Purpose: This study was designed to evaluate optimal lymphadenectomy for patients with noncurative resection after endoscopic submucosal dissection (ESD) for early gastric cancer using the eCura system. Methods: We examined 80 patients who underwent additional surgical resection for noncurative resection after ESD for early gastric cancer between January 2013 and February 2020. For comparison, we also examined 54 patients who underwent initial surgical resection for small advanced gastric cancer (<30 mm) with no lymph node metastases clinically, who were not indicated for ESD, during the same period. All patients were classified into three groups by risk level according to the eCura system, and the rate of lymph node metastasis was calculated in each group. Results: In the 80 patients treated with ESD, the median age was 71 years (40–90 years), 73 were men, the median follow-up period was 31 months (0–82 months), the rate of undifferentiated carcinoma was 23.8% (19 patients), and the rate of lymph node metastasis in each group was low risk, 4.0% (1/25 patients); intermediate risk, 11.1% (4/36); and high risk, 26.3% (5/19). One patient in the high risk group underwent D1 lymphadenectomy alone because of a comorbidity and died of recurrence of lymph node metastasis 3 months after additional surgical resection. The recurrence sites were lymph node stations 8a and 12a, which would have been dissected if D2 lymphadenectomy had been performed. In the 54 patients who did not undergo ESD, the rate of lymph node metastasis of 20.4% (11 patients) was higher than that in the high risk group. Conclusion: Patients with noncurative resection after ESD for early gastric cancer who are in the high risk group in the eCura system are more likely to have lymph node metastasis, and adequate lymphadenectomy including D2 lymphadenectomy should be considered for these patients.

Purpose: An algorithm for early diagnosis of pancreatic cancer (PC) has yet to be established. The goal of this study was to perform a retrospective assessment of the clinical features of resected PC diagnosed during surveillance for hepatocellular carcinoma (HCC) in chronic liver disease (CLD). Materials and Methods: The subjects were 110 consecutive patients who underwent resection of PC at our hospital between January 2011 and December 2019. These patients were divided into the HCC surveillance (HS) group, comprising 16 patients diagnosed with PC during follow-up of CLD; and a non-surveillance (NS) group of the remaining 94 patients. Clinicopathological outcomes in these groups were compared retrospectively. Result: Three patients in the HS group had a history of HCC treatment. The HS group had a significantly lower proportion of patients with symptoms at diagnosis (12.5% vs. 73.4%, P<0.0001) and a significantly higher rate of resectable PC (93.7% vs. 57.4%, P=0.0020), compared to the NS group. The HS group also had a significantly lower rate of combined vascular resection (6.2% vs. 30.8%, P=0.0218), a significantly higher R0 resection rate (100.0% vs. 86.2%, P=0.0365), and a significantly higher proportion of patients in the early stage (0–IIA) at diagnosis (43.7% vs. 14.9%, P=0.0130). PC was diagnosed by imaging for HCC surveillance in 13 cases (81.3%) in the HS group, while only 5 cases (5.3%) were diagnosed radiographically in the NS group. Conclusion: HCC surveillance in CLD may contribute to detection of asymptomatic and relatively early stage PC or resectable PC. These results show the need to check both the liver and pancreas in imaging during follow-up of CLD.

A 69-year-old woman underwent surgery for esophagogastric junction cancer. Multiple subcapsular nodules of several millimeters in size were identified on the liver surface and diagnosed as liver metastases based on pathological examination. Staging laparoscopy was performed after 2 courses of chemotherapy and the same nodules were detected, but the pathological diagnosis was biliary microhamartoma. Finally, the patient underwent curative surgery. In this case, thermal effects of the ultrasonic energy device with an inadequate resection margin in the initial partial hepatectomy was a major obstacle to pathological diagnosis. In addition, the primary lesion was a well differentiated tumor without severe atypia, which could increase the difficulty in pathological diagnosis. This rare entity should be listed as a differential diagnosis of small nodules of the liver, especially when coexisting with gastrointestinal cancers. This report suggests the importance of obtaining a sufficient amount of liver specimens without thermal artifacts, since such artifacts may cause inappropriate identification of structural and morphological findings of tissue components, leading to diagnostic pitfalls.

The rapid increase in cases of coronavirus disease 2019 (COVID-19) has increased the number of patients undergoing surgical treatment after COVID-19 infection. If possible, it is recommended that surgical treatment should be delayed for at least 7 weeks following COVID-19 infection to reduce the mortality risk. However, in some cases delaying surgical treatment may be life-threatening due to rapid cancer progression and emergency situations. Here, we report a case of a patient with advanced gastric cancer who underwent surgery 6 weeks after COVID-19 infection with measures taken against nosocomial infection.

The patient was an 81-year-old female who visited our emergency outpatient department with a chief complaint of epigastric pain. A blood examination revealed an increase in hepatobiliary enzymes. CT resulted in a diagnosis of cholangitis with obstructive jaundice due to common bile duct stones or a bile duct tumor, and the patient was hospitalized urgently. ERCP revealed a radiolucent image from the common hepatic duct to the common bile duct. A tumor could not be excluded, but only bile duct stent deployment was conducted without biopsy, given the critical stage of inflammation. A biopsy was performed later under ERCP after alleviation of the symptoms, and resulted in a pathological diagnosis of tubular adenocarcinoma ranging from well-differentiated to moderately differentiated types. Extrahepatic bile duct resection, biliary tract reconstruction, and lymph node clearance were conducted for bile duct cancer. A pathological examination gave a diagnosis of “true carcinosarcoma.” The patient was followed up without postoperative adjuvant chemotherapy, but CT revealed a finding of suspected multiple liver metastases at 117 days postoperatively. S-1 was started, but the patient passed away at 223 days postoperatively. Here, we report a case of “true carcinosarcoma” that showed a morphology characteristic of cases originating from the bile duct.

A 67-year-old man presented with diarrhea and urinary retention. Abdominal CT revealed an ileal tumor and the patient was referred to our hospital. Double-balloon endoscopy did not establish a diagnosis and the tumor was resected. The tumor was 15 cm in diameter, 50 cm proximal to the terminal ileum, and had invaded the cecal wall and the serosa of the bladder. Ileocecal resection with ileostomy was performed. Histopathologic findings for the resected specimen showed diffuse infiltration of polygonal tumor cells mainly in the submucosa and tumor cells with melanin pigments in cytoplasm. Immunohistochemical staining was positive for HMB-45, Melan A and S-100, consistent with a diagnosis of melanoma. There was no melanoma in other organs, which led to a diagnosis of primary ileal melanoma. Adjuvant pembrolizumab was given for 6 months, but then a peritoneal metastasis was found on F-18 FDG-PET/CT, and was treated with nivolumab and ipilimumab combination therapy. The lesion markedly decreased in size and the response was maintained for one year postoperatively. We report this very rare case as an example of a patient with primary ileal melanoma.

The patient was a 61-year-old man who presented with a complaint of swelling in the left inguinal region. This region was swollen to the size of a child’s head. A CT scan showed a large inguinal hernia and poor contrast in the hernia capsule and small intestine in the abdominal cavity. A midline incision in the lower abdomen made through an inguinal approach revealed an inguinal hernia classified (new JHS classification) as a L3 type hernia and poor color tone and peristalsis in the small intestine over 250 cm. The patient was discharged from hospital on the 24th day after surgery. In Maydl’s hernia, preoperative imaging evaluation is important because inguinal incision alone may miss the ischemic bowel in the abdominal cavity. In a case of giant inguinal hernia, a strategy that takes into account the risk of postoperative abdominal compartment syndrome (ACS) is necessary, and measures to avoid massive bowel resection are also required. In our case, we found that a wait-and-see transabdominal preperitoneal (TAPP) approach was a useful treatment option to avoid massive bowel resection and ACS.