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The prognosis of patients with intrahepatic cholangiocarcinoma (ICC) is still poor, and the 5-year survival rate in patients undergoing radical surgery (R0) is less than one-third. Since the prognosis depends mainly on tumor factors, so early diagnosis is necessary. To extend the survival time of these patients with a poor prognosis, cases of long-term survival were examined based on the results of our experiences and the literature. It was found that the hepatitis virus was highly involved in the carcinogenesis of ICC, and patients who were infected with hepatitis virus had rather good survival. J. Med. Invest. 68 : 15-21, February, 2021.

Background Panitumumab is the first human combinatorial antibody for the treatment of metastatic colorectal carcinoma. Dermatologic toxicity of all grades occurs in more than 90% of patients. However, there are few reports of purpura induced by anti-epidermal growth factor receptor antibody. Renal failure is also uncommon as an adverse event of anti-epidermal growth factor receptor antibody. Case presentation A 67-year-old Japanese man with advanced colon cancer received monotherapy with panitumumab. General malaise, bilateral edema of his legs, and bilateral purpura of his forearms developed 2 days after the second cycle of panitumumab. A skin biopsy was performed to evaluate the purpuric lesions on his left leg and leukocytoclastic vasculitis was diagnosed. Blood tests showed grade III acute renal failure with a blood urea nitrogen level of 33.8 mg/dL and a creatinine level of 3.10 mg/dL. Conclusions This is the first reported case of leukocytoclastic vasculitis followed by purpura and acute renal failure associated with panitumumab.

Background IgG4-related disease (IgG4-RD) is a pathological condition that is characterized by an infiltrate composed of IgG4-positive plasma cells and recently recognized as an immune-mediated condition. It causes tissue throughout the body to become stiff and thickened due to autoimmune reactions that cause fibrosis and scarring. Disease-related changes commonly occur in the salivary glands, bile duct, pancreas, and lungs, but are seldom seen in the small bowel. A diagnosis of IgG4-RD is suspected if a high level of IgG4 is found on a blood test. The ideal diagnostic method is pathological examination, but because the clinical manifestations of IgG4-RD are very diverse and nonspecific, the disease may often go undiagnosed until an unrelated biopsy or resection specimen is obtained. The most common treatment for IgG4-RD is steroid use. However, tapering or stopping steroid administration is seen to result in recurrence in approximately 50% of cases. A complete cure is therefore considered extremely difficult. Case presentation A 69-year-old man with gastrointestinal obstruction underwent small bowel resection for two lesions. On histopathological examination, the specimen showed features of IgG4-RD. We performed several tests to detect other characteristics of IgG4-RD, but were unable to find any. The patient is being followed up regularly for a year and is being observed for any symptoms of recurrence. Conclusions We present a case of IgG4-RD wherein the ileum wall was significantly sclerosed, leading to gastrointestinal tract obstruction; therefore, we resected two sections of the ileum. We believe that resection of IgG4-RD lesions can help avoid long-term steroid use in patients, because the surgery completely eliminates the pathological origins of the condition.

A number of previous studies have reported that 30-50% of patients with colorectal cancer (CRC) harbor Kirsten rat sarcoma viral oncogene homolog (KRAS) mutations, which is a major predictive biomarker of resistance to epidermal growth factor (EGFR)-targeted therapy. Treatment with an anti-EGFR inhibitor is recommended for patients with KRAS wild-type metastatic colorectal cancer (mCRC). A recent retrospective study of cetuximab reported that patients with KRAS p.G13D mutations had better outcomes compared with those with other mutations. The aim of this retrospective study was to assess the prevalence of KRAS p.G13D mutations and evaluate the effectiveness of cetuximab in mCRC patients with KRAS p.G13D or other KRAS mutations. We reviewed the clinical records of 98 mCRC patients with KRAS mutations who were treated between August, 2004 and January, 2011 in four hospitals located in Tokyo and Kyushu Island. We also investigated KRAS mutation subtypes and patient characteristics. In the patients who received cetuximab, univariate and multivariate analyses were performed to assess the effect of KRAS p.G13D mutations on progression-free survival (PFS) and overall survival (OS). Of the 98 patients, 23 (23.5%) had KRAS p.G13D-mutated tumors, whereas 75 (76.5%) had tumors harboring other mutations. Of the 31 patients who received cetuximab, 9 (29.0%) had KRAS p.G13D mutations and 22 (71.0%) had other mutations. There were no significant differences in age, gender, primary site, pathological type, history of chemotherapy, or the combined use of irinotecan between either of the patient subgroups. The univariate analysis revealed no significant difference in PFS or OS between the patients with KRAS p.G13D mutations and those with other mutations (median PFS, 4.5 vs. 2.8 months, respectively; P=0.65; and median OS, 15.3 vs. 8.9 months, respectively; P=0.51). However, the multivariate analysis revealed a trend toward better PFS among patients harboring p.G13D mutations (PFS: HR=0.29; 95% CI: 0.08-1.10; P=0.07; OS: HR=0.23; 95% CI: 0.04-1.54; P=0.13). In conclusion, treatment with cetuximab may be more clinically beneficial in mCRC patients with a KRAS p.G13D mutation, compared with those harboring other mutations. However, further investigation is required to clearly determine the benefits of cetuximab treatment in patients with KRAS p.G13D mutation-positive mCRC.

We describe a case of chylous ascites with strangulated ileus, and review all 22 cases (including our case) of chylous ascites with strangulated ileus reported in the English and Japanese literature. The patient we describe was a 51-year-old woman with medical history of radiotherapy for cervical cancer of the uterus 15 months prior to being admitted to our hospital with abdominal pain after consuming a meal. A computed tomography (CT) scan revealed ascites, expansion of the small intestine, and whirl sign. Laparotomy revealed chylous ascites with an incarcerated internal hernia of the small intestine, which was released without intestinal resection. In our case the postoperative phase was uneventful, and as in the other 21 literature cases reviewed, treatment by either detorsion, release of the incarcerated internal hernia, or incision of the adhesion band without intestinal resection resulted in rapid improvement in the color of the intestine. It is considered that minimally invasive laparoscopic laparotomy should be selected as the treatment of first choice, because the degree of strangulation is slight in cases where chylous ascites is associated with strangulated ileus.

Purposes : Pancreatoduodenectomy (PD) was performed for 6 periampullary cancer patients by using methods verified by quality randomized controlled trials (RCT) in a low-volume center (LVC). The purpose of this study was to verify the clinical results. Methods : No-touch pylorus-resecting pancreatoduodenectomy (PrPD), antecolic gastrojejunostomy, pancreatico-jejunostomy with a lost stent tube to the main pancreatic duct, and early removal of a prophylactic drain were performed. Results : The drain could be removed 4 days after opera- tion, and no pancreatic fistula was observed in all cases. Solid food could be started on POD4 after removing the drain. Furthermore, postoperative systemic chemotherapy could be started earlier. Conclusion : Although we have only a few PD cases a year in our institution, PD can be conducted safely without complications by using the methods verified by quality RCTs. J. Med. Invest. 62 : 188-194, August, 2015

Purposes : The purpose of this study was to verify the outcome of the emergency one stage resection and anastomosis procedure for patients with obstructed colorectal cancer. Methods : An emergency one stage resection and anastomosis procedure was performed for 40 patients with obstructive colorectal cancer. The outcome was verified and compared dividing into two groups. 17 patients under the age of 70 in (Group A), 23 patients 70 years and over in (Group B). Results : The operative mortality rate in both groups was 0%. As a result, postoperative complications were not significantly different between the two groups. The overall survival rate after a 5-year period in both groups was 41.8%, regarding all patients and the survival curves for the two groups, was not significantly different. The 5 year survival rate in stage II or III showed no differences between the two groups. Conclusion : The one-stage resection and anastomosis of the large bowel could be applied safely to emergency patients, which in turn allows for excellent shortterm operative results in both groups mentioned. This particular procedure should be positively enforced, even in elderly patients in their 70’s.

A 74-year-old male with abdominal pain was admitted to the emergency room in our hospital. The high value of serum amylase was shown in his blood test. The postcontrast computed tomography (CT) showed the huge retroperitoneal tumor with a thinwalled mass occupying most of the part of the right retroperitoneal space. The tumor spread into the soft tissues around the pancreas ; as a result, the duodenum was compressed and the pancreas was displaced to the right side. The irregular pancreatic outline, obliterated peripancreatic fatty tissue and fluid in the left anterior pararenal space were revealed, so acute pancreatitis was diagnosed. The diagnostic biopsy of retroperitoneal tumor was done, and the pathological findings of retroperitoneal mass revealed dedifferentiated liposarcoma. The medical treatment against acute pancreatitis was performed firstly. After the patient recovered from that, the surgical resection of the tumor with the right kidney and right adrenal gland was completed successfully. The patient remained well, without any evidence of recurrence three months after surgery. However, the histology showed dedifferentiated liposarcoma ; therefore, postoperative regular examination is necessary.

症例は55歳，女性．1999年9月に直腸癌（RS-S，type 2，5.5×4.0cm大，ss，n4+（19/49），stage IV）に対して低位前方切除術を実施した．UFT 600mg/日内服にて経過観察中，術後2年4カ月のCT検査で大動脈分岐部左に3cm大の腫大リンパ節を指摘された．CEA値も19ng/ml と高値で，大動脈周囲リンパ節再発と診断した．他部位に再発の所見なく，左尿管の一部を付けて再発腫瘍を切除した．切除標本の病理学的検索ではadenocarcinoma，metastaticの診断であった．術後放射線治療（50Gy）を追加し，5'-DFUR 600mg/日+Krestin内服を5年間行った．再手術後9年の現在，再発の徴候なく健在である．再発大腸癌に対する化学療法の治療成績は著明に改善されているが，それのみで治癒を得るには至っていない．孤立性の大動脈周囲リンパ節再発は切除により治癒の可能性もあり，切除の適応についても考慮すべきである．

横行結腸原発mucosa-associated lymphoid tissue(以下MALT）リンパ腫に対する腹腔鏡下手術の1例を報告する.大腸MALTリンパ腫はまれな疾患であり,治療法が確立されていないが,外科的治療が選択されることが多い.そのなかで,腹腔鏡下手術の報告例は,検索した限りでは自験例を含めて5例のみであった.症例は64歳男性.主訴は便潜血反応陽性精査.大腸内視鏡検査にて,横行結腸に粘膜下腫瘍様の腫瘤の集簇を認めた.生検にてMALTリンパ腫を疑い,腹腔鏡補助下横行結腸部分切除術を施行した.病理組織学的検索では小型から中型の異型リンパ球の増殖を認めた.免疫染色にてCD79a陽性，CD20陽性,bcl-2陽性でMALTリンパ腫と診断.術後15カ月現在再発兆候を認めていない.