A-78-year-old woman presented with difficulty swallowing. She was diagnosed as having advanced upper gastric cancer with invasion to the esophagus and the diaphragm. Biopsy examination of the tumor showed MSI-high and HER2-negative. The patient received 4 courses of SOX plus nivolumab in combination. After the chemotherapy, the size of the tumor decreased remarkably. We performed total gastrectomy with D2 lymph node dissection. Pathological examination revealed no residual cancer at the primary tumor location and the regional lymph nodes. The patient has shown no recurrence for 9 months without adjuvant chemotherapy. We conclude that SOX plus nivolumab in combination as first-line chemotherapy is an effective strategy against advanced gastric cancer.

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.

We first reviewed surgical outcomes and pathological findings of 32 patients(laparoscopic group: LDP n=11, open group: ODP n=21)who underwent distal pancreatectomy for pancreatic cancer from January 2018 to October 2022. Then we reviewed long-term outcomes, and recurrence type for 20 patients(LDP: n=5, ODP: n=15)from January 2018 to February 2021.

A 59-year-old woman underwent simple abdominal total hysterectomy with bilateral salpingo-oophorectomy, partial omentectomy, and extirpation of intrapelvic disseminated nodules for right fallopian tube cancer with rectal metastasis and peritoneal dissemination as primary debulking surgery(PDS). The histopathological diagnosis was high grade serous carcinoma( HGSC)of the right fallopian tube. After adjuvant chemotherapy with 4 courses of paclitaxel-carboplatin(TC), low anterior resection of the rectum for rectal metastasis and pelvic and para-aortic lymph node dissection were performed as interval debulking surgery(IDS). Histopathologically, lymph node metastasis was detected only in the right obturator lymph node. After adjuvant chemotherapy with 4 courses of TC, bevacizumab maintenance monotherapy was administered. Three years after PDS, laparoscopic splenectomy for splenic metastasis and extirpation of the solitary peritoneal metastases were performed as secondary debulking surgery(SDS). After adjuvant chemotherapy with 4 courses of TC, olaparib maintenance monotherapy was administered. The patient has remained alive without recurrence for 4 years after SDS and for 7 years after PDS. No case of metachronous splenic metastasis from fallopian tube cancer with synchronous rectal metastasis has been reported; however, long-term prognosis may be expected with PDS, IDS and SDS for platinum-sensitive HGSC.

A 69-year-old woman was admitted to a territory hospital because of severe right hypochondoralgia after 2 weeks of internal medicine for persistent epigastralgia. Gastroduodenal endoscopy revealed a large tumor with a fistula in the duodenal bulb that expanded to the stomach. Histopathologically, the biopsy specimen indicated a poorly differentiated adenocarcinoma and HER2 negative. Computed tomography revealed that the tumor invaded the left lobe of the liver. The patient was referred to our hospital for cancer treatment. After 1 course of chemotherapy with S-1 and CDDP, laparoscopic gastroenterostomy bypass was performed because of tumor hemorrhage and poor food intake. However, the tumor hemorrhage and poor food intake continued, and the tumor enlarged. Therefore, left hemihepatectomy and distal gastrectomy with resection of the duodenal bulb were performed 1 month after bypass surgery. Histological testing confirmed the diagnosis of duodenal large-cell neuroendocrine carcinoma invading the liver without lymph node metastasis. Adjuvant chemotherapy was not administered, and the patient has been alive without recurrence for 7 years and 3 months. Neuroendocrine carcinoma of the non-ampullary duodenum is very rare; however, a large cell type without lymph node metastasis may be a factor in the long-term prognosis.

A 69-year-old man with dysphagia was diagnosed with advanced esophageal cancer by upper gastrointestinal endoscopy. He had undergone pancreatic tail and partial transverse colon resection for pancreatic cancer, and right hilar lymph node biopsy and partial lower lobe resection for the diagnosis of pulmonary sarcoidosis. Contrast-enhanced computed tomography(CT)scan showed no change over time in lymph node enlargement in the mediastinum, so metastasis of esophageal cancer was considered to be negative. Therefore, the diagnosis of advanced esophageal cancer, Mt, type 2, T2N0M0, cStage Ⅱ, was made, and surgery was performed after 2 courses of DCF therapy. Because of the adhesions in the thoracic cavity and possible problems with elevation of the gastric tube and blood flow due to resection of the pancreatic tail, it was decided to perform two-stage operation. Although imaging studies over time, as in the present case, can help in the diagnosis, it is difficult to distinguish whether enlarged lymph nodes are reactive changes or metastases. In this study, we experienced a case of thoracic esophageal cancer complicated by sarcoidosis with enlarged mediastinal lymph nodes.

Until now, the standard treatment regimen was cisplatin plus 5-FU as the chemotherapy for unresectable advanced esophageal cancer. Immune checkpoint inhibitors have brought about changes to the cancer treatment. Ipilimumab plus nivolumab was approved in June 2022 for unresectable advanced esophageal cancer. An 86-year-old woman who was normal ADL and cognitive function was diagnosed with unresectable esophageal cancer with multiple lymph node metastasis. We thought surgery or chemotherapy is impossible because of her age and health status, so we treated with ipilimumab plus nivolumab. After 2 cycles, tumor became reduced in size on endoscopic examination and accumulation in primary lesion and lymph node metastases was decreased considerably on positron emission tomography/computed tomography(PET-CT). Though the cycle after initiation of chemotherapy was uneventful, tumor regrowth on the examinations at 5 months. The patient's condition of the disease was improved temporarily after change chemotherapy to paclitaxel as the second-line therapy, but she died due to disease progression at 11.4 months from initiation of treatment. Ipilimumab plus nivolumab can become one of the effective treatments for patients who are impossible to treat with conventional chemotherapy.

Neoadjuvant chemotherapy(NAC)is prescribed for resectable esophagogastric junctional cancer on the basis of esophageal invasion length, lymph node metastasis, and pathological diagnosis. Due to a lack of consensus in Japan, however, discussion regarding its use is necessary. This study comprised 6 patients who underwent surgical resection after receiving NAC in our department from 2018 to 2022. All the patients were male, with a median age of 67 years. Three patients underwent SP therapy, 2 received SOX therapy, and 1 received both SOX and HER therapy. A total gastrectomy was performed in 3 cases, a fundectomy in 1 case, and a subtotal esophagectomy with gastric tube reconstruction in 2 cases. The histological types were tub2 in 3 cases; and tub1 plus pap, por1 plus pap, and NEC in 1 case each, respectively. One case was ypStage ⅠA, 2 cases were ⅠB, 1 was ⅡA, 1 was ⅡB and 1 was pCR. Currently, all the patients remain alive and without recurrence. NAC has, therefore, been demonstrated to be an effective therapeutic strategy for esophagogastric junctional cancer in this study. However, further research with a larger sample size is required.

A case is a female of 61-year-old. She visited her local doctor with a chief complaint of frequent burping. She was hospitalized for gastric cancer with pyloric stenosis. Although open gastrectomy was planned the gastric cancer was unresectable due to pancreatic invasion and peritoneal dissemination. Cytology with abdominal lavage was CY0. She underwent gastrojejunostomy. She was treated by 19 courses of chemotherapy with SOX therapy for 2 years. The tumor reduced, and she underwent distal gastrectomy as conversion surgery. Pathological findings were por2>muc>tub2>tub1, ypT2(ypMP), INF c, int, Ly1a, V0, pPM0, pDM0, pN0(0/43), ypStage ⅠB, R0, Grade 2b. Adjuvant chemotherapy(S-1 and docetaxel)was administered after conversion surgery. She is alive without recurrence for 1 year and 6 months after gastrectomy. We report a case of Stage Ⅳ gastric cancer treated with conversion surgery after chemotherapy.

The patient was a 78-year-old woman. She presented with anemia and a positive fecal occult blood test. Endoscopic findings revealed type 3 advanced gastric cancer. As it had metastasized to the para-aortic lymph node(PALN: No. 16a2 lat), it was diagnosed as gastric cancer at cardia cT4aN1(No.1)M1(No.16a2 lat), cStage Ⅳ. She was administered S-1, oxaliplatin, and nivolumab(SOX plus Nivo)therapy as a first-line treatment. SOX plus Nivo resulted in a remarkable reduction of the lymph nodes, which were PR. After 3 courses of chemotherapy, a laparoscopic proximal gastrectomy was performed, with D2 plus No. 16a2 int/lat lymph nodes dissection as conversion surgery. Histopathological examination was pT3N0M0, and R0 resection was pStage ⅡA. She was discharged at POD21 and started S-1 from POD69. The patient is alive with no signs of recurrence 10 months postoperatively.

Gastric mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN) is an extremely rare form of gastric neoplasm, and its prognosis is often poor. This is a case report wherein the primary site increased during chemotherapy against gastric adenocarcinoma and was diagnosed with gastric MiNEN after total gastrectomy. A 71-year-old man was diagnosed with gastric adenocarcinoma complicated with liver and para-aortic lymph node metastasis. Chemotherapy with S-1, oxaliplatin, and trastuzumab was initiated. Although the size of metastatic lesions was reduced after six courses of treatment, a part of the primary site of gastric tumor rapidly. Pathological rebiopsy of the primary site suggested a neuroendocrine carcinoma, and he was finally diagnosed with gastric MiNEN after total gastrectomy. Thus, second-line chemotherapy was then initiated showing good response. We herein report a case of MiNEN with a rare diagnostic process.

The prognosis of patients with B-cell non-Hodgkin lymphoma (B-NHL) has improved with the use of anti-CD20 based immunochemotherapy. However, management of relapsed or refractory disease remains a challenge, indicating a high unmet need for novel treatments. Epcoritamab (recombinant) is a humanized immunoglobulin G1 (IgG1) bispecific antibody that simultaneously binds to CD3 on T cells and CD20 on B cells or tumor cells inducing T-cell mediated cytotoxicity against CD20-positive B cells. It demonstrated consistent cytotoxic effects in B-cell lymphoma cell line-derived xenograft models, patient-derived xenograft models, and cynomolgus monkey studies. Pharmacological studies in cynomolgus monkeys showed peak plasma concentrations of cytokines were lower with subcutaneous versus intravenous administration. To reduce the risk of cytokine release syndrome (CRS) and improve convenience, Epcoritamab has been developed as a subcutaneous formulation.To further reduce the risk of CRS, clinical trials utilized a priming dose and incremental dose increases. In Phase I/II overseas trials with relapsed, progressive, or refractory B-NHL patients, the recommended Phase II trial dose was determined based on safety, efficacy, and pharmacokinetic model simulation results. The Phase II dose-expansion part demonstrated the efficacy and high tolerability of epcoritamab monotherapy at the recommended dose. Similar efficacy and tolerability were observed in Japanese Phase I/II trials in relapsed or refractory B-NHL patients. Based on these results, epcoritamab received the approval in September 2023 for the treatment of "relapsed or refractory large B-cell lymphoma (DLBCL, HGBCL, PMBCL)" and "relapsed or refractory follicular lymphoma (Grade 3B)" in Japan.

A 30-year-old man underwent a right high orchiectomy for a testicular tumor. A computed tomography (CT) scan revealed para-aortic and mediastinal lymph node and lung metastases, consequently he was diagnosed with pTxN3M1aS2 stage III B, mixed germ cell tumor (teratoma, fibrosis). The bleomycin, etoposide, and cisplatin protocol was initiated after the placement of an inferior vena cava filter for common iliac venous thrombus. Human chorionic gonadotropin (HCG) positivity was observed at the end of the fourth course despite the immediate decrease in tumor markers after the treatment's initiation. The HCG levels remained low and positive after three vinblastine sulfate, ifosfamide, and cisplatin protocol and two paclitaxel, ifosfamide, and cisplatin protocol courses. A subsequent CT scan revealed a developing lymph node metastasis; hence, retroperitoneal and mediastinal lymph node dissections were performed biphasically.Residual tumor resection is indicated for patients with non-seminoma having localized retroperitoneal lesions or resectable lesions and high alpha-fetoprotein. However, the lymph node dissection, performed here, stabilized the patient's condition in a non-HCG-negative and HCG stain-negative state, suggesting that elevated HCG may be attributed to abnormal feedback from chemotherapy.

(Objective) To evaluate prognostic factors of metastatic urothelial carcinoma treated with immunotherapy. (Materials and methods) Fifty patients treated with pembrolizumab at Osaka Rosai hospital during 2017-2022 were examined. The treatment efficacy was evaluated using Response Evaluation Criteria in Solid Tumors, Version 1.1. (Results) Radical surgery was performed in 40 of 50 patients. According to the Bellmunt risk classification, which considers the performance status, presence of anemia, presence of liver metastasis, and interval from previous chemotherapy, 10 cases had risk 0; 23, risk 1; 13, risk 2; and 4, risk 3. The objective response rate (complete and partial remission) during immunotherapy was achieved in 15 cases. The median times of overall survival (OS) from first-line treatment initiation and immunotherapy initiation were 18.7 and 10.9 months, respectively. Multivariate analysis revealed lower platelet counts (<200,000/μL), increased C-reactive protein levels (≥0.75 mg/dL), and NLR (elevated neutrophil-lymphocyte rate) (≥6) to be poor prognostic factors for OS. Considering these three factors, the median OS of the low-risk (0 or 1) and high-risk (2 or 3) groups was significantly different, at 13.8 and 3.5 months, respectively (p<0.001). (Conclusion) Early switching from immunotherapy to the next treatment should be considered for high-risk patients.

A 72-year-old man was referred to our hospital because of right renal tumors. Ultrasound examination revealed two masses in the right renal hilum. Contrast-enhanced computed tomography (CT) scan showed 25 mm and 10 mm soft tissue density nodules with poor contrast effect in the right renal hilum. Positron emission tomography-CT scan showed an accumulation of SUVmax of 6.65 in the same area. A CT-guided biopsy was performed, and immunostaining revealed the presence of IgG4-positive plasma cell clusters and a high serum IgG4 level of 658 mg/dL. A definitive diagnosis of IgG4-related disease was made, and the patient was placed under observation.A CT-guided biopsy is helpful for the diagnosis of IgG4-related disease and should be considered when masses are found in the unilateral renal hilum.

(Objective) We examined if the degree of preoperative hydronephrosis influences the occurrence of postoperative intravesical recurrence (IVR) in patients with upper tract urothelial cancer (UTUC). (Material and method) From January 2010 to March 2022, a total of 237 patients underwent total nephroureterectomy and partial cystectomy for UTUC at our hospital. For this study, 169 patients were selected after excluding 57 patients with a history of bladder cancer, 10 patients who received postoperative intravesical anticancer drug injection and 1 patient with inadequate data. Cases with Society for Fetal Urology (SFU) Grade 2 or higher (renal pelvis and several calyces observed) on preoperative computed tomography were considered to have hydronephrosis. Multivariate analysis was performed by selecting four known risk factors: tumor localization (ureter tumor), positive preoperative urine cytology, multiple upper tract ureteral carcinomas, and carcinoma in situ of UTUC. (Result) There were 120 male patients (71.0%) and 49 female patients (29.0%), with a median age of 71 years. The median observation period was 43 months. IVR was observed in 46 patients (27.2%) after surgery; 82 patients (49.1%) had SFU Grade 2 or higher (preoperative hydronephrosis) and 25 had SFU Grade 4 (dilatation of the renal pelvis and calyces and thinning of the renal parenchyma). There was a correlation between SFU Grade progression and an increase in IVR rate. Compared with patients without hydronephrosis, the presence of SFU Grade 4 hydronephrosis was found to be an independent associate factor after adjusting for known risk factors in multivariate analysis (p=0.02, hazard ratio 3.02, 95% confidence interval 1.18-7.75). (Conclusion) Patients with preoperative SFU Grade 4 hydronephrosis are more likely to have IVR. Postoperative intravesical anticancer drug injections and more frequent cystoscopies may be beneficial for these patients.

A 70-year-old man was referred to our institution because of a left seminal vesicle tumor revealed by computed tomography (CT) for postoperative follow-up of malignant melanoma. The prostate-specific antigen level (1.03 ng/mL) was not elevated. We performed transrectal ultrasound-guided seminal biopsy, and the pathological diagnosis was schwannoma. We decided to do follow-up because it was a benign tumor. However, the maximum diameter of the tumor increased over time from 21 mm to 47 mm during 7 years of follow-up. Since malignant potential could not be denied by image diagnosis, we decided to resect the tumor radically. The patient received robot-assisted laparoscopic left seminal vesicle resection. The pathological diagnosis was schwannoma with no malignant features. In such cases, robot-assisted surgery has great advantages in terms of expansion of the operative field and understanding of the three-dimensional structure.

We present a case of retroperitoneal carcinosarcoma. A 48-year-old woman with left-sided abdominal pain and a 15 cm tumor in the lower left renal retroperitoneal region on computed tomography (CT) was referred to our hospital. Contrast-enhanced CT showed a well-defined tumor with contrast effect on the retroperitoneum. Magnetic resonance imaging (MRI) demonstrated a heterogeneous cystic mass and well-enhanced mural nodules in the tumor on T2-weighted images. Her levels of serum CA-125 and CA-19-9 were high at 44.7 and 143.0 U/mL, respectively. Although she was diagnosed with primary retroperitoneal mucinous cystadenocarcinoma and underwent surgical resection, the pathological diagnosis was a carcinosarcoma on the retroperitoneum. No adjuvant therapy was given. CT findings at 2 months revealed local recurrence and multiple pulmonary metastases. She received paclitaxel (175 mg/m2 on day 1) and carboplatin (area under the curve of 6 on day 1) (TC) every 3 weeks. After two courses of TC therapy, some pulmonary metastases disappeared and shrank, but the progression of local recurrence was observed. However, after seven total courses of TC therapy, local recurrence further progressed, with the infiltration of the abdominal wall and lumbar pain, which was determined to be progressive disease (PD). A comprehensive genomic profiling test revealed no actionable genetic mutations. She died of cancer five months after the disease recurred. Carcinosarcoma is a rare tumor with poor prognosis, for which no established treatment exists beyond surgical resection. In this case, the therapeutic agent could not be determined; however, genomic analysis should be performed to guide the treatment of carcinosarcoma in advanced cases.

The patient in this case is a 67-year-old male. The previous physician examined the patient due to the primary complaint of ulcers on the penis, and the patient was diagnosed with squamous cell carcinoma (cT1N0M0). Our clinic performed a penectomy.Since vascular invasion was negative, a lymphadenectomy was not performed, and the patient was subsequently observed. However, four months after the surgery, we confirmed that the cancer had metastasized to the left inguinal lymph node and the left external iliac lymph node.The patient completed the fourth cycle of the TIP treatment before we performed an inguinal pelvic lymphadenectomy, and the patient succeeded in complete remission.Presently, two years and five months after the lymphadenectomy, no recurrence was found.

Denys-Drash syndrome (DDS) is characterized by rapidly progressing nephropathy, Disorders of Sex development, and Wilms tumor. Gonadal removal is recommended owing to the increased risk of developing gonadal tumors; however, the optimal timing remains uncertain. Herein, we report three cases with gonadoblastoma discovered in excised gonads. Case 1 involves a 13-year-old girl for whom peritoneal dialysis (PD) was initiated at 6 months of age. The left gonad removal at 9 months revealed hypoplastic testicular tissue. At 2 years and 8 months, kidney transplantation and bilateral nephrectomy were performed. A living kidney transplant was received at the age of 10 years. Subsequently, virilization signs and right gonadal swelling led to a diagnosis of gonadoblastoma during right gonadectomy at 13 years and 7 months. Case 2 involves a 6-year-old girl for whom PD was initiated 1 month after birth. Left nephrectomy was performed at 1 years and 11 months, followed by right nephrectomy at 5 years and 4 months. At the age of 6 years and 1 months, living kidney transplantation and simultaneous right gonadectomy revealed gonadoblastoma with a dysgerminoma component, without metastasis. Left gonadectomy 3 months post-transplantation revealed testis pathology. Case 3: involves a 4-year-old girl for whom PD was initiated 9 days after birth. Bilateral nephrectomy was performed at 1 year of age. Bilateral gonadectomy at 4 years and 5 months revealed bilateral ovotestis with a left gonadoblastoma component. While gonadoblastoma has limited malignant findings, it serves as the precursor of highly malignant gonadal tumors, highlighting the importance of timely excision. In DDS cases, determining the optimal timing for gonadectomy remains complex owing to variations in nephropathy progression. The priority given to PD initiation and Wilms' tumor prevention further complicates excision timing. Notably, the case of dysgerminoma in our 6-year-old patient appears to be one of the youngest cases in the literature.