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A 70s-year-old man with pancreatic body cancer underwent evaluation by endoscopic-ultrasound guided tissue acquisition(EUS-TA), followed by distal pancreatectomy. Histopathological findings showed a well differentiated pT3N0M0 adenocarcinoma. Adjuvant S-1 chemotherapy was completed, and annual upper gastrointestinal endoscopy was performed. Three years postoperatively, a type 0-Ⅱc lesion was detected at the posterior gastric wall, at the location where the EUS-TA was performed. The initial biopsy showed no obvious malignant findings, but a repeat biopsy 6 months later revealed a well-differentiated adenocarcinoma. Therefore, we performed 4 courses of gemcitabine+nab-paclitaxel, subsequently performed partial gastrectomy. Histopathological findings of the resected stomach specimen showed a well differentiated adenocarcinoma extending from the subserosa to the submucosa. Then, we diagnosed as needle tract seeding(NTS)of pancreatic cancer. Twelve months after partial gastrectomy, there were no signs of recurrence. EUS-TA is a useful method for diagnosing pancreatic tumor. However, knowledge regarding NTS of pancreatic cancer due to EUS-TA is limited by the fact that this is a rare event. We herein report a case of NTS due to EUS-TA, which was performed partial gastrectomy.

Synchronous gastric cancer(GC)is rare. We performed simultaneous robotic surgery in 2 cases of colorectal cancer and one case of renal cancer with GC. In case 1(GC cStage Ⅰ, rectal cancer[RC]cStage ⅡB, and descending colon cancer cStage ⅢB), peritoneal dissemination of RC was observed during surgery. Robotic high anterior resection, left hemicolectomy, and D3 lymph node dissection(LND)were performed, followed by distal gastrectomy and D1 LND. The operation time was 600 minutes, with an estimated blood loss of 0 mL. In case 2(GC cStage ⅡA, RC cStage ⅡB), robotic distal gastrectomy, D2 LND, low anterior resection, and D3 LND were performed. The operation time was 648 minutes, with an estimated blood loss of 0 mL. In case 3(right renal cancer cStage Ⅰ, GC 1: cStage ⅡA, and GC 2: cStage ⅡA), a robotic partial right nephrectomy, total gastrectomy, and D2 LND were performed. The operation time was 926 minutes, with an estimated blood loss of 447 mL. Discussion: Although simultaneous surgery for multiple cancers is lengthy and highly invasive, it avoids the risk of tumor growth during the waiting period and adhesion during reoperation. These procedures were performed safely and proved to be beneficial in terms of operating room utilization and cost. Conclusion: Simultaneous robotic surgery for GC is a viable option for patients with synchronous cancers.

Many cases with esophageal cancer recurrence have worse clinical survival. Treatment with immune checkpoint inhibitor (ICI)has been reported to result in significantly longer overall survival. We investigated the clinical outcomes in 30 patients with esophageal cancer recurrence who underwent neoadjuvant chemotherapy followed by surgery, chemotherapy, and chemoradiotherapy. Results: Of the 30 patients investigated, 25 were men. Median patient age was 70(range 52-84)years. The recurrence sites are as follows: 17 in locoregional, 5 in lung, 2 in bone, 3 in liver, and 5 in others. The overall survival in early recurrence(within 6 months after surgery)cases and multiple recurrence cases were significantly shorter than that in later recurrence(>6 months after surgery)and single recurrence(p=0.031, p<0.01). Of 30 recurrence cases, 9 cases (30%)achieved complete response(CR). Five of CR cases were treated by chemotherapy with ICI. In esophageal cancer recurrence, treatment with ICI showed good response and survival benefit. In future, the indication of ICI is evaluated for adjuvant therapy after surgery.

The patient was a 60s male. He underwent esophagectomy and gastric tube reconstruction for Barrett's esophageal cancer( pT3N1M0, pStage Ⅲ). Postoperatively, anastomotic leakage and mediastinitis resulted in septic shock. On the 8th day after first surgery, he transferred to our hospital. At the time of admission, qSOFA was 3 points. We judged to be difficult to treat with conservative treatment. Emergency right thoracotomy drainage underwent with resection of the esophagogastric anastomosis and cervical esophagostomy construction. He was discharged on the 55th postoperative day with home enteral nutrition. He underwent presternal ileocolic reconstruction on the 97th day after right thoracotomy drainage. On the 19th day after reconstruction, oral intake was started. The general condition is good without recurrence, and oral intake is sufficient at 1 year after reconstruction. We report a case of anastomotic leakage with septic shock after esophageal cancer surgery successfully treated by 2 stage ileocolic reconstruction.

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.

Palliative stoma creation for malignant gastrointestinal obstruction improves quality of life, and advances in chemotherapy have resulted in long-term survival after stoma creation. We reviewed early and late complications in 24 patients treated with palliative stoma creation. Results: 14 men(58%)and 10 women(42%)had a median age of 60 years. Twenty-three patients(96%)were able to eat more than a porridge diet postoperatively, and the median The ColoRectal Obstruction Scoring System(CROSS)improved from 1(0-3)to 4(2-4)(p<0.001). Postoperative complications(all Clavien-Dindo grades)were observed in 10 patients(42%), with a longer postoperative hospital stay in the complication group than in the group without complication(median 34 days: 17 days, p=0.026). When divided into long-term survivors and short- term survivors based on a median overall survival of 101 days, more stoma prolapse occurred in the long-term survivors(4 cases 33% vs 0 cases 0%, p=0.028), one of which required repair surgery. Conclusion: Long-term survivors after exploratory stoma creation are more likely to develop a stoma prolapse. Careful surgical manipulation and postoperative support system including stoma care are important.

A 20-year-old man presenting with abdominal pain and distension from 3 months ago was admitted to our hospital. Colonoscopy showed a type 1 tumor in the transverse colon. The biopsy was moderately differentiated adenocarcinoma. Abdominal enhanced CT revealed intussusception associated with the tumor. After non-invasive reduction of intussusception was performed, a full-body examination revealed no findings suggestive of distant metastases or other Lynch syndrome- related tumors. We performed laparoscopic right hemicolectomy. Lynch syndrome was suspected based on his family history, MMR protein immunohistochemistry and MSI-High, but genetic testing was rejected due to cost reasons. If young people have chronic abdominal symptoms and a family history of suspected hereditary colorectal cancer, a close examination of colon cancer should be performed.

Gut microbes are one of the essential components of the tumor microenvironment, the same as interstitial stroma, angiogenesis, and immunity. With the advancement of technology, it has become possible to analyze various bacterial flora without culturing microbiomes comprehensively. There are a massive amount of gut microbes in the large intestine compared with other organs. It has been reported that some species of gut microbes, such as Fusobacterium nucleatum, are involved in the progression and metastasis of colorectal cancer and resistance to chemotherapy, with multiple mechanisms. The interstitial stroma composed of an extracellular matrix is also one of the crucial components of the tumor microenvironment involved in cancer progression and metastasis. It has been reported that fibrosis in the invasive front of the primary tumor and metastatic lymph nodes is a poor prognostic factor in colorectal cancer. Gut microbes affect not only cancer cells but also various surrounding factors such as fibrosis and angiogenesis. Gut microbes produced many kinds of enzymes, including protease, elastase, and collagenase, which degrade the surrounding extracellular matrix and secreted cytokines to induce inflammation and remodel a cancer-specific environment. It is important to consider the cancer microenvironment, including gut microbes and interstitial stroma, for treating colorectal cancer.

A 60s female with complaint of epigastric discomfort revealed 0-Ⅱb lesion in gastric fornix on upper gastrointestinal endoscopy and exhibited signet-ring cell carcinoma on histopathologic examination of biopsy specimens. A thoracoabdominal CT scan suggested tumors in right breast and left lung, and biopsy revealed invasive lobular carcinoma and primary lung adenocarcinoma, respectively. As results of multidisciplinary discussion of the treatment strategy for triple cancers, it was decided to perform robotic proximal gastrectomy, D1+ lymph node dissection, and esophagogastrostomy. The gastric lesion was diagnosed as gastric metastasis of breast cancer(T2N1M1, Stage Ⅳ)because immunohistochemical staining findings showed ER(+), GCDFP-15(+), and GATA-3(+). Two months later, she underwent the left upper lobectomy, and was diagnosed with lung acinar adenocarcinoma(pT2N0M0, pStage ⅠB). Six months after gastrectomy, she is currently on hormone therapy with aromatase inhibitors for breast cancer.

Retroperitoneal liposarcoma is a relatively rare disease, with a high recurrence rate and poor prognosis. We encountered 8 patients with retroperitoneal liposarcoma who underwent surgery in Shiga University of Medical Science Hospital. We often encounter elderly male patients without symptoms. Of the 8 patients, 6 received extensive resection that included the surrounding organs or tissues; however, 3 patients demonstrated positive surgical margins, which resulted in liposarcoma recurrence. Despite the additional resection in the 3 recurrent cases, all the patients had a tumor relapse. One patient with an unresectable tumor received chemotherapy. The other patients received surgical treatment 3 times. One patient developed an unresectable relapse after receiving chemotherapy. Another patient attained long-term survival by adjuvant chemoradiotherapy combined with 3 surgeries. Aggressive surgical resection to achieve a negative surgical margin and careful postoperative follow-up seem important for the treatment of retroperitoneal liposarcoma. This study suggests that postoperative adjuvant therapy may contribute to the improvement of prognosis. Further findings must be accumulated to clarify the significance of postoperative adjuvant therapies in the future.

An 80s man presenting with general malaise and anorexia was referred for treatment of abdominal tumor. Abdominal contrast-enhanced CT revealed a tumor in the left renal cavity. The inside of the tumor coexisted with a fat component and a solid component having a contrast effect. In addition, 2 solid tumors were found to be in contact with the stomach, away from the primary lesion. Based on these findings, retroperitoneal liposarcoma with intraperitoneal metastases was diagnosed. The patient underwent excision of the retroperitoneal tumor and local gastrectomy. The size of the main tumor was 21×18 cm, and the weight was 2.0 kg. Histopathology of the resected specimen showed dedifferentiated liposarcoma and its metastases. The resected margin of the excised tumor was negative. Liposarcoma has a high local recurrence rate, and the status of a resected margin of the tumor is an important factor for prognosis. Here, we report a case of dedifferentiated liposarcoma with metastatic lesions that could be completely resected.

Introduction: We evaluated the effectiveness of palliative stomas created to resolve symptoms of bowel obstruction., Methods: We retrospectively evaluated patient characteristics and outcomes in 16 cases of palliative enterostomy performed to resolve malignant bowel obstruction., Results: The median age of the patients was 64 years, and the most common original cancer was colorectal cancer(11 cases, 69%). Oral intake was recovered in 15 patients after the surgery(94%), and the colorectal obstruction scoring system(CROSS)score improved from 2 to 4. Postoperative complications(Clavien-Dindo grade Ⅱ or higher)were observed in 8 cases(50%), in which serum albumin levels were less than 3.5 g/dL(p=0.077), resulting in longer hospital stays(p=0.041). The median overall survival time was 107 days, and longer survival time was achieved in patients aged younger than 70 years, with CA19-9 levels C37.7 U/mL and postoperative CROSS score of 4, who were administered postoperative chemotherapy. The chemotherapy was feasible after surgery when CROSS scores improved to 4(p=0.019)., Conclusion: Palliative stomas contributed to the improvement in oral intake of patients with terminal cancer. This improvement may allow patients to receive postoperative chemotherapy, which leads to longer survival times.

It is hard to determine treatment strategy for radiation induced carcinoma, because radiation cause fibrosis to adjacent organ.The patient was in the 70's, who underwent 70 Gy radiation therapy for prostate cancer 5 years ago.He visited hospital because of fecal occult blood.Endoscopic examination revealed laterally spreading tumor(LST)in rectal front wall, and he referred to our hospital in purpose of endoscopic submucosal dissection(ESD).We performed ESD for LST, following transanal minimally invasive surgery to suture mucosal defect.He discharged out hospital 9 days after operation without any adverse event except anal pain.Suturing of mucosal defect after ESD might be potent to prevent postoperative complications in radiation induced rectal cancer.

A 70's man presenting with a chief complaint of stomachache was found to have advanced gastric cancer with a deep ulcer and some lymph-node metastases. We decided performing a curative operation after 2 courses of S-1 plus cisplatin. On the first course day 13 of chemotherapy, he complained of severe epigastralgia, and we diagnosed as generalized peritonitis due to perforation of gastric cancer. We performed an urgent laparoscopic operation, which made perforation simple closure and omentopexy. Curative distal gastrectomy with D2 lymph node dissection was successfully performed on postoperative day 16.

The patient is male in his 60's. He underwent endoscopic examination for anemia, which was found during screening of high PSA value. Endoscopic examination revealed a gastric cancer and 3 colorectal cancers. Histological results from biopsy was HER2 positive poorly differentiated adenocarcinoma in gastric tumor and moderately differentiated adenocarcinoma in colorectal tumor. Chest CT showed a pulmonary nodule in the middle right lung. Histological diagnosis was TTF-1 positive adenocarcinoma, meaning primary lung cancer. Histological examination of prostate biopsy also showed adenocarcinoma. Clinical stages were Stage III B of gastric cancer, Stage III a of colorectal cancer, Stage I A of lung cancer and Stage I of prostate cancer. Neoadjuvant chemotherapy for gastric cancer was performed because gastric cancer with advanced clinical stage was regard as a prognostic factor. Neoadjuvant chemotherapy shrinked gastric and colorectal cancers, so we performed distal gastrectomy for gastric cancer and super low anterior resection for colorectal cancer. Patient was discharged 22 days after operation without any serious adverse events. Hormonal treatment for prostate cancer and radiation therapy for lung cancer were performed. Now this patient is alive without any recurrence.

A 70-year-old woman presenting with abdominal pain was admitted to our hospital. Abdominal contrast CT revealed a small intestine tumor of 10 cm with active bleeding and performed partial resection of the small intestine including tumor. Pathological findings were high risk GIST of the small intestine because of spindle cells and c-kit positive. Imatinib 400mg/day as adjuvant chemotherapy was administered. However administration was stopped for 15 days because of the Grade 4 erythema multiforme. Recurrence of peritoneal dissemination was observed in 2 years after surgery and tumor resection was performed, but complete resection was difficult. Within 5 years after surgery, tumor resection was performed on a total of 5 times peritoneal disseminative recurrences, and it was possible to avoid the appearance of symptoms due to tumor augmentation.

Perforated gastric cancer is relatively rare disease. Between 2006 and 2016, we treated 8 cases with perforative gastric cancer. These cases accounted for 15%of the 53 cases with the upper gastrointestinal tract perforated cases. The median age of perforated gastric cancer case was 66(37-80)years, which was significantly higher than that of perforated benign upper gastrointestinal ulcer(55, 12-97 years)(p=0.033). These patients were divided into 2 groups; 3 cases who died up to 3 months as poor prognosis group and 5 cases who survived more than 4 months as good prognosis group. Poor prognosis group tended to be higher Glasgow prognostic score(GPS)(p=0.05)and lower serum albumin level(p=0.05)than good prognosis group. GPS and serum albumin level may predict the prognosis of perforated gastric cancer patients.

A 62-year-old woman visited our hospital because of dysphagia. She was diagnosed with upper-middle esophageal type 4 cancer, which was 9 cm in length, according to the results of endoscopy. Squamous cell carcinoma was demonstrated using endoscopic biopsy. A CT scan revealed that the tumor had directly invaded into the trachea(cT4). Chemoradiotherapy(CRT) (5-FU and CDDP with 50 Gy of radiation)was administered. Although CT after CRT resulted in shrinkage of the tumor and no further tracheal invasion, esophageal stenosis remained. Therefore, salvage surgery(subtotal esophagectomy with 3-field lymph node dissection)was performed. Pathologically, no carcinoma cells were found in the resected specimen and a com- plete response(grade 3)was diagnosed. The patient received adjuvant chemotherapy(tegafur/uracil at 300mg/day per os) for 1 year. The patient is alive with no relapse of carcinoma more than 5 years after the first treatment.

An 80's woman was diagnosed with eccrine porocarcinoma of the head in 2010.T he tumor was removed surgically but relapsed in the cervical and axillary lymph nodes 2 years later.The patient underwent surgery, and received systemic chemotherapy and radiation.Chest CT after treatment revealed an irregular mass and thickened skin in the left breast.Core needle biopsy specimens were used to diagnose metastasis of eccrine porocarcinoma.A wide excision with a 1 cm margin was performed under local anesthesia.After surgery, supraclavicular lymph node recurrence was detected.The patient received palliative care because there was no effective treatment available.Eccrine porocarcinoma is a rare malignant tumor of the intraepidermal sweat duct.Breast metastasis from malignant disease is also rare.To our knowledge, breast metastasis of eccrine porocarcinoma has not been reported.

Survival of Stage IV gastric cancer is poor. We report 2 cases of Stage IV gastric cancer with positive peritoneal washing cytology or peritoneal dissemination that were successfully treated with gastrectomy and hyperthermic intraperitoneal chemotherapy( HIPEC)followed by systemic chemotherapy. Case 1: A 59-year-old woman. She was diagnosed with advanced gastric cancer and underwent gastrectomy with HIPEC. Her peritoneal washing cytology was positive during the gastrectomy. After the surgery, she underwent chemotherapy consisting of 8 courses of combination S-1 plus CPT-11 and 19 courses of PTX. It has been 5 years and 7 months since she had the surgery and she survives without recurrence of the cancer. Case 2: A 60-year-old woman. She was diagnosed with advanced gastric cancer and peritoneal dissemination(peritoneal cancer index: 3 points). She underwent gastrectomy, hemi-colectomy, and HIPEC. After the surgery, she underwent chemotherapy, 35 courses of combination S-1 plus PSK/DOC, and 13 courses of S-1 plus PSK. It has been 5 years since her surgery and she survives without exacerbation of the cancer. These cases suggest a gastrectomy and HIPEC followed by systemic chemotherapy may represent an effective treatment for advanced gastric cancer with a small amount of peritoneal metastasis.

Purpose: We herein report the clinical outcomes of hyperthermic intraperitoneal chemotherapy(HIPEC)in patients at high risk of colorectal peritoneal metastasis., Patients and Methods: We enrolled 21 patients with advanced colorectal cancer who were received HIPEC between 2009 and 2014. Retrospectively, we evaluated the short-term and long-term outcomes of these cases., Results: We performed HIPEC for 12 patients with primary cancer and 9 with recurrent cancer. Perioperative complications characteristic of HIPEC did not occur. Seventeen patients(81%)had postoperative recurrence, 5 of whom had a peritoneal recurrence, and all of them already had synchronous peritoneal metastasis at the time of HIPEC. Patients with a higher peritoneal cancer index(PCI)had a tendency towards a higher rate of peritoneal recurrence than those with a lower PCI(11[median]vs 4; p=0.08).

Perianal lesions are a frequent complication of Crohn's disease (CD) and include fistula, abscess, anal ulcer, skin tag, anal stricture, and carcinoma. Perianal fistula is the most commonly observed condition and exhibits multiple incidence and intractable characteristics. The starting point for the management of perianal fistula is an accurate diagnosis, which requires careful exploration during an EUA. The condition is treated with medications such as antibiotics, immunosuppressants, or anti-tumor necrosis factor agents. However, it is difficult to maintain long-term remission. Surgical therapy is selected according to the type of fistula and can include conventional fistulotomy, seton drainage, diverting stoma, and anorectal amputation. After fistulotomy, recurrence is frequent and there is an increased risk of incontinence. Seton drainage is the preferred treatment to improve symptoms and preserve anal function. Stoma is useful to relieve symptoms but difficult to indicate for young patients. The optimum treatment for perianal fistula associated with CD remains controversial. Currently, the goal of therapy for these patients has shifted from complete fistula closure to reducing drainage from the fistula to improve their quality of life. Ongoing careful management is important to control anal symptoms and maintain long-term anal function in the treatment of patients with CD, while monitoring them to detect possible progression to anorectal carcinoma.