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An 86-year-old male underwent pancreatoduodenectomy with resection and reconstruction of portal vein for pancreatic cancer. He was admitted to our hospital because of severe anemia and dyspnea ten months later. Computed tomography showed varices at the biliary-enteric anastomosis in the elevated jejunum caused by portal venous stenosis, which was suspected as the cause of anemia. Therefore, the patient underwent balloon dilatation of the portal vein followed by stent placement and coil embolization of the collaterals using a transileocolic portal vein approach. After the procedure, portal venous flow was improved, and the collaterals disappeared. The patient has been asymptomatic with no recurrence for three years and four months.

A 72-year-old man with general fatigue was referred, and CT and MRI revealed a pancreatic mass with necrosis that was suspected of invading the stomach, splenic artery, celiac artery, liver, and portal vein. Upper gastrointestinal endoscopy showed an extrinsic mass with ulcer formation in the posterior wall of the upper gastric corpus and irregular mucosa in the lower esophagus incidentally. Biopsy showed squamous cell carcinoma from both lesions, leading to the diagnosis of pancreatic adenosquamous carcinoma and early esophageal cancer. We performed distal pancreatectomy with splenectomy, total gastrectomy, partial hepatectomy, superior mesenteric-portal vein resection, and reconstruction. The pathological results revealed pancreatic adenosquamous carcinoma and infiltration of cancer cells at the dissected peripancreatic margin. Therefore, we administered radiotherapy(50.4 Gy to the retroperitoneal region)in postoperative month 2. Endoscopic mucosal resection was performed for the early stage esophageal cancer lesion in postoperative month 5. Three courses of S-1 were administered as adjuvant therapy since postoperative month 7, and he is currently alive without recurrence 1 year and 8 months after surgery. Multidisciplinary treatment can be effective for locally advanced pancreatic adenosquamous carcinoma.

Double cancer of intrahepatic cholangiocarcinoma and gastric cancer is rare. A 62-year-old man underwent gastrectomy for gastric cancer. The pathological findings were tub1tub2, m, ly0, v0, n0, Stage I A. Two years and a month later, a liver tumor(diameter of 3 cm)and a pelvic mass(diameter of 2.5 cm)were observed. Metastasis from gastric cancer was suspected and chemotherapy(SOX)was administered. However, after 5 courses, CT revealed worseningof the liver tumor (diameter of 12 cm)and pelvic mass(diameter of 3 cm). Intrahepatic cholangiocarcinoma and its peritoneal metastasis were also suspected. There was a limit to treatment with chemotherapy, and it was difficult to judge whether to target gastric cancer or intrahepatic cholangiocarcinoma for chemotherapy. In addition, the lesions were localized in the right lobe of the liver and the pelvis. Therefore, we decided to perform resection. As a second-stage operation, pelvic mass extraction and portal vein embolization were performed first. The pathological result of the pelvic mass assessment was mucinous carcinoma. Subsequently, expansive right hepatectomy was performed. The pathological findings were also suggestive of mucinous carcinoma, which was finally diagnosed as intrahepatic cholangiocarcinoma and peritoneal dissemination. Six months after the surgery, several recurrent nodules were observed in the pelvis and GEM plus CDDP was initiated. Currently, 1 year after surgery, there are no restrictions in the activities of daily life of the patient and he is treated on an outpatient basis.

In the treatment of hepatocellular carcinoma, atypical, off guideline multidisciplinary approaches are sometimes effective. A 70-year-old man was diagnosed with multiple hepatocellular carcinomas, multiple bone metastases, and a right adrenal metastasis. Sunitinib was started and the primary hepatic lesions and bone metastases disappeared. However, his adrenal metastasis worsened. Sorafenib, radiotherapy, and some investigational agents were administered, but the adrenal metastasis did not respond. There were no other new lesions except the adrenal lesion 4 years after the initial treatment, so we decided to perform a resection. In the left half lateral decubitus position, the adrenal mass was removed with right thoracolaparotomy. After the surgery, his tumor markers quickly returned to normal. Seven years after the initial treatment(2 years and 4 months after the last surgery), he is alive without any recurrence. Multidisciplinary treatment with chemotherapy, radiotherapy, and surgery may result in long term survival even for patients with advanced hepatocellular carcinoma with multiple extra-hepatic lesions.

A 67-year-old man with elevated hepatobiliary enzymes was referred to our hospital for further examination. Computed tomography indicated hilar cholangiocarcinoma of Bismuth type Ⅳ and revealed invasion of the right hepatic artery and the left portal vein. We diagnosed locally advanced unresectable hilar cholangiocarcinoma, and performed 5 courses of chemotherapy with gemcitabine plus S-1. After chemotherapy, the tumor was significantly reduced in size and vascular invasions were alleviated, so we decided to perform surgical resection. An extended left hepatectomy with caudate lobe and extrahepatic bile duct resection was performed. Although the intraoperative pathological examination was positive for cancer at the hepatic margins, we did not perform further bile duct resection because of the difficulty. After the surgery, we administered adjuvant chemotherapy with gemcitabine for 5 courses. Another 8 courses of gemcitabine plus S-1 therapy were given because of elevation of CA19-9. The tumor marker levels normalized, and the patient is still alive without findings of recurrence 4 years after the first treatment. Multidisciplinary treatment with chemotherapy and surgery may suggest the possibility of increasing long term survival even for patients with locally advanced unresectable cholangiocarcinoma.

症例は64歳，女性．皮膚掻痒感，全身倦怠感を主訴に当院初診となった．T. Bil 15.1と高度の黄疸があり，腹部CT検査で肝内胆管の拡張と肝S4に8cm大の嚢胞を認めた．ERCP，PTCD造影では左右肝管から総胆管にかけてなだらかな圧排，狭窄像があり，血清CA19-9は20,600U/mlと著明な上昇を示したが，画像所見から良性の単純性肝嚢胞と診断した。嚢胞を穿刺しドレナージ後に，塩酸ミノサイクリンの注入療法を行ったところ，嚢胞は縮小し，黄疸も改善した．特に合併症や副作用はなく退院し，現在外来で経過観察中である．良性非寄生虫性巨大肝嚢胞が原因で閉塞性黄疸を呈することは極めて稀であり，今回われわれは，巨大肝嚢胞による閉塞性黄疸に対して，塩酸ミノサイクリンを注入し良好な結果を得た1例を経験したので報告する．

症例は42歳，男性．検診で肝機能障害を指摘され，当院を紹介受診し，腹部CT検査と腹部超音波検査で肝内側区域に腫瘤性病変を認め，精査加療目的で入院とした．腹部MRI検査で左肝内胆管の閉塞と右前後区域の分岐部にも胆管壁の不整像があり，腹部血管造影検査では左門脈枝の完全閉塞と門脈本管の左右分岐部付近での狭窄を認めた．以上より切除不能胆管癌と診断し，減黄後にGemcitabine 400mg/body/week投与と放射線照射（50.4Gy）を施行した．3カ月後の腹部MRI検査で腫瘤は縮小し，6カ月後には腫瘤を指摘できなかった．その後，治療開始から9カ月目に溶血性尿毒症症候群（以下HUS）を発症し，血漿交換などを施行したが2カ月後に死亡した．切除不能胆管癌は予後不良であり，今回われわれは化学放射線が奏効した後にGemcitabineによると思われる溶血性尿毒症症候群をきたした1例を経験したので，文献的考察を加えて報告する．

An intramural pseudocyst in the alimentary tract develops as a rare complication of acute pancreatitis or trauma. A 60-year-old woman with pancreatic head cancer underwent preoperative radiological examinations, which revealed a 45-mm cystic mass around the second portion of the duodenum. Endoscopic ultrasonography confirmed a cystic lesion in the submucosal layer of the duodenum and fine needle aspiration cytology of the cystic contents suggested adenocarcinoma. The cystic fluid was amylase-rich, at 17040 U/l. We performed pancreaticoduodenectomy for the pancreatic head cancer. Pancreatography of the resected specimen showed a communication between the main pancreatic duct and the cystic lesion. The cut surface of the resected specimen revealed a cystic lesion, which surrounded the duodenum. Pathologically, the cystic lesion was diagnosed as a pseudocyst, located between the dissociated smooth muscle layers of the duodenum.