We report a rare case of primary carcinoma of the duodenal bulb, diagnosed 23 years after total gastrectomy with Roux-en-Y reconstruction. A 57-year-old woman with Gardner’s syndrome had undergone a total colectomy 26 years previously, followed by a total gastrectomy for a huge desmoid tumor 23 years previously. She was referred to our hospital because of an abdominal tumor. On physical examination, a hard elastic mass was palpable in the epigastric region of the abdomen. Computed tomography revealed a mass near the duodenal bulb, with invasion to the abdominal wall, liver, common bile duct, and pancreas. A percutaneous needle biopsy of the tumor showed adenocarcinoma. Surgery was performed under a diagnosis of primary carcinoma of the duodenum bulb. On intraoperative examination, the primary carcinoma was found to invade the abdominal wall, liver, common bile duct, and pancreas. The tumor and its invasive lesions were resected. Eight months after the operation, the patient received anticancer drugs because of liver metastasis.

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We report a rare case of hepatocellular carcinoma (HCC) originating from a healed pyogenic liver abscess. A 75-year-old man was treated with antibiotic therapy for multiple abscesses in the posterior and lateral hepatic segments caused by Klebsiella infection. Abscesses disappeared 10 months later, and regular follow-up was interrupted. Two years later, a 6-cm liver tumorwas found at the same site of lateral segment liver abscess by CT scan. The tumor was thick with an irregular capsule and septums, and was diagnosed from radiological findings and elevated serum alpha-fetoprotein as combined hepatocellular and cholangiocarcinoma, necessitating the left hepatectomy with hilar lymphnode dissection. Histopathologically, the confluent multinodular HCC had no aspects of cholangiocarcinoma. The scarred tissue, presumably from the healed liver abscess was found inside the tumor. HCCs are sometimes associated with liver abscesses, but HCCs arising from a previous liver abscess are rare. Regular stringent checkups with diagnostic imaging are required following ideopathic liver abscess treatment.

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A 79-year-old woman with jaundice was referred to our hospital for further examination and possible surgery. Abdominal ultrasonography, computed tomography, and endoscopic retrograde cholangiopancreatography showed an extrahepatic bile duct cancer with a portal vein tumor thrombus. Subtotal stomach-preserving pancreaticoduodenectomy with the extraction of a portal vein tumor thrombus by portal vein resection and reconstruction was performed. Histopathologically, the bile duct tumor consisted of adenocarcinoma and squamous cell carcinoma components, indicating adenosquamous carcinoma. Moreover, carcinoma in situ was found in the pancreas head. Therefore, the final diagnosis was synchronous double cancer of the bile duct and pancreas. The patient had multiple liver metastases and lymph node metastases two months after surgery, and died four months after surgery.

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We report 3 resected cases of pancreatic cancer after neoadjuvant chemoradiation therapy (NACRT). All cases were diagnosed as borderline resectable disease with vascular involvement according to the NCCN guidelines. Preoperative imaging after NACRT showed partial response or stable disease in primary tumor size, and no changes in the site of vascular involvement. Negative margin statuses were confirmed intraoperatively, and subtotal stomach-preserving pancreatoduodenectomy with resection of the superior mesenteric vein was performed in all 3 cases. Histopathological examination revealed that more than 60 percent of the tumor cells had disappeared, and there were discrepancies between the preoperative imaging and histopathological findings. NACRT is promising for pancreatic cancer, and we believe surgical exploration is necessary because radiographic findings are less accurate after NACRT.

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A 49-year-old man was admitted to our hospital because of left lower abdominal pain. On admission, he was febrile and had mild rebound tenderness in the left lower abdomen. Laboratory data showed leukocytosis and high values of serum CRP. Computed tomography (CT) scans of the abdomen after administration of contrast material showed an air-containing mass. The mass consisted of two elements; one had a thick wall and the other had no wall. We diagnosed this lesion as mesenteric abscess caused by penetration of the jejunal diverticulum. Immediate resection revealed an inflammatory mass in the jejunal mesentery located about 70 cm distal from the ligament of Treitz. The resected specimen contained a penetrating diverticulum, forming an abscess. Preoperative CT images corresponded well with pathologic findings. Similar cases have rarely been reported and preoperative diagnosis of penetrating jejunal diverticulum is usually difficult.

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An 83-year-old man, who had previously undergone an appendectomy, was seen at our hospital because of a positive reaction on fecal occult blood test. Colonoscopy and a barium enema showed a 30 mm pedunculated mass on the ileocecal valve. The biopsy showed no signs of malignancy. We diagnosed the lesion as lipohyperplasia and the patient was observed regularly in the outpatient clinic, but the patient developed a positive reaction on fecal occult blood test, loose stool and mild pain in the right lower abdomen 6 months later. Computed tomography (CT) examination revealed a fat density mass in the ascending colon and multiple diverticula of the terminal ileum. Operation was performed under the diagnosis of lipohyperplasia of the ileocecal valve and chronic diverticulitis of the terminal ileum. Because the mobilization of ileocecal part was difficult due to the strong adhesion between the ileum end and retroperitoneum, we transfered from laparoscopic assisted surgery to open surgery and performed an ileocecal resection. Histological findings of the specimen revealed multiple diverticulitis of the terminal ileum and ascending colon. Therefore, we believe that the multiple diverticula was formed by the increased internal pressure of the terminal ileum due to mechanical obstruction by lipohyperplasia of the ileocecal valve.

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We report an unusual case of a 55-year-old man who had cecal cancer with prostatic and testicular metastases. Right hemicolectomy was performed under the diagnosis of cecal cancer in August 2003. The pathological findings showed mucinous adenocarcinoma, se, n2, ly3, v2, Stage IIIB. Because of urination difficulty since about January 2006, prostate biopsy was performed in December 2006. Histological examination showed metastatic mucinous adenocarcinoma from cecal cancer. Pelvic exenteration was performed in November 2007 because no metastatic site was found apart from the prostate. In December 2010, enlargement of the right scrotum was noted. CT and PET-CT revealed a right testicular tumor which was suspected to be metastasis from cecal cancer. After Right orchiectomy pathological examination showed testicular metastasis from cecal cancer. Among patients with colorectal cancer, the most frequent metastatic sites are the liver, lung and bone, and prostatic or testicular metastases are rare. Because surgical resection of those metastatic sites is not only helpful in confirming the diagnosis but might also improve prognosis and QOL, it is considered one therapeutic option.

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A 65-year-old woman presented with dull pain in her lower right abdomen. CT examination revealed intussusception in the ileocecal region and emergency surgery was performed. Intussusception extending to the center of the transverse colon was found, and manual repositioning revealed a tumor in the cecum. A diagnosis of cecum cancer with lymph node metastasis was made, and right hemicolectomy with D3 lymphadenectomy was performed. The resected specimen showed a type 2 4.5 by 3.8 cm tumor in the cecum. On histological examination, desmin, S-100 and CD34 were negative and c-kit was strongly positive. A diagnosis of cecal gastrointestinal stromal tumor (GIST) with lymph node metastasis was made. Treatment with imatinib was started 8 weeks after the operation, but CT performed one month later showed multiple hepatic metastases and celiac lymph node metastasis. Treatment was changed to sunitinib and some improvement was seen, but the patient died 5 months and 2 weeks after surgery. Cecal GIST with lymph node metastasis is very rare and no cases have so far been reported in Japan.

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Endocrine cell carcinoma (ECC) of the rectum is a relatively rare neoplasm with a poor prognosis. The mechanisms of its development and progression remain unclear, and there is no established remedy. We reported a long surviving case of early ECC of the rectum with lymph node involvement. A 57-year-old man with melena was found to have rectal cancer by endoscopy. The tumor was biopsied and diagnosed immunohistochemically as ECC. He underwent low anterior resection with lymph node dissection on October, 2003. Histopathologically, the tumor was composed of fascicular proliferation cells invading the submucosal layer and had lymph node metastasis. Moreover, the tumor cells were immunohistochemically positive for both NCAM and synaptophysin, confirming the diagnosis of ECC. Well differentiated adenocarcinoma (WDA) and tubulovillous adenoma (TVA) coexisted with ECC in the tumor. p53 staining was positive in TVA, WDA and ECC. The MIB-1 index of ECC was higher than those of TVA and WDA. He was discharged on postoperative day 24. He underwent adjuvant chemotherapy with UFT/LV and 5-DFUR. He is alive without recurrence, 8 years and 7 months since surgery. This case suggests that ECC has a high potential of lymph node metastasis and that colectomy with lymphadenectomy is essential to long-term survival even in early cancer. The morphological appearances in this case provide some information on the pathogenesis of ECC.

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Adult Bochdalek’s hernia and superior mesenteric artery syndrome are both rare diseases. A 73-year-old man was admitted to our hospital because of abdominal distention and nausea. Abdominal CT revealed a diaphragmatic hernia with an incarcerated transverse colon and left kidney causing duodenal obstruction. The patient underwent conservative therapy for 5 days but was ineffective, so an operation was performed. We released the incarcerated organs and closed the hernia orifice with interrupted sutures. The postoperative course was uneventful and he was discharged on postoperative day 18. He has had no recurrence of hernia for six months after surgery. No cases of adult Bochdalek’s hernia causing superior mesenteric artery syndrome have been reported to date.

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