Introduction : The role of local treatment in patients diagnosed with de novo stage IV breast cancer is unclear. The impacts of locoregional surgery (LRS) on survival and local control were examined retrospectively.

Methods : The subjects were 55 patients diagnosed with de novo stage IV breast cancer at our hospital between January 2006 and December 2020. The patients were divided into two groups : group A, 10 patients who underwent surgery during treatments ; and group B, 45 patients who did not. The treatment results and prognosis were compared between the two groups retrospectively.

Results : The median survival time was 1090 days in group A and 555 days in group B, with no significant difference (p=0.14). In Group A, 8 patients died, with a median survival of 304 days and a one-year survival rate of 43.8%. Postoperative local recurrence was observed in two cases, but no cases required local treatment at the end of life.

Conclusion : LRS for de novo stage IV breast cancer may contribute to better local control. It can be an option after detailed examination of local and metastatic disease and other treatment possibilities such as Mohs ointment.

Congenital heart disease (CHD) is a risk factor for cholelithiasis, but the therapeutic guidelines for cholelithiasis in children with CHD as an underlying disease have not been established yet. A total of 15 children with CHD who were diagnosed with cholelithiasis in our hospital from January 2015 to December 2020 were enrolled in this study to clarify the therapeutic guidelines. Their CHDs included cyanotic heart disease in 13 children. Their ages when they were first diagnosed ranged from 24 days after birth to 9 years and 4 months of age. When they were first seen at our hospital, 13 children had gallbladder stones and in three of the 13, the stones had fallen into the common bile duct. Although ursodeoxycholic acid was administered to 10 children, their stones had not shrunk. Cholecystectomy was performed in six children. Four out of five children who had common bile duct stone presented with strong symptoms, but their stones were spontaneously dissolved. In the remaining one child, the stone was removed by using an endoscope. Gallbladder stone in children with CHD is associated with complication in a high frequency and the prognosis of children who develop complications is poor. Bile acid litholysis is also ineffective. Accordingly, we should consider cholecystectomy even if the child patient is asymptomatic. We can expect spontaneous dissolution of common bile duct stone, but endoscopic or surgical choledocolithotomy is useful, if the stone is not dissolved.

Objective : To report short-term results of the recently introduced mini- or less-open sublay operation (MILOS) technique for abdominal wall hernia.

Method : We analyzed the surgical results of six cases in which MILOS repair was performed for abdominal wall hernias with less than 5-cm protrusion through the hernia orifice. Further, the results were compared with 39 cases where the laparoscopic intraperitoneal onlay mesh (IPOM)-Plus technique was used.

Results : There were no intraoperative complications in patients in the MILOS repair group. The average operation time was 133.3 minutes for MILOS repair and 123.4 minutes for the laparoscopic IPOM-Plus technique, the difference not being statistically significant (P = 0.545). Post-operative pain on the day after surgery and 7 days after surgery was significantly lesser with MILOS repair (P = 0.019 and 0.031, respectively).

Conclusion : MILOS repair for abdominal wall hernia can be performed safely even during the introduction period of surgical procedure without extending the duration of the operation, and the postoperative pain is less than that of the laparoscopic IPOM method.

Pseudoangiomatous stromal hyperplasia (PASH) is a benign tumor composed mainly of stromal proliferation with vascular-like spaces. Herein, we report two cases of PASH, including a case presenting rapid growth.

Case 1 : A 39-year-old woman manifested a left breast mass of 2 cm in diameter. After 2 years, she visited the hospital and found that the mass size increased to 3 cm. It rapidly enlarged to 10.5 cm 1 month later. A needle biopsy showed fibrosis. The patient underwent excision. Pathological examination revealed a vascular-like gap and stromal growth, positive for CD34 and α-smooth muscle actin ; eventually, she was diagnosed with PASH.

Case 2 : A 2.5 cm mass was palpated in the left breast of a 30-year-old woman. Ultrasound revealed a vascular-like gap appearance. Further, a needle biopsy showed stromal growth. We suspected PASH and performed excision.

PASH is a hyperplastic disease with indistinct borders and is difficult to diagnose using biopsy. Although PASH is rare, psuedoangiomatous hyperplasia without mass formation exhibits a high incidence (23%) in some surgical specimens. The concept of this disease should be kept in mind while diagnosing a benign mass.

Spindle cell carcinoma is an extremely rare histological breast tumor type, accounting for 0.1-0.2% of all breast cancers. Its prognosis has been said to be poor, except for a sub-type of fibromatosis-like metaplastic carcinoma.

Mammary hamartoma is also a rare breast tumor known as “breast in breast”, accounting for 5% or less of all benign breast tumors. Although coexistence of malignancy with a hamartoma is uncommon, 24 cases of breast cancer arising in mammary hamartomas have been reported. Most of their histological types were ductal or lobular carcinoma, 17 invasive, 5 non-invasive, and one mixed, except for one mucinous carcinoma. This report presents the 25th case of breast cancer arising in a mammary hamartoma, and the first case whose histological type was spindle cell carcinoma.

An 85-year-old woman was referred to our hospital with a left breast tumor. On imaging, the tumor consisted of a double structure : the outer structure was well demarcated and homogeneous, high-echoic, adipose tissue density, 8.0 cm in diameter ; and the inner was irregular, low-echoic, soft tissue density, and 4.5 cm in diameter. She underwent partial mastectomy, and the pathological diagnosis was spindle cell carcinoma arising in a left mammary hamartoma, pT2NxM0 ; Stage IIA.

The patient was a 46-year-old woman who had received right breast conserving surgery and axillary lymph node dissection (II) for right breast cancer elsewhere 5 years previously. The final pathological diagnosis was invasive lobular carcinoma, pT3N1 (1/22) M0 pStage IIIA. Four years later, she complained of severe constipation and, following a close examination, she was diagnosed with rectal cancer (signet-ring cell carcinoma) cT4bN0M0, cStage II. Infiltration into the uterus and sacral bone was suspected with a CT scan. After colostomy, we started administration of FOLFOXIRI plus bevacizumab (Bev), S-1 plus Bev, followed by Hartmann's procedure. Immunostaining of the rectal lesion showed ER (+), PgR (-), HER2 (1+), and E-cadherin (-). The rectal lesion was similar in morphology to the primary breast cancer. The diagnosis of rectal metastasis of invasive lobular carcinoma was made. Oral letrozole treatment was started, and she has been followed without metastasis for 3 years after the rectal surgery. It is known that invasive lobular carcinoma sometimes causes gastrointestinal metastasis, but its diagnosis is often difficult in clinical practice. The diagnosis and treatment policy for rectal metastasis of breast cancer are discussed.

We present a case of breast metastases of advanced primary serous ovarian cancer, in which differential diagnosis from invasive ductal carcinoma (IDC) was required.

A 43-year-old woman presented with a mass of the right breast. during chemotherapy for postoperative recurrence of ovarian cancer. Ultrasonography showed a low-echoic mass measuring 15 mm in diameter in the lower-lateral quadrant of the right breast and swelling of the right axillary lymph nodes. The pathological diagnosis by a biopsy of the right breast tumor was IDC and that of the right axillary lymph node was ovarian cancer metastasis. She received chemotherapy with a poly ADP-ribose polymerase inhibitor which was only effective for the axillary lymph nodes, but not for the right breast mass. Additionally, another left breast tumor appeared and was diagnosed with IDC. Then we performed bilateral mastectomy. The bilateral breast masses and axillary lymph nodes were positive for CA125 on immunohistochemistry (IHC), suggesting metastases from the ovarian cancer (high-grade serous carcinoma). Ovarian cancer metastases to the breast and/or axillary lymph nodes are very rare, and the accurate diagnosis is difficult. However, the history of advanced ovarian cancer and IHC of CA125 are expected to be helpful for the differential diagnosis.

Impalement injury is an open injury caused by a relatively blunt structure other than a knife and is relatively rare. An open injury caused by a cow horn is an example of impalement injuries. We report a case of video-assisted thoracic surgery for a chest wound and a lung injury caused by the horn of a bull. A 41-year-old man was horned by a bull with the weight of about 1,000 kg and was bounced to a height of about 3 m. He was brought into our hospital by ambulance with a wound in the right chest and the right thigh. Emergency surgery was performed for right traumatic hemopneumothorax and lung injury caused by the right thoracic impalement injury. First, thoracoscopy showed a free bone fragment of the third rib to have stabbed in the upper lobe of the right lung. A 4-cm incision was made directly above the third rib to remove this fragment. We then sutured and repaired the lung injury. The postoperative course was good, and the patient was discharged on independent gait on the 11th postoperative day. We report this case of chest trauma caused by a rare implement injury treated by surgery, with a review of the literature.

A 64-year-old woman who fell from her chair at the entrance of her home suffered trauma on her right chest and was referred to our hospital. Chest radiography and computed tomography showed fractures of the fifth and sixth right ribs. Since continuous injection of pain killers was effective in reducing her pain, she was scheduled to be discharged. However, sudden onset right chest pain developed again on the 11th day after the injury. Computed tomography revealed significant right pleural effusion. Right hemothorax was diagnosed by the insertion of a chest tube. Emergency surgery was performed with thoracoscopic assistance. Several blood clots were observed, occupying the right thoracic cavity. The sharp end of the fractured seventh rib protruding into the thoracic cavity causing laceration of the nearby diaphragm was considered to be the cause of hemothorax. Partial resection of the seventh right rib and suture closure of the injured diaphragm were performed. She was discharged on the 22nd day, without any post-operative complications. It is necessary to consider the delayed possibility of a hemothorax due to diaphragmatic injury in patients with middle or lower rib fractures.

A 37-year-old man presented to our hospital with vomiting and upper abdominal pain. Upper gastrointestinal endoscopy showed a 0-IIc lesion in the lesser curvature of the angler region, which was diagnosed as gastric cancer by a biopsy. Preoperative contrast-enhanced computed tomography (CT) scan showed a vascular anomaly of the celiac trunk. According to the Adachi classification, which classifies the patterns of branches of the celiac trunk into 28 groups with six types, his pattern was type VI. Type VI is a type in which the left gastric and splenic arteries form a common trunk, and which lacks a common hepatic artery. Accurate grasping of the vascular running pattern is essential for safe surgery. By sufficient preoperative imaging evaluation, we could perform laparoscopic surgery for gastric cancer with a rare vascular running pattern safely.

A 78-year-old woman who presented with frequent urination and residual urine was diagnosed with primary advanced sigmoid colon cancer which had invaded the bladder, right ureter, and ileum end. After neoadjuvant chemotherapy, the tumor response to the therapy was classified as stable disease. There were no unresectable factors. Thus, we performed total pelvic exenteration to remove the ileocecal region, left-sided colon, bladder, bilateral ureters, uterus and ovary, and ileal conduit formation. The postoperative course was uneventful, but she started to have loss of appetite after discharge. An arterial blood gas sample demonstrated hyperchloremic metabolic acidosis (pH 7.12) with a normal anion gap caused by chloride reabsorption via the ileal conduit. Symptomatic remission was gained with intravenous administration of sodium bicarbonate. The patient is now on alkalinizing therapy with oral sodium bicarbonate without any symptoms such as appetite loss. Metabolic acidosis due to ileal conduit is rare, however, colorectal surgeons should recognize the complications after urinary diversion.

A 78-year-old woman presented complaining of abdominal pain. Signs of peritoneal irritation were present, there was an elevated inflammatory response (WBC 218.1×10³/μL and CRP 24.14 mg/dL), and abdominal computed tomography showed ascites and a large mass with a maximum diameter of 15 cm in the intrapelvic small intestine. Small intestinal perforation and peritonitis were diagnosed, and emergency surgery was performed. A tumor was present in the jejunum, which was perforated at this site. The tumor was invading the sigmoid colon, appendix, right ovary, and retroperitoneum, forming a massive abscess. The retroperitoneal invasion was severe, and sigmoid colectomy with colostomy was performed together with partial jejunectomy and combined resection of the right ovary and appendix, with some tumor tissue left behind. Monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL) was diagnosed on the basis of pathological investigations. The patient's postoperative course was generally uneventful, and she started chemotherapy at another hospital on postoperative Day 25, but regrowth of the remaining tumor caused ureteral stenosis and hydronephrosis, and she died of the cancer on Day 71. A case of MEITL that required extensive multiple organ resection is presented along with a brief discussion of the literature.

External iliac lymph node metastasis of colon cancer is rare. A case of appendiceal cancer in which an isolated right external iliac lymph node metastasis was found after laparoscopic resection and was safely resected laparoscopically is presented. An 83-year-old man with a history of laparoscopic right inguinal hernia repair (TAPP) underwent laparoscopic ileocecal resection for ascending colon infiltration of appendiceal cancer, and the result was pT4bN1M0 Stage IIIc R0 CurA. Tumor markers were increased 3 months after the operation, and computed tomography showed a 17-mm mass around the right external iliac artery and vein. No other metastases were found, the patient was diagnosed with solitary lymph node metastasis, and resection was selected. The surgery was performed laparoscopically, and the tumor was removed by excising a part with the hernia mesh. From the clinical pathological findings, it was considered to be lymph node metastasis of appendix cancer. He is alive without recurrence 5 months after the operation. There are few reports on right external iliac lymph node metastasis from right colorectal cancer, suggesting the usefulness of surgical resection. This case is reported along with a review of the literature.

A 78-year-old man underwent laparoscopic right hemicolectomy for ascending colon cancer (T3N0M0, Stage IIa). He was discharged home 14 days after surgery. He ate tuna sashimi at his home a week after his discharge, after which watery stool and difficulty in oral intake were observed. At the time of his outpatient visit, he had severe dehydration, and computed tomography showed acute enteritis. He was started on fluid replacement therapy and admitted on an emergency basis. Aeromonas caviae was detected on stool culture, and bacterial enteritis was diagnosed. After admission, his general condition improved, and he was discharged home on the 15th day. Enteritis after colon cancer surgery, pseudomembranous enteritis due to Clostridium difficile, and postoperative ischemic enteritis are common, and bacterial enteritis is rare. Aeromonas is a causative agent of food poisoning, but there are few reports of enteritis in postoperative patients, and this case is considered to have shown a rare course.

The case involved an 80-year-old woman who had been taking prednisolone for leg ulcers due to livedoid vasculitis. She was diagnosed with sigmoid colon cancer during treatment for a foreign body in the colon and underwent laparoscopic sigmoid resection. She underwent computed tomography-guided drainage on the 6th postoperative day because of an intra-abdominal abscess due to the surgical procedure. Although the inflammatory findings improved rapidly, an intractable fistula was found in the transverse colon. On the 21st postoperative day, the fistula was confirmed by a lower gastrointestinal endoscope, when the endoscope was exchanged for an upper GI endoscope to perform band ligation with an endoscopic variceal ligation device. She had a good postoperative course and was discharged 28th postoperative day. Endoscopic fistula closure for intractable fistulas after gastrointestinal surgery may accelerate the treatment period and is a useful treatment if endoscopy can be safely performed.

Two cases of mixed neuroendocrine carcinoma and non-neuroendocrine neoplasm (MiNEN) are presented. A 50-year-old woman noticed an abdominal mass. Transverse colon cancer [cT3N2bM0 cStage IIIc] was diagnosed by computed tomography and colonoscopy. Right hemi-colectomy and lymphadenectomy were performed. Pathological examination showed combined features of adenocarcinoma and neuroendocrine carcinoma. The pathological diagnosis was MiNEN, pT3N0M0 pStage IIa. The patient received 8 courses of adjuvant CapeOX chemotherapy. At 12-month follow-up, the patient was well with no evidence of recurrence. A 72-year-old man was found to be positive for fecal occult blood. Colonoscopy showed a sigmoid colon polyp. The patient underwent endoscopic mucosal resection (EMR) of the polyp. The pathological diagnosis was MiNEN with deep submucosal (SM) invasion. Based on these findings, additional resection (laparoscopic sigmoidectomy and D3 lymph node dissection) was performed. The pathological diagnosis was MiNEN, pT1bN1M0 pStage IIIa. However, the patient did not wish to receive chemotherapy. At 60-month follow-up, the patient was well, with no evidence of recurrence. Although the prognosis of MiNEN is quite poor, multidisciplinary treatment resulted in a relatively good course. These cases are reported with a review of the literature.

A case of juvenile rectal cancer that underwent combination chemotherapy and surgery is presented. A 17-year-old woman presented with a 2-month history of abdominal pain and diarrhea. Inflammatory bowel disease was initially suspected, but colonoscopy showed an irregular ulcerative legion suggestive of colon cancer. The biopsy specimen showed mucinous carcinoma with signet ring cells. Computed tomography showed an 8-cm tumor causing bowel obstruction. Laparoscopic colostomy was performed, and small resectable metastatic peritoneal lesions were found. The stage was T4aN2M1c1 Stage IVa. The plan was to give her chemotherapy first and then resect the tumor, because the cancer was in a very advanced stage. Although the tumor became smaller after 3 courses of CAPOX, the serum CEA level was significantly elevated. High anterior resection of the rectum and proximal D3 lymph node dissection were performed with a combination of laparoscopic and open procedures. After the surgery, she was given courses of FOLFIRI and bevacizumab, but peritoneal recurrence was found 4 months later. Since the result for micro-satellite instability was found to be high (MSI-H), she was given pembrolizumab, and she remained stable with the tumor size remaining the same size for 2 years 3 months.

An 89-year-old woman developed anal pain in November 2020 and visited a nearby clinic. She was then referred to our hospital in December on suspicion of anal canal cancer. Colonoscopy showed a neoplastic lesion in the anal canal, with neuroendocrine carcinoma on biopsy examination, with atypical ductal epithelial areas in some areas. No distant metastasis was found, and robot-assisted laparoscopic abdomino-perineal resection of the rectum and anal canal + lymph node dissection was performed in January of the following year. The resected specimen showed the pathological findings of neuroendocrine carcinoma in the superficial part of the lesion and adenocarcinoma in its deep part. These findings were rare compared with the cases previously reported. The diagnosis was mixed neuroendocrine-non-neuroendocrine neoplasm, Stage IIA, according to the UICC TNM Classification System (8th Edition). The patient's postoperative course was uneventful, and she was discharged 27 days after the operation.

Case 1 : A 35-year-old female patient underwent laparoscopic bilateral adrenalectomy for bilateral adrenal pheochromocytomas. As the right pheochromocytoma was too large (13.5 cm) to be removed only by a laparoscopic procedure, hand-assisted laparoscopic surgery (HALS) was used after adequate exposure of the tumor.

Case 2 : An 82-year-old female underwent laparoscopic left adrenalectomy for a pheochromocytoma 10 cm in size. The posterior and superior surfaces of the tumor were dissected using a laparoscopic procedure, which was then converted to HALS.

Both cases required an extended skin incision for the hand port to facilitate removal of the tumor. HALS is a tactile technique that enables protective tumor traction and surgical field development. The laparoscope enables observation in the retroperitoneal region of the upper abdomen, where maintaining a surgical field of view is anatomically difficult. HALS for large pheochromocytomas is a safe, minimally invasive, and curative management procedure.

Spontaneous retroperitoneal hematoma (SRH) is a rare complication of antithrombotic therapy and is not related to trauma, medical procedures, or abdominal aortic aneurysm. We describe a patient with abdominal compartment syndrome due to SRH that required surgical evacuation of the hematoma. A 41-year-old man was referred to our hospital with abdominal pain and hypovolemic shock. Abdominal computed tomography revealed a large retroperitoneal hematoma in the right retroperitoneal region. After resuscitation and transcatheter angioembolization, intensive care was provided. However, the in-tra-abdominal pressure and serum creatinine levels did not improve. We performed surgical evacuation of the hematoma on day 10 of hospitalization. The postoperative course was uneventful, and the patient was discharged on hospital day 37. Surgical evacuation is an effective procedure that should be considered in patients with abdominal compartment syndrome due to SRH.

We encountered a case of incarcerated falciform ligament hernia that originated from an abnormal falciform ligament. In our hospital, we use a technique known as “indocianine green (ICG) fluorescence imaging,” which can evaluate blood flow on an endoscopic image, thereby providing an opportunity to avoid intestinal resection.

The patient was a 53-year-old woman who presented at the emergency department with worsening upper abdominal pain lasting several hours. On clinical examination, a diagnosis of incarcerated falciform ligament hernia was made and emergency laparoscopic surgery was performed. The incarcerated small intestine was manually dissected to disentangle it. Adequate blood flow in the entire incarcerated small intestine was ensured by ICG fluorescence imaging through detection of infrared emission. Necrosis was, thus, ruled out, and the small intestine was preserved. The patient had no complications and was discharged from the hospital on the sixth day after surgery.

ICG fluorescence imaging can evaluate blood flow on an endoscopic image, and it is, therefore, considered to be a useful method that obviates the need to tow the incarcerated intestinal tract out of the abdominal cavity through a small incision on the abdominal wall.

A 74-year-old woman visited our hospital complaining of a painful, irreducible bulge in the right groin area. Her abdomen was soft and flat, without signs of peritoneal irritation on palpation. Blood examination showed a white blood cell count of 8,900/μL and C-reactive protein of 13.22 mg/dL. Computed tomography (CT) revealed a right femoral hernia. Emergency laparoscopic surgery was performed with a diagnosis of incarcerated right femoral hernia. A perforated appendix with purulence in the hernia sac was detected, which was passing through the right femoral canal. The first surgery involved laparoscopic appendectomy and intraperitoneal drainage. After 4 months, the second surgery comprised of laparoscopic mesh repair using the transabdominal preperitoneal approach.

Femoral hernia with incarceration of the appendix is rare and is known as de Garengeot hernia. We successfully accomplished the two-stage surgery with laparoscopic appendectomy and laparoscopic hernia repair in order to manage the de Garengeot hernia. We will report this case with a literature review.