtaining approval from the Ethics Review Committee of our hospital., Results: Three patients conducted LPSD were all males with a median age of 74 years, and diagnoses were adenomas of duodenum in 2 cases and gastrointestinal stromal tumor of duodenum in 1 case. The median blood loss was small amount. The median operative time was 430 minutes, and the median postoperative hospital stay was 13 days. One of the cases was performed with conversion to HALS. In LPSD, an intraoperative ultrasonography and an intraoperative radiographic contrast study were performed to confirm that the ampulla of Vater was preserved. There were no postoperative complications., Conclusion: We experienced cases performed LPSD in our hospital. We need further research for feasibility and safety of the procedure.

We report a case of postoperative multiple recurrence of hepatocellular carcinoma(HCC)treated with atezolizumab plus bevacizumab. A 73-year-old man with a chief complaint of abdominal distention was indicated a 90-mm-sized tumor extending from the lateral hepatic segment to the extrahepatic region by a contrast-enhanced CT scan of the abdomen. He underwent a laparoscopic liver resection of the lateral segment for suspected HCC, and was diagnosed as pStage Ⅱ HCC. Six months after surgery, multiple recurrent at intrahepatic lesions and suspected lymph node recurrence or peritoneal dissemination were observed, and tumor markers were markedly elevated. The patient was diagnosed with multiple intrahepatic and extrahepatic recurrences of postoperative HCC and started combination chemotherapy with atezolizumab (1,200 mg/body)plus bevacizumab(15 mg/kg). After the initiation of the therapy, tumor size reduction and normalization of tumor markers were observed, and at 17 months postoperatively, tumor size reduction has been maintained and tumor markers were in the normal range. We report a case of postoperative intrahepatic and extrahepatic multiple recurrences of he patocellular carcinoma treated with atezolizumab plus bevacizumab.

Introduction: Laparoscopic pancreaticoduodenectomy(LPD)has been covered by insurance since 2016 in Japan. Advance LPD and robotic pancreaticoduodenectomy(RPD)has been also covered by insurance since 2020 in Japan. We report our technique and the short-term outcome of RPD performed in our institution., Surgical Procedures: As a first step, the resection phase was performed laparoscopically. Pancreato-jejunostomy and choledocho-jejunostomy were performed robotically (hybrid-RPD). As a second step, Kocher maneuver and jejunal transection were performed laparoscopically. Other procedures were performed robotically(modified-RPD). As a final step, all procedures were performed robotically(pure-RPD)., Surgical Techniques: RPD is performed in reverse Trendelenburg supine position. An extended Kocher maneuver is performed. The common bile duct is then identified and transected after proximal aspect is secured with a surgical bulldog clamp. IPDA is divided by using an energy device after clip placement. The pancreatic neck is then divided with the use of scissors. Pancreato-jejunostomy was performed by modified Blumgart and pancreatic duct to jejunal mucosa method. Choledocho- jejunostomy was performed with continuous and interrupted suturing., Patients and Method: Between 2020 and 2022, 45 patients underwent RPD at our institution. Cases were divided into hybrid-RPD(n=20), modified-RPD(n=9) and pure-RPD(n=16)., Results: No significant differences were noted between hybrid-RPD, modified-RPD and pure-RPD groups with respect to patient age(73.6, 68.7, 70.6 years old), gender(male/female 15/5, 6/3, 8/8), respectively. The operation time was longer(667, 770, 746 minutes)and the resection time was longer(286, 399, 380 minutes)in modified- RPD and pure-RPD than hybrid-RPD group. In the pure-RPD group, the resection time was decreasing(y=-12.0×+ 481.5)as a learning curve. No significant differences were noted between hybrid-RPD, modified-RPD and pure-RPD groups with respect to reconstruction time(388, 371, 367 minutes)and the estimated blood(261, 199, 293 mL), respectively. All postoperative pancreatic fistula was under Grade B., Conclusion: Although further studies are still needed to confirm the benefit of RPD, RPD is safe, minimally invasive, and effective approach to the management of pancreatic tumor.

An 80-year-old female patient visited our hospital with scrutinizing acid reflex after meals. Esophagogastroendoscopy (EGD)and computed tomography(CT)showed a 25 mm submucosal tumor of the stomach in the lesser curvature of the middle stomach. A pathological examination using endoscopic ultrasound-guided fine needle aspiration(EUS-FNA) revealed gastrointestinal stromal tumor(GIST). The combination of laparoscopic and endoscopic approaches to neoplasia with the non-exposure technique(CLEAN-NET)was undertaken via a 2.5 cm single umbilical incision. The tumor was identified by EGD, and the scheduled dissected line was confirmed both from the mucosal and serosa side with an endoscope and laparoscope, respectively. The serosal and muscular layers were incised with an electric knife from outside the gastric wall; hypertonic saline solution was locally injected to swell the submucosal layer; partial gastric resection was performed with an automatic suture device without capsule damage. The operation time was 61 minutes, and there was blood less. The patient was discharged 6 days after the operation without complications. Histopathological findings showed GIST, 16× 14 mm, c-kit(+), CD34(+). The tumor was very low risk, as per the modified-Fletcher classification. Currently, 5 months after the operation, follow-up is underway without recurrence.

Total gastrectomy for remnant gastric cancer is one of the most difficult procedures in gastric cancer surgery. In our hospital, we have performed laparotomy so far, but in recent years we have shifted to laparoscopic surgery. We verified the safety and usefulness of laparoscopic surgery from the surgical cases in our hospital. We compared the surgical outcomes of 26 patients who underwent laparotomy or laparoscopic total gastrectomy for remnant gastric cancer after 2010. 19 patients had undergone gastrectomy for gastric cancer, and 7 patients had done for benign diseases. In the gastrectomy of remnant gastric cancer, laparotomy was performed in 19 patients and laparoscopic surgery was performed in 7 patients. The laparoscopic group had a long operation time(274 vs 402 min), less bleeding(434 vs 124 mL), more lymph node dissection(11 vs 20 lymph nodes). The rate of postoperative complications(Clavien-Dindo classification more than Grade 2)was low(42.1 vs 28.6%), and the length of hospital stay after surgery was short(14 vs 10 days). No postoperative death was observed in all patients. Conclusion: It was considered that laparoscopic surgery can be safety performed and is a useful surgical procedure for remnant gastric cancer.

A 60-year-old man was referred to our hospital after he was diagnosed with advanced gastric cancer. When he visited our hospital, upper gastrointestinal endoscopy revealed a type 3 tumor on the posterior wall of the middle greater curvature of the stomach, and histopathological examination revealed a well-differentiated adenocarcinoma(tub1). CT scan showed wall thickening with contrast effect in the middle part of the stomach. In the operation, the peritoneal lavage cytology was negative(CY0), but white nodules were found in the Douglas pouch, the great omentum, and mesentery, and the pathological examination showed adenocarcinoma(P1c). The patient was diagnosed as cT4aN0M1P1cCY0, Stage ⅣB and received S-1 plus CDDP therapy. After 4 courses of chemotherapy, the tumor was reduced. Staging laparoscopy showed no obvious peritoneal dissemination, and the peritoneal lavage cytology and scar nodules in the great omentum and Douglas pouch showed no evidence of malignancy(P0CY0). Therefore, the patient was able to have a conversion surgery, and underwent total gastrectomy with Roux-en-Y reconstruction and cholecystectomy. Pathological examination revealed type 3 tub1, ypT1bN0M0, pStage ⅠA, and the pathological effect of chemotherapy was Grade 1b. The patient was treated with S- 1 for 2 years as adjuvant chemotherapy, and the chemotherapy was terminated because no recurrence was observed by the CT and the laparoscopy. The patient has remained recurrence-free for a total of 10 years since then.

We report a case of laparoscopic sigmoid colon resection for sigmoid colon cancer after cystectomy for bladder cancer and ileal conduit surgery for urinary tract reconstruction. The patient was a male in his 70s. The patient presented to the Department of Gastroenterology with the complaint of nausea and loss of appetite, and findings that were suspicious of intestinal obstruction. The diagnosis was obstructive sigmoid colon cancer. The patient had a history of bladder cancer and had undergone cystectomy and ileal conduit surgery. Intraoperatively, we considered placing a ureteral stent to identify the left ureter through the dorsal mesentery of the sigmoid colon, but we decided that stent placement would be difficult because of a history of conduit stenosis during a previous close examination of a patient with pyelonephritis. On the 21st day, a laparoscopic- assisted sigmoid colon resection was performed. The surgery was completed without any problems such as intraoperative ureteral injury. The patient was discharged home on the 23rd postoperative day. Ten months after the surgery, the patient is alive without recurrence.

A 78-year-old man was diagnosed with a liver tumor on follow-up CT after thoracic aortic aneurysm surgery. Esophagogastroduodenoscopy revealed a type 2 tumor in the gastric antrum, a biopsy showed poorly differentiated adenocarcinoma, and CT revealed multiple liver metastases, resulting in a diagnosis of clinical Stage ⅣB(cT4aN0M1[HEP]). S-1/oxaliplatin (SOX)chemotherapy was started. However, after 9 courses of chemotherapy, the primary tumor continued to increase in size. Ramucirumab/paclitaxel(RAM/PTX)was started; after 3 courses, CT revealed shrinkage of the primary tumor and disappearance of multiple liver metastases. PET-CT showed no abnormal FDG accumulation in the stomach, surrounding lymph nodes, and liver. Therefore, the patient was considered to have a PR in efficacy, and a decision to perform conversion surgery was made based on the assumption that curative resection was possible. The patient underwent laparoscopic distal gastrectomy D2 lymph node dissection and Billroth Ⅰ reconstruction. The pathological result was M, Ant, type 2, por, ypT2N0M0, ypStage ⅠB, while the histological effect of the chemotherapy was Grade 0. The patient was treated with paclitaxel as adjuvant chemotherapy, which was discontinued 1 year after surgery owing to no recurrence. No recurrence has been noted during 2 years of follow-up.

The patient is a 67-year-old female. She was diagnosed with left breast cancer cT2N1M0, Stage ⅡB, Luminal B-like, and was desided dose-dense AC therapy(ddAC)plus dose-dense paclitaxel therapy(ddPTX)as preoperative chemotherapy. After completing 4 courses of ddAC and visiting to start the first course of ddPTX, she presented with symptoms of fatigue and shortness of breath on exertion. Chest X-ray showed no abnormality and echocardiography showed decreased left ventricular wall motion, leading to a diagnosis of doxorubicin-induced cardiac dysfunction. Preoperative chemotherapy was discontinued and surgery was decided. Two weeks later, CT imaging was performed for preoperative evaluation, which showed the appearance of diffuse pale ground-glass opacity in the bilateral lung fields, and a diagnosis of drug-induced interstitial pneumonia was made. After 3 weeks of steroid treatment, the symptoms improved and the ground-glass opacity disappeared on CT imaging. We were keenly aware that interstitial pneumonia can develop with pale ground-glass opacity that is difficult to diagnose without CT imaging, and that the need for CT should always be considered.

A 28-year-old woman realized a left breast tumor. Mammography and ultrasonography revealed focal asymmetric density on the MI area(category 3)and a low-echoic 10 mm tumor with unclear boundaries. We performed an US-guided breast biopsy to confirm the diagnosis. The histopathological examination result suspected nodular fasciitis; however, borderline phyllodes tumor cannot be denied. Tumorectomy was performed under general anesthesia. The final histopathological examination revealed nodular fasciitis due to amplifying fibroblasts with irregular directions. Nodular fasciitis is a benign lesion and sometimes disappears spontaneously. Tumorectomy is often needed to confirm the diagnosis that cannot be identified by needle biopsy. We report a case of breast nodular fasciitis needed to differentiate from borderline phyllodes tumor.

The patient was a 58-year-old woman. She was diagnosed with cT4b, cN3c, cM1, cStage Ⅳ, Her2 positive breast cancer with liver, lung and bone metastases. Seven days after the first visit, she came to our hospital for dyspnea. Chest X-ray, chest CT, and echocardiography showed a decrease in EF to 50.6% due to a large amount of pericardial effusion, and she was diagnosed with cardiac tamponade. On the same day, pericardial drainage was performed urgently. The cytopathology of pericardial fluid was malignant, that is to say, she was diagnosed with cancerous pericarditis. Pericardial drainage relieved respiratory distress, and echocardiography showed disappearance of pericardial fluid and improvement of EF up to 80.4%. Docetaxel plus trastuzumab plus pertuzumab therapy was started 10 days after pericardial drainage as first-line treatment. After starting chemotherapy, the response has continued for 6 months without re-accumulation of pericardial fluid.

The patient is a 69-year-old female. She was aware of a right breast mass about a year ago, but left it alone. In March 2021, she visited our hospital with a 11 cm mass occupying the right breast and self-destruction due to skin invasion. The diagnosis of invasive ductal carcinoma of the breast(ER-positive, PgR-positive, HER2-negative), cT4bN1M0, Stage ⅢB was made, and preoperative chemotherapy was decided. We expected a high response rate for bevacizumab(Bv)because it was predicted that the skin defect would increase at surgical resection if a response to chemotherapy was not achieved, and in April 2021, paclitaxel(PTX)plus Bv therapy was initiated. After 4 courses, the mass had shrunk to 5 cm and a marked response had been achieved. However, she was unable to continue the treatment due to peripheral neuropathy. Therefore, considering the period of delayed wound healing due to Bv, we decided on AC therapy followed by surgery. In December 2021, Bt plus Ax was performed and the wound could be closed without skin grafting. Since PTX plus Bv therapy is expected to have a high response rate, we considered it to be one of the effective treatment options for locally advanced breast cancer.

The patient was male, 50s. He visited his local doctor with complaints of hematochezia and hematuria. He underwent colonoscopy, which revealed a circumferential lesion in the sigmoid colon, and he was referred to our department for further examination and treatment. A urinalysis at the time of admission revealed leukocytes(3+)and bacteria(2+), suggesting that the sigmoid colon cancer was invading the bladder. The urologist performed cystoscopy, which showed internal invasion of the bladder, and at this point, including the CT findings, it was needed that a combined bladder resection was necessary. We decided to undergo neoadjuvant chemotherapy(NAC)with the possibility of bladder preservation. FOLFOXIRI plus bevacizumab was selected as the regimen, and a total of 6 courses were performed. After NAC, the effect was judged PR. The patient underwent laparoscopy-assisted resection of the sigmoid colon and partial resection of the bladder wall. The pathological diagnosis was ypStage Ⅱc. Postoperatively, the patient received 6 courses of FOLFOX as adjuvant chemotherapy. Currently, about 8 months after surgery, no recurrence has been observed.

A 63-year-old female patient underwent resection of a gastrointestinal stromal tumor(GIST)at the age of 48 years. After surgery, she had adjuvant chemotherapy. She had been recurrence-free for 10 years. Two years after completion of medical therapy, local peritoneal recurrence of GIST was observed, and medical therapy with imatinib was restarted. The response was good, but 1 year after resumption of medical therapy, progression was observed, and imatinib resistance was suspected, and recurrent tumor resection was performed. After the reoperation, the patient continued medical treatment with imatinib. Two years after the reoperation, a tumor suspected to be recurrent was found in the abdominal cavity. Tumor resection was performed. Histopathological examination revealed c-kit and CD34 positivity, leading to a diagnosis of recurrence of GIST. Imatinib is the mainstay of treatment in patients with recurrent GISTs, and sunitinib may be considered if the patient becomes resistant to imatinib, or surgical treatment may be considered if the lesion can be resected. In this study, we report a case of GIST with peritoneal dissemination in which imatinib therapy was continued after surgery, but the disease recurred twice. We investigate the prognostic value of continued imatinib therapy after surgical resection of locally recurrent GIST.

Introduction: Laparoscopic liver resection(LLR)has been reported as a safe, minimally invasive, and effective approach to the management of liver tumor. The aim of this study was to analyze the perioperative results and outcomes of LLR for the elderly hepatocellular carcinoma(HCC)patients and to compare to the non-elderly HCC patients., Patients and Method: Between May 2010 and November 2021, 725 patients(HCC 407, CRC Mets 171, others 147)patients underwent LLR at Kansai Rosai Hospital. 407 patients who underwent LLR for HCC were divided into 2 groups those who were over 80 years old(n=67)and under 79 years old(n=340). The patient age was 82.7 and 68.8 years, while the male to female ratio was 41/26 and 238/102 in the elderly and non-elderly groups, respectively. According to the liver cancer study group of Japan, the pathological Stage 0/Ⅰ/Ⅱ/Ⅲ/Ⅳ was 23/34/8/2 and 117/146/57/20 patients(p=0.1086)in the elderly and non- elderly groups, respectively. This study was approved by the Human Ethics Review Committee of Kansai Rosai Hospital(Certificate Number: 2101006)., Results: The elderly group had an average operation time of 316.1 minutes, an estimated blood loss of 277.3 g, and a hospital stay of 14.3 days. The non-elderly group had an average operation time of 347.2 minutes, an estimated blood loss of 233.7 g, and a hospital stay of 12.9 days. No significant differences were noted between the elderly patients and the non-elderly patients with respect to the rate of procedure, operation time, intraoperative blood loss, hospital stay, morbidity, and postoperative laboratory data., Conclusion: The LLR was undergone in safety, even for the over 80 years old patients. The results of LLR for HCC over 80 years old were comparable both in short-term results with under 79 years old group. It was considered that the minimally invasiveness of LLR allows comparable surgical treatment for the elderly with non-eldery.

The laparoscopic surgery is less invasive and better cosmetic. The laparoscopic liver resection(LLR)has been accepted for the insurance in April 2010, and increasingly performed in many hospitals, and also expected in metastasis of colorectal cancer. We retrospectively examined the results of LLR for liver metastasis of colorectal cancer. From June 2010 to July 2021, 174 cases of LLR for liver metastasis of colorectal cancer were performed in our hospital. The operation time was 384.5 minutes, the blood loss was small amount, and the postoperative hospital stay was 8 days. The complications were post-bleeding in 1 case, bile leakage in 7 cases, SSI in 16 cases, and no surgery-related deaths were observed. The 3-year disease-free survival rate was 22.8%, and the 5-year overall survival rate was 53.3%. In the comparison between single LLR and multiple LLR, the operation time and the blood loss increased, but there was no significant difference in the length of postoperative hospital stay. In initial LLR and repeat LLR, there were no significant differences in the operation time, blood loss, and postoperative hospital stay. In the primary lesion and simultaneous LLR and heterochronous LLR, the operation time and blood loss were not significantly different, but postoperative intra-abdominal abscess and SSI were more happened, and the postoperative hospital stay was significantly extended. LLR for liver metastasis of colorectal cancer can be safely performed at multiple sites or multiple times, and good treatment results have been obtained, so it was considered to be an effective treatment method.

We report a case of sphenoid bone metastasis from breast cancer detected with diplopia, as first site of recurrence. Forty- year-old woman with left breast cancer underwent breast-conserving surgery and sentinel lymph node biopsy. The diagnosis was papillotubular carcinoma, pT1pN0, ER(+), PgR(+), HER2(-). Tweleb years later, the examination of diplopia revealed left abducens nerve palsy for sphenoid bone metastasis from breast cancer. Radiation therapy(a total dose of 36 Gy with VMAT)was administrated as topical treatment, but diplopia did not improve. After that, systemic treatment was performed, and 2 years and 6 months have passed since the recurrence was found, she is still alive. We need to be careful of orbital metastasis as a symptom of metastasis from breast cancer.

The patient was a 75-year-old woman who was referred to our department because she had type 3 advanced gastric cancer on the posterior wall of the gastric body. Following a thorough examination, she was diagnosed as cT4aN3M1 (#16a1 int, #16b2 lat), cStage Ⅳ, an unresectable advanced gastric cancer with multiple extranodal lymph node metastases. As radical resection was not possible, chemotherapy(SOX therapy)was started. After the start of chemotherapy, the main lesion and metastatic lymph nodes shrank markedly. At the time of 7 courses, it was judged that R0 resection by conversion surgery was possible, and surgical treatment was performed. The patient underwent sub-total gastrectomy with D2 dissection and para-aortic lymph node dissection. The specimen was submitted for pathological examination and showed no residual tumor component including the main lesion and dissected lymph nodes, indicating a complete pathological response. She was started on S-1 as adjuvant chemotherapy on postoperative day 51 and has been recurrence-free for approximately 5 months after surgery.

We report a case of non-exposed endoscopic wall-inversion surgery(NEWS)performed by TANKO technique for gastric GIST. A 52-year-old man was diagnosed as having gastric GIST. A 2 cm-sized tumor was found in the lesser curvature of the middle body of the stomach, and an endoscopic biopsy revealed GIST. A 2.5 cm umbilical incision was made and TANKO surgery was performed. After seromyotomy around the tumor, the outer serosal muscularis was sutured closed to invert the tumor into the stomach. The inverted tumor was resected from the stomach wall and recovered using endoscopic techniques. NEWS is an operation developed to resect a tumor without exposing it into the abdominal cavity and is expected to avoid the risk of postoperative abdominal abscess and peritoneal dissemination. On the other hand, the TANKO is a procedure with excellent plastic technique and can be performed in this operation.

We report a case of cholangiocellular carcinoma(CCC)with high-frequency microsatellite instability(MSI-H)in Lynch syndrome that was managed using a multimodal treatment approach including an immune checkpoint inhibitor. The patient was a 74-year-old man who presented with fever as the chief complaint. He had a history of Vater's papilla cancer and colorectal cancer in Lynch syndrome. A diagnosis of CCC in the left lobe of the liver was made, and left hepatectomy and left caudate lobectomy were performed. From about 2 years and 5 months after the operation, the patient developed several episodes of cholangitis, and recurrence of CCC was diagnosed based on the results of biliary cytology. Gemcitabine and cisplatin therapy was started, but exacerbation of bile duct stenosis associated with cancer progression was observed, and pembrolizumab, an immune checkpoint inhibitor, was started as the solid cancer had an MSI-H status. The tumor markers then improved and the cholangitis subsided. We experienced a case of recurrence of CCC with MSI-H in Lynch syndrome managed by multimodal treatment including an immune checkpoint inhibitor.

The patient was a 78-year-old man who underwent upper gastrointestinal endoscopy, revealing a sub-circumferential type 2 tumor in the lower body of the stomach. Histopathology revealed poorly differentiated adenocarcinoma. Computed tomography(CT)showed lymph node and liver metastasis(S6, S8), which corresponded to clinical Stage Ⅳ(cT4bcN2cM1 [HEP]). Five courses of XP therapy were administered for Stage Ⅳ disease. The sizes of the primary lesion and metastatic liver tumors were reduced, and a partial response was achieved. Distal gastrectomy and partial hepatectomy were performed. The resected specimen was diagnosed as ypT4b(transverse colon mesenteric), ypN0, ypM1(HEP). Thus, the final Stage was Ⅳ. During adjuvant chemotherapy with S-1, the para-aortic, left common iliac, and external peri-iliac lymph node metastases were detected by CT imaging 6 months after the operation. This prompted XP therapy resumption. The lymph node metastases worsened despite 2 additional XP courses. Progressive disease prompted the change in regimen to PTX plus RAM. After 7 courses, swollen lymph nodes were observed and CPT-11 was initiated. Since the disease continued to progress, nivolumab therapy was administered. The para-aortic, left common iliac, and external peri-iliac lymph nodes shrank after nivolumab initiation. The patient has responded well to nivolumab for more than 3 years without immunological adverse events.

We report the case of a patient who underwent additional surgical resection of a rectal neuroendocrine tumor(NET)G1 with a tumor diameter of 5 mm after endoscopic resection, and lymph node metastasis was observed. The patient was a 33- year-old woman. A lower gastrointestinal endoscopy was performed to examine the blood in the stool. A submucosal tumor of 5 mm in size was found in the rectum Ra, and endoscopic mucosal resection was performed. Pathological examination of the resected tissue revealed NET G1; HE staining revealed negative margins and no vascular invasion, but additional immunostaining revealed lymphatic invasion(Ly1a). Additional surgical resection was decided, and a laparoscopy-assisted low anterior resection D3 were performed. The surgical resection specimen showed no residual NET component in the rectum, but metastasis was found in one lymph node. The postoperative course of the patient has been uneventful, and the patient is currently undergoing without recurrence 6 months after the surgery. In the case of NET G1, it is important to search for detailed vascular invasion by immunostaining even in small lesions, and if vascular invasion is found, additional surgical resection should be considered.

Introduction: Laparoscopic surgery is a safe, minimally invasive, and effective approach in managing abdominal malignancies. Laparoscopic anatomical resection has been covered by insurance in Japan since 2016. Here, we have reported the short-term outcomes of gallbladder cancer in laparoscopic cholecystectomy, gallbladder bed resection, or S4a/S5 liver resection with lymph node dissection., Patients: Between May 2012 and December 2020, 28 patients underwent laparoscopic cholecystectomy for gallbladder cancer at Kansai Rosai Hospital. Two patients underwent laparoscopic choledochotomy with lymph node dissection, 6 patients underwent gallbladder bed resection, and 7 patients underwent S4a/S5 liver resection. The control group included 13 patients who received open surgery between July 2010 and November 2019. The patient age was 74.2 and 74.4 years, while the male to female ratio was 19/24 and 8/5 in the laparoscopic and open surgery groups, respectively. According to the Japanese Society of Hepato-Biliary-Pancreatic Surgery, the pathological stage was 0/Ⅰ/Ⅱ/Ⅲ A/ⅢB/ⅣA/ⅣB in 4/17/13/4/2/1/2 and 0/1/2/3/1/1/5 patients(p=0.0100)in the laparoscopic and open surgery groups, respectively. This study was approved by the Human Ethics Review Committee of Kansai Rosai Hospital(Certificate Number: 2101001)., Results: The laparoscopic surgery group had an average operation time of 223.3 minutes, an estimated blood loss of 18.7 g, and a hospital stay of 8.5 days. The open surgery group had an average operation time of 514.5 minutes, an estimated blood loss of 1,274.3 g, and a hospital stay of 33.9 days. There was no postoperative bleeding or bile leakage in both groups. After laparoscopic cholecystectomy, the 5-year disease-free survival rate was 100% among Stage 0 or Ⅰ patients, 64.8% among Stage Ⅱ patients, and 0% in Stage Ⅲ or Ⅳ patients. The 5-year overall survival rate was 100% among Stage 0 or Ⅰ patient and 66.7% among Stage Ⅱ patients. The 1-year overall survival rate was 50% among Stage Ⅲ or Ⅳ patients. After laparoscopic liver resection with lymph node dissection, the 5-year disease-free survival rate was 100% among Stage Ⅰ or Ⅱ patients and 66.7% among Stage Ⅲ or Ⅳ patients. The 5-year overall survival rate was 100% among Stage Ⅰ or Ⅱ patients and 62.5% among Stage Ⅲ or Ⅳ patients., Conclusion: Laparoscopic cholecystectomy in Stage 0 or Ⅰ patients and laparoscopic gallbladder bed resection or S4a/S5 liver resection with lymph node dissection were safe and effective approaches to gallbladder cancer management.

Cholangiolocellular carcinoma(CoCC)was first reported by Steiner et al in 1959. CoCC resembles cholangiocellular carcinoma( CCC)grossly and presents a variety of imaging findings, which often makes preoperative diagnosis difficult. In Japan, CoCC is rare, accounting for only 0.56% of primary liver cancers. We report the results of laparoscopic liver resection (LLR)for CoCC at our institution. Among 845 liver resections(678 LLR and 167 open liver resections)performed at Kansai Rosai Hospital from 2010 to 2020, only 13 were CoCC. Eight patients underwent LLR except for 5 patients who required vascular reconstruction and lymph node dissection. Median age was 71 years (55-77), gender was male/female(7/1), stage was Ⅰ/Ⅱ/Ⅲ/ⅣA(3/3/1/1), liver function was Child-Pugh A/B/C(7/1/0), and liver damage A/B/C(6/2/0). The preoperative diagnosis was 1 CoCC, 3 CCC and 4 HCC. The operative procedure was 3 Hr 0, 3 Hr 1 and 2 Hr 2. The operative time was 342 minutes(168-488), the blood loss was 51.3 g(0-400), and the postoperative hospital stay was 14 days(5- 53). The 5-year disease-free survival rate was 83.3%, and the 5-year overall survival rate was 85.7%. Recurrence was seen in 1 patient. The 5-year survival rate after curative resection of CoCC has been reported to be 73-83%, compared with 28- 36% for CCC. LLR for CoCC at our institution showed good perioperative results. Long-term results were comparable to those reported for liver resection. LLR for CoCC was considered an appropriate technique with good perioperative and long- term results.

The patient was a 56-year-old woman. who was aware of a tumor in her left axilla and consulted a nearby doctor. She was referred to our hospital for a detailed examination. No abnormalities were found in the breast by visual inspection, mammography, or breast ultrasound examination. One 29 mm swollen lymph node was found in the axilla. Fine needle aspiration cytology revealed malignant lymphoma; thus, so axillary lymph node excision biopsy was performed, and a diagnosis of axillary lymph node metastasis of breast cancer was made. However, no abnormalities were found. Based on the information presented above, the patient was diagnosed with occult breast cancer cT0N1M0, Stage ⅡA, and breast preservation plus axillary lymph node dissection up to level Ⅱ was performed. No metastases were found in the dissected lymph nodes. The treatment policy for occult breast cancer has not yet been established. We report this case with a review of the literature.

Atezolizumab plus bevacizumab combination therapy is the first cancer immunotherapy that has shown efficacy in the treatment of hepatocellular carcinoma(HCC). We report a case of HCC with recurrent peritoneal dissemination for which atezolizumab plus bevacizumab combination therapy was effective. The patient, a 63-year-old man, underwent transarterial embolization(TAE)for ruptured HCC, and a mass with dissemination on the caudal side of liver S3 was observed. Laparoscopic lateral hepatic resection plus resection of the dissemination plus cholecystectomy was thus performed in September 2019. However, in November 2019, multiple peritoneal dissemination recurrence was observed, and lenvatinib therapy was initiated. In May 2020, PD was observed, and we had switched to sorafenib therapy. However, in October 2020, further tumor growth and rapid increase in tumor markers(AFP 25,668 ng/mL, PIVKA-Ⅱ 64,960 mAU/mL)were observed, and the patient was judged to have PD. Atezolizumab plus bevacizumab combination therapy was initiated in the same month. Subsequently, a CT scan in January 2021 showed a marked decrease in tumor size, indicating PR. The tumor markers have since normalized(AFP 5 ng/mL, PIVKA-Ⅱ 28 mAU/mL). The patient has been treated with atezolizumab plus bevacizumab combination therapy again and is maintaining PR as an outpatient.

We present a case of jejunal perforation just below the Treitz ligament treated with primary suture after administration of ramucirumab(RAM). The patient was a 74-year-old male. He was diagnosed with Stage Ⅳ sigmoid colon cancer with liver and lung metastasis. Laparoscopic sigmoid colon cancer resection was performed previously. As adjuvant chemotherapy, the patient received 3 courses of CapeOX plus bevacizumab(BEV)and 20 courses of FOLFOX plus BEV and was in PR. After operation for liver and lung metastases, the patient was observed without any treatment, but pelvic recurrence and lung metastasis were noted, and FOLFIRI plus RAM was started. On the 7th day after the second course, the patient experienced abdominal pain. Since an intestinal perforation was suspected, emergency surgery was performed on the same day. There was a 5-mm-diameter perforation in the jejunum just below the Treitz ligament, and were small ischemic changes near the perforation. The rest of the intestine was clear, the perforation was suspected due to RAM. Since anastomosis was difficult, we performed primary suture and decompression of the location. The postoperative course was uneventful, and the patient was discharged on POD 18. Currently, RAM has been discontinued and chemotherapy is being continued with FOLFIRI.

A 50s year old woman was referred to former hospital for abdominal pain and melena. Colonoscopy revealed an ascending colon cancer(cT4aN1bM0, cStage Ⅲb, UICC)and gastrointestinal endoscopy revealed an esophagogastric junction cancer(cT1bN0M0, cStage ⅠA, UICC). Preoperative CT showed mild bilateral hydronephrosis. Laparoscopic right hemicolectomy( Lap-RHC, D3)was performed for ascending colon cancer then, and abdominal CT was taken 2 days before the robot-assisted proximal gastrectomy(RAPG, D1+). Right hydronephrosis was observed. No evidence of obvious ureteral damage was found during Lap-RHC. When retrograde pelvic ureterography was performed and a stenosis was found at the right renal pelvis and ureteral junction. It is considered that the ureter stenosis became prominent due to the postoperative inflammatory change of Lap-RHC. RAPG was performed as scheduled. Two months after discharge, a renal fistula was constructed. Pyeloplasty is scheduled to be performed in the future.

A 62-year-old man was referred to our hospital with complaints of upper abdominal pain and weight loss while being treated for diabetes mellitus at his family doctor. He was diagnosed as locally advanced unresectable pancreatic adenocarcinoma that involved superior mesenteric artery(SMA). Gemcitabine(GEM)and S-1 combined chemoradiotherapy(CRT) was administered. After CRT, CT test showed improved involvement of SMA, and radical resection was possible. We performed the radical pancreaticoduodenectomy and adjuvant chemotherapy, and he has been followed up for more than 5 years after the operation without recurrence. For locally advanced unresectable pancreatic adenocarcinoma, CRT or chemotherapy is recommended in the Pancreatic Cancer Practice Guidelines(2019 edition). However, the prognosis is extremely poor. We report a case of locally advanced unresectable pancreatic adenocarcinoma that was successfully curatively resected due to the good response of CRT.

The patient is an 85-year-old female who had previously undergone a mastectomy for right breast cancer at the age of 42 years. In September 2020, she visited our hospital with a chief complaint of a chest wall tumor. Physical examination revealed a 3×3 cm ulcerative lesion on the right side of the center chest wall. She underwent a skin biopsy of the tumor under local anesthesia and was diagnosed with a recurrence of right breast cancer(ER positive, PR positive, HER2 negative). PET-CT revealed localized skin thickening on the right side of the sternum and FDG accumulation in the same area, with no other findings suggestive of distant metastasis. Treatment was started with anastrozole and is still ongoing. In this article, we report a very rare case of recurrence 43 years after surgery.

Pancreatic neuroendocrine tumor(p-NET)is a relatively rare disease, and treatment is multidisciplinary with resection, local therapy, radiotherapy, and chemotherapy. We report on a case in which long-term survival was achieved by multidisciplinary treatment. The case is a 47-year-old male. He was referred to our hospital because of the diagnosis of pancreatic tail tumor and underwent distal pancreatectomy in May 2008. And he was diagnosed as p-NET G1 by the pathological results. After 3 TACE treatments and 1 partial liver resection for recurrent liver metastasis, multiple liver metastases and lymph node metastases were found in August 2014. As a result of the everolimus treatment, the determination of efficacy to lymph nodes was CR and liver lesions were CR with the addition of TACE treatment. In July 2017, he had multiple liver metastases and right humeral metastases, and has been treated with radiotherapy for bone metastases and has maintained CR. After TACE in November 2017, he received 9 rounds of lanreotide treatment. In December 2018, he again had liver metastases and lymph node recurrence. He has been treated with everolimus treatment again and is maintaining SD in outpatient treatment.

Laparoscopic pancreaticoduodenectomy(LPD)is less invasive and provides better cosmetic outcomes than open pancreaticoduodenectomy( OPD). LPD without vascular excision and lymph node dissection has been covered by insurance since 2016 in Japan. On the other hand, secondary small bowel volvulus is a rare condition caused after abdominal operation. A 77-year-old woman underwent a laparoscopic pancreaticoduodenectomy with pancreatic cancer of pT2N0M0, pStageⅠB. She suffered from epigastric pain after meal. The abdominal CT revealed counterclockwise rotation of the SMV on SMA about 540 degree. Gastrointestinal endoscopy showed no abnormal findings in May 2017. Her abdominal pain was disappeared in July 2017. But the pain was recurred in May 2019. The abdominal CT revealed mesenteric edema and counterclockwise rotation about 810 degree. Her abdominal pain was disappeared again in February 2020. The counterclockwise rotation was decreased about 540 degree. Between May 2012 and February 2020, 50 patients underwent LPD at Kansai Rosai Hospital. 111 patients who received OPD between 2010 and February 2015 were included for comparison. No significant differences were noted between the LPD and OPD groups with respect to patient age(67.9 vs 70.3), gender(M/F: 31/19 vs 70/41). The intraoperative blood loss was lower(106 g vs 1,064 g, p<0.0001)and the operation time was longer (624 vs 535 min, p<0.0001)in the LPD group than the OPD group. Small bowel volvulus over 270 degree was 7/43 vs 5/106(p=0.0338), and over 360 degree was 6/44 vs 1/110(p=0.0014), respectively. Small bowel volvulus after pancreaticoduodenectomy was frequently observed in the laparoscopic group.