Curative resection is necessary to survival in pancreatic cancer, however after surgery, pathologic examination sometimes diagnoses the remains of cancer at the resected stump. Therefore, it is necessary to evaluate the stump by intraoperative rapid pathological examination. 5-aminolevulinic acid(5-ALA)is an endogenous natural amino acid and precursor of the heme pathway. 5-ALA is metabolized and accumulated as protoporphyrin IX(Pp IX)that is photosensitive substance. 5-ALA mediated photodynamic diagnosis(PDD)(ALA-PDD)has high diagnostic ability. Andwe previously reportedusefulness of ALA-PDD for lymph node metastasis and peritoneal dissemination in gastric cancer and colorectal cancer patients. A case was 73-year-oldman who hadpancreatic headcancer. Since pancreatic cancer invasion to the inferior vena cava(IVC)was suspected during the operation, fluorescence observation was undergone. Pp IX fluorescence signal observedin the tissue around IVC by fluorescence observation. And, the tissue diagnosed adenocarcinoma by pathological findings. Therefore, it was judged that curative resection was difficult and the operation was completed. In conclusion, it was suggested that ALAPDD may be one of the methods of intraoperatively diagnosing the residual lesion of pancreatic cancer.

We report a case of a 71-year-old woman.She visited our hospital with a complaint of high fever and abdominal distention. She has been pointed out intraductal papillary mucinous neoplasm(IPMN)4 years ago.Abdominal CT showed cystic legion, 80mm in diameter, on the pancreas.The lesion was unclear at the boundary between the main pancreatic duct and in contact with the stomach, transverse colon.Upper endoscopic and colonoscopic examination revealed the exhaustion image from the intestional tract but not pointed out the malignant findings.We performed total pancreatectomy, total gastrectomy and partial transverse colectomy.Pathological examination revealed the intraductal papillary mucinous carcinoma but the tumor did not invaded the stomach and colon.It is known that some cases of IPMN form fistulae to adjacent organs.We report a case of IPMN penetrating into the stomach and colon.

The patient was a male in his early 60s. Diabetes had aggravated 6 months earlier, and the patient was referred to our hospital for close examination. On contrast CT, enhanced mass shadows filling the lumen of the main pancreatic duct, which was dilated throughout the pancreas, were observed, and the mass was diagnosed as an adenocarcinoma on EUS-FNA. Based on these findings, main-duct IPMN was suspected and total pancreatectomy was performed. On macroscopic observation of the resected specimen, outgrowth of a solid tumor was observed in the main pancreatic duct, whereas only low-level mucus retention was noted in the pancreatic duct. Histopathological examination revealed a papillary/tubular tumor growth, suggesting interstitial infiltration throughout the pancreas. On immunostaining, the tumor was partially positive for MUC5AC, based on which the patient was diagnosed with an intraductal pancreatic mallignant tumor, with difficulty in differentiating between IPMC and ITPC. Clinicopathologically, many aspects regarding ITPN remain unclear. Further accumulation of such cases and investigation of the tumor pathology are necessary.

A 61-year-old woman was introduced for consultation with a chief complaint of frequent vomiting. CT revealed a pancreatic body cancer approximately 40mm in size; an invading stenosis from the horizontal part of the duodenum to the jejunum, superior mesenteric artery, and portal vein, splenic vein obstruction, lymphadenopathy, and some ascitic fluid. We diagnosed a passage disorder due to the invasive stenosis from the horizontal part of the duodenum of the pancreatic body cancer to the jejunum, and subsequently performed a duodenum and jejunum bypass operation. We controlled cancer pain with opioid analgesia, and S-1 monotherapy was chosen as the primary chemotherapy. A tendency to increase and the cancer pain of the tumor was aggravated when 5 courses took effect, so gemcitabine plus nab-paclitaxel(GEM plus nab-PTX)therapy was chosen as the second-line chemotherapy because of adverse Grade 3 events due to difficulties with S-1 internal use. We tapered off the opioid analgesia dosage because the cancer pain was relieved after 1 course. The imaging top indicated stable disease at the end of 5 courses, but the pain was relieved so opioid pain killers were unnecessary. Foreign continuation is under treatment with 10-course GEM plus nab-PTX therapy after initial diagnosis. Currently, the patient has undergone 5 courses of S-1 for approximately 18 months, and has achieved stable disease. The only adverse events were nausea, fatigue, Grade 1 malaise, and Grade 2 alopecia, as detected with imaging.

A 70-year-old man with distal bile duct carcinoma underwent a subtotal stomach-preserving pancreaticoduodenectomy without adjuvant chemotherapy. One and a half years after the surgery, elevated levels of serum SPan-1(38.1 U/mL)were observed and CT scans demonstrated a solitary metastasis, 25mm in size, in segment 8 of the liver. The patient received 2 courses of gemcitabine-cisplatin combination chemotherapy. No new lesions were detected after chemotherapy and the patient underwent a partial liver resection of segment 8. The pathological examination revealed a metachronous distant metastasis originating from the bile duct carcinoma. Subsequently, the patient received S-1 adjuvant chemotherapy for 6 months. Following completion of all therapies, the patient survived without tumor recurrence for 3 years and 10 months after the initial operation. Thus, surgical interventions might be effective in improving prognosis among selected patients with postoperative liver metastasis of bile duct carcinoma.

An 84-years-old man underwent total gastrectomy with D1 plus lymph node dissection in December 2015, and diagnosed as Stage III B neuroendocrine carcinoma of the stomach. An abdominal computed tomography revealed swollen paraaortic lymph nodes and left adrenal grand in May 2016. Since his serum level of CA19-9 was elevated, he was thus diagnosed as having recurrence, and was started chemotherapy with ramucirumab(RAM). After introduction of the chemotherapy, his serum level of CA19-9 was decreased gradually and metastatic foci were also decreased in size. Although the patient required relatively longer administration interval according to the severity of general fatigue, he continued the chemotherapy without severe adverse effects until he rejected further treatment in January 2017, and satisfactory therapeutic result was acquired. While the prognosis of gastric neuroendocrine carcinoma is reported to be very poor, no definitive therapeutic guideline is available at present. Especially in elderly patients, we should pay considerable attention to the selection of chemotherapeutic agents because of their own adverse effects. In the present case, RAM could be administered safely, and it seemed that RAM might become a useful therapeutic option for gastric neuroendocrine carcinoma even in elderly patients.

The common type carcinoma of gastric cancer is divided into 3 groups, papillary adenocarcinoma(pap), well differentiated tubular adenocarcinoma(tub1)and moderately tubular adenocarcinoma(tub2). In this study, we tried to individualize treatments of them by evaluating their clinicopathological features.

As the treatment for the liposarcoma, there is no effective chemotherapy and a surgical remedy is required. We present the case of a 64-year-old man who complained about difficulty in swallowing and discomfort of throat. Computed tomography revealed a large enhancing left sided retroperitoneal mass invading the retroperitoneal space and it was displaced to the right. Preoperative diagnosis was retroperitonealmal ignant tumor. Tumor excision were performed and around 4.0 kg tumor was removed though its size was too big and resected it separately. Tumors increased 5 months later and became the second enucleation. After the second operation, we used eribulin as postoperative adjuvant chemotherapy. However, we needed extraction 3 times by the surgery because it recurred as peritonealdissemination. We continue surgicaltreatment and chemotherapy together as there are a part increasing relatively slowly and a high grade part increasing rapidly.

A 69-year-old man was admitted for the growing anal tumor and referred to our hospital. The tumor was about 40mm in size, and by biopsy, he was diagnosed the adenocarcinoma. Based on this diagnosis, abdominoperinealresection and edge resection were performed. Histopathologicalfindings showed mucinous carcinoma originating from analgl and with pagetoid spread. Postoperative chemotherapy was not performed, but 1 year 6 months after the surgery, inguinall ymph node recurrence was found, and lymph node dissection was performed. One year after the operation, recurrence was not found.

A 68-year-old man presented with malaise and abdominal swelling.Lower gastrointestinal endoscopy revealed a type 2 circumferential sigmoid colon cancer.Computed tomography suggested the cancer infiltrating bladder and abdominal wall with abscess.Because of locally advanced infiltration, the patient was treated with capecitabine plus oxaliplatin(CapeOX) plus bevacizumab therapy after loop-colostomy.After 2 courses of chemotherapy, a CT revealed tumor reduction and increased abscess, which was punctured drainage.After 4 courses of chemotherapy, a CT revealed abscess reduction, we tried to operation.Sigmoidectomy with combined resection of abdominal wall and bladder total hysterectomy and fascia lata grafting were performed.The pathological diagnosis was tub1, T4b, ly2, v2, PN0, N0, M0, Stage II, pR0, Grade I a.We reported a case of curative resection of locally advanced sigmoid colon cancer treated with combined resection of bladder and abdominal wall after CapeOX therapy.

A 74-year-old man was referred to our hospital for further investigation of a cystic lesion in the pancreatic body, which had been detected by ultrasonography at a local hospital. He was diagnosed as intraductal papillary mucinous neoplasm(IPMN) and further preoperative examinations were conducted. Upper gastrointestinal endoscopy demonstrated a type 0-II c tumor of the greater curvature in the upper third of the stomach. Endoscopic ultrasonography showed no sign of submucosal invasion. Endoscopic submucosal dissection(ESD)was carried out and pathological examination of a specimen revealed well differentiated adenocarcinoma with submucosal invasion, which fulfilled the indication for additional gastrectomy with lymph node dissection. Laparoscopy-assisted proxymal gastrectomy with D1 plus lymph node dissection and distal pancreatectomy with splenectomy was performed. Pathological examination demonstrated intraductal papillary mucious adenoma(IPMA)in the pancreatic body and no residual gastric cancer in a specimen, however 7lymph node metastases from gastric cancer was confirmed(pN3a), including 3 metastatic lymph nodes incidentally-detected adjacent to the pancreatic parenchyma. We report a rare case of early gastric cancer with N3 lymph node metastases, with a brief literature review.

Occult breast cancer, which develops as a metastatic lesion with no primary tumor detected in the breast, is a rare breast cancer. A 68-year-old female patient particularly complained of the presence of a right axillary mass. The mass in the right axilla was palpable, but no tumor was found in both the breasts on palpation, ultrasound examination, or MRI. Partial breast resection and axillary lymph node dissection were performed following a diagnosis of invasive ductal carcinoma by core needle biopsy. There was no mammary gland tissue present around the tumor due to the pathology of the disease, and the tumor was diagnosed as occult breast cancer. As the cancer was ER negative and HER2 positive, treatment with a combination of FEC, docetaxel, and trastuzumab was initiated. Radiotherapy, which irradiated the right supraclavicular fossa and the right mammary gland, was administered. No disease recurrence and mammary tumor has been reported in the patient till date. Treatment of occult breast cancer generally includes local therapy such as radiation and surgery. However, in the present case, we did not operate upon the breast; instead we treated the right breast and the right supraclavicular fossa with radiation therapy. As the tumor was HER2 positive, we reasoned that local control of disease would be likely if treatment with chemotherapy and trastuzumab was performed effectively.

Neuroendocrine carcinoma(NEC)is known as rapid tumor growth, high grade malignancy and poor prognosis. We report a case of huge pancreatic NEC successfully performed conversion surgery after EP therapy. A 70-year-old female, was presented to our hospital with appetite loss. CT scan revealed huge tumor, 15 cm in diameter, locating at the pancreas with possible involvement to liver, stomach, common hepatic artery, left gastric artery and gastroduodenal artery. Peritoneal dissemination and para-aortic lymph node metastasis were also suspected. EUS-FNA showed neuroendocrine carcinoma with almost 100%positive staining rate of Ki-67. We immediately started etoposide/cisplatin(EP)therapy. After 6 courses of EP, the tumor shrank remarkably and peritoneal disseminations were disappeared. Common hepatic artery and gastroduodenal artery became free from the tumor. However, after 7 courses of EP, CT and PET-CT revealed tumor re-growth. Also renal impairment could not afford to continue EP therapy. Therefore we decided to perform conversion surgery. In the guideline in Japan, there is no content specialized for surgical treatment for NEC. Moreover, second-line of chemotherapy for NEC has not been established. In the future, accumulation of NEC cases will contribute to develop effective multidisciplinary treatment.

We hereby report a case of long-term survival of metastatic and recurrent duodenal gastrointestinal stromal tumor(GIST) treated with multimodality managements. A 59-year-old man was diagnosed with duodenal GIST and underwent surgical resection of a primary lesion of the duodenum. Since the pathological findings on mitotic rate indicated its high risk of recurrence, the systemic treatment by imatinib mesylate was given shortly after the surgery. Six months later, metastatic lesions being considered to be imatinib-resistant were observed in the remnant liver. Since there were no other drugs available for GISTs in clinic at that time, surgery of central bisegmentectomy with partial resection of the liver was performed to eliminate all metastatic lesions. However, recurrences had been repeatedly diagnosed afterward. In response to them, four more surgery for recurrent liver or peritoneal tumors, two transcatheter arterial chemoembolizations(TACE)and one radiofrequency ablation(RFA)were performed on the basis of its resectability. Sunitinib malate had been given since it was approved for imatinib-resistant GISTs in clinic. Eventually, as long as 99 months had passed since we observed the first evidence of the resistance to imatinib mesylate when he died from the GIST.

A 70's man underwent subtotal stomach preserving pancreatoduodenectomy(SSPPD)for pancreatic head cancer. The pathological diagnosis was adenosquamous carcinoma(ASC)of the pancreas. Two months after surgery, a recurrent tumor in the remnant pancreas was confirmed with a CT scan and suspected to be ASC by endoscopic ultrasound-guided fine needle aspiration(EUS-FNA). As the recurrent lesion was limited in the pancreas, total remnant pancreatectomy(TP)was performed 4 months after SSPPD. The final pathological diagnosis was ASC. Two months after TP, liver and para-aortic lymph node metastases were revealed. The patient has been alive for 14 months after SSPPD with chemotherapy. Because of its rarity, it is difficult to implement treatment plans for recurrent ASC in the remnant pancreas.

The patient was a 57-year-old woman. Preclinical examination of malignant lymphoma revealed 0-I sp type of early rectal cancer in the upper rectum, 20 cm from the anal margin. Endoscopic mucosal resection was performed and positive deep margins were pathologically diagnosed. Additional intestinal resection with lymph node dissection was deemed necessary, but ABVD therapy was initiated because the clinical stage of the malignant lymphoma was Stage III b or higher. Two months after detecting elevated CEA, S8 liver metastasis was pointed out, and examination of weakness of the right upper limb revealed nodular, multifocal brain metastasis. After chemotherapy for malignant lymphoma, bevacizumab(BV)plus Xelox therapy was initiated. After administering 4 courses, partial loss of multiple brain metastases and reduction of the liver metastatic lesion were confirmed; therefore, partial resection of the liver via laparoscopy was performed. After surgery, BV plus Xelox therapy was resumed, but since the lower lobular lung metastasis was confirmed after 8 courses, partial resection of the left lower lobe with thoracoscopy was performed. After lung resection, BV plus FOLFIRI therapy was administered, and 12 months after the onset of treatment for brain metastasis, recurrence was not detected.

We here report a case of endoscopy-assisted partial duodenal resection for duodenal adenoma in a patient with familial adenomatous polyposis(FAP). A male underwent total proctocolectomy with ileal pouch anal anastomosis in 1997. Since 2004, duodenal adenomas occurred and the atypical grade of adenoma was gradually aggravated. Therefore, he underwent endoscopy-assisted partial duodenal resection in 2013. The pathological finding of the specimen showed well-differentiated tubular adenocarcinoma(pM, ly0, v0). No recurrence has been observed at 4 years after the operation. Endoscopy-assisted partial duodenal resection was minimum invasive surgery and considered to be useful for the patients with duodenal adenoma.

A 78-year-old woman was diagnosed with a gastrointestinal stromal tumor(GIST)of the stomach, gradually increasing from 5 years prior. The tumor was suspected to invade the pancreatic body tail and spleen, as observed with computed tomography. Because the patient refused to undergo resection, we administered imatinib mesylate for 6 years. Since early rectal cancer was revealed, the patient was referred for resection and underwent laparoscopic low anterior resection and partial gastrectomy. Histopathologically, the tumor was replaced by tissues with myxomatous changes, and no viable tumor cells were detected. This was a rare case of GIST, resected after long-term chemotherapy by imatinib mesylate, and pathological complete response was achieved.

We report a case of chemotherapy with FOLFOXIRI plus cetuximab for liver metastasis of sigmoid colon cancer. The patient was a 40's man who was diagnosed with sigmoid colon cancer with liver metastasis. Colonoscopy revealed a type 2 tumor with stenosis in the sigmoid colon. He underwent sigmoidectomy under laparotomy, and after the operation, received 7 courses of chemotherapy with FOLFOXIRI plus cetuximab. The liver tumor was sufficiently reduced, and laparotomy and liver right lobectomy were performed. Histopathology revealed a modified, Grade 2 tumor regression. He has been followed for 1 year 4months after the operation.

A 93-year-old woman was admitted to the hospital because of respiratorydiscomfort. A chest CT scan indicated aspiration pneumonitis and, simultaneously, intussusception was observed in the splenic flexure region. Abdominal enhance CT scan revealed a tumor in the advanced region of intussusception. Laparoscopy-assisted ileocecal resection was performed. Since the intussusception was difficult to reduce laparoscopically, the ileocecum was mobilized and the intussusception was reduced manually. In the resected specimen, a type 1 tumor was observed in the cecum and histopathologic ally diagnosed as cercal cancer. We report a case with intussusception due to colorectal cancer treated bylaparoscopic surgery.