The study presents the case of a 71-year-old woman who visited a nearby hospital for epigastric pain and weight loss. A CT scan showed a mass in the gallbladder, and the CEA level was high, so she was referred to our hospital for further investigation. Abdominal US, CT, and MRI suggested gallbladder cancer with para-aortic metastasis, and the histological findings on the EUS-FNA confirmed the diagnosis. Since surgical resection was not indicated, chemotherapy was performed(gemcitabine plus cisplatin). After 10 courses of chemotherapy, CT and MRI showed downsizing of para-aortic lymph nodes, and no accumulation of FDG was found on FDG-PET. Confirming the downstaging of cancer, conversion surgery, comprising an extended cholecystectomy and a lymph node resection, was performed. The pathological diagnosis showed no lymph node metastasis. No recurrence was observed after 12 months of surgery. Initially, unresectable gallbladder cancer with para-aortic lymph node metastasis was indicated to be compatible with preoperative chemotherapy and conversion surgery.

We reported a case of Type 4 rectal cancer performed laparoscopic surgery. A 73-year-old man had diarrhea and constipation and underwent colonoscopy. From the first colonoscopy, histological findings of biopsy showed non-neoplastic cells. The results of colonoscopy strongly suggested the possibility of Type 4 rectal cancer. Therefore, we performed colonoscopy twice and he was diagnosed Type 4 rectal cancer. Computed tomography revealed no distant metastasis. He underwent radical laparoscopic surgery. The histopathological diagnosis was pStage Ⅲc(The 9th edition). He then received adjuvant chemotherapy but was relapsed at bones and lymph nodes. He died 18 months later after surgery.

The patient is a 54-year-old man who was diagnosed with advanced unresectable esophageal cancer. He underwent three courses of FP therapy and was followed up for observation after chemoradiotherapy and PR. Metastasis appeared in the upper lobe of the left lung and new lung metastasis was found in the lower lobe of the right lung despite FP therapy 2 years and 1 month after the start of treatment. Nedaplatin and docetaxel were administered as a second-line chemotherapy; however, the lung metastasis worsened. Consequently, nivolumab was introduced as a third-line chemotherapy. The metastases in the lower lobe of the right lung disappeared with pneumonia after 6 courses of nivolumab, which was diagnosed as a peritumoral infiltration(PTI). PTI is difficult to distinguish from drug-induced lung injury and should be diagnosed carefully because it is an imaging finding that reflects the desired antitumor effect.

An-81-year-old man presented to another doctor complaining of epigastric pain. He was referred to us after the laboratory data revealed a high serum CEA and abdominal ultrasonography showed the space occupying lesion in the left liver. Abdominal CT revealed advanced gallbladder cancer infiltrating the liver and colon and found annular pancreas surrounding the descending portion of duodenum. We chose partial hepatectomy(S4a+S5), extrahepatic bile duct resection with hepaticojejunostomy and partial colectomy. Pathological diagnosis of the tumor was pT3N1M0, gallbladder cancer. The patient was discharged on the 21 days after operation. The frequency of malignant tumors in adult annular pancreas are not revealed. But some cases present with adult annular pancreas complicating the biliary tract tumor. We experienced a case of advanced gallbladder cancer with adult annular pancreas and report our case and review the pertinent literature.

Conversion surgery(CS)post chemotherapy for unresectable pancreatic cancer is often reported recently. Although it is still controversial about adaptation of CS, it could possibly be one of the useful choices of treatment for unresectable pancreatic cancer. We report 3 cases of CS which eventually turned out to be pathological complete response.

The patient is a 79-year-old woman who visited her local doctor with a chief complaint of abdominal pain. A lower gastrointestinal endoscopy revealed a circumferential type 3 mass in the transverse colon. The patient was diagnosed with transverse colon cancer (cT3N0M0, cStage Ⅱa)and underwent laparoscopic transverse colectomy(D3). The postoperative course was good, and she was discharged on POD 9. Pathological results showed a diagnosis of medullary carcinoma(pT3N0M0, pStage Ⅱa)with MSI-high. The patient was treated with UFT/UZEL for 6 months as postoperative adjuvant chemotherapy. The patient has been recurrence-free for 1 year and 6 months postoperatively and is under outpatient follow-up. Medullary carcinoma is a rare histologic type that is estimated to account for 2-3% of all colorectal cancers. Medullary carcinoma of the colon is more common in elderly patients, women, and the right side of the colon, with a relatively favorable prognosis. We report a case of medullary carcinoma of the transverse colon in which the patient had a relatively long survival, with some discussion of the literature.

A 79-year-old man was scheduled for surgery for hepatocellular carcinoma(HCC)after transcatheter hepatic arterial embolization for rupture. Two weeks before surgery, the patient came to our hospital with a chief complaint of back pain. First, we performed biliary drainage, under the diagnosis of HCC with obstructive jaundice due to haemobilia. Hepatectomy was performed when the patient's condition stabilized. It should be kept in mind that haemobilia may occur after TAE for HCC with bile duct tumor thrombus, and appropriate treatment should be performed when bleeding occurs.

A 70-year-old man was admitted to our hospital with a chief complaint of right lower abdominal pain during defecation. The contrast-enhanced CT scan showed a highly expanded appendix, so we suspected an appendiceal mucinous neoplasm, but the diagnosis did not clearly suggest cancer. So, we decided to perform laparoscopic surgery. Based on the intraoperative findings, it was considered that radical resection may be possible by partial cecal resection, and the patient underwent the procedure. Mucinous adenocarcinoma(MACA)was revealed by the postoperative pathological diagnosis. However, because the histological type was G1(well-differentiated)and no metastasis to regional lymph nodes(No. 201)was observed, we decided not to perform an additional ileocecal resection with LN dissection. The patient had a good postoperative course and was discharged from the hospital on postoperative day 4. The patient is still alive, 9 months postoperatively, with no recurrence.

We report a case in which a gastric submucosal tumor at the esophagogastric junction was resected by endoscopic intragastric surgery with minimally invasive and function-preserving. A 30s-year-old man was referred to our hospital because of an abnormal findings pointed by a barium examination at a health check up. Upper gastrointestinal endoscopy and endoscopic ultrasound revealed a submucosal tumor approximately 60 mm in size on the posterior wall of the gastric fundus. Endoscopic ultrasound-fine needle aspiration was carried out and pathological result was a leiomyoma. The tumor was an intraluminal and extraluminal growth extending from the dorsal esophagus to the cardiac region, but considering the patient's young age, we decided to perform endoscopic intragastric surgery to preserve the function of stomach. A 30 mm median incision was made above the umbilicus, and the anterior wall of the gastric body was incised and the intragastric surgery was started using the double protector method. The mucosal surface of the tumor was located at the fundus, but the tumor developed into the dorsal aspect of the lower esophageal muscle layer. The tumor was carefully dissected and resected by intragastric manipulation. Postoperative oral contrast examination revealed no obvious stenosis, and gastric peristalsis was normal.

A man in his 80s was referred to our hospital with the chief complaint of perianal erosion. Colonoscopy revealed a peripheral flat lesion in the anal canal. Since immunohistological examination showed positive for CK20 and negative for GCDFP15, we made a preoperative diagnosis of anal canal cancer with Pagetoid spread. It was diagnosed as cT1bN0M0, cStage Ⅰ by TNM classification, and laparoscopic abdominoperineal resection with TpTME was performed. Negative biopsy of the perianal skin was confirmed both preoperation and during the operation. The postoperative course was uneventful, and no urinary dysfunction was observed. The patient was discharged 15 days after the operation. The histopathological diagnosis was negative margin. The patient is alive without recurrence 1 year after the operation. Adenocarcinoma of anal canal with Pagetoid spread is rare, and differentiation from Paget's disease is important for determining treatment policy. By conducting a detailed examination of the extent of tumor progression and using TpTME together, it was possible to perform surgery that both secured the CRM and preserved urinary function.

A 78-year-old woman was examined in the outpatient department with a chief complaint of swelling of the left breast. Examination confirmed a 10 cm mass in the left breast as along with edema and redness of the skin, following which a diagnosis of invasive micropapillary carcinoma was made after biopsy. The CT imaging showed left chest wall invasion, multiple axillary lymph node metastases, and left carcinomatous pleuritis. Since this a case of advanced breast cancer, we initiated treatment with bevacizumab plus paclitaxel. After 8 months, her medication was changed to eribulin, owing to progression of the cancer, which continued even up to 4 months. We then initiated abemaciclib plus letrozole therapy as the third treatment. We observed tumor reduction and clearing of pleural effusion with no serious adverse events, and continued her therapy for 11 months before the cancer progressed. We report a case of chemotherapy-resistant breast cancer and carcinomatous pleuritis in an older adult patient for which abemaciclib plus letrozole therapy was effective.

Robotic surgery for head and neck cancer [transoral robotic surgery (TORS)] was covered by insurance in Japan in 2022. The number of hospitals performing this surgery is gradually increasing. The indications for TORS are Tis, T1, and T2, without extra nodal involvement of metastatic lymph nodes of oropharyngeal, hypopharyngeal, supraglottic carcinoma. In TORS, the important point is not only robotic manipulation technique, but also knowledge of pharyngeal inside-out anatomy, setting of retractor, docking of the robotic arm and instrument, and accurate evaluation of the extent of tumor invasion. The introduction of single-port robot might affect the expansion of surgical indications for TORS.

The World Health Organization Classification of the Tumours, 5th Edition Central Nervous System Tumours(WHO CNS5), has undergone ground-breaking changes in collaboration with cIMPACT-NOW(the Consortium to Inform Molecular and Practical Approaches to CNS Tumor Taxonomy). Tumors are now classified and named according to the tumor type alone, and the tumor grading is defined within each tumor type. CNS WHO grading is based on either histological or molecular criteria. WHO CNS5 promotes the molecular finding-based classification system and diagnostic criteria, including DNA methylation-based molecular classification. In particular, the classification and CNS WHO grades have extensively been restructured for gliomas. Adult gliomas are now classified into three tumor types according to the IDH and 1p/19q status. Diffuse gliomas with morphological features of glioblastoma and IDH mutation are no longer classified as glioblastoma, IDH-mutant, but as astrocytoma, IDH-mutant, CNS WHO grade 4. Diffuse gliomas without IDH mutation but with molecular features of glioblastoma are classified as glioblastoma, IDH-wildtype. Pediatric-type gliomas are classified separately from adult-type gliomas. Although the shift toward the molecular classification is inevitable, the current WHO classification system has limitations. WHO CNS5 should be regarded as an intermediate stage toward further refined, better structured classification systems in the future.

We investigated pre-operative factors affecting trifecta achievement in robot-assisted partial nephrectomy (RAPN). We retrospectively analyzed 81 patients who underwent RAPN from December 2016 to September 2021 with final malignant pathologies. Trifecta was defined as negative resection margin (RM),warm ischemic time (WIT) less than 25 minutes, and no severe perioperative complications (Clavien-Dindo＜III). Factors affecting trifecta achievement were analyzed using sex, age, body mass index, RENAL nephrometry score (low or moderate/high complexity), surgical approach (transabdominal or retroperitoneal), tumor diameter and surgical experiences of each surgeon. Negative RM, WIT less than 25 minutes, and no severe complications were obtained in 75 (93%), 65 (80%), and 79 patients (98%), respectively. The trifecta was achieved in 60 patients (74%). In multivariate regression analysis, surgical experience (OR:0.92, 95% CI : 0.86-0.99) was significantly associated with trifecta achievement. Receiver operating characteristic curve analysis identified 9 cases as the optimal cut-off values for the predication of trifecta achievement (AUC＝0.69,p ＝0.11). The achievement of WIT less than 25 minutes (65 vs 90%, p＜0.01) and trifecta (58 vs 84%,p ＜0.05) were significantly lower in surgical experiences less than 9 cases than in 9 or greater. We conclude that surgical experience in RAPN is an important factor affecting WIT and trifecta achievement in the initial series.

A man in his 70s was admitted to our hospital due to jaundice and upper abdominal pain. Laboratory findings indicated elevated serum hepatobiliary enzyme and amylase levels. Contrast-enhanced computed tomography revealed smooth wall thickening of the terminal bile duct (tBD) with a faintly enhanced inner line. ERCP revealed stenosis from the tBD to the ampulla of Vater (AV) with upstream dilatation. Intraductal ultrasound (IDUS) circumferentially revealed a thickened wall preserving a three-layered structure throughout the same region. Furthermore, a thick innermost hyperechoic layer was identified in the bile duct portion of the AV (Ab). Findings suggestive of adenocarcinoma were obtained from the tissue samples from the biliary stricture using biopsy forceps. Thus, pancreatoduodenectomy was performed. A pathological examination revealed a thickened AV wall spreading over the tBD with hyperplasia of the glands and smooth muscle fibers. In addition, low-grade biliary intraepithelial neoplasia (BilIN) was scattered throughout the lesion, and high-grade BilIN was partly observed in the peribiliary glands of the Ab. Based on these results, a diagnosis of carcinoma in situ arising in adenomyomatous hyperplasia (ADMH) of the AV was made. To date, there are no reports on ADMH-associated carcinoma of the BD or AV. We here report this original case with the IDUS findings, which are presumed to reflect the histologic features of ADMH showing ductal proliferation surrounded by smooth muscle fibers. Also, we discuss the process through which carcinoma arises from ADMH in AV.

A rare kind of malignant lymphoma, called primary effusion lymphoma (PEL) is associated with human herpesvirus 8 (HHV-8), and characterized by lymphomatous effusion in the bodily cavities. Although the initial clinical presentation of primary effusion lymphoma-like lymphoma (PEL-LL) is similar to that of PEL, PEL-LL is HHV-8 negative and has a favorable prognosis. A PEL-LL diagnosis was made after an 88-year-old man was admitted to our hospital with a pleural effusion. His disease regressed after effusion drainage. He demonstrated disease progression to diffuse large B-cell lymphoma after two years and ten months. Our example demonstrates that aggressive B-cell lymphoma can develop from PEL-LL.

A 59-year-old-woman complained of weight loss and abdominal pain. A CT scan revealed a 20 cm large retroperitoneal mass, and she was diagnosed with diffuse large B-cell lymphoma via biopsy of the mass. After 75% CHP therapy, she developed an acute abdomen and CT revealed generalized peritonitis. Amylase in the ascites fluid was elevated, and infiltration into the pancreas was suspected on CT before treatment, suggesting a pancreatic fistula caused by tumor shrinkage. Enterobacteria were found in ascites fluid culture, suggesting a gastrointestinal perforation complication. The patient was refractory to treatment, and death was confirmed due to progression of the primary disease. The pathological autopsy revealed diffuse pancreatic infiltration, suggesting that the pancreatic fistula was caused by pancreatic injury. Pancreatic fistula is a known complication of surgical procedures but is rarely caused by tumor shrinkage due to chemotherapy. Since there is no preventive method for pancreatic injury caused by tumor shrinkage, early diagnosis and early treatment of pancreatic fistula are critical, and ascites fluid analysis, including amylase, was thought to be useful for the diagnosis.

The patient was 40s male, who underwent laparoscopic low anterior resection for his upper rectal cancer with final pathology results of tub2, pT3(SS), no lymph metastasis and fStage Ⅱ. He was followed up without adjuvant chemotherapy. Half a year after surgery, tumor marker was elevated and CT scan revealed multiple liver metastases. He was treated with oxaliplatin, irinotecan, Leucovorin and 5-fluorouracil(FOLFOXIRI)plus bevacizumab because of RAS mutant type. In the third courses, he has pain in the lower extremities and was diagnosed with acute lower extremity arterial occlusion. Subsequently, chemotherapy was resumed with the exception of bevacizumab, in combination with DOAC, which resulted in tumor shrinkage and allowed resection of the liver metastases.