Purpose: The aim of this study was to evaluate perineural invasion (PNI) of rectal cancer as a prognostic factor. Method: Subjects were 412 patients undergoing intestinal resection for rectal cancer, and patients who had undergone surgery between 1996 and 2005 were investigated retrospectively, of whom patients who received surgery between 2006 and 2010 were evaluated prospectively. Results: PNI was found in 144 patients (35.4%), of which 43.7% was in upper rectal cancerand 24.7% in lower. Multivariate logistic regression analysis showed that PNI was significantly associated with upper rectal cancer (P<0.001), lymphatic invasion (P<0.001), vascular invasion (P=0.003), and poorly differentiated component at tumor front (P=0.046). The PNI-positive group had a significantly worse survival curve. 3- and 5-year overall survival rates of PNI-positive cases were 56.2% and 37.3%, respectively. The survival rates of the PNI-negative group were 79.6% and 72.6% (P<0.001). The PNI-positive group in patients without lymphatic metastasis (stage II) also had poor prognosis, and the 5-year overall survival rate was 44.0%. In contrast, the survival rate for the PNI-negative group was 82.7% (P=0.008). The overall survival rate was significantly associated with lymph node metastasis (P<0.001), T3/T4 (P<0.001), and PNI (P=0.001), however, not associated with lymphatic invasion and vascular invasion. Local recurrence was also significantly related to T3/T4 (P<0.001, odd’s ratio 3.03), and PNI (P=0.003, odd’s ratio 2.60). Conclusion: In this study, PNI in patients with rectal cancer was significantly associated with prognosis and local recurrence. It was suggested that PNI was indispensable and valuable as a prognostic factor more than lymphatic invasion and vascular invasion.

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A 64 year-old woman complained of dysphagia. Esophagogastroduodenoscopy showed an elevated tumor (type-1) in ‍the middle thoracic esophagus, and biopsy specimens taken from the tumor histopathologically revealed neuroendocrine carcinoma and carcinosarcoma. CT showed a tumor 32 mm in diameter in the middle esophagus, and swelled lymph nodes around the gastric cardia. The patient underwent thoracic esophagectomy and digestive reconstruction using a gastric tube through the retrosternal route. The resected specimen showed the tumor in the middle esophagus, 40×30 mm in diameter. Because the majority of the tumor consisted of the tumor cells immunohistochemically with positive reaction for synaptophisin and chromogranin A, the tumor was diagnosed as neuroendocrine carcinoma. In the stroma of the tumor, spindle shaped tumor cells infiltrate, and this component was diagnosed as carcinosarcoma. Furthermore, glandular component was sporadically observed, and squamous cell carcinoma was spread surrounding the tumor. The tumor was diagnosed as neuroendocrine carcinoma with sarcomatous, squamous, and glandular components of the esophagus. This type of esophageal neuroendocrine carcinoma is very rare and we report herein with a review of the literature.

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The association between malignant solid tumors and nephritic syndrome has been established. According to our search of PubMed from 1950 to September, 2012, only one case in which surgery for gastrointestinal stromal tumor (GIST) of the stomach resulted in remission of nephrotic syndrome has been reported. Here-in, we describe a case with membranous nephropathy in which gastric GIST resection led to remission of nephrotic syndrome. A 73-year-old man complaining of bilateral pedal edema was referred to our hospital and given a diagnosis of nephrotic syndrome. Renal biopsy using immunofluorescence staining strongly suggested secondary membranous nephropathy associated with malignancy. Further examination showed a gastric tumor 10 cm in diameter adjacent to wide portions of the pancreas and the crus of the diaphragm. Under suspicion of gastric GIST, we performed total gastrectomy with distal pancreatectomy. After surgery, serum total protein and albumin were increased and the urine protein to creatinine ratio was decreased.

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We report a case of hemophilia B diagnosed as a bleeding from subcutaneous tissue and muscles following the cholecystectomy in an elderly patient. A 70-year-old man, undergoing the laparoscopic cholecystectomy diagnosed as a gallbladder stone. Postoperative subcutaneous bleeding occurred on postoperative day 1 (POD1). Abdominal CT showed a mild fluid collection at a tract of the drain without a space of the post cholecystectomy. We diagnosed the bleeding from a port insertion part of the right lateral abdomen. We performed hemostasis by electrocoagulation and ligation under local anesthesia. We suspected a blood disorder because hemostasis was difficult. He was given a diagnosis of hemophilia B (factor IX: 17%) on POD5. Following initiation of replacement therapy of factor IX, Abdominal drain was removed on POD7. He was discharged on POD15. His daughter was determined as a hemophilia B gene carrier (factor IX: 56%) and his grandson was also given a diagnosis of hemophilia B (factor IX: 14%) after this episode. If the patient has unexpected bleeding after surgery, hematologic disorders must be considered particularly in elderly patients.

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The patient was a 66-year-old man, who was given a diagnosis of multiple endocrine neoplasia type 1 (MEN-type 1), two years previously. Upper gastrointestinal endoscopic examination disclosed a small elevated lesion which was diagnosed as a gastric neuroendocrine tumor. Additional examination revealed a high serum gastrin level, and a tumor in the pancreatic body on abdominal enhanced CT. We performed the selective arterial calcium injection (SACI) test to detect the location of gastrinoma. The feeder of the pancreatic tumor was the dorsal pancreatic artery branched from the superior mesenteric artery by angiography, but the serum gastrin level was not elevated by the SACI test. The meaningful serum gastrin elevation beyond diagnostic criteria was obtained only samples from the gastroduodenal artery. Therefore we judged that the feeding artery for the gastrinoma was the gastroduodenal artery, and performed subtotal stomach-preserving pancreatoduodenectomy including the pancreatic tumor located in the mid-body of the pancreas. Careful immunohistological staining revealed that the pancreatic tumor was gastrinoma, and that multiple small gastrinomas were identified in the duodenum. His postoperative serum gastrin level normalized and he remains well with no recurrence.

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We report 2 cases whereby patients underwent surgical resection of the isolated lung metastases from pancreatic cancer after radical pancreatectomy. Case 1: A 79-year-old woman underwent distal pancreatectomy with combined resection of the left adrenal gland for pancreatic cancer (pT4N0M0 Stage IVa). The lung metastases were identified 20 months after surgery, and she underwent thoracoscopic partial resection of the lung. Histological findings showed lung metastases from the pancreatic cancer. After the lung operation, she is living in tumor bearing with the lung and bone metastases for 18 months. Case 2: A 52-year-old man underwent subtotal preserving pancreatoduodenectomy for a pancreatic cancer (pT3N1M0 Stage III). The lung metastases were identified 54 months after surgery, and he underwent resection of the right upper lobe and partial resection of the lung. Immunohistochemical findings showed lung metastases from pancreatic cancer. After the lung operation, he died at 12 months because of having multiple brain metastases. If isolated lung metastasis of pancreatic cancer is found, there is a possibility that tumor resection is indicated for the better prognosis.

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We encountered a case of right external iliac lymph node recurrence after radical resection for ascending colon cancer, which was successfully treated by surgical resection. A 66-year-old woman underwent right hemicolectomy with lymph node dissection for ascending cancer in February 2002. A 6-cm tumor was resected and found histologically to be moderately to poorly differentiated adenocarcinoma with lymph node metastasis along the marginal colic artery. The tumor stage was IIIa. In January 2003, a pelvic CT scan delineated a 3-cm mass on the abdominal side of the right external iliac vessels. The diagnosis was isolated right external iliac lymph node recurrence from primary ascending colon cancer. No other recurrent lesions were found, and en bloc resection with external iliac vein was performed. The cross-section of the resected specimen showed a smooth margin. Histological findings confirmed lymph node recurrence of ascending colon cancer. Nine years and nine months after the operation, the patient is recurrence free. This recurrence was extremely rare, and more case reports are needed to determine the mechanism behind these metastases.

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We report a case treated with 5 operations and chemotherapy using ifosfamide and adriamycin (IA)for a leimyosarcoma of the mesosigmoid and its peritoneal recurrences. A 57-year-old woman wasadmitted due to the presence of an abdominal mass. Abdominal CT showed a tumor of the mesentery ofthe sigmoid colon. FDG-PET showed a SUV max 4.1 for the tumor. Based on the diagnosis of amesenteric tumor of the sigmoid colon, it was surgically removed. Histopathologically, the tumorconsisted of spindle cells with a positive reaction to α-smooth muscle actin (SMA) and noreaction to KIT, CD34 or S-100. Therefore, the tumor was diagnosed as a leiomyosarcoma. Nine, 13 and17 months after the first operation, repeated operations were performed for peritoneal recurrences.Nineteen months after the first operation, CT showed a recurrence at the mesentery of the transversecolon. Four courses of chemotherapy using IA was performed, and the tumor size reduced from 64 to 25mm in diameter. A 5th surgery was then performed. Thirty-six months after the first operation, thepatient is alive without recurrence.

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Desmoplastic small round cell tumor (DSRCT) is an uncommon, poor prognostic tumor which is found mainly in young adults. A 23-year-old woman was admitted to our hospital with a complaint of anal pain. Pelvic CT revealed a 50-mm tumor in the anal and swollen lymph nodes in the bilateral inguinal region. DSRCT was diagnosed by biopsy, and Mile’s operation with bilateral inguinal lymph nodes dissection was performed. Though adjuvant radiation was performed to prevent recurrence of the disease, 6 months later, she experienced multiple distant metastasis. She was treated with multiagent chemotherapy (18 courses of VDC-IE, 13 courses of gemcitabine/docetaxel) which inhibited tumor growth for long periods. Here, we report a case of perianal DSRCT.

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Purpose: QOL was assessed in patients with fecal incontinence due to rectal prolapse and intussception who underwent laparoscopic ventral rectopexy (LVR). Methods: Eighteen patients were evaluated. Fecal incontinence was evaluated according to the fecal incontinence severity index, and constipation using the constipation scoring system before and 3–6 months after LVR. QOL was evaluated with short-forum 36 health survey (SF-36) and fecal incontinence quality of life scale (FIQL) at the same time. Results: Fecal incontinence and constipation significantly improved after LVR, respectively (P<0.0001, P=0.005). Five subscales of SF-36 and four subscales of FIQL significantly improved after LVR. Conclusions: These results suggest that defecatory disturbance and QOL in the patients with rectal prolapse and intussception improved after LVR in the short term.

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