Search

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

Background: Contrast-enhanced dual-energy computed tomography produces iodine maps (i-maps) based on tissue iodine concentration (IC). We analyzed the features of i-maps in operable breast cancer. Methods: I-maps made from patients with operable breast cancer were retrospectively reviewed. The mean IC of the whole tumor and visual patterns (sharp/obscure) were analyzed with respect to pathological features. The tumor extent was retrospectively verified with dynamic contrast-enhanced magnetic resonance of mammary gland (MRM) and pathological specimens. Results: The median IC of 858 cases was 4.3 (interquartile range [IQR]: 4.0–5.1) mg/mL. The IC of the luminal A-like subtype of invasive breast cancer was significantly higher than that of the human epidermal growth factor 2 (HER2) and triple-negative (TN) subtypes (luminal A-like: 4.5 [IQR: 4.3–5.5] mg/mL vs. HER2: 3.9 [IQR: 3.5–4.4] mg/mL and TN: 3.8 [IQR: 3.6–4.2] mg/mL; both p < 0.05). The IC was significantly correlated with the histological grade and Ki-67 labeling index. Sharp visual patterns correlated with the estrogen receptor and Ki-67 labeling index, while obscure patterns correlated with the HER2 subtype. I-maps underestimated tumor extent in 84 (9.8%) of the 532 partial resection cases, especially in lobular carcinoma and mucinous carcinoma. Conclusions: The IC and visual patterns correlated with the pathological features of operable breast cancer. Most breast cancers are identifiable on i-maps; however, the adjunction of MRM is preferred for tumors with low IC on i-maps to evaluate tumor extent.

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

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

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

4038 Background: Neoadjuvant chemotherapy followed by surgery (NAC-S) is the standard therapy for locally advanced esophageal squamous cell cancer (ESCC) in Japan. The aim of this phase II trial was to assess the efficacy and safety of the addition of adjuvant S-1 after R0 resection in patients treated with NAC-S. Methods: Key eligibility criteria were as follows: ESCC of clinical stage IB-III (without T4 disease); aged 20 to 75 years; ECOG performance status 0 or 1; and performed neoadjuvant chemotherapy (5-FU + cisplatin). All patients registered before surgery. Patients received adjuvant therapy with 4 cycles of S-1 (80 mg/m2/day) that is administered orally for 4 weeks of a 6-weeks cycle. The primary endpoint was three-year relapse free survival (RFS). Results: A total of 52 patients were enrolled between January 2016 and January 2019. Two patients (one with small cell carcinoma and the other with synchronous malignancy) were excluded from analysis. Five patients were diagnosed as R1 or R2. Seven patients did not receive adjuvant S-1 due to adverse events of surgery in 5 patients, refusal to adjuvant S-1 in a patient, and forgot to start in a patient. Thirty-eight patients received adjuvant S-1, with 32 patients completing 4 cycles. The median relative dose intensity of adjuvant S-1 was 85.8%. Median follow-up time among survivors after surgery was 4.5 years (range 0.2-5.6). Three-year RFS in intention to treat population was 72.3% (90% confidence interval [CI] 59.9-81.5), suggesting that the primary endpoint was met, and 3-year overall survival was 85.0% (90% CI 73.9-91.6). Grade 3 or higher adverse event with an incidence 10% of greater were neutropenia (13.2%), anorexia (13.2%), and diarrhea (10.5%). There was no treatment-related death. Conclusions: Adjuvant S-1 showed promising efficacy with manageable safety profile for patients with resectable ESCC after NAC-S, and warrants further evaluation in larger studies. Clinical trial information: UMIN000020204.

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

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

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

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

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

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

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

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

Highlights • Few cases of splenic hamartomas associated with thrombocytopenia have been reported. • Imaging findings in splenic hamartomas are non-specific, variable, and making definitive preoperative diagnosis difficult. • Surgery is necessary for diagnosis when malignancy cannot be ruled out. • Surgery may also improve symptoms of hypersplenism, including thrombocytopenia., Introduction Hamartomas are rare, benign tumors of the spleen. Few cases of splenic hamartomas associated with thrombocytopenia have been reported. Presentation of case An asymptomatic 64-year-old man with myelodysplastic syndrome was found to have a splenic tumor. Laboratory tests were significant for thrombocytopenia, with a platelet count of 7.8 × 104/μL. Ultrasonography showed splenomegaly (10.8 × 6.6 cm), and a hypoechoic splenic mass (8.0 × 7.0 cm). Color doppler ultrasound revealed blood flow within the mass, and the mass density was homogeneous on abdominal computed tomography (CT). Contrast-enhanced CT showed heterogeneous enhancement of the splenic mass during the arterial phase. Positron emission tomography (PET)-CT showed no significant fludeoxyglucose (FDG) accumulation within the mass. The differential diagnosis included splenic hamartoma, splenic hemangioma, splenomegaly associated with extramedullary hematopoiesis, and malignant tumor, including solitary splenic metastasis. A laparoscopic splenectomy was performed due to the possibility of malignancy, the presence of thrombocytopenia, and the risk of splenic rupture. The resected specimen showed a localized, well-demarcated, 8.0 × 7.0 cm splenic mass. Histological examination revealed abnormal red pulp proliferation and the absence of normal splenic structures. The patient’s post-operative course was uneventful. His platelet count improved on post-operative day 1 and he was discharged on post-operative day 9. He remained in good health with a normal platelet count one month after surgery. Discussion Making definitive preoperative diagnosis is difficult in splenic hamartomas. Surgery is necessary for diagnosis when malignancy cannot be ruled out. Conclusions Surgery may also improve symptoms of hypersplenism, including thrombocytopenia.

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

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

Background: Radiofrequency ablation (RFA) is an effective treatment for hepatocellular carcinoma (HCC). However, rare but serious complications may occur after RFA. We describe a case of diaphragmatic hernia associated with RFA. Case Presentation: A 68-year-old man with a history of hepatitis C-related liver cirrhosis was admitted to our hospital because of lower abdominal pain. Three years earlier, he underwent RFA for HCC in segment 8. Computed tomography revealed that the intestine was intruding into the right thoracic cavity through a diaphragmatic hernia. On the basis of the diagnosis of right diaphragmatic hernia with a strangulated ileus, an emergency operation was performed. Perforation of the strangulated transverse colon into the right thoracic cavity was suspected, and a combined approach of laparotomy and thoracotomy was utilized. The operative findings showed that the diaphragmatic hernia was 3.5 × 2.0 cm in diameter, and it was simply sutured with a nonabsorbable suture material. Resection of the intruded ischemic transverse colon was completed, and a covering ileostomy was performed. The patient was discharged without any complications. Conclusions: RFA is widely used for the treatment of HCC. Reports of early- and late-phase complications indicate that heat damage contributes to the fragility of neighboring organs. The occurrence of diaphragmatic hernia after RFA is one of the delayed complications. Although it rarely occurs, this complication requires emergency surgery. In conclusion, if perforation of the intestine into the thoracic cavity is suspected, thoracolaparotomy should be considered as a treatment option to prevent postoperative massive empyema.

Anal metastasis of colorectal cancer is rare, and no standardized effective therapeutic strategy exists. We report a case of abdominoperineal resection for anal metastasis of rectal cancer. A 65-year-old man underwent laparoscopic low anterior resection for rectal cancer in August 2013. Histopathological examination revealed a moderately differentiated adenocarcinoma( tub2, pSS, ly3, v2, pN1, H0, P0, M0, Stage III a, Cur A). In February 2015, he complained of anal discomfort, and tumor markers were elevated. Enhanced CT revealed a 15-mm high-density solid tumor in the anal canal. The results of needle biopsy indicated a moderately differentiated adenocarcinoma. This tumor was suspected to be metastasis from rectal cancer, and we performed abdominoperineal resection. Histopathological examination revealed a moderately differentiated adenocarcinoma, which was the same histological type as the primary rectal cancer and was covered with normal anal epithelium. Collectively, the findings indicated anal metastasis from rectal cancer. The patient is alive without recurrence for 18 months after resection. Anal metastasis should be considered as a differential diagnosis in patients with anal discomfort who have a history of colon/rectal cancer. Abdominoperineal resection may be an effective treatment modality for this condition.

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

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

We describe here a thoracic esophageal cancer with an unusual type of duplicated inferior vena cava. A 58-year-old man was referred to our hospital because a tumor in his lower esophagus had been identified by endoscopy and radiology. Computed tomography scans showed an unusual type of duplicated inferior vena cava characterized by both common iliac veins flowing back into the left-sided inferior vena cava, which drained into the azygos vein, whereas the right-sided one had no drainage. Esophagectomy was performed 3 weeks later after preoperative chemotherapy. Because the patient could have developed thrombosis of the left-sided inferior vena cava and severe hypotension caused by decreased venous return to the heart if the azygos vein had been severed, the azygos vein was preserved. Thus, when performing surgery for thoracic esophageal cancer, the surgeon should check for a duplicated inferior vena cava and preserve the azygos vein if necessary.

We herein report the case of a patient with an acute cervicomediastinal hematoma secondary to the spontaneous rupture of a parathyroid adenoma. A 47-year-old female presented with swelling and pain in the neck. She had no history of trauma or of having undergone any medical or odontological procedures. An ultrasound examination revealed the presence of an obscure mass located behind the right lobe of the thyroid gland. A computed tomography scan showed the presence of a low-density lesion extending from the retropharynx to the mediastinum, a high-density lesion located behind the right lobe of the thyroid gland and a right pleural effusion. Because the patient's neck swelling and anemia gradually worsened, she underwent emergency surgery. The neck was found to be swollen due to a hematoma; however, no abscesses were detected in the operative field.Thoracoscopy of the right chest showed no active bleeding. The fragmented mass was histopathologically diagnosed as a parathyroid adenoma with acute hemorrhage, which is quite rare. Our experience suggests that, in patients with severe cervicomediastinal hematomas without any trauma or trigger, a diagnosis of spontaneous rupture of a parathyroid gland lesion should be considered.

Preoperative treatment is a promising strategy for improving long-term outcomes in advanced esophageal cancer. Two tumor response evaluation criteria for preoperative treatment are available: response evaluation criteria in solid tumors (RECIST) and histological criteria. This prospective study aimed to identify which was a better surrogate end point for survival in the preoperative setting.We analyzed all eligible patients (n=164) from the preoperative treatment group in a phase III trial comparing preoperative versus postoperative 5-fluorouracil plus cisplatin for clinical stage II or III esophageal cancer. Intercriteria reliability was evaluated with the proportion of agreement and the kappa coefficient. For validity analyses, hazard ratios (HR) of response to nonresponse and differences in response rates between short- and long-term survivors were evaluated.The clinical and histological response rates were 37.8% (62 of 164) and 20.1% (33 of 164), respectively. The proportion of agreement for response to nonresponse between the 2 criteria was 70.3%, and the kappa coefficient was 0.34. The HR for death in patients with histological response (0.22, 95% confidence interval 0.09-0.55, P0.001) was lower than for those with RECIST response (0.55, 95% confidence interval 0.33-0.91, P=0.018). The difference in response rates between short- and long-term survivors according to histological criteria (27 vs. 7%, P0.001) was larger than with RECIST (42 vs. 30%, P=0.13).Intercriteria agreement was relatively low, and histological criteria yielded more valid assessments of response than RECIST. Histological response rate seemed to be the better surrogate end point of survival in the preoperative setting.

Congenital cystic adenomatoid malformation (CCAM) in adolescents or adults is extremely rare. In this case study, a 17-year-old boy was admitted to our clinic for the treatment of a giant bulla in the lower lobe of the right lung. Preoperative imaging studies led to the diagnosis of cystic lung disease. The patient underwent wedge resection of the right lower lobe with VATS, and histological examination confirmed the presentation of type 1 CCAM. A thoracoscopic lobectomy was performed after the second surgery because of postoperative air leakage.Herein, we report a case of CCAM in an adolescent. VATS was a suitable procedure for the operation. Between the parenchyma-saving resection and lobectomy for CCAM, we believe that the lobectomy is the better treatment option when the extent of the disease cannot be determined clearly or it is extremely large. Therefore, strategies for deciding between parenchyma-saving resection and lobectomy for the treatment of CCAM should be developed.

Advanced sigmoid colon cancer with stenosis was discovered in a man in his 50's who presented with constipation. A radiological examination revealed peritoneal dissemination. Transverse colostomy was scheduled for the treatment of bowel obstruction. Multiple disseminated nodules were confirmed, and adenocarcinoma was detected from a nodule in the omentum. Eight courses of SOX plus bevacizumab caused the primary tumor to shrink and disseminated nodules to become radiologically undetectable. The patient underwent sigmoid colectomy 8 weeks after the last bevacizumab administration, and no disseminated nodules were found during the procedure. Histological assessment revealed no evidence of cancer cells in the colon and lymph nodes, and the histological effect was judged as Grade 3.

Gastrointestinal stromal tumors (GISTs) of the esophagus are a rare entity. Diagnosis of GIST is currently based on immunohistochemical staining of c-KIT or CD34. However, some tumors have clinicopathologic features of GIST but do not express c-KIT or CD34. A few GISTs contain mutations within a receptor tyrosine kinase protein, platelet-derived growth factor receptor alpha (PDGFRA). We herein report a case of esophageal GIST that was KIT negative and had a PDGFRA mutation. A 75-year-old male who had a giant submucosal tumor in the lower part of the thoracic esophagus underwent surgical resection. Immunohistochemical staining of the tumor revealed that it was uniformly negative for KIT, but partially positive for CD34, and negative for S-100 protein and smooth muscle actin (SMA), which led to the final diagnosis of GIST. PDGFRA genetic testing revealed a mutation in exon 12. The mitotic index was over 5/50 high-power fields, and necrotic changes were noted. Adjuvant chemotherapy using imatinib mesylate was administered. The patient has been disease free for 2 years. To the best of our knowledge, this is the only reported case of esophageal GIST that was KIT negative and had a PDGFRA mutation. In cases of digestive submucosal tumor that are difficult to diagnose because of c-KIT or CD34 negativity despite being suspicious for GIST, PDGFRA genetic testing may help for diagnosis of this minority type of GIST.

近年，肺腺癌においてもinvasive micropapillary carcinomaについて報告されており，リンパ節転移や胸膜浸潤，肺内転移の頻度が高いことが報告されている．今回，われわれは多数のリンパ節に転移を認めた原発性肺癌の1例を経験した．症例は60歳，男性．胸部CTで右肺S6aに18mm大の腫瘤を認め，肺門リンパ節の腫大も指摘された．術前診断はT1N1M0 StageIIAの右下葉肺癌であった．術中まず針生検を行い，迅速病理で肺癌であることを確認し，胸腔鏡補助下右下葉切除+ND2aを行った．組織学的所見で，micropapillary pattern（MPP）を認め，縦隔リンパ節を含めた23/45のリンパ節に転移を認めていた．最終診断はpT1N2M0 StageIIIAであった．MPPを伴う肺線癌はリンパ節転移をきたしやすく，予後不良であり，十分に留意する必要がある．

完全内臓逆位に合併した肺癌に対する胸腔鏡下切除術を経験したので報告する．症例は58歳男性．検診の胸部X線で左上肺野に異常陰影を指摘された．胸腹部CTで胸腹部内臓の完全逆位を認めており，さらに左肺上葉に2cm大の結節影を認めた．手術は腫瘍を胸腔鏡下に部分切除を行い，迅速病理検査で腺癌と診断されたため完全胸腔鏡下に左上葉切除を施行した．左肺は上中下葉の3葉に分葉し，肺動静脈は正常の鏡像を呈しており，その切除手技は通常の右肺上葉切除術の手順とまったくの鏡像での手順となった．

自然血気胸は胸腔内出血を伴う自然気胸であり，自然気胸の1～12％に合併する比較的稀な疾患である．時に大量出血や血腫形成を伴うため，輸血や緊急手術が必要となる．我々は1994～2007年までに自然血気胸を8例経験した．このうち6例に対し，胸腔ドレーン挿入後1日以内に胸腔鏡下手術を施行した．全例無輸血で，術後合併症や再発は認めていない．不必要な輸血や再膨張不良を避けるために，自然血気胸は早期に胸腔鏡下手術を実施すべきである．

ラジオ波焼灼療法 (radiofrequency ablation; 以下, RFA) は肝腫瘍に対する低侵襲治療法として広く実施されているが, 合併症としてさまざまな周囲組織臓器の損傷が報告されている. 我々は肝細胞癌に対するRFA後に発症した横隔膜ヘルニア嵌頓の1例を経験したので報告する. 患者は75歳の男性で, 肝右葉S4, S7, S8の肝細胞癌に対して肝動注療法と経皮的RFAを受けていた. RFAから10か月後に突然の腹痛と腹部膨満にて救急搬送された. 胸部X線検査では右横隔膜上に異常ガス像を認め, 胸腹部CTでは肝彎曲部の結腸が右胸腔内に脱出していた. 横隔膜ヘルニア嵌頓によるイレウスと診断し, 緊急手術を施行した. 肝腫瘍に接する横隔膜に直径3cmのヘルニア門を認めた. 結腸右半切除, 回腸人工肛門造設, ヘルニア修復術を施行し, 術後149病日に退院した.

Endoscopic microwave coagulation therapy (EMCT) was successfully applied to two male patients aged 94 and 84 with obstructive jaundice due to upper bile duct and lower bile duct carcinoma, because of their refusal of resection. A single 15-second exposure of microwave (30 W) was delivered during each treatment to the cancerous tissue using a monopolar shielded wire electrode under guidance of percutaneous cholangioendoscopy. Treatment was repeated a total of two times at interval of a week and no complication was encountered. Patients have subsequently lived for 26 and 20 months without jaundice. These results indicate that EMCT for patients with bile duct cancer without no metastasis and high operative risk might be an effective therapy for local control.

十二指腸乳頭部癌はさまざまな臨床症状を呈するが, 急性膵炎を発症することは比較的まれである. 我々は重症急性膵炎を契機に発見された十二指腸乳頭部癌の1例を経験したので, 過去の本邦報告9例の文献的考察を加えて報告する. 症例は58歳の男性で, 心窩部痛を主訴に近医を受診し, 当院へ紹介され緊急入院した. 血液検査にて血清アミラーゼの上昇を認め, 腹部CTにて膵全体の腫大と膵周囲のfluid collectionを認めた. 重症急性膵炎 (Stage 2) と診断し, 動注療法を含めた集中治療を行い症状は軽快した. 原因精査のためのERCP施行時に十二指腸乳頭部の発赤と襞の集中を認め, 生検にて腺癌と診断された. 幽門輪温存膵頭十二指腸切除術, D2リンパ節郭清を施行し, 病理組織学的にStage IIIの十二指腸乳頭部癌と診断した. 術後15か月目の現在, 再発なく外来通院中である.

目的．10 cm前後の開胸創に開胸器をかけ，胸腔鏡はライトガイドとして使用した胸腔鏡補助下肺葉切除術（A群）と，4 cmの小開胸創には開胸器は用いず完全モニター下で施行した完全鏡視下肺葉切除術（P群）をretrospectiveに比較する．対象と方法．対象は非小細胞肺癌cStage IAで，A群42例，P群38例では，上葉の場合は上縦隔の，下葉では気管分岐部のリンパ節郭清を原則とした．両群ともに同様な手術操作とし，軟性鏡，バイポーラシザーズを使用した．結果．P，A群の順に平均値（検定結果）で結果を示す．手術時間248分，202分（p＝0.0001），出血量146 g, 263 g（n.s.），在院日数8.0, 15.0日（p＜0.0001）であった．リンパ節の郭清個数は，上縦隔リンパ節で11個，7.2個，分岐部リンパ節で4.7個，4.8個と同等であった．合併症は，5例の13.2％，11例の26.2％に発症し，その中では遷延性肺瘻が3例の7.9％，5例の11.9％であった．術後創部痛によるボルタレン座薬TMの使用量は15 mg，45 mg（p＜0.001）であった．両群とも在院死亡，術後直接死亡は認めず，2年生存率には差を認めていない．結語．P群では胸壁への低侵襲化により術後創部痛は軽減した．手技上の工夫により操作性と安全性が確保されたが，さらに呼吸器外科を標榜する施設で普遍的に施行可能な術式が望まれる．

拡大胸腺摘出術後にCyclosporin Aを投与し，貧血を改善することができた赤芽球癆合併胸腺腫の1例を報告する．症例は75歳，男性．労作時呼吸困難を主訴に受診し，高度の貧血を指摘された．骨髄検査にて赤芽球無形成を認め，胸部CTにて前縦隔に4cm大の充実性腫瘍を認めた．赤芽球癆合併胸腺腫と診断し，輸血にて貧血を改善した後，拡大胸腺摘出術を施行した．病理組織学的にWHO分類type B1，正岡分類II期の胸腺腫と診断された．術後1ヵ月経過しても貧血の改善が認められなかったため，Cyclosporin Aの投与を開始したところ，網状赤血球の上昇と貧血の改善を認めた．術後12ヵ月経過した現在，外来にて経過観察中で，貧血の進行や胸腺腫の再発は認めず良好に経過している．