An 86-year-old male underwent laparoscopic distal pancreatectomy for intraductal papillary mucinous carcinoma(IPMC). Pathological examination revealed pT3N1aM0, pStage Ⅱb. One year post-surgery, tumor markers elevated, and CT showed a soft tissue in the left anterior pararenal space. Suspecting lymph node metastasis or peritoneal dissemination recurrence of IPMC, a nodule localized in the left upper abdomen was excised laparoscopically. Pathological examination confirmed recurrence of IPMC with peritoneal dissemination, infiltrating the co-resected stomach. Chemotherapy with gemcitabine alone was initiated, and after 2 courses, tumor markers decreased, and no signs of recurrence were observed on CT. Though there are reported cases where resection has shown therapeutic effects for disseminated pancreatic cancer recurrence, high-quality evidence is lacking. In this case, surgery was performed for both diagnosis and treatment, and the disseminated nodule was localized, allowing for resection without excessive invasiveness. Given the possibility of future recurrent lesions, chemotherapy is also being administered. This case suggests that local resection for disseminated pancreatic cancer recurrence may be effective as part of multimodal treatment, but further case accumulation is necessary to establish a treatment strategy.

Staging laparoscopy(SL)for patients with pancreatic cancer is used to identify occult abdominal metastasis (OAM). The aim of this study is to analyze the efficacy and safety of SL.

The patient is a 67-year-old male. His chief complaints were epigastric pain and abdominal distension. He had a history of hepatitis B and was referred to our hospital after an abdominal ultrasound at a nearby clinic detected a liver tumor. Contrast-enhanced CT revealed Vp4 hepatocellular carcinoma diffusely occupying the entire left lobe of the liver, accompanied by a tumor thrombus in the main portal vein. The tumor thrombus in the main portal vein was associated with a high risk of portal vein obstruction, so we initiated local radiotherapy(50 Gy/25 Fr)and anticoagulant therapy, followed by combination immunotherapy(atezolizumab+bevacizumab). After 7 courses, significant tumor shrinkage was achieved, and we planned a liver resection. However, during the drug-free period, tumor markers increased, and new lesions were detected in liver segment 5, leading us to abandon resection and resume combination immunotherapy. After 10 courses, the patient developed liver atrophy, ascites, splenomegaly, and thrombocytopenia. We continued treatment, stopping bevacizumab while administering diuretics and combining with CART, but treatment was halted due to the progression of liver cirrhosis. Four months after discontinuation of treatment, contrast-enhanced CT showed multiple early-enhancing lesions in liver segment 4, indicating recurrence. Blood flow in the left branch of the portal vein had resumed via collateral pathways, so we performed transcatheter arterial chemoembolization(TACE)twice. At 2 years and 4 months after starting treatment, tumor markers normalized, and at 3 years and 9 months after starting treatment, the patient maintained a state of clinical complete response(cCR).

Bridge to surgery(BTS)using a self-expandable metallic stent(SEMS)for the treatment of obstructive colorectal cancer (CRC)improves the patient's quality of life. However, its long-term outcomes remain controversial. The aim of this study was to clarify the outcomes of SEMS as a"bridge to surgery"(BTS)for obstructive CRC of Stage Ⅱ and Ⅲ by one-to-one propensity-score matching. This retrospective cohort study was conducted at a triple center from January 2013 to December 2020. Patients with obstructive CRC underwent primary resection as a normal course(NC)or placement of a SEMS as a BTS. They were divided into SEMS and NC groups, and their short- and long-term outcomes were compared. Overall, 208 patients with obstructive CRC of Stage Ⅱ and Ⅲ were evaluated(SEMS group: 104, NC group: 761). The 2 groups showed no significant differences in perioperative outcomes. The 5-year overall survival was not significantly different between groups(77.8% vs 80.4%, p=0.422). As a BTS, the use of SEMS for obstructive CRC of Stage Ⅱ and Ⅲ is effective with at least equivalent short- and long-term outcomes.

Local control is important in the treatment of locally advanced rectal cancer. Recently, an increasing number of centers are offering total neoadjuvant therapy(TNT)for local and systemic control. A 71-year-old man with Ra rectal cancer was referred to our department, and was diagnosed as cT4b(seminal vesicle)N2aM0, cStage Ⅲc by CT and MRI. The diagnosis of locally advanced rectal cancer led to the decision to perform TNT. Laparoscopic low anterior resection, combined vasectomy, and ileostomy were performed, with an operating time of 549 minutes and blood loss of 130 mL. Histopathological diagnosis was ypT3N0M0, ypStage Ⅱa. The histological response to treatment was Grade 2. One year after surgery, the patient is alive and with no recurrent cancer.

Small intestinal metastasis from gastric cancer via hematogenous or lymphatic vessels has rarely been reported. We herein report 2 cases of these small intestinal metastasis from gastric cancer. Case 1 was diagnosed with Stage ⅣB advanced gastric cancer. We performed palliative distal gastrectomy and Roux-en-Y reconstruction. After performing chemotherapy, complete response was obtained and the chemotherapy was suspended. One day the patient presented to our hospital with vomiting. Under the diagnosis of adhesive ileus, conservative treatment was done, but not effective. We, therefore, performed surgery, revealing the small intestinal stricture by the tumor. Case 2 was also diagnosed with Stage ⅣB advanced gastric cancer. The patient subsequently underwent chemotherapy for several years. During the fifth-line of chemotherapy, the patient visited our hospital with the symptoms of abdominal pain. Under the diagnosis of perforated peritonitis, we performed emergent surgery, revealing small bowel perforation and stenosis by the tumor. In both cases, we performed partial resection of small intestine and pathological examination showed metastatic small intestinal tumor from gastric cancer via hematogenous or lymphatic invasion.

A 78-year-old woman diagnosed with hepatitis B had been treated with entecavir at our hospital. In December 202X, blood test showed elevated AFP 19 ng/mL and PIVKA-Ⅱ 46 mAU/mL. Abdominal CT showed tumors in S2 and S6/7 of the liver, and the patient was referred to our department. Abdominal CT showed that the S6/7 tumor was 40 mm in size, with contrast enhancement in the early phase and little contrast enhancement in the late phase, while the S2 tumor was 15 mm in size with both early and late phase contrast enhancement. MRI diffusion-weighted images showed hyperintensity in both S2 and S6/7 tumors. The patient was diagnosed with hepatocellular carcinoma and a posterior segment resection of the liver and a partial S2 resection of the liver were performed. The resected specimen showed a 10 mm whitish nodule in S2 and a 40 mm yellowish nodule in S6/7. Immunohistological findings of the resected specimen showed that the S2 tumor was positive for AFP, Glypican-3, CK19, and MUC-1, and the pathological diagnosis was co-existing combined hepatocellular cholangiocarcinoma and hepatocellular carcinoma. The patient was discharged on post-operative day 11 and has been alive without recurrence after surgery.

A 68-year-old man diagnosed with ascending colon cancer(cT3[SS], cN2a, cM0)declined surgical treatment; therefore, systemic chemotherapy was administered. After 18 courses of systemic chemotherapy(mFOLFOX or FOLFIRI), the patient underwent laparoscopic right hemicolectomy. Preoperative colonoscopy and computed tomography did not detect any tumor, however histopathological examination revealed a viable residual tumor in the subserosal layer. The patient did not receive adjuvant chemotherapy and is alive with no recurrence 3.5 years after surgery. There is no consensus on the efficacy of neoadjuvant chemotherapy for colon cancer. In the case presented herein, neoadjuvant chemotherapy resulted in a clinically complete response, with a residual tumor only in the subserosal layer. Based on this case, for advanced colon cancer treated via neoadjuvant chemotherapy, curative resection may still be recommended over a watch-and-wait approach even if clinically complete response is achieved.

The patient was a 76-year-old man who presented with dark urine, white stools, and jaundice. He was suspected of having distal bile duct cancer and was referred to our hospital. A second biopsy was performed at our hospital, and the patient was diagnosed with primary neuroendocrine carcinoma(NEC)of the bile duct. A laparoscope-assisted subtotal stomach-preserving pancreaticoduodenectomy was performed, and postoperative pathological diagnosis was primary bile duct NEC, pT3pN2cM0, pStage ⅢA. The patient had an uneventful postoperative course and was discharged 20 days after surgery. After discharge, the patient received 4 courses of CBDCA+VP-16 as postoperative adjuvant chemotherapy. He has remained recurrence-free for 13 months after surgery.

A 77-year-old man was diagnosed pancreatic head cancer(cT4cN0cM0, cStage Ⅲ)with a contrasting-enhanced CT scan showing soft-tissue shadow in contact with the SMA less than 180 degrees and extensive invasion of the SMV. After neoadjuvant chemotherapy(GnP was selected due to the possibility of unresectability), subtotal stomach-preserving pancreaticoduodenectomy( SSPPD)with resection and reconstruction portal vein was performed. Intestinal derotation procedure in combination with surgery, and there was no evidence of SMA invasion, and J2A, which was also suspected to be invaded on preoperative imaging, could be preserved. The complicated portal vein reconstruction(long reconstruction distance requiring grafting and reanastomosis of J1V+J2V to J3V+ICV)could be performed in a joint operation with cardiovascular surgery. The pathological results of the excised specimen showed that ypT3, ypN1a, M0, ypStage ⅡB, and R0 surgery were feasible, and the patient was discharged on the 19th day after surgery without any postoperative complications. The surgical approach using the intestinal derotation procedure and joint surgery with other departments were useful in safely performing surgery for highly locally advanced pancreatic cancer.

The patient was a 70s-years-old male. Subtotal stomach-preserving pancreaticoduodenectomy and Child modified reconstruction was performed for lower bile duct cancer. Seven months after surgery, the patient developed pulmonary metastasis recurrence, and 9 months after surgery, the soft tissue shadow at the hepatic hilum had increased and portal vein obstruction had occurred, so best supportive care was adopted. Diarrhea began at the 10 months after surgery. 13 months after surgery, the patient was hospitalized with respiratory dysfunction due to malignant pleural effusion. One week after admission, the patient exhibited liver dysfunction and a high fever of 41.0℃; blood cultures were submitted and MEPM/ VCM was initiated, after which the fever subsided tomorrow. Edwardsiella tarda (E. tarda) was detected in the blood culture results obtained 2 days later, and based on the clinical symptoms, the patient was diagnosed with bacteremia resulting from cholangitis due to E. tarda. If recurrence occurs in the hepatic hilum after pancreaticoduodenectomy, intestinal fluid reflux is likely to occur, leading to cholangitis due to E. tarda, and bacteremia can be fatal, so this should be kept in mind as an oncology emergency.

The patient was a 76-year-old woman. When she visited a nearby clinic for pedal edema and palpitations, she was found to have severe anemia, which led to a referral to our hospital. Cecal cancer with regional lymph node metastasis and tumor thrombosis in the superior mesenteric vein were diagnosed. However, because no distant metastasis was detected, extended right hemicolectomy was performed. Only the first jejunal vein was preserved because the tumor thrombosis extended from the ileocolic vein to the superior mesenteric vein, and complete(R0)resection was achieved. When ileocolic anastomosis was performed, marked edema was detected in the ileum. Thus, the last branch of the ileal vein and the right ovarian vein were anastomosed to complete the surgery. Although liver metastasis occurred in the early postoperative period, she was placed under wait-and-see observation according to her request. She died of hepatic failure 1 year and 8 months later. In this case of cecal cancer with extensive invasion and tumor thrombosis in the superior mesenteric vein, we performed combined resection of the superior mesenteric vein and revascularization. A survival time of 1 year and 8 months was achieved by resection alone. This case suggests that combined resection of the superior mesenteric vein together with revascularization may be an effective treatment strategy for advanced colorectal cancer with invasion and tumor thrombosis in the superior mesenteric vein.

We report a case of retroperitoneal abscess due to penetration of colonic diverticulosis during chemotherapy for sigmoid colon cancer. The patient was a 56-year-old man who was outpatient for chronic rheumatoid arthritis and was diagnosed sigmoid colon cancer with multiple simultaneous liver and lung metastases. The antitumor drugs were effective and the primary tumor was resected, and chemotherapy was continued due to progression of liver metastasis. After the molecular targeted drug was changed to bevacizumab, the patient was hospitalized with a diagnosis of colonic diverticulitis and was discharged with conservative therapy. Two months after discharge, the patient was hospitalized due to fever and gait disorder. Abdominal CT scan revealed abscess(12×7 cm)around the right kidney extended to abscess(15×4 cm)along the right iliopsoas muscle to the right hip joint. The retroperitoneal cavity was drained through right lumbar region and right inguinal area, and the retroperitoneal abscess disappeared. The patient improved gait disorder and was discharged from the hospital. The retroperitoneal abscess caused after the administration of bevacizumab, was fortunately possible to eliminate the retroperitoneal abscess by performing incision and drainage from extraperitoneal cavity.

The da Vinci surgical system has been updated from Si to Xi with several new features. This study investigated the invasiveness of robot-assisted rectal cancer surgery performed at our hospital using Si and Xi.

In recent years, advancements in diagnostic techniques have led to occasional reports of surgical resection cases for pancreatic cancer initially identified as carcinoma in situ. High-grade pancreatic intraepithelial neoplasia(PanIN)is considered equivalent to carcinoma in situ, and early intervention for this lesion holds potential for significantly improving patient outcomes. In our institution, we have adopted minimally invasive approaches including laparoscopic distal pancreatectomy (LDP)since April 2010 and robot-assisted distal pancreatectomy(RDP)since September 2020. Here, we report a case where RDP was performed in September 2023 for a male patient in his 70s with suspected pancreatic body cancer and main pancreatic duct stricture confirmed on endoscopic retrograde cholangiopancreatography(ERCP). Despite normal tumor marker levels, surgical resection was deemed necessary. Postoperative pathology revealed high-grade PanIN without lymph node involvement. The patient experienced a pancreatic fistula postoperatively, managed with endoscopic ultrasonography-guided transmural drainage, and was discharged after 36 days. As of 10 months post-surgery, the patient remains disease-free. In this report, we present our experience of RDP for high-grade PanIN. Further accumulation of cases and investigation are necessary for the diagnosis of PanIN and the indications for surgical resection.

A 72-year-old man complained of right lower abdominal pain. A CT scan showed an acute appendicitis. Laparoscopic appendectomy was performed. Histopathological examination of the resected specimen identified goblet cell adenocarcinoma(GCA), predominantly extending through the muscularis propria of the appendix. The tumor invaded into the serosal tissue. Subsequently, robotic-assisted ileocecal resection with D3 lymphadenectomy was performed. The final pathological diagnosis was GCA(pT3N0M0, pStage ⅡA). GCA of the appendix is a rare entity that exhibits characteristics of both carcinoid and adenocarcinoma. We report this as a relatively rare and significant case, accompanied by a review of relevant literatures.

A 74-year-old male was referred to our department for intermittent right abdominal pain that was initially noted 1 month prior. Colonoscopy revealed a type 2 tumor in the ascending colon, for further examination, he was diagnosed with ascending colon cancer(cT4, cN2, cM0). He was performed laparoscopic right hemicolectomy and D3 lymphadenectomy. Subsequently, he received chemotherapy with CAPOX therapy for 8 courses. But right testicular metastasis and bilateral inguinal lymphadenopathy, abdominal para-aortic lymphadenopathy were recurred 18 months after the operation. He was performed right orchiectomy, where the tumor was proved colon cancer with MSI-high. Therefore, he received cancer immunotherapy with pembrolizumab, and got reduction of bilateral inguinal lymph nodes and abdominal para-aortic lymph nodes after 1 month from the start of administration. Now, 28 months later from the start, he maintains complete clinical response(cCR).

In patients with ER-positive HER2-negative unresectable breast cancer, who are refractory to chemotherapy, surgery may not be performed even after endocrine therapy. CDK4/6 inhibitors have been used as first-line treatment for unresectable breast cancer since their approval in Japan. We investigated the primary treatment of ER-positive HER2-negative inoperable breast cancer and its efficacy in our hospital. 14 patients diagnosed between March 2017 and October 2022 were included. Three patients were treated with endocrine therapy alone(HT), 6 with CDK4/6 inhibitors(all 6 with palbociclib[PAL]), and 5 with chemotherapy(CT). Median age at diagnosis was 83, 74.5, and 67 years, respectively. In the HT group, 2 patients died, 1 patient discontinued due to metastasis. In the PAL group, 2 patients discontinued due to adverse events, 4 patients underwent surgery. All 5 patients in the CT group underwent surgery. In some patients who were refractory to chemotherapy, the combination of CDK4/6 inhibitors reduced tumor size to the extent that surgery was possible, suggesting the effectiveness of this combination as first-line treatment.

A 71-year-old man underwent endoscopic mucosal resection(EMR)of a sigmoid colon polyp 7 years ago. The pathological result was adenocarcinoma(pap+tub2+tub1), pTis, ly(-), v(-). Then he was under observation. This time, a 20 mm submucosal tumor-like finding was found near the scar after EMR, and a biopsy revealed a diagnosis of adenocarcinoma (tub2). CT scan showed lymphadenopathy beside sigmoid colon. There were no non-resectable factors, so a laparoscopic sigmoid resection was performed. The pathological result showed adenocarcinoma(tub2), and although some parts were continuous with the mucosa, the majority of the tumor was located from submucosa to subserosa, and it was diagnosed as direct invasion into the lymph nodes outside the wall, and the possibility of lymph node recurrence was suspected. He underwent adjuvant chemotherapy CAPOX. In order to establish the optimal surveillance of colon carcinoma in situ, it is important to accumulate further cases and evidence.

Retroperitoneal leiomyosarcoma is a rare disease, and the prognosis is relatively poor. Here, we report a case in which radical resection of retroperitoneal leiomyosarcoma was possible with combined resection and reconstruction of the inferior vena cava and left renal vein. An 81-year-old patient was referred to our hospital for treatment of a retroperitoneal tumor. After detailed examination, a 5 cm-sized hypervascular solid tumor with invasion from the inferior vena cava(IVC)to the left renal vein(LRV)and tumor thrombus was found. The resection was performed, in which the IVC and LRV were resected together, and IVC was anastomosed end-to-end, and LRV stump and IVC were anastomosed end-to-side. The pathological diagnosis was leiomyosarcoma, and the patient has been undergoing follow-up observation for 1.5 years, with no recurrence. Retroperitoneal leiomyosarcoma is a rare disease, and the only treatment is complete resection of the tumor, including IVC. Even if complete resection is performed, the prognosis is poor, however, there have been a small number of reported cases of long-term survival after complete resection, so aggressive treatment is recommended.