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This patient visited our hospital for the purpose of detailed examination of prostate cancer in his seventies. Abdominal contrast-enhanced computed tomography(CT)revealed a low-density mass of 2 cm in the pancreatic head. He was diagnosed with pancreatic cancer. Pancreaticoduodenectomy was performed after 2 courses of gemcitabine and S-1 therapy were performed as neoadjuvant chemotherapy. An intraoperative clamp test of the gastroduodenal artery showed that the pulsation of the common hepatic artery and the proper hepatic artery was weak but sufficient, so the gastroduodenal artery was cut and the operation was completed as planned. A blood test on the 1st day after the operation showed elevated levels of AST 537 U/L, ALT 616 U/L, and 7 hours later blood sampling showed further increases in AST 1,455 U/L, ALT 1,314 U/L. After a detailed review of the preoperative CT, celiac artery stenosis due to compression of the arcuate ligament was suspected, and urgent median arcuate ligament release was performed on the same day. Dissection of the arcuate ligament significantly improved the pulsation of the common hepatic artery and proper hepatic artery. Postoperatively, hepatic enzymes improved and ISGPS showed Grade B pancreatic juice leakage, but the patient was discharged from the hospital on the 49th postoperative day without any other complications. He took S-1 as adjuvant chemotherapy, and no signs of recurrence have been observed 9 months after the operation.

We report a case of local recurrence of intrahepatic bile duct cancer that was successfully treated using chemotherapy and radiation therapy. A man in his 80s underwent hepatic resection for intrahepatic cholangiocarcinoma, and abdominal CT 11 months after surgery revealed local recurrence around the dissected surface. He was diagnosed with a local recurrence of intrahepatic cholangiocarcinoma and started systemic chemotherapy(GEM plus CDDP plus S-1). After 11 courses of chemotherapy, stereotactic body radiation therapy(SBRT)was administered to the same site at 50 Gy/10 Fr, as the local recurrence area had increased, although no distant metastases were detected on imaging. The patient was then started on chemotherapy( GEM plus S-1), but after 2 courses, 8 courses of GEM alone were administered at the patient's request. No increase in tumor markers was observed, but an increase in the low-absorption area was observed on imaging. Thereafter, the regimen was changed to S-1. Three months later, the same area was reduced in size and obscured on imaging evaluation. The patient is still taking it 12 months later. No recurrence has been observed since 2 years and 7 months after the start of treatment for local recurrence. This case suggested that multidisciplinary therapy might be useful for local recurrence of intrahepatic cholangiocarcinoma.

A 50s female was diagnosed as rectal cancer with multiple liver metastases after fecal occult blood scrutiny. Liver metastases were multiple in both lobes and involved the right Glisson's capsule. We determined that the liver metastases were unresectable and initiated FOLFOXIRI plus panitumumab treatment. After 6 courses of chemotherapy, rectal cancer resection was performed. After 12 courses of chemotherapy, the liver metastases which had extensively involved the right Glisson on imaging, shrank until the P7 root was visible. If S7 Glisson could be preserved, the radical resection was planned. If not, associated liver partition and portal vein ligation for staged hepatectomy(ALPPS)was planned. Intraoperatively, it was determined that preservation of S7 Glisson was possible and blood flow preservation in the S7 region was feasible, and an anterior segment hepatic resection(S5-6-8)and lateral segment hepatic partial resection(S2/3)were performed. She was discharged on the 18th day and has been under outpatient observation 12 months after hepatectomy.

A 73-year-old woman underwent left nephrectomy for renal cell carcinoma(RCC). The computed tomography(CT)and magnetic resonance imaging(MRI)revealed a 20-mm tumor in the pancreatic tale showing early enhancement in the arterial phase 16 years after surgery. Fluorodeoxyglucose positron emission tomography(FDG-PET)showed slightly uptake (maximum standard uptake value: SUVmax 2.3)and EUS-FNA showed a hyper-vascularized tumor in the pancreatic tail. A single pancreatic metastasis from RCC was diagnosed, and we performed distal pancreatectomy. The histopathological diagnosis was a metastatic pancreatic tumor from RCC. The postoperative course was uneventful and 1 month after surgery, she is alive with no recurrence.

A 66-year-old man with a history of frequent diarrhea was diagnosed with rectal cancer with obstruction and a pelvic abscess. Following a transverse colostomy, he was referred to our hospital. The initial diagnosis was rectal cancer(cT4a N1bM0, cStage Ⅲb)and a pelvic abscess due to tumor perforation. To address this condition, we performed neoadjuvant chemotherapy using a combination of 5-fluorouracil, Leucovorin, oxaliplatin, and irinotecan(FOLFOXIRI). Following 6 courses of FOLFOXIRI, the abscess disappeared and no signs of tumor progression and distant metastases were detected. Subsequently, we performed radical resection with D3LD2 lymph node dissection, leading to a pathological diagnosis of ypT3N1aM0, ypStage Ⅲb. The patient then underwent adjuvant chemotherapy with capecitabine and oxaliplatin(CAPOX). No recurrence was observed after 9 months of follow-up.

Introduction: The key drugs of first-line chemotherapy for metastatic esophageal cancer are 5-FU and cisplatin(CF). However, the treatment strategy for unfit patients of CF regimen remains controversial., Methods: Fifty patients who received first-line chemotherapy including platinum-containing drug for metastatic esophageal cancer between 2018-2022 at Osaka National Hospital were analyzed. They were divided into 4 groups according to estimated creatinine clearance(Ccr) at the beginning of the treatment; Group A(over 60 mL/min)31 patients, Group B(50-59 mL/min)12 patients, Group C(30-49 mL/min)5 patients, and Group D(under 30 mL/min)2 patients. The background and treatment outcome data of each group were retrieved retrospectively and compared., Results: Group B, C, D had more elderly patients than Group A. Each Group B, C, D included 1 patient who received FOLFOX regimen. More than half patients in Group B, C, D reduced the dose of CDDP and the initial dose of CDDP was adequately reduced according to Ccr. Group B, C, D had more patients with decreased renal function over Grade 1 than Group A. The clinical response rate was Group A 65%, Group B 42%, Group C 60%, Group D 50%, respectively. There were no patients who ceased the treatment due to adverse events., Conclusion: Adequate dose reduction of CF regimen would become more important in the era that only CF regimen can be a partner of immune-checkpoint inhibitor.

A 78-year-old woman underwent total gastrectomy with distal pancreatectomy and splenectomy for type 3 gastric cancer and a cystic tumor of the pancreas. Her pathological diagnosis was pT4aN3bM0, pStage ⅢC, and HER2-negative. Capecitabine and oxaliplatin was started as an adjuvant therapy, and capecitabine was administered until 1 year postoperatively. Thirteen months after surgery, she had a recurrence in S3 of the liver and underwent liver resection due to solitary metastasis. The postoperative diagnosis was peritoneal dissemination of gastric cancer with invasion of the falciform ligament. S-1 was started postoperatively. Ten months after surgery, she had a recurrence in S3 of the liver and underwent repeated resection. It invaded into the diaphragm and pericardium, and the final diagnosis was recurrent peritoneal dissemination of gastric cancer. After 5 courses of paclitaxel and ramucirumab, nivolumab was started as a fourth-line therapy for the recurrence of the right supraclavicular lymph nodes, bone, and liver. She had some immune-related adverse events(irAE), including hypothyroidism and hypoadrenocorticism, which required management, but she maintained PR more than 2 years after the initiation of the treatment. Multimodality therapies, including repeated resection and nivolumab, were considered to help her long-term survival.

Malignant tumor occurring in the inguinal region are relatively infrequent, and metastatic tumor is extremely rare. We report a case of inguinal hernial sac metastasis of cecal cancer resected with TAPP approach. The case is a 80's man. One year and 6 months after cecal cancer surgery, contrast-enhanced computer tomography(CT)examination revealed a solitary tumor in the right inguinal canal. We diagnosed inguinal hernia sac metastasis of cecal cancer and performed surgery. The mass in the hernia sac was resected with the TAPP approach. Histopathological findings were consistent with peritoneal metastasis directly to the inguinal hernia sac. The patient has been alive without 2 years after metastasectomy. It is necessary to treat patients with a history of malignant disease with keeping the possibility of inguinal hernia sac metastasis in mind.

We report a case of advanced gastric cancer with simultaneous liver metastasis in which long-term survival has been obtained by multimodal therapy. Case 75-year-old, male. Esophagogastroduodenoscopy revealed advanced type 2 cancer in the greater curvature of the angular incisure. Computed tomography showed a single 20 mm mass was found in liver S2. Histopathological findings indicated that differentiated adenocarcinoma(tub1, HER2 3+). Diagnosis was gastric cancer, cT4aN0M1HEP, Stage Ⅳ. Tumor shrinkage was obtained after 2 courses of capecitabine/cisplatin/trastuzumab. Laparoscopic distal gastrectomy and partial liver resection was performed. Histopathological findings indicated tub1, ypT4aN0M1HEP, ypStage Ⅳ, grade 1a. A single 10 mm recurrence was observed in liver S1/2 13 months after first surgery. After chemotherapy, rehepatic resection was performed. Three years have passed since the last hepatectomy, and the patient is currently undergoing recurrence-free follow-up.

Prognosis of pancreatic cancer is extremely poor due to recurrence in the early postoperative period. However, there are some reports that the prognosis for lung recurrence alone is relatively better than that of others. In this study, we report the cases of lung recurrence alone after radical resection of pancreatic cancer performed at our hospital. Among 255 cases of radical resection of pancreatic cancer performed at our hospital between July 2010 and August 2021, 6 cases in which the initial recurrence site of recurrence was lung alone were included in the study. The median age of the patients was 72 years (62-82), and there were 5 males and 1 female. Four patients had undergone pancreaticoduodenectomy and 2 patients underwent distal pancreatectomy. Four patients received adjuvant chemotherapy, 3 with S-1 and 1 with GEM. No patients underwent surgical resection for recurrence of lung metastasis, and all patients were treated with chemotherapy. The median time to recurrence was 351 days. As initial therapy after recurrence, 3 patients received GEM plus nab-PTX combination therapy and 3 patients received S-1. The median overall survival after recurrence was 1,979 days, and the 1-year and 3-year overall survival rates after recurrence were 100% and 100%, respectively. The prognosis of patients with recurrence of lung metastasis after surgery for pancreatic cancer at our hospital was similarly good as the previous reports.

We report a case of a 73-year-old man who underwent endoscopic mucosal resection (EMR) for early rectal cancer(i ntramucosal cancer)at other hospital 17 years ago. Ten years later, he underwent a total colonoscopy, which showed no recurrence of the tumor. Twelve years later, a mass with calcification was incidentally detected in front of the sacrum, which was diagnosed as a benign tumor at that time. Seventeen years later, he presented with constipation and diarrhea, and was detected of a sub-circumferential tumor in the rectum by a total colonoscopy. Biopsy revealed that the tumor was malignancy. CT showed a mass in the left lateral liver lobe. The mass was suspected of metastasis. Laparoscopic super lower anterior resection was performed for rectal cancer, and pathological examination showed that the tumor was pT4a, N3, M1(H), Stage Ⅳa. One month after surgery, laparoscopic hepatectomy was performed for liver metastasis. Six months after surgery, CT showed multiple lung metastases. He continues to undergo chemotherapy. Although this case was treated with EMR for intramucosal carcinoma, clinical history and pathological findings suggested local recurrence.

A 98-year-old woman presented with hematochezia and a circumferential type 2 tumor in the rectum Rb identified on fiberoscopy. We a performed laparoscopic Hartmann's operation and D2 lymphadenectomy for advanced rectal cancer. A sigmoid colostomy was created via the intraperitoneal route. On the postoperative day 12, the patient experienced abdominal pain. Computed tomography showed that the small intestine formed a closed loop in the pelvic space. The patient was diagnosed with a strangulated bowel obstruction of the small intestine for which an emergency exploratory laparotomy was performed. The small intestine, which had passed through a defect between the lifted sigmoid colon and the left abdominal wall, was strangulated by the lifted sigmoid colon. We performed partial resection of the small intestine. The patient died on postoperative day 32 of acute deterioration of aortic valve stenosis. There have been few reports of strangulated bowel obstruction resulting from internal hernia associated with colostomy. These findings demonstrate that it is important to select the appropriate route for colostomy creation in each case.

The patient was a 68-year-old woman without history of surgery. She presented with abdominal pain and leg edema. Ultrasound scan revealed hepatic masses. Colonoscopy and abdominal CT scan revealed unresectable rectal carcinoma with massive multiple liver metastases suspected of invasion of the inferior vena cava. After a transverse colon bi-pore colostomy, 10 courses of FOLFOX plus panitumumab therapy were administered, and the liver tumor was markedly reduced in size and determined to be PR by CT. Considering the possibility of unresectability due to the liver metastases re-growth, surgery was planned with liver-first approach(LFA). First, open resection of the right caudate lobe of the liver, combined resection of the IVC, combined resection of the diaphragm, partial hepatic S2 resection(2 sites), and cholecystectomy were performed, followed by laparoscopic anterior resection(D3)1 month later(R0). Postoperatively, the colostomy was closed after 8 courses of CapeOX(capecitabine alone from the middle of the course). Now the patient is alive and recurrence-free 4 years after the initial diagnosis. Conversion surgery with LFA after chemotherapy can be an effective treatment strategy for colorectal cancer with advanced liver metastases.

A 70s-year-old man visited the gastroenterologist with a complaint of bloody stool. Lower gastrointestinal endoscopy revealed a 50 mm type 0-Ⅰs+Ⅱa lesion in the center of the anterior wall of Rb in 4 cm from anal verge, and he was diagnosed with rectal cancer in cT1bcN0cM0, cStage Ⅰ. Endoscopic submucosal dissection was performed, but it was discontinued due to muscular traction, and was referred to our department at a later date for surgical purposes. Robot-assisted laparoscopic Hartmann's surgery(D2 dissection, sigmoid colon colostomy)was performed, and the pathological result was pT2pN0cM0, pStage Ⅰ with negative resection margins. Three months after the operation, a tumor was found on the left side of the stoma, and he visited us. Biopsy revealed the recurrence of skin metastasis of rectal cancer, and surgical procedure including colostomy and skin tumor resection, ileostomy, and colonic mucus fistula was performed. The patient was transferred to the hospital 3 months after the operation, but 2 months after the transfer, an increasing CEA was observed and CT revealed a local recurrence in the pelvis. Irradiation(45 Gy/15 times)was performed for the pain relief, but the general condition deteriorated thereafter and he died 8 months after the second operation.

Introduction: There is concerned that prognosis of cancer-bearing patients is adversely affected by postponement of cancer treatment due to infection with a new type of coronavirus(COVID-19). We report a case of thoracic esophageal cancer treated with COVID-19 pneumonia during preoperative CRT. A 60-year-old female diagnosed as having Stage Ⅳ thoracic esophageal cancer(cT3N0M1LYM[104R])started receiving preoperative chemoradiotherapy. On the 12th day, she had a fever and was diagnosed with COVID-19 infection. CRT temporarily interrupted and she was treated for COVID-19 pneumonia preferentially. CRT was resumed promptly after remission. Finally, video-Assisted radical esophagectomy was performed. There were no postoperative complications. Nivolumab was started as an adjuvant therapy on the 2nd postoperative months., Conclusions: We experienced a case of thoracic esophageal cancer in which COVID-19 pneumonia was treated during preoperative CRT, and CRT and surgery were completed without complications by appropriate treatment.

A 66-year-old woman was referred to the gastroenterology division of our hospital due to elevation of serum CEA level. Contrast-enhanced CT showed a hypovascular tumor at the body of pancreas. She was diagnosed with pancreatic cancer by EUS-FNA. By laparotomy, we found white nodules on mesentery and abdominal wall, which were diagnosed as peritoneal metastasis. After systemic chemotherapy with 9 courses of gemcitabine(GEM)plus nab-paclitaxel(PTX)and 30 courses of mFOLFIRINOX, the tumor had shrunk and serum CA19-9 level were remarkably decreased. Distal pancreatectomy was performed as conversion surgery. Pathological analysis revealed no remnant cancer cells in the primary tumor or the lymph nodes, confirming a pCR. S-1 was started as adjuvant chemotherapy, and she remains alive without recurrence 8 months after surgery.

A 59-year-old male was referred to our hospital for a thorough examination of liver function abnormality in the background of chronic hepatitis C. Abdominal contrast-enhanced CT showed multiple tumors in the right lobe of the liver, and an 8 cm tumor occupying S7, a tumor thrombus extending from the right hepatic vein to the inferior vena cava, and a tumor thrombus in the right branch of the portal vein. The patient was diagnosed with hepatocellular carcinoma, cT4N0M0, cStage ⅣA. After 5 courses of hepatic arterial infusion therapy, the intrahepatic lesion was significantly reduced, but micropulmonary metastasis appeared, and the tumor thrombus in the inferior vena cava increased to the thoracic inferior vena cava and just below the tricuspid valve. The patient had difficulty blocking blood flow in the inferior vena cava in the pericardial sac. The patient underwent right hepatectomy, tumor thrombus resection of the inferior vena cava, combined resection of the inferior vena cava, and bovine pericardial patch reconstruction under artificial cardiopulmonary support. He was discharged on the 23rd day after surgery and has been under outpatient observation for 16 months while receiving molecular-targeted drugs for lung metastasis.

An 80-year-old female patient visited our hospital with scrutinizing acid reflex after meals. Esophagogastroendoscopy (EGD)and computed tomography(CT)showed a 25 mm submucosal tumor of the stomach in the lesser curvature of the middle stomach. A pathological examination using endoscopic ultrasound-guided fine needle aspiration(EUS-FNA) revealed gastrointestinal stromal tumor(GIST). The combination of laparoscopic and endoscopic approaches to neoplasia with the non-exposure technique(CLEAN-NET)was undertaken via a 2.5 cm single umbilical incision. The tumor was identified by EGD, and the scheduled dissected line was confirmed both from the mucosal and serosa side with an endoscope and laparoscope, respectively. The serosal and muscular layers were incised with an electric knife from outside the gastric wall; hypertonic saline solution was locally injected to swell the submucosal layer; partial gastric resection was performed with an automatic suture device without capsule damage. The operation time was 61 minutes, and there was blood less. The patient was discharged 6 days after the operation without complications. Histopathological findings showed GIST, 16× 14 mm, c-kit(+), CD34(+). The tumor was very low risk, as per the modified-Fletcher classification. Currently, 5 months after the operation, follow-up is underway without recurrence.

Total gastrectomy for remnant gastric cancer is one of the most difficult procedures in gastric cancer surgery. In our hospital, we have performed laparotomy so far, but in recent years we have shifted to laparoscopic surgery. We verified the safety and usefulness of laparoscopic surgery from the surgical cases in our hospital. We compared the surgical outcomes of 26 patients who underwent laparotomy or laparoscopic total gastrectomy for remnant gastric cancer after 2010. 19 patients had undergone gastrectomy for gastric cancer, and 7 patients had done for benign diseases. In the gastrectomy of remnant gastric cancer, laparotomy was performed in 19 patients and laparoscopic surgery was performed in 7 patients. The laparoscopic group had a long operation time(274 vs 402 min), less bleeding(434 vs 124 mL), more lymph node dissection(11 vs 20 lymph nodes). The rate of postoperative complications(Clavien-Dindo classification more than Grade 2)was low(42.1 vs 28.6%), and the length of hospital stay after surgery was short(14 vs 10 days). No postoperative death was observed in all patients. Conclusion: It was considered that laparoscopic surgery can be safety performed and is a useful surgical procedure for remnant gastric cancer.

A 60-year-old man was referred to our hospital after he was diagnosed with advanced gastric cancer. When he visited our hospital, upper gastrointestinal endoscopy revealed a type 3 tumor on the posterior wall of the middle greater curvature of the stomach, and histopathological examination revealed a well-differentiated adenocarcinoma(tub1). CT scan showed wall thickening with contrast effect in the middle part of the stomach. In the operation, the peritoneal lavage cytology was negative(CY0), but white nodules were found in the Douglas pouch, the great omentum, and mesentery, and the pathological examination showed adenocarcinoma(P1c). The patient was diagnosed as cT4aN0M1P1cCY0, Stage ⅣB and received S-1 plus CDDP therapy. After 4 courses of chemotherapy, the tumor was reduced. Staging laparoscopy showed no obvious peritoneal dissemination, and the peritoneal lavage cytology and scar nodules in the great omentum and Douglas pouch showed no evidence of malignancy(P0CY0). Therefore, the patient was able to have a conversion surgery, and underwent total gastrectomy with Roux-en-Y reconstruction and cholecystectomy. Pathological examination revealed type 3 tub1, ypT1bN0M0, pStage ⅠA, and the pathological effect of chemotherapy was Grade 1b. The patient was treated with S- 1 for 2 years as adjuvant chemotherapy, and the chemotherapy was terminated because no recurrence was observed by the CT and the laparoscopy. The patient has remained recurrence-free for a total of 10 years since then.

We report a case of laparoscopic sigmoid colon resection for sigmoid colon cancer after cystectomy for bladder cancer and ileal conduit surgery for urinary tract reconstruction. The patient was a male in his 70s. The patient presented to the Department of Gastroenterology with the complaint of nausea and loss of appetite, and findings that were suspicious of intestinal obstruction. The diagnosis was obstructive sigmoid colon cancer. The patient had a history of bladder cancer and had undergone cystectomy and ileal conduit surgery. Intraoperatively, we considered placing a ureteral stent to identify the left ureter through the dorsal mesentery of the sigmoid colon, but we decided that stent placement would be difficult because of a history of conduit stenosis during a previous close examination of a patient with pyelonephritis. On the 21st day, a laparoscopic- assisted sigmoid colon resection was performed. The surgery was completed without any problems such as intraoperative ureteral injury. The patient was discharged home on the 23rd postoperative day. Ten months after the surgery, the patient is alive without recurrence.

The patient was a 70s man, whose chief complaint of Hematochezia. He visited neighborhood hospital and was diagnosed with lower rectal cancer by colonoscopy. Preoperative CT showed a mass in the bladder, which led to a diagnosis of multiple early stage bladder cancer after a thorough urological examination. We diagnosed that very low anterior resection was necessary for rectal cancer and total bladder resection was necessary for bladder cancer. The patient underwent robotic- assisted total pelvic exenteration with anal preservation. One year and three months have passed since the surgery, and no signs of recurrence have been observed.

A 79-year-old man visited the hospital because of constipation. Colonoscopy showed a transverse colon carcinoma. Dynamic CT showed a renal neoplastic lesion and 2 lesions in the liver with early staining and late wash out, and the liver lesions showed ring enhancement on EOB-MRI. The preoperative diagnosis was either transverse colon cancer, renal cell carcinoma, hepatocellular carcinoma, or metastatic liver cancer. The patient underwent partial transverse colon resection, partial right nephrectomy, and partial hepatic resection. Additional to the 2 liver lesions in S6, an intraoperative ultrasound showed 1 tumor in S5; therefore, 3 partial hepatectomies were performed. Histopathological findings revealed that the tumors in S5 and S6 were liver metastases of transverse colon cancer and renal cell carcinoma, respectively. The final diagnosis was transverse colon cancer, pT4a, pN0, pM1, pStage Ⅳa and papillary renal cell carcinoma, pT1a, pN0, pM1, pStage Ⅳ. For 9 months postoperatively, there was no apparent recurrence.

A 54-year-old woman visited to a doctor nearby medical clinic complaining of loss of appetite. She was diagnosed with right hydronephrosis on abdominal ultrasonography, and referred to our hospital for further examination. Contrast abdominal computed tomography(CT)revealed that a 6.2 cm tumor with a contrast-enhancing effect inside in the retroperitoneum near the lower pole of the right kidney. She was diagnosed with hydronephrosis due to infiltration of the right kidney of a retroperitoneal tumor. The tumor was suspected of invading the duodenum and inferior vena cava, but no obvious lymph node or distant metastasis was observed. Abdominal MRI revealed a tumor showed hyperintensity on T2-weighted and diffusion-weighted images. We performed pancreaticoduodenectomy with inferior vena cava resection and right nephrectomy. The pathological diagnosis was leiomyosarcoma originating from retroperitoneum and pT2, pN0, pM0, pStage ⅢA. The postoperative course was good, and she was discharged 10 days after the operation. Thoracoabdominal CT showed a tumor 4 cm at the hepatic hilum three months after surgery, and EOB-MRI showed many tumors other than the same site, so multiple liver metastases were diagnosed as recurrence. Doxorubicin has been started and is still being treated.

The patient was male, 50s. He visited his local doctor with complaints of hematochezia and hematuria. He underwent colonoscopy, which revealed a circumferential lesion in the sigmoid colon, and he was referred to our department for further examination and treatment. A urinalysis at the time of admission revealed leukocytes(3+)and bacteria(2+), suggesting that the sigmoid colon cancer was invading the bladder. The urologist performed cystoscopy, which showed internal invasion of the bladder, and at this point, including the CT findings, it was needed that a combined bladder resection was necessary. We decided to undergo neoadjuvant chemotherapy(NAC)with the possibility of bladder preservation. FOLFOXIRI plus bevacizumab was selected as the regimen, and a total of 6 courses were performed. After NAC, the effect was judged PR. The patient underwent laparoscopy-assisted resection of the sigmoid colon and partial resection of the bladder wall. The pathological diagnosis was ypStage Ⅱc. Postoperatively, the patient received 6 courses of FOLFOX as adjuvant chemotherapy. Currently, about 8 months after surgery, no recurrence has been observed.

A 63-year-old female patient underwent resection of a gastrointestinal stromal tumor(GIST)at the age of 48 years. After surgery, she had adjuvant chemotherapy. She had been recurrence-free for 10 years. Two years after completion of medical therapy, local peritoneal recurrence of GIST was observed, and medical therapy with imatinib was restarted. The response was good, but 1 year after resumption of medical therapy, progression was observed, and imatinib resistance was suspected, and recurrent tumor resection was performed. After the reoperation, the patient continued medical treatment with imatinib. Two years after the reoperation, a tumor suspected to be recurrent was found in the abdominal cavity. Tumor resection was performed. Histopathological examination revealed c-kit and CD34 positivity, leading to a diagnosis of recurrence of GIST. Imatinib is the mainstay of treatment in patients with recurrent GISTs, and sunitinib may be considered if the patient becomes resistant to imatinib, or surgical treatment may be considered if the lesion can be resected. In this study, we report a case of GIST with peritoneal dissemination in which imatinib therapy was continued after surgery, but the disease recurred twice. We investigate the prognostic value of continued imatinib therapy after surgical resection of locally recurrent GIST.

We report a case of sphenoid bone metastasis from breast cancer detected with diplopia, as first site of recurrence. Forty- year-old woman with left breast cancer underwent breast-conserving surgery and sentinel lymph node biopsy. The diagnosis was papillotubular carcinoma, pT1pN0, ER(+), PgR(+), HER2(-). Tweleb years later, the examination of diplopia revealed left abducens nerve palsy for sphenoid bone metastasis from breast cancer. Radiation therapy(a total dose of 36 Gy with VMAT)was administrated as topical treatment, but diplopia did not improve. After that, systemic treatment was performed, and 2 years and 6 months have passed since the recurrence was found, she is still alive. We need to be careful of orbital metastasis as a symptom of metastasis from breast cancer.

The patient was a 75-year-old woman who was referred to our department because she had type 3 advanced gastric cancer on the posterior wall of the gastric body. Following a thorough examination, she was diagnosed as cT4aN3M1 (#16a1 int, #16b2 lat), cStage Ⅳ, an unresectable advanced gastric cancer with multiple extranodal lymph node metastases. As radical resection was not possible, chemotherapy(SOX therapy)was started. After the start of chemotherapy, the main lesion and metastatic lymph nodes shrank markedly. At the time of 7 courses, it was judged that R0 resection by conversion surgery was possible, and surgical treatment was performed. The patient underwent sub-total gastrectomy with D2 dissection and para-aortic lymph node dissection. The specimen was submitted for pathological examination and showed no residual tumor component including the main lesion and dissected lymph nodes, indicating a complete pathological response. She was started on S-1 as adjuvant chemotherapy on postoperative day 51 and has been recurrence-free for approximately 5 months after surgery.

We report a case of non-exposed endoscopic wall-inversion surgery(NEWS)performed by TANKO technique for gastric GIST. A 52-year-old man was diagnosed as having gastric GIST. A 2 cm-sized tumor was found in the lesser curvature of the middle body of the stomach, and an endoscopic biopsy revealed GIST. A 2.5 cm umbilical incision was made and TANKO surgery was performed. After seromyotomy around the tumor, the outer serosal muscularis was sutured closed to invert the tumor into the stomach. The inverted tumor was resected from the stomach wall and recovered using endoscopic techniques. NEWS is an operation developed to resect a tumor without exposing it into the abdominal cavity and is expected to avoid the risk of postoperative abdominal abscess and peritoneal dissemination. On the other hand, the TANKO is a procedure with excellent plastic technique and can be performed in this operation.

A patient was 70-year-old female. Because unknown fever following operation of left knee in December 20XX-1, abdominal simple CT was performed, diagnosed as cholecystitis and liver abscesses. However, her unknown fever did not improve with antibiotics therapy. Abdominal enhanced CT and MRI revealed to gallbladder cancer with liver invasion and metastases. These lesions were relatively localized in liver S4a/S5 and gallbladder, hepatoduodenal mesentery. Because unknown fever was exhausting, cholecystectomy, S4a+S5 hepatectomy with extrahepatic bile duct resection and lymph node dissemination were performed in January 20XX+1. In these pathological findings, there were moderate to poorly differentiated adenocarcinoma with squamous cell differentiation in almost area of gallbladder, diagnosed as adeno-squamous carcinoma with liver invasion and metastasis(pT3a[SI][H-inf], int, INF-β, ly1, v3, pn1, pN1, pM1, pStage ⅣB). One months after operation, abdominal CT revealed multiple liver metastatic recurrences. She died 7 months after operation. Although gallbladder adeno-squamous carcinoma has a poor prognosis, these many cases had a tendency to local infiltration accompanied with tumor fever. If curative resection might be obtained and the symptoms might be improved, aggressive resection should be performed.

We report a case of cholangiocellular carcinoma(CCC)with high-frequency microsatellite instability(MSI-H)in Lynch syndrome that was managed using a multimodal treatment approach including an immune checkpoint inhibitor. The patient was a 74-year-old man who presented with fever as the chief complaint. He had a history of Vater's papilla cancer and colorectal cancer in Lynch syndrome. A diagnosis of CCC in the left lobe of the liver was made, and left hepatectomy and left caudate lobectomy were performed. From about 2 years and 5 months after the operation, the patient developed several episodes of cholangitis, and recurrence of CCC was diagnosed based on the results of biliary cytology. Gemcitabine and cisplatin therapy was started, but exacerbation of bile duct stenosis associated with cancer progression was observed, and pembrolizumab, an immune checkpoint inhibitor, was started as the solid cancer had an MSI-H status. The tumor markers then improved and the cholangitis subsided. We experienced a case of recurrence of CCC with MSI-H in Lynch syndrome managed by multimodal treatment including an immune checkpoint inhibitor.

The patient was a 78-year-old man who underwent upper gastrointestinal endoscopy, revealing a sub-circumferential type 2 tumor in the lower body of the stomach. Histopathology revealed poorly differentiated adenocarcinoma. Computed tomography(CT)showed lymph node and liver metastasis(S6, S8), which corresponded to clinical Stage Ⅳ(cT4bcN2cM1 [HEP]). Five courses of XP therapy were administered for Stage Ⅳ disease. The sizes of the primary lesion and metastatic liver tumors were reduced, and a partial response was achieved. Distal gastrectomy and partial hepatectomy were performed. The resected specimen was diagnosed as ypT4b(transverse colon mesenteric), ypN0, ypM1(HEP). Thus, the final Stage was Ⅳ. During adjuvant chemotherapy with S-1, the para-aortic, left common iliac, and external peri-iliac lymph node metastases were detected by CT imaging 6 months after the operation. This prompted XP therapy resumption. The lymph node metastases worsened despite 2 additional XP courses. Progressive disease prompted the change in regimen to PTX plus RAM. After 7 courses, swollen lymph nodes were observed and CPT-11 was initiated. Since the disease continued to progress, nivolumab therapy was administered. The para-aortic, left common iliac, and external peri-iliac lymph nodes shrank after nivolumab initiation. The patient has responded well to nivolumab for more than 3 years without immunological adverse events.

We report the case of a patient who underwent additional surgical resection of a rectal neuroendocrine tumor(NET)G1 with a tumor diameter of 5 mm after endoscopic resection, and lymph node metastasis was observed. The patient was a 33- year-old woman. A lower gastrointestinal endoscopy was performed to examine the blood in the stool. A submucosal tumor of 5 mm in size was found in the rectum Ra, and endoscopic mucosal resection was performed. Pathological examination of the resected tissue revealed NET G1; HE staining revealed negative margins and no vascular invasion, but additional immunostaining revealed lymphatic invasion(Ly1a). Additional surgical resection was decided, and a laparoscopy-assisted low anterior resection D3 were performed. The surgical resection specimen showed no residual NET component in the rectum, but metastasis was found in one lymph node. The postoperative course of the patient has been uneventful, and the patient is currently undergoing without recurrence 6 months after the surgery. In the case of NET G1, it is important to search for detailed vascular invasion by immunostaining even in small lesions, and if vascular invasion is found, additional surgical resection should be considered.

Introduction: Laparoscopic surgery is a safe, minimally invasive, and effective approach in managing abdominal malignancies. Laparoscopic anatomical resection has been covered by insurance in Japan since 2016. Here, we have reported the short-term outcomes of gallbladder cancer in laparoscopic cholecystectomy, gallbladder bed resection, or S4a/S5 liver resection with lymph node dissection., Patients: Between May 2012 and December 2020, 28 patients underwent laparoscopic cholecystectomy for gallbladder cancer at Kansai Rosai Hospital. Two patients underwent laparoscopic choledochotomy with lymph node dissection, 6 patients underwent gallbladder bed resection, and 7 patients underwent S4a/S5 liver resection. The control group included 13 patients who received open surgery between July 2010 and November 2019. The patient age was 74.2 and 74.4 years, while the male to female ratio was 19/24 and 8/5 in the laparoscopic and open surgery groups, respectively. According to the Japanese Society of Hepato-Biliary-Pancreatic Surgery, the pathological stage was 0/Ⅰ/Ⅱ/Ⅲ A/ⅢB/ⅣA/ⅣB in 4/17/13/4/2/1/2 and 0/1/2/3/1/1/5 patients(p=0.0100)in the laparoscopic and open surgery groups, respectively. This study was approved by the Human Ethics Review Committee of Kansai Rosai Hospital(Certificate Number: 2101001)., Results: The laparoscopic surgery group had an average operation time of 223.3 minutes, an estimated blood loss of 18.7 g, and a hospital stay of 8.5 days. The open surgery group had an average operation time of 514.5 minutes, an estimated blood loss of 1,274.3 g, and a hospital stay of 33.9 days. There was no postoperative bleeding or bile leakage in both groups. After laparoscopic cholecystectomy, the 5-year disease-free survival rate was 100% among Stage 0 or Ⅰ patients, 64.8% among Stage Ⅱ patients, and 0% in Stage Ⅲ or Ⅳ patients. The 5-year overall survival rate was 100% among Stage 0 or Ⅰ patient and 66.7% among Stage Ⅱ patients. The 1-year overall survival rate was 50% among Stage Ⅲ or Ⅳ patients. After laparoscopic liver resection with lymph node dissection, the 5-year disease-free survival rate was 100% among Stage Ⅰ or Ⅱ patients and 66.7% among Stage Ⅲ or Ⅳ patients. The 5-year overall survival rate was 100% among Stage Ⅰ or Ⅱ patients and 62.5% among Stage Ⅲ or Ⅳ patients., Conclusion: Laparoscopic cholecystectomy in Stage 0 or Ⅰ patients and laparoscopic gallbladder bed resection or S4a/S5 liver resection with lymph node dissection were safe and effective approaches to gallbladder cancer management.

Cholangiolocellular carcinoma(CoCC)was first reported by Steiner et al in 1959. CoCC resembles cholangiocellular carcinoma( CCC)grossly and presents a variety of imaging findings, which often makes preoperative diagnosis difficult. In Japan, CoCC is rare, accounting for only 0.56% of primary liver cancers. We report the results of laparoscopic liver resection (LLR)for CoCC at our institution. Among 845 liver resections(678 LLR and 167 open liver resections)performed at Kansai Rosai Hospital from 2010 to 2020, only 13 were CoCC. Eight patients underwent LLR except for 5 patients who required vascular reconstruction and lymph node dissection. Median age was 71 years (55-77), gender was male/female(7/1), stage was Ⅰ/Ⅱ/Ⅲ/ⅣA(3/3/1/1), liver function was Child-Pugh A/B/C(7/1/0), and liver damage A/B/C(6/2/0). The preoperative diagnosis was 1 CoCC, 3 CCC and 4 HCC. The operative procedure was 3 Hr 0, 3 Hr 1 and 2 Hr 2. The operative time was 342 minutes(168-488), the blood loss was 51.3 g(0-400), and the postoperative hospital stay was 14 days(5- 53). The 5-year disease-free survival rate was 83.3%, and the 5-year overall survival rate was 85.7%. Recurrence was seen in 1 patient. The 5-year survival rate after curative resection of CoCC has been reported to be 73-83%, compared with 28- 36% for CCC. LLR for CoCC at our institution showed good perioperative results. Long-term results were comparable to those reported for liver resection. LLR for CoCC was considered an appropriate technique with good perioperative and long- term results.

The patient was a 56-year-old woman. who was aware of a tumor in her left axilla and consulted a nearby doctor. She was referred to our hospital for a detailed examination. No abnormalities were found in the breast by visual inspection, mammography, or breast ultrasound examination. One 29 mm swollen lymph node was found in the axilla. Fine needle aspiration cytology revealed malignant lymphoma; thus, so axillary lymph node excision biopsy was performed, and a diagnosis of axillary lymph node metastasis of breast cancer was made. However, no abnormalities were found. Based on the information presented above, the patient was diagnosed with occult breast cancer cT0N1M0, Stage ⅡA, and breast preservation plus axillary lymph node dissection up to level Ⅱ was performed. No metastases were found in the dissected lymph nodes. The treatment policy for occult breast cancer has not yet been established. We report this case with a review of the literature.

A woman in her 30s visited our hospital complaining primarily of melena. Colonoscopy revealed the presence of a type 1 tumor in 2 cm from anal verge. Contrast-enhanced CT showed an unresectable massive liver metastasis in the left lobe of the liver and another metastasis in the right lobe. The patient received front-line chemotherapy with Leucovorin, fluorouracil, oxaliplatin, and irinotecan(FOLFOXIRI)plus bevacizumab(BEV). A year later, a marked reduction of liver metastases and primary lesions was confirmed by CT scan imaging. A multidisciplinary team recommended resection of the liver metastases followed by laparoscopic intersphincteric resection for primary lesions. However, after 1 year, a recurrence was diagnosed in the liver; hence, FOLFOXIRI plus BEV was reintroduced for volume reduction. The patient underwent a repeat hepatectomy since enough volume reduction was confirmed. One year later, she experienced a re-relapse of the metastasis in the liver. Currently, she is still undergoing chemotherapy following 7 years since the first visit. Long-term survival can be expected following surgical treatment during chemotherapy.

Atezolizumab plus bevacizumab combination therapy is the first cancer immunotherapy that has shown efficacy in the treatment of hepatocellular carcinoma(HCC). We report a case of HCC with recurrent peritoneal dissemination for which atezolizumab plus bevacizumab combination therapy was effective. The patient, a 63-year-old man, underwent transarterial embolization(TAE)for ruptured HCC, and a mass with dissemination on the caudal side of liver S3 was observed. Laparoscopic lateral hepatic resection plus resection of the dissemination plus cholecystectomy was thus performed in September 2019. However, in November 2019, multiple peritoneal dissemination recurrence was observed, and lenvatinib therapy was initiated. In May 2020, PD was observed, and we had switched to sorafenib therapy. However, in October 2020, further tumor growth and rapid increase in tumor markers(AFP 25,668 ng/mL, PIVKA-Ⅱ 64,960 mAU/mL)were observed, and the patient was judged to have PD. Atezolizumab plus bevacizumab combination therapy was initiated in the same month. Subsequently, a CT scan in January 2021 showed a marked decrease in tumor size, indicating PR. The tumor markers have since normalized(AFP 5 ng/mL, PIVKA-Ⅱ 28 mAU/mL). The patient has been treated with atezolizumab plus bevacizumab combination therapy again and is maintaining PR as an outpatient.

We present a case of jejunal perforation just below the Treitz ligament treated with primary suture after administration of ramucirumab(RAM). The patient was a 74-year-old male. He was diagnosed with Stage Ⅳ sigmoid colon cancer with liver and lung metastasis. Laparoscopic sigmoid colon cancer resection was performed previously. As adjuvant chemotherapy, the patient received 3 courses of CapeOX plus bevacizumab(BEV)and 20 courses of FOLFOX plus BEV and was in PR. After operation for liver and lung metastases, the patient was observed without any treatment, but pelvic recurrence and lung metastasis were noted, and FOLFIRI plus RAM was started. On the 7th day after the second course, the patient experienced abdominal pain. Since an intestinal perforation was suspected, emergency surgery was performed on the same day. There was a 5-mm-diameter perforation in the jejunum just below the Treitz ligament, and were small ischemic changes near the perforation. The rest of the intestine was clear, the perforation was suspected due to RAM. Since anastomosis was difficult, we performed primary suture and decompression of the location. The postoperative course was uneventful, and the patient was discharged on POD 18. Currently, RAM has been discontinued and chemotherapy is being continued with FOLFIRI.

A 69-year-old female underwent a mesh repair for an abdominal incisional hernia 4 years previously in our hospital. She visited local hospital for abdominal pain and fever. Abdominal CT showed a localizes abscess formation above the mesh, then she was taken to our hospital. We suspected mesh infection and performed emergent mesh removal. After the operation, we examined for her anemia. Her colonoscopy and CT findings pointed to transverse colon cancer. We performed right hemicolectomy, and final diagnosis was transverse colon cancer pT4aN0M0, pStage Ⅱb. She underwent adjuvant chemotherapy, and 9 months after surgery, no recurrence was found.

A 50s year old woman was referred to former hospital for abdominal pain and melena. Colonoscopy revealed an ascending colon cancer(cT4aN1bM0, cStage Ⅲb, UICC)and gastrointestinal endoscopy revealed an esophagogastric junction cancer(cT1bN0M0, cStage ⅠA, UICC). Preoperative CT showed mild bilateral hydronephrosis. Laparoscopic right hemicolectomy( Lap-RHC, D3)was performed for ascending colon cancer then, and abdominal CT was taken 2 days before the robot-assisted proximal gastrectomy(RAPG, D1+). Right hydronephrosis was observed. No evidence of obvious ureteral damage was found during Lap-RHC. When retrograde pelvic ureterography was performed and a stenosis was found at the right renal pelvis and ureteral junction. It is considered that the ureter stenosis became prominent due to the postoperative inflammatory change of Lap-RHC. RAPG was performed as scheduled. Two months after discharge, a renal fistula was constructed. Pyeloplasty is scheduled to be performed in the future.

A 62-year-old man was referred to our hospital with complaints of upper abdominal pain and weight loss while being treated for diabetes mellitus at his family doctor. He was diagnosed as locally advanced unresectable pancreatic adenocarcinoma that involved superior mesenteric artery(SMA). Gemcitabine(GEM)and S-1 combined chemoradiotherapy(CRT) was administered. After CRT, CT test showed improved involvement of SMA, and radical resection was possible. We performed the radical pancreaticoduodenectomy and adjuvant chemotherapy, and he has been followed up for more than 5 years after the operation without recurrence. For locally advanced unresectable pancreatic adenocarcinoma, CRT or chemotherapy is recommended in the Pancreatic Cancer Practice Guidelines(2019 edition). However, the prognosis is extremely poor. We report a case of locally advanced unresectable pancreatic adenocarcinoma that was successfully curatively resected due to the good response of CRT.

The patient is an 85-year-old female who had previously undergone a mastectomy for right breast cancer at the age of 42 years. In September 2020, she visited our hospital with a chief complaint of a chest wall tumor. Physical examination revealed a 3×3 cm ulcerative lesion on the right side of the center chest wall. She underwent a skin biopsy of the tumor under local anesthesia and was diagnosed with a recurrence of right breast cancer(ER positive, PR positive, HER2 negative). PET-CT revealed localized skin thickening on the right side of the sternum and FDG accumulation in the same area, with no other findings suggestive of distant metastasis. Treatment was started with anastrozole and is still ongoing. In this article, we report a very rare case of recurrence 43 years after surgery.

Advances and improvements in cancer diagnosis and treatment have made it possible to find multiple primary cancers. We report here a rare case of metachronous quintuple cancer involving the stomach, rectum, colon, liver and prostate. An 80s‒ year‒old male was referred to our hospital with abnormality on upper GI series. He had undergone a distal gastrectomy in May 2005. Postoperative diagnosis was advanced gastric cancer (pT2N1M0, pStage ⅡA). In August 2006, anterior resection was performed with a diagnosis of advanced rectal cancer(pT3N0M0, pStage Ⅱa). For ascending colon polyps, endoscopic submucosal dissection was performed with a diagnosis of adenocarcinoma in adenoma(pTisN0M0, pStage 0)in September 2007. In June 2016, laparoscopic ileocecal resection was performed with a diagnosis of advanced cecum cancer(pT3N0M0, pStage Ⅱa). Follow up CT images showed a liver tumor in S4. Partial liver resection was performed in October 2010. Postoperative pathological diagnosis was hepatocellular carcinoma(pT2N0M0, pStage Ⅱ). Prostate cancer(cT2aN0M0)was treated by androgen deprivation therapy from February 2018. Although he had high‒frequency microsatellite instability, germline mutations in hMLH1 and hMSH2 genes were not detected. Histopathological examination showed that each tumor was an independent tumor and had not metastasized from any others. The patient had a good clinical course after these treatment until now.

Pancreatic neuroendocrine tumor(p-NET)is a relatively rare disease, and treatment is multidisciplinary with resection, local therapy, radiotherapy, and chemotherapy. We report on a case in which long-term survival was achieved by multidisciplinary treatment. The case is a 47-year-old male. He was referred to our hospital because of the diagnosis of pancreatic tail tumor and underwent distal pancreatectomy in May 2008. And he was diagnosed as p-NET G1 by the pathological results. After 3 TACE treatments and 1 partial liver resection for recurrent liver metastasis, multiple liver metastases and lymph node metastases were found in August 2014. As a result of the everolimus treatment, the determination of efficacy to lymph nodes was CR and liver lesions were CR with the addition of TACE treatment. In July 2017, he had multiple liver metastases and right humeral metastases, and has been treated with radiotherapy for bone metastases and has maintained CR. After TACE in November 2017, he received 9 rounds of lanreotide treatment. In December 2018, he again had liver metastases and lymph node recurrence. He has been treated with everolimus treatment again and is maintaining SD in outpatient treatment.

Five patients with gastric metastasis from breast cancer were treated in our hospital. About the histopathological types of primary breast cancer, 4 patients were invasive ductal carcinomas and 1 was invasive lobular carcinoma. One patient was found by gastrointestinal fiberscopy for a detailed examination of her high CEA, 2 for stenosis, 1 for bleeding and 1 for epigastralgia. After the diagnosis of gastric metastasis, 2 patients were treated with chemotherapies, 1 with hormone therapy and 2 with palliative treatments. One of them was treated with gastroduodenal stenting for pyloric stenosis, but she was died by bleeding from gastric lesion. Based on the results, constriction and bleeding with gastric metastasis is considered to be severe condition in the treatment of metastatic breast cancer.

A 80s year old man was referred to our hospital with melena. Colonoscopy revealed an elevated lesion in the sigmoid colon. Laparoscopic sigmoidectomy(D2)was performed in August 2011. Postoperative diagnosis was advanced sigmoid colon cancer(pT2N1M0 and pStage Ⅲa, UICC). In January 2015, He suffered from epigastric discomfort after meals. Gastrointestinal endoscopy revealed advanced gastric cancer and superficial esophageal cancer. For esophageal cancer, endoscopic submucosal dissection was performed with a diagnosis of cStage 0-Ⅱa(UICC). Laparoscopic distal gastrectomy with Billroth Ⅰ reconstruction was performed for gastric cancer with a diagnosis of pT1bN0M0 and pStage ⅠA(UICC). Follow up CT and MRI images in October 2016 showed a liver tumor in S4/S5. Laparoscopic partial liver resection was performed. Postoperative pathological diagnosis was hepatocellular carcinoma pT1N0M0, pStage Ⅰ(UICC). We finished following up period of the sigmoid colon cancer. Gastric cancer and esophageal cancer are followed up by gastrointestinal endoscopy once a year. Hepatocellular carcinoma is followed up every 3 months. He has no recurrence until now.

A 90s woman was diagnosed as having cT4aN2M0, cStage ⅢA, advanced gastric cancer. As she was severely malnourished owing to pyloric stenosis, a peripherally inserted central catheter (PICC)was placed in her left arm, and total parenteral nutrition(TPN)was initiated. She complained of dyspnea, and radiography revealed right pleural effusion on day 4 of TPN. Contrast computed tomography revealed that the tip of the catheter had perforated the vessel wall of the superior vena cava and had migrated into the mediastinal space. After thoracocentesis, the catheter was removed under fluoroscopic guidance after hemostasis was achieved. Thus, the possibility of catheter deviation should be considered in case of dyspnea and pleural effusion during TPN.

The patient was a 77-year-old woman. She underwent a partial gastrectomy at the age of 40, and a partial colectomy at the age of 75 following a diagnosis of a carcinoid. In November 2019, a 1.5 cm mass with a clear boundary was found in the pancreatic tail, which was strongly stained uniformly. And furthermore, multiple masses between 2 cm and 3 cm with a clear boundary was found inside liver segment S1 and S6 and S7 and S8 on CT, which was strongly stained at the edge in the early phase and was seen as a low density area in the late phase. At a result of image examination, it was diagnosed as a pancreatic tail neuroendocrine tumor and its multiple liver metastases. The distal pancreatectomy, posterior segmentectomy, and partial S1 lt and S8 liver resection were performed. With postoperative pathological diagnosis, the pancreatic tumor was accessory spleen, and liver tumor were epithelioid type GIST which were positive for CD34 and PDGFRA and negative for c- kit. The pathology specimen of colectomy was re-examined, and the diagnosis from the previous surgery was changed to GIST from a carcinoid. Epithelioid type GIST was associated with a PDGFRA gene mutation and was known to have many gastric origins. Based on the clinical course, it was diagnosed as recurrence of gastric GIST at 40 years after 30 years or more.

We present a case of locally advanced rectal cancer(LARC)treated by robot assisted intersphincteric resection(ISR)and lateral lymph node dissection(LLND)after neoadjuvant chemotherapy(NAC). The patient was a 69-year-old female with the diagnosis of adenocarcinoma of the rectum Rb. The clinical stage diagnosis was cT3N0M0, cStage Ⅱ. NAC with FOLFOXIRI(5-fluorouracil/oxaliplatin/leucovorin/irinotecan)plus bevacizumab(BEV)was inisiated as NAC. Tumor volume reduction of primary lesion was evaluated by CT scan and colonoscopy after 6 courses of FOLFOXIRI plus BEV including omit of BEV on last course and were judged as partial response(PR)and no distant metastasis. With maintenance of tolerability for surgery even after NAC, robot assisted ISR and LLND were safely performed with curative resection. The histopathological treatment effect of post NAC was diagnosed as Grade 1b and the final pathological stage was ypT3pN0cM0, ypStage ⅡA. We experienced a case of LARC was performed FOLFOXIRI plus BEV as NAC followed by robotic ISR and LLND with anal preservation.