A 66-year-old male came to our hospital because of occult blood in stool and anemia. The patient was diagnosed as unresectable advanced gastric cancer,( ML/Less, type 2, tub2, cT4b[liver], cN+, cM0, cStage Ⅳ, HER2 negative). He was given oxaliplatin plus S-1 therapy. In the 3rd course of chemotherapy, he had severe anemia, and active bleeding from the tumor. To control the bleeding he underwent distal gastrectomy, lateral segmentectomy of the liver, and S4 partial hepatectomy. The patient underwent adjuvant chemotherapy with docetaxel plus S-1. Three months after surgery, lymph nodes recurrence was observed. He underwent second-line therapy with paclitaxel and ramucirumab. Seven months after surgery, lymph nodes recurrence was increased. He was switched to third-line therapy with nivolumab. He is currently arrive 12 months after surgery.

A 68-year-old male patient underwent laparoscopic pyloric gastrectomy(D2)in October 2015 for gastric cancer, pStage ⅠB. In August 2017, a 3 cm large abdominal wall metastasis in the left lateral abdomen was removed. In September 2019, a 2 cm tumor was found in the left inguinal region. The left inguinal area was repaired using mesh with the TAPP technique because of a large abdominal wall defect centered on the inner inguinal ring. Three and a half years after the resection, he is continuing complete response(CR)with nivolumab therapy.

A 87-year-old female was pointed out wall thickness in the upper part of gastric body for examination of anemia. The mass had a contrast effect, some of it protruded outside the wall, and the surrounding lymph nodes were enlarged. Upper endoscopy showed irregular ulcerative lesion with submucosal volume from posterior wall to the greater curvature in the upper part of gastric body. Biopsy was performed, and GIST of stomach was diagnosed. Surgery was performed for the GIST of the stomach. During open surgery, invasion of pancreatic tail was observed, therefore proximal gastrectomy with D1 lymph node dissection and distal pancreatectomy were performed. Pathologically, the tumor measured 95×78×65 mm with mitotic figures(38/50 high-power fields). Immunohistochemical analysis revealed that tumor cells expressed positive results for c-kit, α-SMA and CD34, and negative results for S-100 and desmin on the basis of the histology and immunostaining profile, the tumor was diagnosed as a GIST. The patient was classed as high risk according to Fletcher's risk classification. Tumor invades pancreatic tail, and lymph node metastasis was observed. She was discharged on the postoperative day 27 and alive without tumor recurrence at 6 months after surgery, not undergoing adjuvant chemotherapy.

The patient is a 69-year-old man. 17 years ago, a colectomy was performed for colorectal cancer, and a disseminated nodule was found during the operation, so the disseminated nodule was also resected. After the surgery, 12 courses of FOLFOX4 were administered, and there was no recurrence thereafter. He was diagnosed with hepatocellular carcinoma 12 years after the colectomy and underwent liver resection. Fifteen years after the colectomy, a mass shadow appeared in the right inguinal region, and inguinal lymph node metastasis of hepatocellular carcinoma or colorectal cancer was suspected. In the same year, he underwent the tumor resection and histopathological diagnosis revealed colon cancer inguinal lymph node metastasis. After the lymph node resection, he has been followed up for 2 years with no recurrence of colorectal cancer. It is extremely rare to have a solitary inguinal lymph node recurrence 15 years after colon surgery.

The aim of this study was to investigate the short-term outcomes of surgery for colorectal cancer(CRC)in the elderly aged over 90 years old. We retrospectively analyzed 1,043 patients with stage Ⅰ-Ⅳ CRC who underwent curative surgery in our institutions between 2013 and 2022. The patients were divided into the super older(aged ≥90 years, 20 patients) and non-super older groups(aged 80-89 years, 243 patients). The short-term outcomes were compared between the 2 groups. There were no significant differences in tumor location, stage, surgical approach, duration of operation and blood loss. The incidence of severe postoperative complications did not differ between the 2 groups. In conclusion, our study suggested that surgery for colorectal cancer could be as safely performed in super elderly patients as in non-super elderly patients.

The patient was a 54-year-old male at the time of initial examination. He was aware of numbness and weakness in the left hemisphere of his body and came to see the hospital. He was diagnosed with brain metastasis of lung cancer and started treatment(cT2N0M1[Brain]). He underwent gamma knife for the head lesion and nivolumab for the lung lesion. The patient's lesions shrank with the success of the medical treatment, but recurred with small intestinal metastasis. He underwent a partial resection of the small intestine and was treated again with nivolumab, which resulted in a complete response. He is currently alive without recurrence. We have experienced a very rare case of recurrence-free survival after treatment for brain metastasis and small intestinal metastasis of lung cancer.

A 67-year-old man visited our hospital for epigastric pain. Esophagogastroduodenoscopy(EGD)revealed type 2 gastric cancer from the cardia to the gastric angle, and histopathological examination revealed papillary adenocarcinoma(pap), HER2-positive. Contrast-enhanced CT showed wall thickening mainly in the posterior wall of the gastric body, enlarged lymph nodes that were lumped together with the main lesion, and 8 low-absorption areas with ring shaped contrast effects in both lobes of the liver. The patient was diagnosed as gastric cancer cT4aN(+)M1[HEP], clinical Stage ⅣB. Six courses of capecitabine plus cisplatin plus trastuzumab(XP plus Tmab)therapy and 17 courses of capecitabine plus trastuzumab(X plus Tmab)therapy were performed. After chemotherapy, liver and lymph node metastases disappeared on CT and MRI. EGD showed residual gastric cancer, and the policy was to resect the primary tumor. Laparoscopic total gastrectomy with D2 lymph node dissection was performed. Pathological results showed T1b(SM)depth, no lymph node metastasis, and histologic response was Grade 2a. Six courses of X plus Tmab were administered as postoperative adjuvant chemotherapy, but were discontinued at the patient's request. Currently, 5 years have passed since the first chemotherapy and 3.5 years have passed since the surgery, and the patient is alive without recurrence, suggesting that the conversion surgery may have contributed to the prolonged survival.

We report a case of right advanced breast cancer with multiple lung metastases in a 66-year-old woman. Her breast cancer( invasive ductal carcinoma, cT4bN1M1, Stage Ⅳ)was resected in October 2007(mastectomy plus axillary lymph node dissection)after local arterial infusion therapy(total dose 5-FU 4,735 mg plus adriamycin 180 mg), which caused bilateral lung arterial embolism due to deep vein thrombosis in right her leg. She had to be treated by anticoagulant therapy, mechanical ventilation and placement of IVC filter before her operation. Subsequent chemo-endocrine therapy(docetaxel 6 courses plus anastrozole)was continued. In October 2008, a CT scan showed disappearance of multiple lung metastases (complete response). In November 2015 (8 years after her operation), a CT scan showed recurrence of multiple lung metastases and endocrine therapy was changed to tamoxifen. A year later, a CT scan showed disappearance of multiple lung metastases(complete response)again and keep a condition of complete response in her breast cancer until May 2023 (15 years after her operation).

A 61-year-old woman presented at a nearby clinic with a complaint of a mass in the right axilla. Initial imaging examinations, including mammography, ultrasonography, and breast MRI, did not reveal any obvious intramammary lesions, although a swollen lymph node was observed in the right axilla. Fine-needle aspiration cytology confirmed malignancy. Hence, a core needle biopsy was performed. The results indicated a suspected metastasis of invasive ductal carcinoma(ER-, PgR-, HER2-); however, the primary tumor could not be definitively determined. Despite an extensive whole-body examination, the primary tumor remained unidentified. Nonetheless, metastasis of occult breast cancer in the right axillary lymph node was postulated. Subsequent axillary dissection revealed metastases in only one lymph node. Taking the clinical findings into consideration, the patient was diagnosed with right occult breast cancer, and chemotherapy and radiotherapy were planned.

The use of nivolumab as first-line therapy for unresectable advanced gastric cancer has now become a standard practice, and its efficacy has been established. This is the first report of a patient with advanced gastric cancer who underwent conversion surgery after first-line nivolumab combination chemotherapy. The patient was a 58-year-old woman. Her medical history included hypertension and dyslipidemia. She had advanced gastric cancer with extensive lymph node metastasis in the left supraclavicular fossa and around the abdominal aorta. After confirming the HER2-negative status and the PD-L1 CPS score to be ≥5, nivolumab was administered in combination with chemotherapy. After the treatment, she underwent a total gastrectomy with D2 dissection, combined splenectomy and pancreatic tail resection for adhesions, and para-aortic lymph node sampling as a conversion surgery. There was no obvious cancerous remnant in the resected specimen, and the pathological response was Grade 3. The patient was alive and recurrence-free at 4 months postoperatively.

As genomic medicine advances, opportunities for molecular pathology diagnosis by pathologists to be used as companion diagnostics is increasing. Pathological specimens must be useful not only for pathological diagnosis, but also for genetic testing panel and molecular pathology diagnosis. Companion diagnostics performed by pathologists uses immunohistochemical staining and fluorescence in situ hybridization to determine patient eligibility for molecular target drugs and immune checkpoint inhibitors. By accurately observing a wide variety of diagnostic criteria and performing with high precision, pathological diagnosis will become closer to therapeutic pathology.

Cysts are abnormal fluid-filled sacs found in various human organs, including the liver. Liver cysts can be associated with known causes such as parasite infections and gene mutations, or simply aging. Among these causes, simple liver cysts are often found in elderly people. While they are generally benign, they may occasionally grow but rarely shrink with age, indicating their clear association with aging. However, the mechanism behind the formation of simple liver cysts has not been thoroughly investigated. Recently, we have generated transgenic mice that specifically overexpress fibroblast growth factor (FGF)18 in hepatocytes. These mice exhibit severe liver fibrosis without inflammation and spontaneously develop liver cysts that grow with age. Our findings suggest that simple liver cysts can be induced by fibrosis accompanied by sterile inflammation or injury, whereas fibrosis accompanied by severe inflammation or injury may lead to cirrhosis. We also discuss the detrimental effects of disease- and aging-associated fibrosis in various organs, such as the heart, lungs, and kidneys. Additionally, we provide a brief summary of the two currently approved anti-fibrotic drugs for idiopathic pulmonary fibrosis, nintedanib and pirfenidone, as well as their possibility of future expansion of application toward other fibrotic diseases.

A 2-year-old, male patient presented with an 18-month history of scattered, brown macules and nodules up to 2 cm in size on his trunk and extremities. These macules were accompanied by pruritus and were positive for Darier's sign. A skin biopsy of a brown macule on the left thigh revealed a dense accumulation of CD117-positive, round or oval cells with amphophilic cytoplasm within the upper to middle dermis. The patient was otherwise healthy and had normal laboratory and imaging test results. Sequence analysis of genomic DNA from a skin biopsy demonstrated the presence of an Asp419del mutation in exon 8 of the KIT gene. Based on these findings, maculopapular cutaneous mastocytosis (MPCM) was diagnosed. The patient received H 1-antihistamine. Although the pruritus resolved, the brown macules remained for one year after the initial treatment. To the best of our knowledge, only three cases of cutaneous mastocytosis (CM) with an Asp419del mutation, including the present case, have been reported in the Japanese literature to date; moreover, while the previous two cases were of DCM, the present case was the first instance of MPCM. Normally, the symptoms of childhood-onset MPCM are dormant until puberty. However, a recent study reported that many MPCM patients may experience persistent or exacerbated symptoms. The present study therefore evaluated 53 Japanese cases of childhood onset MPCM with a KIT gene mutation and discussed the patients' clinical outcomes.

Surgeries for brainstem lesions and adjacent areas needs meticulous manipulation in the profoundly deep surgical field. Moreover, it is associated with a high risk of complications pertinent to resection. The opportunity for a surgeon to amass extensive surgical experience in these lesions is limited. Additionally, the reduced tissue mobility in the brainstem, compared to other lesions, makes selecting the optimal surgical approach critical. Preoperative simulation is pivotal in surmounting these challenges. However, the limitations of preoperative simulations should be recognized in accurately depicting diminutive vessels and cranial nerves around the brainstem. Incorporating intraoperative anatomical observations and data from intraoperative monitoring into a surgical strategy is imperative. Here, we present three cases in which we believe preoperative simulation was effective; a cavernous hemangioma of the brainstem, trochlear schwannoma, and diffuse midline glioma in the pons.

What is the most important factor to achieve successful surgery for deep-seated brain tumors with preservation of brain functions? Definitely, it is to identify the tumor origin site at which a tumor arose and select appropriate surgical approaches that immediately lead directly to the site in the early stage of surgery, minimizing damages of cortices and important white matter bundles, and controlling main arterial supply to the tumor. For this, neurosurgeons must have thorough knowledge of brain anatomy and function, and tailor the best surgical approach for each patient, based on three-dimensional anatomical simulation. For lesions situated in the posterior and lower part of the thalamus and extending to the lateral part, two "cross-court" approaches; the occipital transtentorial/falcine and infratentorial supracerebellar transtentorial approaches, provide a wide corridor to even the lateral aspect of the thalamus and early access to the posterior choroidal arteries, usually main feeders of this territory tumors, without damaging any cerebral cortices and major white matter bundles. Here, we describe the selection of approaches for two representative cases and demonstrate surgical procedures and postoperative courses.

With the development of endoscopic and peripheral instruments, endonasal or transcranial endoscopic surgery for skull-base tumors has become more common. Preoperative simulation makes it relatively easy to understand the anatomical relationship between skull base tumors and the surrounding vital structures, which vary with each case. This may lead to the avoidance of complications and an improvement in the removal rate. Especially in cases of skull base tumors where multiple surgical approaches are possible, the three-dimensional model can be used to confirm the surgical field for each approach and consider the most appropriate. With the development of endovascular treatment and radiotherapy, experience in craniotomy has decreased. Young neurosurgeons need to develop skills to learn as efficiently as possible from their limited experience. Therefore, it is extremely useful to provide an environment that allows for easier preoperative simulations.

The case is a 78-year-old male. The chief complaint was melena and weight loss. After careful examination, the patient was diagnosed with advanced rectal cancer, and 3 courses of capecitabine plus oxaliplatin therapy were performed as preoperative chemotherapy. He underwent robot-assisted laparoscopic rectal resection, D3 lymphadenectomy, lateral lymphadenectomy, and temporary colostomy, and was discharged on hospital day 15. Postoperative pathological diagnosis showed only ulcerative lesions in the rectum, and malignant cells could not be confirmed. After postoperative adjuvant chemotherapy, the patient is alive without recurrence on an outpatient basis. There are many reports that it is slightly lower than radiotherapy. Therefore, it is important to select a more appropriate preoperative treatment, and the concentration of future cases is recognized.

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.