Objective : Breast-conserving surgery with partial resection of the nipple and areola was performed in patients with early-stage breast cancer with suspected intraductal growth in the intrapapillary duct and subareolar region. We investigated the curability and safety of this approach.

Methods : Preoperative breast magnetic resonance imaging (MRI, 3.0 T) was performed to evaluate intraductal growth. We investigated 29 consecutive patients who underwent this procedure between May 2015 and December 2019.

Results : The mean age of patients was 58.5 years. The primary focus was detected in the nipple-areolar and other areas in 10 and 19 patients, respectively. Preoperative breast MRI revealed Tis in nine, T1 in 15, and T2 in five patients. Of the 10 patients in whom intraductal growth was detected on preoperative breast MRI, the intrapapillary duct was thickened and clearly visualized in all four patients who were accurately diagnosed following postoperative histopathological evaluation. Among 29 patients, postoperative histopathological evaluation showed intraductal growth outside the areola in only one patient. Postoperative histopathological evaluation showed a positive surgical margin in two patients with a positive lateral margin on the nipple side ; one patient showed a positive deep margin and the other showed a positive lateral margin. All cancer-positive specimens were positive only for intraductal cancer.

Conclusion : Positive lateral margins on the side of the nipple were observed in only 2 patients who underwent this surgical procedure ; both patients showed intraductal involvement. Therefore, we conclude that this surgical procedure would be feasible with regard to safety and curability.

A 60-year-old woman presented with a diffuse tumor mainly in the right lobe of the thyroid gland, involving the right internal jugular vein and tracheal cartilage and multiple pulmonary metastases, which grew rapidly. Based on the clinical course and a cytology, the cytological findings the diagnosis of undifferentiated carcinoma of the thyroid gland (suspected anaplastic carcinoma) was made (T4aEx2N1aM1 stage IVC). Since there was a risk of causing oncological emergency due to bilateral recurrent nerve paralysis, lenvatinib was started immediately. A partial response (PR) was achieved within 2 weeks and the patient was maintained on lenvatinib for 2 years and 2 months. At that time, the patient underwent total thyroidectomy without leaving gross residual tumor for local control. The pathological diagnosis was widely invasive follicular carcinoma with extensive scarring of the tumor other than the intravascular lesion. Lenvatinib was resumed following I^-131 therapy and again a PR was maintained for 1 year and 4 months. We report a case of advanced thyroid cancer that was successfully treated with a multidisciplinary approach, with a review of the literature.

A 76-year-old woman with a 7-year history of chronic lymphocytic leukemia (CLL) was asymptomatic and was therefore only followed-up. However, an increased white blood cell count, particularly the percentage of lymphocytes, as well as systemic lymph node enlargement necessitated the initiation of chemotherapy. Screening mammography revealed focal asymmetrical densities in the right breast, and the patient was referred to our department for further evaluation. Ultrasonography revealed a geographic hypoechoic lesion (22 mm) in the C area of the right breast, suggesting ductal carcinoma in situ. We observed bilateral axillary lymph node enlargement ; however, the hilum of lymph nodes was preserved. Histopathological evaluation of a needle biopsy specimen revealed lymphocytic infiltration, and immunohistochemical analysis of lymphocytic surface markers revealed cells showing immunopositivity for CD20, CD5, and CD23, leading to a diagnosis of CLL with intramammary infiltration. Chemotherapy was initiated for CLL progression. The white blood cell count (specifically the percentage of lymphocytes) decreased together with disappearance of the intramammary lesion, 3 months after treatment initiation. The differential diagnosis should include extramedullary infiltration in patients with hematopoietic malignancy, who present with intramammary lesions.

We report a case of giant breast angiosarcoma. A 20-year-old woman noticed enlargement of her right breast and consulted her family doctor. The symptom had been stable for 4 months. Granulomatous mastitis was suspected. However, she complained that the enlargement had become rapid, and she was referred to our hospital. Her right breast was found to have swollen to 20 cm in diameter and had subcutaneous hemorrhages. Breast ultrasound revealed a tumor in the entire right breast, with a heterogeneous echoic lesion and internal blood flow signals. Contrast CT and MRI images demonstrated a tumor shadow with partial contrast effect occupying the entire right mammary gland. There was no distant organ metastasis. Based on careful core needle biopsy, the tumor was diagnosed as an angiosarcoma. She underwent total mastectomy with excision of the overlying skin and the pectoralis major muscle, and dissection of the axillary lymph nodes. The skin defect was reconstructed with a latissimus dorsi myocutaneous flap. Post-mastectomy radiation therapy was performed on the chest wall, and no other adjuvant therapy was scheduled. Approximately 2 years after treatment, she was free of recurrence. Herein, we report a case of breast angiosarcoma, discuss it, and review the literature.

The patient was a 50-year-old woman. At the age of approximately 18 years, she noticed a small, finger-sized tumor in her left axilla and visited a medical institution ; however, no relevant abnormality was identified. In approximately 2004, the tumor gradually increased in size and began drooping. Thereafter, skin erosion with exudate and odor appeared. She visited our hospital in 2018. A tumor that was slightly larger than an adult's head was found in her left breast. The skin covering the tumor was dark red and showed venous dilatation. A core needle biopsy was performed ; however, no definitive diagnosis was made because of the presence of necrotic tissue. When the clinical and imaging findings were considered, a diagnosis of malignant phyllodes tumor was made and surgery was performed. The tumor was located outside the mammary gland and was partially attached to the latissimus dorsi muscle. The resected specimen weighed 7.4 kg. Macroscopically, the tumor was fibrous with clear boundaries, necrosis in the center, and some self-destruction of the skin. The pathological diagnosis was low-grade fibromyxoid sarcoma (LGFMS). On the basis of intraoperative findings, it was considered that the tumor originated from the axillary soft tissue. No recurrence has occurred 2 years after the surgery. We here report a rare case of LGFMS originating from axillary soft tissue.

A 73-year-old man who had received coronary artery bypass grafting with a right gastroepiploic artery for effort angina a year earlier at our hospital returned to us due to chest pain developed after dinner. An abdominal CT scan showed prolapse of the small intestine and the omentum into the thoracic cavity, so emergency surgery was performed with the diagnosis of incarcerated diaphragmatic hernia. Operative findings included a 5.5 cm hernia orifice at the diaphragm on the dorsal aspect of the sternum, through which the small intestine and the omentum had herniated. The hernia contents showed no ischemic signs and were reduced back into the abdominal cavity. The hernia orifice was repaired with direct closure. The patient was discharged 9 days after the operation. The hernia orifice coincided with the GABG route. It is necessary to keep in mind that diaphragmatic hernia can be a cause of chest pain after CABG surgery.

Patient 1, an 80-year-old man, developed synchronous bilateral pneumothorax caused by lung metastasis of bladder cancer. Right pneumothorax improved by chest drainage, but the left pneumothorax did not respond to the treatment. Then thoracoscopic partial resection of the left lung was performed.

Patient 2, a 63-year-old man, developed pneumothorax three times during a follow-up period after thoracoscopic subtotal esophagectomy for esophageal cancer, and he required operation for each episode. In the first episode, pneumothorax affected the bilateral lungs. Surgical findings included multiple nodules on the surfaces of the lungs with air leakage from one of them. We determined that he had bilateral pneumothorax caused by air leakage from the right lung tumor and pleuro-pleural communication and performed partial resection of the right lung. We did not close the pleuro-pleural communication. In the second episode, he also developed bilateral pneumothorax. We performed partial resection of the left lung tumor and closure of the pleuro-pleural communication. In the third episode, he developed only right pneumothorax and partial resection of the right lung was performed.

The patient 1 developed synchronous bilateral pneumothorax, while the patient 2 had bilateral pneumothorax in which pneumothorax of either lung was transmitted to other lung via pleuro-pleural communication. We present these two cases of bilateral pneumothorax caused by a metastatic lung tumor through different mode of development.

A 73-year-old woman was referred to our hospital due to sudden abdominal pain and hematemesis. Abdominal enhanced computed tomography showed massive free air and ascites in the abdominal cavity, a dilated stomach with large perforation, and extravasation from the perforated gastric wall. A diagnosis of rupture of the stomach with intraperitoneal bleeding was made. Emergency laparotomy revealed an 8-cm perforation in the lesser curvature of the upper gastric wall, with no evidence of peptic ulcer, malignancy, or necrosis. We sutured the perforated gastric wall, achieved hemostasis, and drained the intraperitoneal space using irrigation. The postoperative course was favorable, and the patient was discharged on postoperative day 26. Spontaneous rupture of the stomach is very rare in adults and had poorer prognosis than upper gastrointestinal perforation, commonly observed in disease such as peptic ulcer. Clinicians are advised to consider spontaneous rupture of the stomach as a differential diagnosis when upper gastrointestinal perforation with acute gastric dilatation occurs in adults. In such cases, an emergency laparotomy is essential for survival.

Gastric endocrine tumors are rare, accounting for 0.1-0.6% of all gastric malignancies. Brain metastases from gastric cancer are also rare, with a reported frequency of around 0.5%. There have only been case reports of sporadic brain metastases from gastric cancer.

A patient who underwent surgery for a poorly differentiated cancer of the stomach was diagnosed as having gastric neuroendocrine cancer after surgery. The patient could not tolerate the adjuvant therapy for gastric cancer. Two years after the operation the tumor marker pro-gastrin-releasing peptide (ProGRP) increased gradually, and recurrence was suspected, but no metastatic lesion could be identified. Three years after the operation, a computed tomography (CT) scan of the lower part of the neck was scheduled, and unexpectedly find a brain metastasis, which resulted in the diagnosis and treatment of an asymptomatic, sporadic brain metastasis. This case is reported with particular consideration of the period until recurrence.

Stage IV gastric cancer often causes pyloric stenosis that requires surgery or stenting, however, it can be difficult in some cases. Recently we have experienced a case of Stage IV gastric cancer with pyloric stenosis in which both pain relief and chemotherapy were achieved by utilizing a cervical esophageal fistula through percutaneous transesophageal gastro-tubing (PTEG). A 72-year-old woman presented with epigastric pain and vomiting. Upper gastrointestinal endoscopy found type 4 gastric cancer accompanied by pyloric stenosis, with abdominal CT findings of lymphadenopathy and peritoneal dissemination. Our initial plan was chemotherapy after gastrojejunal bypass, however, surgical findings showed that gastric cancer had spread widely and was not amenable to bypass surgery. She had pains associated with postoperative nasogastric tube placement, which decreased her ADL. Construction of a cervical esophageal fistula and removal of the nasogastric tube eliminated her pains and improved her ADL without developing stenotic symptoms, which led us to provide her with chemotherapy. Thus, construction of a cervical esophageal fistula by PTEG before chemotherapy is considered useful for the patients with Stage IV gastric cancer with pyloric stenosis for which surgery and stenting are difficult, given that it enabled oral feeding in some cases due to tumor shrinkage by chemotherapy.

Granulocyte-colony stimulating factor (G-CSF)-producing gastric cancer is a rare disease with a very poor prognosis. A case of this disease that recurred rapidly and progressed is presented. A 76-year-old man who had epigastric pain was admitted to our hospital. Upper gastrointestinal endoscopy and biopsy showed a tumor of 5.0 cm or more, a poorly differentiated adenocarcinoma (por). Abdominal enhanced computed tomography (CT) showed a giant mass of 7.0 cm on the wall of the lesser curvature and multiple enlarged lymph nodes around the stomach. The preoperative laboratory data showed leukocytosis and a high serum G-CSF level (1,010pg/ml). There were no apparent sources of infection or blood diseases. A G-CSF-producing gastric cancer was suspected, and total gastrectomy was performed. Pathological findings were por, pT4a(SE), pN1, M0, and Stage IIIA. The tumor cells were positive on G-CSF immunological staining. Postoperatively, the leukocyte count improved once, but it then gradually increased. On postoperative day (POD) 19, abdominal enhanced CT showed two low-density masses, one larger than 5.0 cm in the body of the pancreas and one 3.0 cm in the tail of the pancreas. The masses suspected to be abscesses enlarged gradually, and recurrence of the G-CSF-producing gastric tumor was diagnosed. S-1+trastuzumab treatment was started on POD 25. The patient was discharged on POD 34, but developed cardiopulmonary arrest on POD 36.

A 53-year-old female patient presented with gastric cancer. An upper GI endoscopy showed a type 2 lesion in the lesser curvature beneath the cardia. A pathological analysis of a biopsy specimen demonstrated poorly differentiated tubular adenocarcinoma. An abdominal computed tomography scan revealed para-aortic lymph node swelling with metastasis. Based on these findings, clinical stage IV gastric cancer (cT4aN + M1) was diagnosed, and the patient received six courses of chemotherapy with S-1 + oxaliplatin (SOX). Thereafter, the tumor shrank significantly. The para-aortic lymph node had become indistinct and smaller. The chemotherapy induced a partial response, and total gastrectomy with D2 lymph node and para-aortic lymph node dissection was performed. Subsequent histopathological examination revealed no residual cancer cells in the area or any of the lymph nodes. The therapeutic response was grade 3, and a pathological complete response was diagnosed. She continues to receive oral S-1 adjuvant chemotherapy and has remained recurrence-free more than seven months after the operation.

A 36-year-old man presented with abdominal pain and melena. An abdominal CT scan showed a whirl-like pattern around the superior mesenteric artery (SMA) of the intestine. We diagnosed the case as midgut volvulus and performed emergency laparotomy. Upon laparotomy, we saw a bowel in the midgut area which was wrapped by an omentum-like membrane had twisted around the SMA by 180 degrees in a counterclockwise direction. As ischemic change was absent, we opened the membrane to reduce the volvulus and to replace the bowels to the normal anatomical locations. Intestinal malrotation is a developmental anomaly originating from embryonic interruption of the rotation and/or fixation of the intestines in varing extents. This case was characterized by the development of volvulus where a midgut bowel which had been unfixed to the retroperitoneum was wrapped by an omentum-like membrane and twisted. We could not encounter similar case reports as far as we could review. Although the mechanism why the bowel was wrapped by the membrane is still obscure, we consider a possibility that the herniating process of the midgut into the umbilical cord in the prenatal period might play some causative role.

A 68-year-old man presenting with anemia and melena was found having a type 2 tumor at the ascending colon by colonoscopy. A preoperative CT scan revealed not only the ascending colon tumor, but also wall thickening of the terminal ileum which had been demonstrated by a CT scan conducted 8 years previously. An ileal tumor was suspected. Laparoscopic ileocecal excision was thus performed with the diagnosis of ascending colon cancer and an ileal tumor. Operative findings included edematous bowel thickening completely encircling the intestine from about 25 cm to 35 cm from the terminal ileum, in a morphology of a tumor. Grossly the ileal tumor was 90 × 80 mm in size, and on its section, an area from the lamina propria of mucous membrane to the submucosal tissue was white in color and hypertrophied to 15 mm in the maximum diameter. Histopathology revealed proliferation of spindle-shaped Schwann cells and large oval-shaped ganglion cells. Immunostaining resulted in S-100 positive. Accordingly, ganglioneuroma was diagnosed.

Ganglioneuroma is a benign tumor arisen from the sympathetic ganglion, and ganglioneuroma arisen in the intestine is extremely rare. In a review of the literature, this is the first case of ganglioneuroma without associating with neurofibromatosis type I and/or multiple endocrine neoplasia, and this bowel-derived tumor had largest diameter among those reported so far. In order to establish the therapeutic guidelines including diagnosis and clinical observation, further accumulation of clinical cases would be mandatory.

Solitary fibrous tumor (SFT) is a rare disease that mainly occurs in the pleura. In recent years, extrapleural SFTs have been reported. Among them, SFT originating from the mesorectum is rare. We report a case of a primary mesorectal SFT that was completely resected.

The patient was a 64-year-old man in. Computed tomography (CT) scan for postoperative observation of gastric cancer revealed a 30-mm enhanced tumor with a smooth surface in the mesorectum. Colonoscopy showed no mucosal lesions at the same site, but a sigmoid lesion was happened to be revealed. Since the sigmoid colon lesion was SM invasive cancer, we decided to perform additional excision, including the tumor resection. Laparoscopic observation demonstrated a white nodule with a clear border in the mesorectum. We performed the removal of the nodule followed by sigmoid colectomy. Histopathological findings showed that spindle-shaped tumor cells with poor nuclear atypia proliferated in the stroma where was rich in collagen fibers with hyalinization. The tumor cells were CD34(+)/c-kit(+)/STAT6(+). We diagnosed it as solitary fibrous tumor. The patient is alive without recurrence 4 years after the operation.

A 17-year-old man complaining of abdominal swelling was found to have a large hepatic tumor in the right lobe of the liver on computed tomography (CT). Viral markers were negative, and serum alpha-fetoprotein (AFP) was with in normal limits, but PIVKA-II was abnormally high. On enhanced CT and magnetic resonance imaging (MRI), the tumor showed progressive enhancement, but some parts of it were not enhanced. Most parts of the tumor showed a slight decrease in EOB uptake, which was atypical for hepatocellular carcinoma. Since a malignant tumor could not be excluded, and there was a possibility of rupture, right trisegmentectomy was performed. The patient's postoperative course was uneventful. Pathological examination showed β-catenin-activated hepatocellular adenoma and no malignancy. PIVKA-II was immediately decreased after the hepatectomy. A case of a rare, large hepatocellular adenoma in a young man is presented.

A 53-year-old man presented with a chief complaint of upper abdominal pain. Cholangitis or cholecystitis was diagnosed, and endoscopic papillotomy was performed, followed by laparoscopic cholecystectomy. From postoperative Day 10, he developed fever and septic shock, and on Day 13, widespread, irregularly shaped purpura appeared rapidly on the legs and trunk, leading to a diagnosis of acute infectious purpura fulminans. He was brought through the acute phase with antibiotic administration, anticoagulant therapy, artificial ventilation, and dialysis. However, an ulcer developed over the right peroneus longus muscle, and debridement was performed. The patient's general condition improved with multimodal treatment, and he was transferred to another hospital on postoperative Day 136. Acute infectious purpura fulminans is a syndrome in which an infection causes rapidly progressing ischemic necrosis, predominantly in the distal extremities, shock, and disseminated intravascular coagulation. It has a poor prognosis, with a mortality rate exceeding 30%, and since there is no established method of treatment, it is vital to start appropriate treatment at an early stage and endeavor to maintain the peripheral circulation. No previous case of purpura fulminans following laparoscopic cholecystectomy has been reported either in Japan or elsewhere.

Here, we have reported a case of mucosa-associated lymphoid tissue (MALT) lymphoma of the gallbladder and review previously reported cases. A 69-year-old man presented with anorexia at our hospital one year ago. Computed tomography (CT) revealed a tumor in his gallbladder, but the patient did not to revisit the doctor. One year later, he presented with right upper abdominal pain and anorexia. CT revealed a high-density tumor measuring 37 × 25 mm in the gallbladder. During the one year, the tumor appeared to have had a slow growth rate and had not invaded of the liver and lymph nodes. Positron emission tomography (PET) revealed a maximum standardized uptake value of 11 in the tumor. Hence, a clinical diagnosis of gallbladder cancer made, and cholecystectomy with hepatectomy and lymph node dissection without bile duct resection was performed. Pathological examination revealed MALT lymphoma of the mucosa-serosa of the gallbladder ; no liver invasion or lymph node metastasis was noted. The patient's follow-up did not include chemotherapy after surgery. MALT lymphoma of the gallbladder is rare and difficult to diagnose before surgery.

A 50-year-old woman with breast cancer presented for evaluation of a mass near the gallbladder. Abdominal computed tomography (CT) and magnetic resonance imaging revealed a 2 cm round tumor anterior to the pancreatic head, with a clear boundary between the mass and the pancreas. The tumor displayed enhancement on the abdominal CT scan. All studies suggested a diagnosis of either a gastrointestinal stromal tumor or a neurogenic tumor arising in the mesentery of the colon. The woman had lymph node metastases from breast cancer and received preoperative chemotherapy. For 6 months, the tumor in the abdomen remained of the same size. After completion of chemotherapy, the tumor was resected. Histopathology revealed that the mass was a paraganglioma. No recurrence has been observed 2 months after surgery. Anti-HER2 therapy for breast cancer has continued. Two factors made it difficult to diagnose the cause of the mass. First, paragangliomas anterior to the pancreatic head are rare. Second, the paraganglioma was non-functional, and the patient was asymptomatic. Hence, this case demonstrates a rare manifestation of a paraganglioma.

A 29-year-old Nepalese woman, 18 months prior to surgery, developed hydatid cysts due to echinococcosis in Nepal. She was treated with albendazole for 10 months, and she then came to Japan. After coming to Japan, she underwent a medical examination because of abdominal distention. Computed tomography (CT) showed multiple cysts in the abdomen. The maximum diameter was 18 cm, continuous with the spleen. An echinococcus-related cyst was suspected, and she was referred to our department for surgical treatment. Because the serum was positive for echinococcus antibodies and the cyst was huge, cystectomy with splenectomy was performed. The intraoperative findings showed that the giant cyst was integrated with the spleen, and there were three cysts around the spleen and two cysts around the uterus. A total of 6 cysts were resected. The cysts were filled with green abscess fluid and numerous parasite eggs. The patient's postoperative course was uneventful, and she was discharged on the 15th day. Pathological findings showed cuticles in the cysts, which were diagnosed as simple cystic echinococcosis.

A 57-year-old man was referred to our hospital after an abdominal mass was identified by ultrasound scanning during a health checkup. Upper and lower gastrointestinal endoscopy examinations were both unremarkable. Contrast-enhanced computed tomography (CT) showed an irregular, 5-cm mass in the mesenteric region of the right lower abdomen that was densely stained from the early contrast phase, together with faintly contrasted, thickened peritoneum at the liver surface, near the bilateral iliac arteries, and around the rectum. Positron emission tomography CT (PET-CT) showed abnormal fluorodeoxyglucose (FDG) uptake at these sites. Peritoneal dissemination of an unknown primary cancer or peritoneal mesothelioma was suspected, and diagnostic laparoscopy and tumor biopsy were conducted to reach a definitive diagnosis. Detailed inspection of the entire peritoneal cavity showed numerous white peritoneal nodules, both solitary and in clusters, ranging from the ranging from around 1 mm to 10 mm. The mass in the right lower abdomen was pale reddish white, firm rubbery, and continuous with the greater omentum. This mass was resected and diagnosed as epithelial malignant mesothelioma on histopathological examination. The patient was discharged without complications on postoperative Day 2 and referred to an oncologist. The pathological diagnosis was confirmed on postoperative Day 13, and the patient was started on therapy with pemetrexed sodium hydrate and platinum on postoperative Day 23.