We report the long-term term survival of a patient with mass-forming intrahepatic cholangiocarcinoma (ICC), who was successfully treated with repeated resections of recurrent hepatic and pulmonary metastases after initial surgical treatment, along with a review of the literature. A 72-year-old man was admitted in February 2011 because of suspected hepatic recurrence of ICC. He had undergone hepatectomy of segments 4a and 5, lymphadenectomy, and cholecystectomy in November 2005 for mass-forming ICC, followed by biweekly low-dose gemcitabine (600 mg/body) treatment for approximately 2 years as postoperative adjuvant chemotherapy. Partial hepatectomy of segment 6 was subsequently performed for a mass measuring 2 cm in diameter, and the pathology of the tumor was similar to that of the previous ICC lesion. Furthermore, a solitary nodule measuring 1 cm in diameter in the upper right pulmonary lobe was removed under video-assisted thoracic surgery in January 2013. This tumor was pathologically diagnosed as a metastatic tumor deriving from the recurrent hepatic ICC, based on its histopathological findings. The patient is doing well and is disease-free at 11 years and 4 months after initial surgical treatment for ICC. Repeated resections of solitary hepatic and pulmonary recurrences might be clinically beneficial in patients with ICC, provided that appropriate patient selection is made.

Here we discuss the case of an 84-year-old man who presented with marked leukocytosis and elevated CRP levels. His abdominal ultrasound showed a liver mass, 50 mm in diameter, in segment 5. A diagnosis of liver abscess was made, and antibiotic administration was initiated. However, his original symptoms did not show any improvement. A biopsy of the liver mass confirmed adenocarcinoma. We suspected that this was granulocyte-colony stimulating factor (G-CSF)-producing cancer of the intrahepatic bile-duct or gallbladder with invasion of the liver, which had led to the marked leukocytosis and elevated serum G-CSF levels. Cholecystectomy and subsegmentectomy of liver segments 5 and 4a were performed because the tumor invaded liver segment 4a. After the surgery, leukocyte count and CRP and serum G-CSF levels normalized. Pathology reports confirmed that the resected mass was gallbladder adenosquamous carcinoma. Immunohistochemical staining revealed that the tumor cells were partially positive for G-CSF. Therefore, we diagnosed this carcinoma as a G-CSF-producing gallbladder adenosquamous carcinoma. Abdominal CT performed on postoperative day 28 showed multiple metastatic recurrences in the right liver, and the patient’s physical condition gradually deteriorated until he died on postoperative day 91. This was a very rare case of G-CSF-producing gallbladder adenosquamous carcinoma.

We present a case of a 56-year-old man who worked at a printing company which uses organic solvents. The patient visited his local physician with a chief complaint of continuous upper abdominal pain for a month. Atrophy of the gallbladder and minor abnormality in liver function were suspected, so the patient was referred to this hospital. A neoplastic lesion was observed in both the cystic ductal portion of the common bile duct and the lower bile duct according to various imaging examinations, and adenocarcinoma was detected in both ducts by biopsy. Multicentric cancer occurring in the mid-bile duct and lower bile duct was diagnosed, and subtotal stomach-preserving pancreaticoduodenectomy was performed. No anomalous arrangement of the pancreaticobiliary ducts was observed in the excised specimen, and moderately-differentiated adenocarcinoma and well-differentiated adenocarcinoma were observed in both the mid-bile duct and lower bile duct. No gross or pathological continuousness was observed between the ducts. Synchronous multiple cancers in the extrahepatic bile duct without anomalous arrangement of the pancreaticobiliary ducts is extremely rare. A correlation between chronic exposure to organic solvents and the occurrence of multicentric cancer can be suspected.

We report 3 cases of intractable pancreatic ascites successfully treated by surgery. Conservative treatment had been ineffective in all 3 patients and preoperatively their general condition was poor. Case 1: A 58-year-old man with alcoholic chronic pancreatitis and massive ascites was admitted to our hospital. Preoperative CT scan showed a pancreatic stone in the head of the pancreas with dilatation of the main pancreatic duct. He underwent the Frey operation. Case 2: A 50-year-old man with alcoholic acute pancreatitis and massive ascites was admitted to our hospital. A pancreatic fistula was diagnosed on the surface of the pancreatic neck by preoperative CT and intra-operative findings. He underwent the Bracey operation. Case 3: A 71-year-old man with alcoholic acute pancreatitis and massive ascites was admitted to our hospital. Preoperative endoscopic retrograde pancreatography had revealed a pancreatic leakage from a cyst in the head of the pancreas communicating with the main pancreatic duct. He underwent subtotal stomach-preserving pancreaticoduodenectomy. All patients had high preoperative inflammatory reactions, hypoalbuminemia, and anemia. Two patients developed respiratory complications and pancreatic fistulae, postoperatively. Because intractable pancreatic ascites leads to serious conditions in patients for whom conservative treatment has failed, surgical intervention should be considered without delay. It is very important for the choice of operative procedure to understand the pathological condition of the particular individual case.

Lymphorrhea is a relatively rare postoperative complication. We report a case of a 78-year-old man who experienced refractory lymphorrhea after pancreaticoduodenectomy with D2 lymph node dissection for pancreatic cancer. Fasting treatment with total parenteral nutrition and subcutaneous injection of octreotide were not effective. We performed percutaneous lymphography using lipiodol from the bilateral inguinal lymphatic vessels because we first took into account the possibility of lymphorrhea due to para-aortic lymph node sampling. However, the lymphorrhea could not be cured. Furthermore, we performed percutaneous transhepatic lymphography (PTL) by using lipiodol because we considered the possibility of lymphorrhea due to lymph node dissection in the hepatoduodenal ligament. Leakage of the lipiodol around the choledochojejunostomy was observed and lymphorrhea was cured completely 5 days after PTL. PTL is considered to be an effective treatment method for intractable lymphorrhea after pancreatic cancer surgery.

We report a rare case of splenic aneurysm and splenic hamartoma with stricture of the celiac artery by median arcuate ligament compression. A 35-year-old man was found to have a splenic tumor on a medical examination. We diagnosed a splenic tumor and splenic aneurysm after further examination. At first, we planned laparoscopic splenectomy after embolization of the splenic aneurysm by interventional radiology (IVR), but we could not achieve embolization because of the median arcuate ligament compression. We chose laparotomy for release of the median arcuate ligament, and we continuously embolized the aneurysm by intraoperative IVR. Our hybrid operating room contributed to this procedure. We embolized the splenic artery without ischemia of the pancreatic body and tail by preserving the developed dorsal pancreatic artery. We could safely treat this complicated case, and we believe this experience can be very useful for future cases.

We report a case of inflammatory pseudotumor (IPT) of the spleen. A 65-year-old woman with back pain had a 40 mm splenic mass on abdominal enhanced CT. FDG-PET showed abnormal uptake in the spleen. We performed splenectomy to rule out malignant lymphoma. Immunohistochemical staining of the tumor showed that the tumor was positive for CD68 and α-SMA, and negative for desmin and ALK-1. The histopathological diagnosis was primary splenic IPT. Given that complete exclusion of malignant disease, such as malignant lymphoma or inflammatory myofibroblastic tumor, is very difficult, splenectomy may be considered for resective diagnosis, even if a benign tumor is suspected by imaging diagnosis.

Lymphangioma of the jejunum is a rare disease which may cause massive bleeding. A 29-year-old man was referred to our hospital for evaluation of melena with severe anemia, in whom esophagogastroduodenoscopy and colonoscopy had failed to reveal the origin of the bleeding. Post-contrast CT detected an unenhanced mass in the small bowel. Subsequent double-balloon enteroscopy detected a soft, friable, and flat mass associated with lymphofollicular hyperplasia in the jejunum. Endoscopic tattooing enabled laparoscopic partial resection of the jejunum. Pathologic examination confirmed the diagnosis of cavernous lymphangioma of 45 mm in diameter.

A 52-year-old man presented with a chief complaint of abdominal distension. Contrast-enhanced abdominal CT showed a 5 cm cystic mass on the cecum that invaded into the right iliopsoas muscle. Colonoscopy showed a protruding tumor on the cecum, and the biopsy specimens revealed adenocarcinoma. Therefore, the patient was given a diagnosis of mucinous cystadenocarcinoma of the appendix with right iliopsoas muscle invasion. Chemotherapy was planned as initial treatment at the previous hospital. However, the patient sought a second-opinion surgical treatment at Tohoku University Hospital. Although the tumor invaded into the right iliopsoas muscle, it was localized without any evidence of additional distant metastases. Therefore, surgical intervention was chosen for his initial treatment at our institution. The tumor was curatively removed by ileocecal resection with partial resection of the right iliopsoas muscle and the right femoral nerve (pT4b, pN0, pM0, pStage II). Complications of the operation were limited to difficulty of right knee extension, which subsequently resolved with post-operative rehabilitation. The patient is now able to walk; he is disease-free, without any signs of recurrence at 20 months post-operation. There is no evidence of effective chemotherapy for advanced mucinous cystadenocarcinoma of the appendix in the literature. Therefore, we present a curative treatment option via extensive surgical resection for patients with advanced mucinous cystadenocarcinoma of the appendix that has invaded into adjacent organs such as the iliopsoas muscle.

The patient was a 49-year-old woman who had cancer of the rectum (Ra-b). She underwent laparoscopic low anterior resection. At 8 months after the first operation, we diagnosed local recurrence in the abdominal cavity and performed abdominal perineal resection with total hysterectomy and adnexectomy. Chemotherapy was provided until 3rd line treatment because she appeared to have peritoneal dissemination. After 22 months from the first operation, erythema of the anterior thoracic region appeared after TAS102 treatment was initiated. Erythema did not improve in spite of performing skin care using steroid ointment. Therefore, she consulted a specialist in dermatology, and cutaneous metastasis of colorectal cancer was diagnosed. Unfortunately, she died after 25 months from the first operation. Skin metastasis of colorectal cancer has generally been regarded as a symptom of advanced systemic metastasis of the disease, and its prognosis is poor. Cutaneous metastasis from colorectal cancer is relatively rare. It is difficult for general surgeons to diagnose skin metastasis. We describe a case of rectal cancer with cutaneous metastasis which was difficult to distinguish from drug eruption, and review the literature.