Introduction : Some studies have reported contralateral axillary, internal mammary, and supraclavicular lymph node metastases in patients with ipsilateral breast tumor recurrence (IBTR). The lymphatic flow pathway may be altered after partial mastectomy, and new sentinel lymph nodes (SLNs) may be identified.

Method : We reviewed 15 cases of sentinel lymph node biopsy (SLNB) performed for IBTR at our hospital over the past 5 years.

Results : Using preoperative lymphoscintigraphy, we identified SLNs in all 15 patients. Radioisotope accumulation was observed in ipsilateral axillary lymph nodes in nine, contralateral axillary lymph nodes in nine, ipsilateral internal mammary lymph nodes in two, and ipsilateral supraclavicular lymph nodes in one patient. Intraoperatively, we identified SLNs in the ipsilateral and contralateral axillary lymph nodes in eight patients each.

Conclusion : This study highlights the feasibility and usefulness of SLNB in patients with IBTR similar to its role in those with primary breast cancer. In our opinion, confirmation of lymphatic flow may be a useful indicator to guide postoperative follow-up even without intraoperative identification of SLNs.

Azygoesophageal recess (AER) is a depression formed due to a deviation of the right pleural cavity to the esophagus in the left pleural cavity, which extends from the azygos vein to the diaphragm. The literature has well established that bullae in the AER are a cause of pneumothorax. We have operated on seven cases of pneumothorax caused by bullae in the AER. The median age of the patients was 75 years, all of whom presented with symptoms of right secondary spontaneous pneumothorax with a moderate emphysematous change. Preoperative chest drainage was unsuccessful. Surgical findings of bullae were mostly white and thin. Bullectomies were performed by use of a stapling device ; the staple line was covered with polyglycolic acid sheets, and the sheets were fixed with fibrin glue. Postoperative recurrence was not observed. Bullae in the AER could be easily missed if the surgical team is not specifically searching for it due to the location of these bullae deep in the pleural cavity. Surgery in this region can be challenging ; operation of a stapling device is restricted by narrow space and limited mobility of the lung parenchyma surrounding the bullae. Pneumothorax caused by bullae in the AER has a great potential to be cured by appropriate treatment. It is important for surgeons to be aware of the potential for the occurrence of bullae in the AER when examining patients with right secondary pneumothorax.

A 51-year-old woman who had been followed up for a 2 cm-sized left breast tumor with calcification diagnosed as ductal adenoma by a core needle biopsy 3.5 years earlier revisited due to bloody nipple discharge of the left breast. Ultrasonography showed the tumor to have grown up to 4 cm in size. A vacuum assisted biopsy was performed and the pathological examination revealed fibroepithelial lesion with hyperplastic epithelial components.

A left partial mastectomy was done due to a growing tendency of the tumor and for ruling out malignancy. Pathological examination demonstrated that phyllodes tumor with hyperplastic epithelial component proliferated in the lactiferous ducts and lobular carcinoma in situ with 0.5 mm-sized microinvasion was observed in places.

Though there were several previous reports about co-existence of breast carcinoma and phyllodes tumor, almost of them were combined with ductal carcinoma. Herein we report this very rare case of phyllodes tumor combined with lobular carcinoma of the breast with review of the previous reports.

A 66-year-old man presented to a local clinic with loss of appetite. The patient was diagnosed with esophageal squamous cell carcinoma and referred to our hospital. We diagnosed his illness as squamous cell carcinoma (SCC) of the middle thoracic esophagus (cT1bN2M0 cStage II). After two courses of neoadjuvant chemotherapy with 5-FU + cisplatin, we performed thoracoscopic subtotal esophagectomy. Histopathology showed SCC concomitant with neuroendocrine cell carcinoma (NEC) in both the primary lesion and a dissected lymph node. After that, the patient developed liver, subcutaneous, brain and chest spinal cord metachronous metastases. We resected the liver, subcutaneous and chest spinal cord metastases. The brain metastasis was treated by resection and radiation therapy. Histopathology showed the only NEC in all these metastases. The patient survives for more than 5 years with the resection-centered treatment despite repeated metachronous recurrences of only NEC.

The 2019 WHO classification defines mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN) as a combination of non-neuroendocrine and neuroendocrine components, with each accounting for more than 30%. Two cases of gastric MiNEN are reported. Case 1 was a 75-year-old man with a preoperative diagnosis of gastric cancer on the posterior wall of the antrum and multiple liver metastases who underwent palliative distal gastrectomy. The pathological diagnosis was MiNEN (adenocarcinoma : 70%, endocrine carcinoma : 30%), pT4a (SE), pNX, M1 (HEP), pStage IV. The patient refused chemotherapy after surgery and died of the original disease 3 months after surgery. Case 2 was a 75-year-old man who was diagnosed with gastric cancer on the antrum-greater curvature and underwent distal gastrectomy. The pathological diagnosis was MiNEN (adenocarcinoma : 40%, endocrine carcinoma : 60%), pT4a (SE), pN1 (#6), M0, pStage IIIA. Peritoneal dissemination was observed 18 months after surgery, but the patient declined aggressive treatment and died of the original disease 21 months after surgery.

An 81-year-old woman who presented to the emergency department complaining of abdominal pain was diagnosed with superior mesenteric artery (SMA) occlusion. Exploratory laparoscopy found no evidence of bowel necrosis. Transcatheter thrombolytic therapy was performed. The subsequent CT scan showed edematous changes in part of the small intestine despite contrast enhancement in the SMA and bowel. The patient had frequent diarrhea and abdominal pain after initial therapy, as well as hypoalbuminemia, considered to be caused by the damaged intestine. This progressed despite the use of human serum albumin. Therefore, re-operation was performed, and 60 cm of intestine were resected, resulting in subsidence of the abdominal symptoms and an increase in the serum albumin level. The resected specimen was dark red, with histopathological changes of mucosal necrosis and an edematous submucosal layer. Protein-losing gastroenteropathy occurring secondary to SMA occlusion has rarely been reported. A case of protein-losing gastroenteropathy treated by intestinal resection is presented.

Liver abscesses caused by members of the Streptococcus anginosus group, part of the oral microbiome, have been increasingly reported in recent years, and investigation of the upper, as well as the lower, gastrointestinal tract is now emphasized. A 68-year-old woman presented with lumbar pain and a fever (temperature ≥40 °C). On investigation, multiple liver abscesses and pyogenic spondylitis were diagnosed, and antibiotic treatment was started. Lower and upper gastrointestinal endoscopies were both unremarkable. Contrast-enhanced computed tomography showed contrast-enhanced irregular thickening of the wall of the small intestine, and Streptococcus intermedius was detected on blood culture. Since this suggested the possibility of bacterial entry via a small intestinal lesion, small bowel endoscopy was conducted, but the lesion was not definitively identified. Laparoscopic partial small bowel resection was conducted on postadmission day 19 with the aims of controlling the bacterial entry portal and diagnosis of the small intestinal tumor. On pathological examination, a cavernous hemangioma with longitudinal ulceration of the intestinal mucosa, findings consistent with this being the entry portal, was found. This case suggests that investigation of the entire gastrointestinal tract, including the small intestine, is important if the causative microorganism is a member of the Streptococcus anginosus group.

A 37-year-old man was seen for Crohn's disease beginning in June 2000. Partial colectomy and abdominal cavity drainage for perforation were performed during balloon-assisted endoscopy for transverse colon stenosis in June 2016. Colorectal cancer was diagnosed on postoperative pathological examination, and the final diagnosis was T4aN0M0 Stage IIb. In January 2019, abdominoperineal resection for rectal cancer was performed, followed in May 2020 by partial colectomy for transverse colon cancer. Microsatellite-instability (MSI) testing demonstrated high-frequency MSI. Lynch's syndrome was diagnosed in MSH2 : c.942+3A>T by genetic testing performed in another hospital. After receiving nivolumab-ipilimumab combination therapy for local recurrence in the pelvis, chemotherapy has been continued using nivolumab, and stable disease has been maintained. This rare case of Lynch's syndrome with Crohn's disease is reported along with a discussion of relevant literature.

A 42-year-old Japanese man was referred to our hospital for lower abdominal pain. Colonoscopy suggested a sub-rectal mass, which was identified as cystic disease in the pelvic cavity on computed tomography and magnetic resonance imaging. He underwent surgery for the precise diagnosis of his persistent constipation. The mass, located between the bladder, seminal vesicle, inferior abdominal nerve pelvic plexus, and upper part of the rectum, was totally removed as a lump with the adjacent fat tissue. Immunohistopathological examination showed that the mass contained bloody fluid and inner lining cells that were positive for CD31 and CD34, diagnosing a true blood cyst. The patient remains well without postoperative recurrence. Blood cysts are commonly located in the neck ; therefore, it is difficult to diagnose them preoperatively when they occur in other sites. It may be important for physicians to bear in mind that a blood cyst can also present as a submucosal rectal tumor.

A 58-year-old man presented to our hospital complaining of upper abdominal pain, and CT scan showed pancreatic arteriovenous malformation (PAVM) in the pancreatic head and body associated with acute pancreatitis and a pancreatic pseudocyst. After conservative treatment for acute pancreatitis, abdominal pain exacerbated rapidly, and CT scan revealed bleeding within the pancreatic pseudocyst. We considered a risk of intra-abdominal hemorrhage and emergency surgery was performed. The initial surgery was completed with gauze compression hemostasis because of the difficulty in identifying the blood vessels due to the severe adhesion around the pancreas and coagulopathy caused by bleeding from many collateral blood vessels of the portal vein system. Two days later, distal pancreatectomy was performed and the pseudocyst which was the bleeding source was removed, but the PAVM could not be completely resected. Although a pancreatic fistula was observed postoperatively, it improved with conservative treatment, and the patient was discharged from the hospital on postoperative day 25. Although the PAVM remained in the pancreatic head, there was no recurrence of pancreatitis or formation of a pseudoaneurysm. Surgery is the radical treatment for pancreatic arteriovenous malformation, but surgical plan is crucial because hemorrhage control is the most critical issue.

The patient was a 32-year-old male. The patient presented to our department with left groin pain and discomfort. Using abdominal computed tomography, a left inguinal hernia was diagnosed, and laparoscopic surgery was performed. Laparoscopic observation revealed no obvious hernia sac. But pressure on the left inguinal region from the body surface revealed a spermatic cord lipoma pushed out from the internal inguinal ring into the abdominal cavity. The lipoma was removed laparoscopically. Since the internal inguinal ring was also enlarged, a mesh (Bard 3D Max^®) was placed according to the transabdominal preperitoneal repair. The patient's symptoms improved after the surgery. Spermatic cord lipoma without a hernia sac may present inguinal hernia-like symptoms and is called a “sacless sliding fatty inguinal hernia.” Spermatic cord lipoma is often found during inguinal hernia surgery through an inguinal incision, but it is hard to detect in laparoscopic hernia repair surgery and may be overlooked.

The patient was an 83-year-old female who had been followed for a long time as an orthopedic symptom due to leg pain. When she visited our hospital with a complaint of vomiting, she was diagnosed with a left incarcerated obturator hernia and a right sciatic hernia on computed tomography. The incarceration was manually reduced, and laparoscopic repair was electively performed for each hernia. During the surgery, a direct inguinal hernia on the right side, an indirect inguinal hernia on the left side, and an obturator hernia were additionally noted. The laparoscopic surgery was performed, and the hernias on the left side were collectively repaired with a transabdominal preperitoneal approach. The sacs of the obturator and sciatic hernias on the right side were inverted and ligated, respectively ; in addition, the obturator hernia sac was crammed into the sciatic hernia ring and secured with sutures. Pelvic hernias should be considered as a possibility when older, skinny females complain of leg pain. As multiple hernias may often coexist, laparoscopic surgery, which can be confirmed and repaired simultaneously, is useful. Since sciatic hernia is a very rare disease and there are only a few reports of it being repaired laparoscopically, we herein report this case with some literature review.