Purpose: Unique treatments of esophageal squamous cell carcinoma (ESCC) in our hospital are neoadjuvant chemotherapy using docetaxel/CDDP/5-FU in cStage II/III (excluding cT4) cases, and chemoradiotherapy using docetaxel/CDDP/5-FU in cT4 or cM1 lymph node metastasis cases. We herein report prognostic analysis of ESCC in a prospective database determined by treatment strategy based on a cancer board. Materials and Methods: Between January 2009 and March 2016, prognostic analyses were performed based on a prospective database of 504 ESCC debated on an esophageal cancer board. Result: (1) Five-year overall survival rate for each cStage (I/IIA/IIB/III/IV) in the surgical treatment cases were 88.3/85.2/83.8/55.8/66.7%, respectively. (2) In the cases of surgical treatment in cStage I/IIB, five-year disease specific survival rate was very good: 95.3/90.2%, respectively. In cStage IIB, neoadjuvant chemotherapy was administered to 90.5% of cases. (3) Surgical treatment outcomes in cStage IIA/III cases were significantly better than nonsurgical treatments except for cT4 cases with poor prognosis (P=0.0229). (4) Long-term survival cases in cStage IV was those with conversion surgery for positive para aortic lymph node metastasis cases. Conclusion: Prognosis was deemed to be optimized by multidisciplinary treatment decision based on esophageal cancer board. Especially, the prognosis of surgical treatment cases was the best and it was considered to be the most recommended treatment at present.

Case 1: A 77-year-old man was given a diagnosis of distal cholangiocarcinoma as a result of an examination for jaundice. Case 2: A 57-year-old man was found to have a duodenal tumor, which was difficult to endoscopically resect as a result of an examination for anemia. Celiac axis (CA) stenosis was noted in abdominal dynamic CT in both cases. Angiography showed strong celiac axis stenosis especially during inspiration and the hepatic arterial flow was supplied via the pancreatic head arcade from the superior mesenteric artery. The CA stenosis was judged to be caused by median arcuate ligament compression, therefore we performed ligament dissection and release of stenosis in surgery. Pancreaticoduodenectomy was performed without revascularization because the normalization of the celiac arterial flow was confirmed by intraoperative angiography. In general, the evaluation of blood flow before and after dissection of the median arcuate ligament is performed only by palpation or Doppler ultrasound. In our cases, we could visually evaluate improvement of the celiac arterial flow compared with the conventional methods by performing intraoperative angiography in a hybrid operating room.

A 60-year-old man was admitted to our hospital because of upper right abdominal pain. CT showed a hypo-vascular mass in the pancreas head. We diagnosed pancreatic adenocarcinoma by fine-needle aspiration biopsy (FNA) of endoscopic ultrasonography (EUS). Pylorus preserving pancreatoduodenectomy was performed. The tumor showed poor duct formation and nuclear irregularities, and was diagnosed as spindle type anaplastic carcinoma by histopathological examination. The patient was discharged from hospital on postoperative day 22. However, 10 days after discharge, he returned to our hospital because of abdominal pain. CT showed multiple liver metastases and peritoneal dissemination. On the 11th day after readmission, he died of disseminated intravascular coagulation (DIC). Anaplastic carcinoma of the pancreas, especially spindle type, is rare and has poor outcome.

A 72-year-old woman consulted our hospital with repeated vomiting and weight loss, and was subsequently admitted to our department. CT images showed a circular tumor with stenosis in the jejunum located at 10 cm from the ligament of Treitz. Double balloon enteroscopy showed a type 2 tumor and a biopsy indicated poorly differentiated adenocarcinoma. Small bowel resection with lymph node dissection was performed. The pathological diagnosis was pT4a (SE) pN0 M0 (fStage II) and adenocarcinoma arose from ectopic gastric mucosa in the jejunum. Ectopic gastric mucosa continued to the tumor by confirming immunostaining. Several cases of adenocarcinoma from ectopic gastric mucosa were previously reported in the esophagus, duodenum and Meckel’s diverticulum. To the best of our knowledge, this is the first case of adenocarcinoma arising from ectopic gastric mucosa in the jejunum except Meckel’s diverticulum. Therefore we report our experience with a review of the literature.

A 64-year-old man with symptoms of melena underwent upper gastrointestinal endoscopy, which revealed a type 2 tumor in the horizontal portion of the duodenum. Radiological examinations showed a solid mass located in the duodenum and jejunum and swelling of lymph nodes in the right subclavian and mediastinum, while no primary lesion was detected. A partial jejunum resection was conducted to control gastrointestinal stenosis and bleeding caused by the tumor. Histologically, the tumors were localized mainly under the submucosal layer. Furthermore, immunohistochemical findings were positive for cytokeratin (CK) 7 and TTF-1, and negative for CK20, respectively. These results suggested that the primary lesion of these metastatic lesions was from lung cancer and contributed to the selection of chemotherapy after resection of the jejunum. Carcinoma of unknown primary (CUP) represents metastatic lesions without an established primary lesion and constitutes 3–5% of all human malignancies. Here, we report on a rare CUP case that was detected by the metastatic lesion in the small intestine.

We report a case of appendiceal endometriosis in a 43-year-old woman undergoing chemotherapy for T-cell acute lymphoblastic leukemia (T-ALL). Abdominal CT for the purpose of therapy evaluation revealed an appendiceal mass, which remained the same size in spite of therapy of T-ALL. Colonoscopy and mucosal biopsy around the orifice of the appendix showed no abnormalities. After considering the possibility of neuroendocrine tumor, CT scans showed neither distant nor lymph node metastases. A single incisional lapaloscopic appendectomy was performed for diagnostic treatment. Histopathological examination showed endometrial glands and stroma in the appendiceal wall. Immunohistochemical staining showed a positive reaction for estrogen receptor, progesterone receptor and CD10, which is characteristic for endometriosis. Therefore, we diagnosed the appendiceal mass as appendiceal endometriosis. Appendiceal endometriosis presents various symptoms such as acute or chronic abdominal pain, which often occur with no relation to the menstrual cycles. Due to insufficiency of typical clinical features, preoperative diagnosis of appendiceal endometriosis is relatively difficult. Although appendiceal endometriosis is rare, it should be included in the differential diagnosis for appendiceal masses in women.

A 79-year-old man presented at our hospital with melena. A colonoscopy showed a hemorrhagic and irregularly shaped tumor approximately 20 mm in diameter in the anal canal. A biopsy was performed and the patient was given a diagnosis of anorectal malignant melanoma. A chest and abdominal CT showed no swelling of lymph nodes around the tumor, and no lung or liver metastasis. An abdomino-perineal resection with D2 dissection was performed. The resected specimen revealed a type I cancer with melanin pigmentation partially on the dentate line approximately 4.0×2.0 cm in diameter. Histopathological examination showed mixed fusiform malignant melanoma cells and signet ring cell adenocarcinoma without a clear border, indicating anorectal composite tumor comprising adenocarcinoma and malignant melanoma. A postoperative CT performed 6 months after resection showed multiple nodules in the lung fields. We therefore suspected the presence of multiple lung metastasis of anorectal malignant melanoma. No additional treatment was given because the patient was an elderly patient and unable to undergo chemotherapy. Anorectal composite tumors comprising adenocarcinoma and malignant melanoma are rare, and to the best of our knowledge there are no previously reported cases in Japan.

A 78-year-old man presented, and we diagnosed poorly differentiated adenocarcinoma of the lower rectum by biopsy examination under colonoscopy. General radiological examination revealed multiple lymph node metastases and synchronous liver metastasis. Metastatic liver tumors were considered to be resectable, so laparoscopic abdominoperineal resection and lateral pelvic lymph node dissection for primary tumor were performed as first-line surgery. Pathological examination of the resected specimen showed combined features of well-differentiated adenocarcinoma and neuroendocrine carcinoma, for which immunohistochemical staining was positive for chromogranin A, synaptophysin and MIB-1 index over 80%, and both components accounted for more than 30%. Furthermore, due to the presence of Paget cells in the anal canal, the case was diagnosed as mixed adenoneuroendocrine carcinoma (MANEC) with Pagetoid spread. Since the number of liver metastases rapidly increased in one month after surgery, systemic chemotherapy was administered. However, the patient died 9 months after surgery. We reported this exceedingly rare case of rectal MANEC with Pagetoid spread to make contribute to the literature review.

A 60-year-old woman with mixed connective tissue disease (MCTD) was admitted because of abdominal pain and vomiting. Abdominal CT showed “whirl sign” around the cecum, so the patient was given a diagnosis of cecal volvulus. The patient underwent emergency operation. The cecum was twisted 360° clockwise around the ileocolic vessels. Although the jejunum and ileum were dilated, the cecum and intestine caused no ischemic change. The patient underwent detorsion of the cecum and cecopexy. The patient was discharged twelve days after surgery. Thirty-seven days after discharge, the patient was admitted for abdominal pain again. The patient underwent emergency operation since we diagnosed recurrence cecum volvulus. The ileum twisted 360° clockwise and detorsion of the twisting ileum was performed. We decided to reoperate the intestinal resection after decompression treatment, because the patient had a possibility of ileal volvulus again. Fifty-one days later from the initial surgery, we operated again. We resected the extended ileum 30 cm. Atrophy of the muscle layer was observed corresponding to the extend site pathologically. There was some possibility of hypoperistalsis due to atrophy of intestinal muscle of MCTD. It is better to evaluate peristalsis using gastrointestinal series in case of bowel volvulus with MCTD.

Inguinal hernia is a complication of peritoneal dialysis; however, neither an established surgical procedure for inguinal hernia repair nor perioperative dialysis management has yet been established. We recently experienced three surgical cases in which inguinal hernia occurring during peritoneal dialysis (PD) was repaired using the direct Kugel patch method. In Case 1, a 60-year-old man developed right inguinal hernia 31 months after the introduction of PD and underwent hernia repair. PD was resumed on the day of the surgery. In Case 2, a 66-year-old man developed left inguinal hernia 19 months after the introduction of PD, and hernia repair was performed. He also resumed PD on the day of the surgery. In Case 3, a 65-year-old man developed left inguinal hernia 30 months after the introduction of PD and underwent hernia repair. PD was also resumed on the day of the surgery. The use of the underlay mesh placement for inguinal hernia repair allows PD patients to resume dialysis on the day of the surgery, thereby reducing various types of burden on such patients.