A 66-year-old woman was referred to our hospital with a chief complaint of a persistent high fever lasting for 3 weeks. She exhibited a high inflammatory response, and an abdominal CT scan revealed a 60 mm mass in the body of the gallbladder. Unable to differentiate between infection and neoplasm, we decided to proceed with surgery. We performed cholecystectomy and distal gastrectomy, because of the gallbladder tumor invasion to the gastric antrum. Pathological examination diagnosed the tumor as adenosquamous carcinoma of the gallbladder with positive lymph node metastasis. Preoperative specimens showed elevated levels of granulocyte-colony stimulating factor(G-CSF), indicating that the tumor was producing G-CSF. Postoperatively, the patient's inflammation improved rapidly. However, at 6 weeks post-surgery, she presented with fever and increased inflammation, and a 40 mm mass was detected at the duodenal stump, leading to a diagnosis of recurrence. Chemotherapy was initiated but proved ineffective, and the patient succumbed 24 weeks after surgery. This report discusses a case of G-CSF-producing adenosquamous carcinoma of the gallbladder, which demonstrated early postoperative recurrence, rapid growth and poor prognosis.

Intraductal papillary mucinous neoplasms(IPMN)are common type of pancreatic cystic tumor, and because of their malignant potential, regular imaging follow-up is necessary. In this report, we described a surgically treated case of IPMN in which a malignant tumor could not be ruled out by preoperative diagnosis. The patient was a 75-year-old woman. An enhanced abdominal CT performed during the follow-up after surgery for uterine cancer revealed a cystic lesion with calcification in the tail of the pancreas. Maximum diameter of the cystic lesion was approximately 26 mm. Magnetic resonance cholangiopancreatography(MRCP)showed a cystic lesion in the tail of the pancreas connected to the main pancreatic duct, and the main pancreatic duct was dilated. We followed up the images, assuming it was IPMN, but the tumor size increased over time and the diameter of the main pancreatic duct was dilated. Therefore, malignant diseases could not be ruled out, then laparoscopic distal pancreatectomy and splenectomy were performed. The pathological findings showed a diagnosis of intraductal papillary mucinous carcinoma(IPMC).

We report a case of advanced esophagogastric junction adenocarcinoma with lymph node metastasis treated with preoperative S-1 plus oxaliplatin, resulting in a pathologic complete response was achieved. A 73-year-old woman was diagnosed with a large type 3 esophagogastric junction tumor with lymph node metastasis(GE, cT3N+M0, cStage Ⅲ), and was treated with 2 courses of neoadjuvant chemotherapy(NAC)with S-1/oxaliplatin combination therapy(SOX therapy). Gastrointestinal endoscopy showed remarkable reduction of the primary tumor, and abdominal computed tomography scan showed reduction of the enlarged lymph node. Robot-assisted esophagectomy with D2 dissection was performed. Histopathological examination revealed no residual tumor cells in the primary tumor or lymph nodes, and the response to chemotherapy was assessed as Grade 3(pCR).

The patient is a 69-year-old male. He was referred from a nearby clinic for the evaluation of anemia. Upper gastrointestinal endoscopy revealed an ulcerative lesion corresponding to A1 in the gastric antrum. Biopsy pathology diagnosed adenocarcinoma(tub2>tub1). One month later, follow-up endoscopy showed that the macroscopic type of the ulcerative lesion had changed to type 1. Further examinations revealed no distant metastasis, leading to a diagnosis of advanced gastric cancer. Consequently, laparoscopic distal gastrectomy was performed. Postoperative pathological examination confirmed the coexistence of undifferentiated carcinoma and neuroendocrine tumor(NET)(G3)within the same lesion. Gastric NETs are classified into 3 types by Rindi et al., based on background factors. This case was diagnosed as Type Ⅲ, as it did not involve type A gastritis, Zollinger-Ellison syndrome, or multiple endocrine neoplasia type 1(MEN1). Type Ⅲ typically presents as a solitary lesion with higher malignancy. Cases of Type Ⅲ gastric NETs coexisting with carcinoma within the same lesion are extremely rare.

In this report, we described a case of an extremely rare primary neuroendocrine tumor of the gallbladder, which corresponds to NET G1 according to the WHO classification. The patient was a 71 year-old man. He was diagnosed as dilated common bile duct by abdominal ultrasound a medical checkup. The patient was referred to our hospital because of a contrast-enhancing mass in the neck of the gallbladder on CT. EUS was performed, and a substantial tumor with contrast effect was observed from the neck to the duct of the gallbladder. The preoperative diagnosis was gallbladder cancer of cT3N0M0, Stage ⅢA. The tumor was suspected of invading the common bile duct. As a result, the operation was extrahepatic biliary resection and biliary reconstruction. A gross examination of the explanted specimen revealed an 8 mm sized cauliflower-like polypoid lesion on the neck of the gallbladder. Histopathologically, the lesion showed hyperplastic polyp-like lesions with substantial, cord-like, tubular, ribbon-like, or individual cellular growths in the intrinsic layer of the mucosa. Immunostaining was diffusely positive for chromogranin A, synaptophysin, and INSM1. Based on the histology of the tumor and the fact that it was Ki-67 positive(1%)with no fission pattern, a diagnosis of gallbladder NET G1, pT1aN0M0, Stage ⅠA was made.

Endoscopic ultrasonography guided fine needle aspiration(EUS-FNA)is an essential diagnostic method for qualitative diagnosis of pancreatic tumors and is widely used for the diagnosis of pancreatic cancer. However, there is a risk of seeding due to traction seeding.

Fibrosarcoma in the mandible in children is a very rare condition. We present a rare case of central mandibular fibrosarcoma in a child, treated with radical tumor resection, reconstructive surgery, long-term prognostic evaluation, and morphofunctional reconstruction. The patient was an 8-year-old boy. In 2008, he was referred to us with a chief complaint of tenderness in the gingiva of the right mandibular molar region. Suspecting an odontogenic benign tumor or cyst, we performed an excisional biopsy. Histopathological examination diagnosed fibrosarcoma. Systemic evaluation showed no metastasis involvement. We performed right mandibular segmental resection, submandibular dissection, and temporary bridging with a mandibular reconstruction plate. Postoperative chemotherapy consisted of 1 course of vincristine, actinomycin D, cyclophosphamide(VAC). The postoperative course was uneventful, with no recurrence or metastasis. In 2010, right mandibular reconstruction with a vascularized fibula flap was performed. In 2017, at the age of 17, alveolar ridge augmentation with iliac corticocancellous bone grafts was performed on the reconstructed mandible, followed by the placement of four dental implants in a staged approach. Three years have passed since the activation of the bridge-type dental implant prosthesis, with no recurrence or metastasis of the fibrosarcoma and satisfactory recovery of oral and maxillofacial function.

A 73-year-old man with middle thoracic esophageal squamous cell carcinoma(SCC)underwent definitive chemoradiotherapy( dCRT)with cisplatin and 5-fluorouracil(CF)concurrently administered with 60 Gy radiotherapy. Clinical complete response was achieved, but thoracic tracheal lymph node metastases(No. 106recL and No. 106pre)were detected 19 months after the completion of dCRT. Following 2 courses of CF therapy, salvage lymphadenectomy was performed via median sternotomy. Combined partial resection of tracheal cartilage and the left recurrent laryngeal nerve ensued due to suspected tumor invasion. Histopathological analysis confirmed the SCC metastases in the No. 106recL and No. 106pre lymph nodes, affirming R0 resection. Adjuvant chemotherapy with S-1 was administered for 24 months. Despite the emergence of multiple lung and left supraclavicular lymph node metastases 24 months after surgery, no local recurrence within the surgical field was noted. A durable response to CF therapy combined with pembrolizumab was achieved, and the patient remains under treatment, exhibiting no signs of disease progression. In the context of salvage lymphadenectomy, attainment of R0 resection within an optimal surgical field holds paramount importance for effective local disease control.

In robotic-assisted gastrectomy for esophagogastric junctional cancer, oncologically feasible and minimal resection margin is required for simple and safety reconstruction. Here, we report 4 surgical cases of junctional cancer of which the proximal margin was marked by ICG fluorescent clip. Intraoperative visibility, distance from proximal margin and pathological finding of the resection margin were evaluated. In all cases, ICG fluorescent clip showed good visibility. The resection margin from oral side was between 1 to 3 mm. No residual cancer was found pathologically. ICG clip can be a simple and accurate method for preoperative marking.

A 52-year-old man presented with a postoperative abdominal ultrasound of left renal cell carcinoma, which revealed a dilated main pancreatic duct in the pancreatic body tail. A 15 mm tumor was noted in the pancreatic head-neck region on CT, and was diagnosed as invasive pancreatic cancer on EUS-FNA. The tumor was diagnosed as resectable pancreatic head-body cancer, and after neoadjuvant chemotherapy, a subtotal stomach-preserving pancreaticoduodenectomy was performed. Postoperative histopathology showed well-differentiated adenocarcinoma, TS1(9 mm), T1bN0M0, Stage Ⅰ, preoperative chemotherapy efficacy was Grade 2, and R0 resection was obtained. At the same time, a 4 mm-sized nodule was found in the center of the pancreatic head, far from the primary pancreatic cancer, and was diagnosed as renal cell carcinoma intrapancreatic metastasis. He received 4 courses of S-1 therapy as postoperative adjuvant chemotherapy for pancreatic cancer, and is alive 23 months postoperatively without recurrence. The coexistence of primary pancreatic cancer and pancreatic metastasis of renal cell carcinoma is extremely rare, and we report this case with a review of the literature.

A 50's postmenopausal woman, she was diagnosed with breast cancer, cT2N3aM0, Stage ⅢC, invasive ductal carcinoma, estrogen-receptor(ER)-positive, progesterone-receptor(PgR)-negative, human epidermal growth factor 2(HER2)-negative. A combination therapy of palbociclib(PAL)and letrozole(LET)was administered to the patient. A method of administration was 125 mg of PAL per day(14 days of treatment followed by 14 days off, 2 courses and 18 days of treatment followed by 10 days off, 8 courses)and 2.5 mg of LET per day every day. This therapy was effective, and the clinical stage showed down staging, T2N1M0, Stage ⅡB. Left total mastectomy and sentinel lymph node biopsy and swelled axillar lymph node resection was performed. Postoperative pathological histology revealed ypT2N1a(1/9). Subsequently this medication (125 mg of PAL per day, 21 days of treatment followed by 14 days off and 2.5 mg of LET per day every day)was continued as an adjuvant therapy and postmastectomy radiation therapy(PMRT 50 Gy)was underwent for her. This patient has survived without recurrence 12 months after operation. PAL probably has a certain effect even if oral administration method were changed.

In March 2023, Trastuzumab deruxtecan(T-DXd)was added for the treatment of inoperable or recurrent breast cancer with low HER2 expression who has a history of chemotherapy. The patient was a 61-year-old woman who had undergone surgery for bilateral breast cancer, and was diagnosed with Stage ⅡA triple negative(HER2-IHC score 0)on the right and non-invasive ductal carcinoma of the breast on the left. Biopsy from metastases was triple-negative(HER2-IHC score 0, PD-L1 negative). Exacerbation of skin metastases was observed despite repeated regimen changes 3rd skin biopsy was diagnosed with low expression of HER2 for the first time, and T-DXd was started. The therapeutic effect of T-DXd was temporarily observed, such as a decrease in tumor markers. It is useful to repeatedly collect tissues from primary and metastatic lesions and re-evaluate biomarkers in order to develop an appropriate treatment plan.

Mohs' hydrophilic cream is a formulation with improved convenience by changing the base material of the conventional Mohs' paste to a hydrophilic cream. We report a case in which Mohs' hydrophilic cream was effective in treating bleeding from breast cancer with cancerous skin ulcers. The patient was a 68-year-old woman. She was admitted to our hospital because of severe anemia due to repeated bleeding from a massive right breast cancer. We used Mohs' hydrophilic cream to control bleeding. It was easy to apply the cream along the shape of the tumor, and after fixation for about 20 minutes, it was easily removed by washing with warm water. The procedure was completed within 60 minutes. After 3 times use of the cream, the surface of the tumor was fixed, and bleeding was controlled. During the treatment period, the cream could be used repeatedly without hardening. Bleeding and exudation were alleviated, so she could receive home care as she wished until she died 7 months later. Compared to the conventional Mohs' paste, Mohs' hydrophilic cream was easier to treat and dispense, just by changing of the base material, and showed good fixation comparable to the conventional paste. We concluded that Mohs' hydrophilic cream is useful for both patients and medical staff.

The patient was a 70-year-old man who underwent distal gastrectomy for gastric carcinoma of the antrum. One year after surgery, the patient developed a recurrence in the cardia lymph nodes. Following chemotherapy, the patient underwent a total resection of the remnant stomach and recurrent lymph nodes 2 years and 10 months after the resection of the primary tumor. The patient was re-treated with chemotherapy following surgery; however, he relapsed again, and pembrolizumab was initiated. After the administration of the 10th round of chemotherapy, the patient suddenly developed thirst and polydipsia. Marked hyperglycemia(BS level, 900 mg/dL)and ketoacidosis were observed; therefore, the patient was diagnosed with fulminant type 1 diabetes mellitus. The patient's symptoms improved after insulin administration, and self-injection was initiated. The patient was treated with pembrolizumab for 2 years with no apparent recurrence. The incidence of type 1 diabetes mellitus as an irAE is approximately 0.5% in patients on pembrolizumab. Although this is a rare complication, early detection and therapeutic intervention are desirable, and attention in daily practice is necessary.

The patient was a 51-year-old man. He was diagnosed with cStage Ⅲb descending colon cancer after a positive stool occult blood test, and the patient was referred to our department for laparoscopic left hemicolectomy with D3 lymph node dissection. Intraoperatively, we incidentally found a mass lesion at the end of the ileum and a large hard enlarged lymph node in the nearby mesentery of the small intestine, so we additionally performed a partial resection of the small intestine and dissection of the regional lymph node. Pathological findings showed that the small intestinal lesion was adenocarcinoma of the small intestine. Follow-up abdominal contrast CT showed an enlarged lymph node within the small intestinal mesentery at the origin of the ileocolic artery. The patient was suspected to have lymph node recurrence of small intestinal cancer, and the patient had radical resection with ileal resection with D3 lymph node dissection. Pathological findings showed lymph node recurrence of small intestinal cancer, and postoperative adjuvant chemotherapy(4 couses of CAPOX therapy)was performed. As of 3 years and 10 months postoperatively, the patient is alive without recurrence.

We analyzed the clinicopathological features and prognosis of 9 patients with primary small bowel adenocarcinoma, excluding duodenal cancer, between January 2009 and February 2024 at our hospital. The mean age of the patients was 68.9(60-82)years, and the male to female ratio was 7 : 2. Seven patients were diagnosed with small bowel cancer preoperatively, and 5 out of 7 patients were diagnosed pathologically. We performed partial resection in 6 patients and laparoscopic partial resection, laparoscopic ileocecal resection and endoscopic mucosal resection in 1 patient respectively. The histological type was well-differentiated adenocarcinoma in 6 patients, moderately differentiated adenocarcinoma in 1 patient, poorly differentiated adenocarcinoma in 2 patients. The pathological Stage was 0 in 2 patients, Stage Ⅱ in 3 patients, Stage Ⅲ in 3 patients, Stage Ⅳ in 1 patient. The median duration of follow-up was 18(1-143)months. Six patients are alive without recurrence, 1 patient died of cancer, and 2 patients died of other diseases. It was assumed that proactive radical surgery and postoperative adjuvant chemotherapy were associated with improved prognosis.

Japanese prospective randomized trial of JCOG0405 showed that preoperative chemotherapy is one of useful treatment options for far-advanced gastric cancer patients with bulky and/or multiple lymph node metastases. Also, CheckMate649 and ATTRACTION-4 trials clarified the efficacy of immune-checkpoint inhibitor, nivolumab, in recurrent gastric cancer patients. Here, we presented an 87-year-old elderly female patient with far-advanced gastric cancer with bulky lymph nodes who was successfully treated by radical robotic gastrectomy following the low-dose preoperative chemotherapy, and achieved a complete response using nivolumab therapy after recurrences. In this case, the immunohistochemistry of cancer tissues suggested the microsatellite instability due to the deficiency of mismatch repair genes such as MLH1 and PSM2. Taken together, recent advances in chemotherapy and/or immunotherapy and minimally invasive surgery facilitate reasonable and personalized treatments even in super elderly patient with far-advanced gastric cancer.

Case 1: The patient was an 80-year-old woman with a history of chemoradiotherapy for cervical cancer 4 years ago. Splenic tumor was detected on contrast CT. On PET-CT showed accumulation of FDG in the splenic tumor. The tumor size increased over time, and a hand-assisted laparoscopic splenectomy(HALS)was performed. Pathological findings were consistent with splenic metastasis from cervical cancer. Case 2: The patient was a 64-year-old woman who had undergone partial mastectomy for right breast cancer 14 years ago. A splenic tumor was detected on an abdominal ultrasound performed for non-alcoholic steatohepatitis. Contrast CT revealed progressively increasing contrast enhancement. PET-CT showed accumulation of FDG in the tumor. Although sclerosing angiomatoid nodular transformation(SANT)was considered first, HALS was opted for due to the possibility of malignancy. The pathological examination confirmed the diagnosis of SANT. Splenic tumors are rare, and preoperative diagnosis is generally difficult. HALS is a less invasive surgical approach compared to laparotomy and appears to be safe and suitable for splenectomy in patients with splenic tumor.

The patient is a 63-year-old man. CT scan revealed a giant mass in the stomach and about 1 cm single mass in the liver. He was diagnosed with gastric cancer with liver metastasis. After 6 courses of nivolumab+SOX therapy, CT scan showed disappearance of the liver metastasis and shrinkage of the primary lesion and surrounding lymph nodes. After more 4 courses, CT scan revealed continued disappearance of the liver metastasis, but the primary lesion grew larger, so distal gastrectomy was performed. Histopathological examination revealed neuroendocrine carcinoma(NEC). We report a case of giant gastric NEC in which the liver metastasis disappeared after chemotherapy and conversion surgery became possible.

It is unclear whether the remnant stomach can be safely preserved, performing distal pancreatectomy in patients with a prior distal gastrectomy. A 74-year-old man was followed up after robotic distal gastrectomy with D2 lymphadenectomy and Roux-en-Y reconstruction for gastric cancer. Contrast-enhanced computed tomography revealed a tumor of the pancreatic tail. Subsequently, the tumor was diagnosed as a resectable pancreatic adenocarcinoma. After neoadjuvant chemotherapy, we performed laparoscopic distal pancreatectomy with splenectomy. Blood flow in the remnant stomach was confirmed by preoperative angiography using splenic artery occlusion test and intraoperative indocyanine green fluorescence imaging. We safely preserved the remnant stomach and the postoperative course was uneventful.