There are various pathological conditions in gallbladder cancer. We aim on the matters that are to be discussed, such as diagnosis and surgical procedure, based on the progression stage and site.

1. Computed tomography has been reported to have a sensitivity and specificity of 33% and 94%, respectively, for early-stage gallbladder cancer ; therefore, it should be noted that the sensitivity is low.

2. Endoscopic ultrasound has excellent diagnostic ability for polypoid lesions with a sensitivity and specificity of 91.7% and 87.7%, respectively ; however, the diagnostic accuracy for invasion depth is 55.5%.

3. In stage T1a diagnosed postcholecystectomy, additional resection is not required as well as in stage T1b, if the diagnosis was based on total cholecystectomy specimens.

4. The standard surgical procedure in T2 cases is gallbladder bed resection plus field lymphadenectomy. In the seventh edition of the Classification of Biliary Tract Cancer, T2 with lesions on the peritoneal side are classified as T2a (SS), while lesions on hepatic side are classified as T2b (SS). T2a has a good prognosis.

5. Surgically, in patients with a tumor invasion depth of T3 or higher, it is essential to consider the balance between safety and prognosis. Diagnosis based on the mode of cancer spread is important. Although R0 resection is technically possible, caution should be observed in the indications for surgery of cancer with hepatic hilar invasion and another organ invasion.

A 91-year-old woman visited a nearby clinic due to pain and swelling in the right breast that started three weeks prior. As no improvement was observed with antibiotic treatment, she was referred to our hospital. She presented with swelling of the right breast and redness of the areola without obvious palpable mass. Mammogram showed increased density of the tissue and thickening of the skin of the right breast. Breast ultrasonography revealed thickening of the skin, edema of the fatty tissue and obscure mammary gland tissue. Needle biopsy was performed to differentiate inflammatory breast cancer but no malignant findings were observed. As there was no findings suggestive of heart failure, Goreisan was administered without concomitant administration of diuretics. Improvement in edema was observed, although gradually, and no difference was observed between the right and left breast 12 months after initiation of the therapy. We report a case of breast edema successfully treated with Goreisan along with a review of literature.

Angiolipoma is an unusual variant of a lipoma with a hemangiomatous component, and angiolipoma of the breast is rare. A 50-year-old woman visited our hospital for evaluation of an abnormality detected on breast ultrasonography. On physical examination, a tender mass was palpable in the left breast. Mammography revealed a well-defined mass in the left breast. Ultrasonography revealed a well-encapsulated and homogeneously hyperechoic subcutaneous nodule in the left breast. Histopathological evaluation of a core needle biopsy specimen confirmed diagnosis of angiolipoma, and she underwent tumorectomy, with post-operative diagnosis of non-infiltrating angiolipoma. Angiolipomas are classified as infiltrating and non-infiltrating types ; most breast angiolipomas are categorized as non-infiltrating-type lesions. Diagnosis of angiolipomas based on imaging studies is challenging, and a core needle biopsy is necessary to definitively diagnose this lesion. Infiltrating angiolipomas are associated with a risk of recurrence ; therefore, diagnostic and therapeutic resection is recommended, and careful postoperative follow-up is important.

Extramedullary relapse of acute myeloid leukemia (AML) in the breast is relatively rare. Here, we report a case of extramedullary relapse of AML in the breast. The patient was a 39-year-old woman who was conscious of breast and subcutaneous tumors one and a quarter year after the remission of AML. Histopathological results confirmed the presence of extramedullary relapses of AML.

Ultrasonography revealed that these tumors were markedly different from other breast tumors that we encountered in daily practice. We considered that these tumors were a relapse of AML from her medical history.

Although tumor-forming AML is relatively rare, clinicians should be aware of the potential to form such tumors, particularly extramedullary AML, in order to provide an early diagnosis of AML.

A 71-year-old woman underwent partial mastectomy for left breast cancer (T1bN0M0). She refused adjuvant therapy and had been followed up without treatments. Three years and five months after the surgery, metastasis to the left axillary lymph node and multiple bone metastases were observed, and further three months later dyspnea appeared. A chest computed tomography showed multiple infiltrative and frosted shadows in both lungs, a transbronchial lung biopsy showed tumor embolization in the blood vessels, and an echocardiography showed right heart failure. We suspected pulmonary tumor thrombotic microangiopathy (PTTM) and continued anticoagulant therapy, but the condition took a progressive downhill course and the patient died on the 20th hospital day. Clinicians should consider PTTM as a differential diagnosis in patients with cancer who develop progressive dyspnea and right heart failure.

We have performed breast-conserving surgery with extraction of the nipple and partial resection of the areola for four cases of early breast cancer in which nipple involvement of breast cancer was suspected.

Before surgery, cancer involvement into the nipple was determined by contrast-enhanced MRI images in all four cases. The case 1 was of Paget's disease in which the entire nipple was enhanced on MRI. In the case 2, a huge tumor was present just under the inverted nipple, and a part of the nipple extending until its base was enhanced. In the case 3, diffusive enhancement circling around the nipple base was seen, suggesting a possible existence of invasive cancer nest. In the case 4, we confirmed intraductal progression in the direction toward the nipple to form a nodular image in the nipple and we determined that there was a possibility of nipple involvement. The case 2 was of encapsulated papilloma including ductal carcinoma in situ. Pathological studies demonstrated invasive cancer nest within the nipple in the case 3, but not in the case 4. In all cases surgical stumps were negative and postoperative irradiation was combinedly used.

In all cases, we performed breast-conserving surgery, comprising extraction of the nipple, associated resection of the areolar skin and subcutaneous structure which situated just above the subareolar lesion, and full thickness resection until fascia of pectoralis major muscle including the nipple and areola. As a spindle-shaped skin incision wound was closed with continuous buried sutures, a dog ear was formed on the areola which expanded like a nipple in shape, and so natural color of the areola skin has been kept.

A 76-year-old man underwent laparoscopic distal gastrectomy for gastric cancer which was detected by a medical checkup. We performed Billroth I reconstruction using delta-shaped anastomosis. Since his postoperative meal intake was favorably restored, he was discharged on the 8^th postoperative day. On the 22^nd postoperative day, he presented with upper abdominal distention and an abdominal CT scan revealed significant expansion of the gastric remnant. Following an upper gastrointestinal endoscopy taken after decompression, he was diagnosed with edematous stenosis at the anastomosis. After systemic administration of steroid was started, his symptom has improved rapidly, and he could restore oral intake from the 5^th day after initiation of the steroid therapy. Thereafter the dose of the steroid was gradually decreased, and the steroid therapy was terminated after a total of 38-day administration. No recurrence of stenotic symptoms has occurred, as of 9 months after the operation. It is considered that systemic steroid therapy for edematous stenosis after delta-shaped anastomosis is minimally invasive and useful.

An 18-year-old woman presented complaining of abdominal pain, vomiting, and an abdominal mass. Blood tests showed anemia (hemoglobin 7.7 g/dL). Abdominal computed tomography showed a massive heterogeneous, air-containing mass in the stomach and an ulcerative lesion on the lesser curvature side of the gastric angle. A massive hairball in the stomach was observed on upper gastrointestinal endoscopy. Endoscopic removal proved difficult, and it was decided to perform surgical removal with a preoperative diagnosis of trichobezoar and gastric ulcer. A small wound retractor was placed in the umbilicus, and an extra-small wound retractor was inserted through this into the stomach. This double wound retractor placement enabled the trichobezoar to be removed by a combination of intragastric and laparoscopic surgery. Previously, this operation would usually have been performed by open surgery via large laparotomy and gastrotomy, but in recent years, a few cases of intragastric surgery via a minimal surgical wound using wound retractors have been reported, although these also included reports of wound infection. This is the first reported case of the use of double wound retractor placement for a trichobezoar in Japan, and since this technique is useful for preventing wound infection and intra-abdominal abscess formation, this case is presented together with a discussion of the literature.

A 63-year-old man presented with anemia. Upper gastrointestinal endoscopy revealed a gastric submucosal tumor at the posterior wall of gastric antrum, and it was followed up on suspicion of gastric lipoma. Half-year later, he developed tarry stools accompanied by severe anemia (Hb : 5.5g/dl). On emergent upper gastrointestinal endoscopy, hemorrhagic ulcers were seen on the known gastric submucosal tumor, so we stopped the bleeding with thrombin. To deal with the high risk of re-bleeding, laparoscopic assisted distal gastrectomy was performed. On the resected specimens, the tumor was 66 × 45mm in size. Histologically, the tumor was diagnosed as benign lipoma. Gastric lipoma which can be gastric liposarcoma and which is accompanied by bleeding or obstruction are in need of resection. There are a variety of therapeutic approaches and surgical procedures. We need to make a right choice of treatment depending on tumor size and location. Gastric lipoma with bleeding is a rare disease, and this case is discussed with reference to the literature.

A 67-year-old woman presented with tarry stool and severe iron deficiency anemia. Upper and colonic endoscopic examinations were performed to search for the source of bleeding and she was diagnosed with a large hiatal hernia (LHH). She had been followed up with conservative treatment for 40 months with an unknown source of bleeding. During this time, massive gastrointestinal bleeding twice and progressive iron deficiency anemia were observed. And during this period, upper and colonic endoscopic examinations were repeated. Forty months after her first visit to the outpatient's clinic, she was urgently admitted to our department of surgery because of an upside-down stomach (USD) due to LHH. Before operation, we reviewed the past upper endoscopy photos and confirmed that she had a Cameron lesion (CL). And operation for LHH was done. Postoperative course was good and now, 60 months after the operation, no hernia recurrence, no gastrointestinal bleeding and no progressive iron deficiency anemia recurred.

Non-specific erosive and ulcerative lesions of the gastric mucosa that occur in LHH are called CL and cause gastrointestinal bleeding and chronic iron deficiency anemia. CL should be suspected in all LHH patients if they have gastrointestinal bleeding or iron deficiency anemia.

The patient was a 45-year-old man. He presented with black stools, and an upper gastrointestinal endoscopy revealed a duodenal tumor. Although the biopsy results showed no translocation of the SYT gene, immunostaining and histology suspected duodenal synovial sarcoma. A subtotal stomach-preserving pancreaticoduodenectomy was performed. The postoperative resection specimens did not show any SYT gene translocation, and synovial sarcoma was ruled out. EWSR1 translocation was observed, however, the fusion gene could not be detected by RNA sequencing. The histological findings suggested that his disease might fit the concept of “round cell sarcoma with EWSR1-non-ETS fusions”, but the final diagnosis was unclassifiable spindle cell tumor. The disease concept of “round cell sarcoma with EWSR1-non-ETS fusions” is a new classification established in 2020, and there are no reports on this classification in Japan. We report our experience of a spindle cell tumor of the duodenum, which is a valuable pathological result.

An 80-year-old man saw a nearby doctor for fever, and he was referred to our hospital for further examination. Computed tomography showed an increased density in fat tissue in the mesentery of the terminal ileum and free air. Multiple diverticula were also observed in the ascending colon. An emergency operation was performed with a preoperative diagnosis of perforation of the ascending colon diverticulum. Right hemicolectomy was performed to remove the abscess in the mesentery together with the ascending colon where the diverticulum had occurred, and reconstruction was performed by a functional end-to-end anastomosis. A perforation site was found in the terminal ileum. Histopathological diagnosis showed perforation of the diverticulum of the terminal ileum and lipomatous hypertrophy of the ileocecal valve. The patient's postoperative course was good, and she was discharged 14 days after the operation. Diverticula of the ileum are rare. In this case, lipomatous hyperplasia of the ileocecal valve might have been a cause of the diverticulum of the terminal ileum because of increased internal pressure.

A 90-year-old man underwent ileocecal resection with an ileostomy for acute perforated panperitonitis due to appendiceal mucinous neoplasm in our hospital. Nine months after the surgery, he presented with prolapse of the ileostomy with the dark-colored top. The physical findings revealed prolapse of the ileostomy with incarcerated intussusception, which was impossible to be reduced manually. We emergently resected the necrotic and poor-circulated part of the protruded ileum, followed by anastomosis of the opposite cut-ends without opening the abdominal cavity. The intussusception was reduced by hand. The patient's postoperative course was uneventful, and the disease has not recurred. This procedure does not need laparotomy, is less invasive and can be a good selection for the disease. We present a case of prolapse of an ileostomy with incarcerated intussusception, which was successfully treated with local resection and reconstruction of the protruded ileum without laparotomy, with the review of the related literature.

A 33-year-old woman presented with a left flank mass. An abdominal CT and MRI scans revealed a 55-mm spherical cystic mass near the Treitz ligament. An operation was performed with the suspected diagnosis of mesenteric teratoma. Intraoperative findings showed that the mass was present in the jejunal mesentery at 20-cm anal side from the Treitz ligament. The patient underwent laparoscopic excision of the mass without bowel resection. The mass was a unilocular cystic lesion. Pathological examination showed no epithelium lining the internal surfaces, and the mass was diagnosed as mesenteric pseudocyst. Mesenteric cystic masses are difficult to diagnose preoperatively, so complete surgical resection without rupturing them is important. The laparoscopic surgery for relatively small masses is less invasive and safe, so it is of value as the diagnostic therapy of the mesenteric cystic masses.

The patient was a 51-year-old woman with chief complaints of abdominal pain and anorexia. A blood test showed a high degree of inflammation. Abdominal computed tomography showed a multifocal cystic lesion in the abdominal cavity, 119×154 mm in size, with inflammation. A diagnosis of abdominal lymphangioma with infection was made, and the patient was treated with antibiotics. The abdominal pain and inflammation disappeared with antibiotic treatment. Magnetic resonance imaging 8 weeks after onset showed that the lymphangioma had shrunk significantly to 28×68 mm. Laparoscopy showed a lymphangioma in the ascending mesocolon, and laparoscopic ileocecal resection was safely performed. The pathological diagnosis was cystic lymphangioma of colonic mesentery.

Cystic lymphangioma, which is congenital and rare in adults, tends to grow rapidly and regress after infection or bleeding. The clinical course of this case is presented along with a review of the relevant literature.

A 43-year-old man presented with anorexia and fever. An abdominal CT scan revealed a 110×70 mm tumor in contact with the small bowel wall in the left common iliac artery. The tumor was diagnosed with an intra-abdominal abscess. The abscess did not respond to antibiotics, leading to continuous drainage via a placed catheter on the next day. He was getting better after drainage. A small intestine contrast examination showed barium accumulation almost coincident with the tip of the catheter, and the ulcer region was found in the jejunum near the abscess. Crohn's disease was suspected, and a small bowel ulcer was found by a double-balloon endoscopy (DBE). But there were few findings suggestive of Crohn's disease by a biopsy. On the 49th hospital day, partial resection of the small intestine including the tumor was performed for diagnosis and treatment. According to the histopathological findings, the definitive diagnosis of this tumor was a high-risk group of gastrointestinal stromal tumor (GIST) of the small intestine with abscess formation. On the 56th day after the operation, oral administration of imatinib mesylate was begun, and he is alive without recurrence for 2 years and 1 month following the operation. Small bowel GIST with intra-abdominal abscess formation is rare and we report with a review of the literature.

Case 1 : A 32-year-old woman presented with intermittent abdominal pain and vomiting. Computed tomography (CT) and colonoscopy (CS) revealed bowel obstruction secondary to ileocecal stenosis. The patient's preoperative serum cancer antigen 125 (CA125) level was elevated, leading to a high index of clinical suspicion for intestinal endometriosis. After decompression using a long tube, we performed single-incision laparoscopic partial ileal resection. The patient's postoperative course was uneventful, and she was discharged on postoperative day 8.

Case 2 : A 37-year-old woman with a history of endometriosis desired to get pregnant and discontinued hormone therapy, which led to repeated episodes of left lower abdominal pain during menstruation. The patient's preoperative serum CA125 level was elevated, and CT and CS revealed stenosis and mucosal edema of the sigmoid colon. We performed single-incision laparoscopic sigmoidectomy, and she was diagnosed with intestinal endometriosis. The patient's postoperative course was uneventful, and she was discharged on postoperative day 9. Histopathological examination of the resected specimen showed intestinal endometriosis. The patient underwent successful minimally invasive single-incision laparoscopic surgery for bowel obstruction caused by intestinal endometriosis.

Crohn's disease is a chronic inflammatory bowel disease, and long disease duration leads to a high risk of cancer-associated inflammation. It is known that ulcerative colitis is associated with multiple cancers or high-grade dysplasia. However, few reports of multiple cancers in Crohn's disease have been published in Japan. A rare Japanese case of Crohn's disease associated with synchronous multiple cancers, which was found by total proctocolectomy, is presented. The clinical presentation, treatment, and epidemiology of multiple cancers in Crohn's disease are discussed in this case report with consideration of the differentiation of those in Japan and in other countries.

A case of postoperative intussusception after laparoscopic sigmoidectomy using double stapling technique (DST) in a 64-year-old man is reported. The patient, who had undergone laparoscopic sigmoidectomy, presented with abdominal pain and was admitted to our hospital 24 days after surgery. Computed tomography and colonoscopy showed intussusception at the previous anastomosis site using DST. Emergent laparoscopic surgery was performed because reduction without resection was thought to be impossible. Resection and re-anastomosis were completed. The patient's postoperative recovery was uneventful, and he was discharged after tolerating full oral intake and return of bowel function. Pathological investigation showed edema and fibrosis of the mucosa, but no lead point lesion was observed. To the best of our knowledge, this is the first case report of postoperative intussusception of an anastomosis using DST. Clinicians should be aware of intussusception as a rare complication of anastomosis using DST, and early diagnosis and intervention can lead to less invasive treatment.

A case of appendiceal goblet cell adenocarcinoma (AGCA), which is newly defined in WHO 5th Edition, is reported. An 85-year-old man was referred to our hospital with a positive fecal occult blood test. A series of clinical examinations showed a type 1 tumor at the appendiceal orifice. Signet-ring cell carcinoma was diagnosed by biopsy. Laparoscopically assisted ileocecal resection was then performed. The tumor was first considered a goblet cell carcinoid, but there were some gaps between the histological and immunostaining findings. Finally, it became clear that this tumor should be diagnosed as an AGCA according to the WHO 5th Edition, which is a newly defined subtype of adenocarcinoma. Since malignancy was considered preoperatively, it was possible to perform tumor resection with regional lymph node dissection, although most malignant appendiceal tumors are discovered after appendectomy.

The patient was an 83-year-old man. He presented with left-sided abdominal pain and was diagnosed with descending colon cancer with intussusception. Because the abdominal symptoms were mild, laparoscopic colon resection was performed on a standby basis. Intraoperative findings showed that the intussusception had spontaneously been resolved. We performed reconstruction with functional end-to-end anastomosis and the patient was discharged without any postoperative problems. The final diagnosis was Stage II descending colon cancer, and the patient was placed on follow-up without postoperative adjuvant therapy. To date, the patient has been free from any recurrence. Preoperative imaging evaluation showed calcification in the tumor area, but postoperative pathological examination showed bone formation in the same area. Colorectal cancer with bone formation is very rare, accounting for only about 0.4% of all cases. In addition, intussusception in adults is reported to account for 6% of all intussusception cases, and telescoping of the descending colon, which is an organ fixed to the retroperitoneum, is particularly rare. No cases of bowel telescoping in descending colon cancer with osteogenesis have been reported so far. We report this case because it was considered to be of value.

Meningocele is the least common form of spina bifida characterized by cystic dilatation of meninges containing cerebrospinal fluid without any neural tissue. We performed laparoscopic Hartmann's surgery on a patient with rectal cancer with a giant posterior meningocele.

A 77-year-old woman who presented with melena was referred to our department of surgery with the diagnosis of rectal cancer. Supine and low head positions were not possible because of a giant meningocele at the hip and buttock which was present at birth. But laparoscopic surgery was done safely under general anesthesia by deforming the operating table to fit the mass and by testing trendelenburg position before surgery.

There is no precedent case of laparoscopic surgery for malignant tumors with a meningocele, and we report the case due to its rarity.

The case of an 85-year-old woman who had undergone laparoscopic sigmoidectomy for sigmoid colon cancer (pStage IIa) is presented. Four years after the sigmoidectomy, locally advanced rectal cancer with right lateral pelvic lymph node metastases was detected, and laparoscopic abdominoperineal resection with D1LD1(Rt-2, Lt-0) was performed. The pathological examination showed a pT3N3M0 (pStage IIIc) tumor, which included two mesenteric lymph node (#241) metastases at the oral side of the previous anastomosis. Since there have been few reports of mesenteric lymph node metastases beyond the anastomotic site of previous surgery, this case is reported along with a review of the relevant literature.

A 47-year-old woman with a 5-day history of epigastric pain visited our hospital. She had tenderness in the region but no fever. Blood test results were unremarkable except for a slightly increased CRP level. Imaging examination revealed a 45-mm-sized cyst with a thick capsule in the round ligament of the liver. Because an infectious cyst was suspected, antibiotics were administered, and her abdominal pain disappeared within a few days. Surgery performed based on the preoperative diagnosis of an abscess of the round ligament of the liver revealed a 5-cm-sized mass in the round ligament of the liver, which was in contact with the surface of the liver for approximately 1.5 cm. The resected specimen measured 55 × 33 mm in size, the lumen was filled with a milky white fluid, and no histopathological continuity with the round ligament of the liver was noted. The inner surface of the cyst wall was lined with multiciliated columnar epithelium, and the subepithelium comprised fibrous connective tissue with loose connective tissue and a smooth muscle layer. The patient was thus diagnosed with ciliated hepatic foregut cyst. Distinguishing ciliated hepatic foregut cyst from an abscess was challenging in the present case because of its atypical growth. Normally, ciliated hepatic foregut cysts grow directly beneath the hepatic capsule, i.e., inwardly ; however, in our case, there was an outward growth to the round ligament of the liver.

A 67-year-old man presented at a local clinic complaining of epigastric discomfort. On detailed examination, intrahepatic bile duct cancer was diagnosed, and left hepatic lobectomy and lymph node resection were performed in October 2015. On histopathological examination, a pathological diagnosis of primary adenosquamous carcinoma of the liver with lymph node metastasis was made, and GEM/S-1 (GS) therapy was started as postoperative adjuvant chemotherapy. This was suspended 5 months postoperatively due to the progression of anemia, but 1 year postoperatively, a recurrent lesion appeared near the anastomosis site. After GS therapy was restarted, the recurrent lesion became unclear. Today, 6 years postoperatively, the patient is surviving with no sign of recurrence.

A 78-year-old man was admitted to our hospital for investigation of liver function abnormalities. Contrast-enhanced computed tomography (CT) showed a high-enhanced tumor in the lower bile duct. Endoscopic retrograde cholangiopancreatography showed stenosis of the lower bile duct and dilation of the upper bile duct. Biopsy of the tumor suggested small cell neuroendocrine carcinoma, and subtotal stomach-preserving pancreatoduodenectomy was performed. Abdominal CT performed 12 months after the surgery showed two metastases in the liver. Chemotherapy was started with etoposide (ETP) and carboplatin (CBDCA). After the chemotherapy, the liver metastases shrank. The patient has remained alive more than 20 months after surgery. Primary NEC of the bile duct is extremely rare, and its prognosis is reported to be extremely poor. The chemotherapy was effective in the present case. Therefore, this case is reported along with a short discussion of the literature.

A 93-year-old woman was admitted to the hospital because of vomiting. Abdominal computed tomography showed a cholecystoduodenal fistula and a 55-mm gallstone in the second portion of the duodenum. Upper gastrointestinal endoscopy showed the impacted gallstone in the second portion of the duodenum, but its endoscopic extraction was unsuccessful. Five days after admission, surgery was performed. An attempt was made to move the impacted gallstone in the second portion of the duodenum to the distal side, but it only moved to the third portion. Finally, the gallstone was removed by opening the wall of the third portion of the duodenum, Primary closure was performed with gastrojejunostomy for decompression. A case of bowel obstruction in the duodenum due to a gallstone is relatively rare, and the treatment strategy for them has not been established. Gallstone ileus most often occurs in elderly patients ; therefore, in the case of obstruction of the duodenum by gallstone, it is necessary to determine the treatment strategy for each case based on each patient's general condition, comorbid diseases, and impacted site.

Pancreatic metastasis from breast cancer is rare, and it is necessary to distinguish it from primary pancreatic cancer to make a treatment plan. A case of a pancreatic tumor diagnosed by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) as a pancreatic metastasis from breast cancer is presented. A 70-year-old woman with left breast cancer underwent mastectomy at the age of 61 years. She received four courses of epirubicin and cyclophosphamide (EC), followed by letrozole for 5 years as adjuvant therapy. In the eighth postoperative year, tumor masses about 1.5 cm in diameter in the pancreas were seen on computed tomography. Transgastric biopsy was performed by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). The lesion was diagnosed as adenocarcinoma, and immunohistological staining confirmed it was estrogen receptor (ER) (+) and progesterone receptor (PgR) (+). These results were similar to the previous breast cancer histopathological classification. It was therefore concluded that it was a pancreatic metastasis from breast cancer, and endocrine therapy was resumed. Biopsy for definitive diagnosis should take into consideration the benefits and disadvantages and minimize the risk to the patient. A case of pancreatic metastasis from breast cancer in which histological examination following EUS-FNA was useful for deciding on the treatment plan is reported.

A 70-year-old man was referred to our hospital for evaluation of Fournier gangrene, which developed during treatment of a urinary tract infection associated with prostate cancer. Contrast-enhanced computed tomography (CT) revealed scrotal fluid collection concomitant with gas and a splenic abscess (maximum diameter 78 mm). After admission, we performed abscess drainage in this patient with Fournier gangrene, and he received antibiotics and conservative treatment. Additionally, after infection was controlled, we planned colostomy for management of rectal stenosis secondary to advanced prostate cancer. The patient developed left upper abdominal pain, 5 days after admission. CT revealed enlargement of the splenic abscess with perisplenic fluid retention. He was diagnosed with acute peritonitis secondary to a ruptured splenic abscess, and we performed emergency splenectomy. During laparotomy, we observed a large amount of white pus discharge from the spleen. The patient underwent sigmoid colostomy after splenectomy and abdominal lavage drainage. Postoperatively, the patient developed portal venous thrombosis ; however, overall, his recovery was uneventful, and he was transferred to the previous hospital 28 days postoperatively. Clinicians should be mindful of the risk of splenic abscess rupture and initiate prompt intervention for a large ruptured splenic abscess, as in our case.

A 62-year-old man presented with a left inguinal swelling. Blood tests did not show any significant findings. Computed tomography revealed a suspected left internal inguinal hernia without evidence of intussusception or bowel obstruction, and findings characteristic of internal supravesical hernia were not evident. Preoperatively, we suspected internal inguinal hernia ; however, intraoperatively, we detected internal supravesical hernia, as well as an internal and external inguinal hernia, and we therefore used a transabdominal preperitoneal approach for hernia repair. The patient's postoperative course was unremarkable. In this study, we report a rare case of internal supravesical hernia concomitant with an internal and external inguinal hernia, together with a literature review.

A 76-year-old woman presented to our hospital with a right upper abdominal mass detected by an abdominal echography. An abdominal computed tomography showed a 14-cm mass in the right upper quadrant of abdomen, which had remarkably pressed the right kidney and the liver. The right adrenal gland was recognized on the periphery of the mass. The inside was mottled low density, and contrast effect was observed on the margin. T2-weighted magnetic resonance imaging showed a mixture of hyperintense and hypointense regions within the mass. The margin of the mass showed low intensity. She was suspected of retroperitoneal chronic expanding hematoma (CEH) of the adrenal gland. Five months later, surgery was performed because an expansion of the mass was observed on CT. The adhesions were possible to be dissected all around, and we excised the mass without damaging its capsule. She was diagnosed with CEH 20cm in size originating from the adrenal gland based on her medical history and pathological findings. CEH is defined as a hematoma which develops following surgery or injury and expands chronically, and rarely originates from the adrenal gland. Although it was a very huge mass in our case, complete resection including its capsule was possible.

A 52-year-old woman underwent health checkup, which revealed a multilocular cystic tumor (7 cm) in the presacral pelvic cavity. The mass was diagnosed as a sacrococcygeal cystic tumor with malignant potential, and we performed surgical resection via an abdomino-sacral approach, followed by laparoscopic surgery. Histopathological examination of the resected specimen revealed a mature sacrococcygeal teratoma. The patient's postoperative course was uneventful, and no recurrence was observed at 1 year and 5 months follow-up. Although rare in adults, mature sacrococcygeal teratomas are known to show malignant changes ; therefore, early surgical resection is recommended. A combined sacral and laparoscopic approach was useful for optimal visualization of the surgical field and procedural safety in our patient.

A 66-year-old woman presented to the emergency department of our hospital for evaluation of abdominal and right leg pain and was hospitalized for follow-up. Abdominal computed tomography performed the following day revealed an incarcerated right obturator hernia, and she was referred to our department for further management. The patient had severe kyphosis secondary to a history of spinal tuberculosis, and the chest and pubis were close to each other. We performed ultrasonography guided manual reduction, followed by elective surgery using an inguinal approach. We discuss our findings in this case report, together with a literature review.

An 82-year-old man with a history of surgery for a right-sided thoracic deformity and hand malformation during infancy was referred to our hospital after reduction of an incarcerated right inguinal hernia at another hospital. Computed tomography revealed a right inguinal hernia and bowel obstruction. The right scrotum did not contain the testis, and a hernia sac and a mass that appeared to be the testis were identified in the subcutaneous tissue. Additionally, we observed a right rib cage deformity, abnormal bone in the right chest, one kidney, and intestinal malrotation. He was diagnosed with a right inguinal hernia, right cryptorchidism, and Poland syndrome. Intraoperatively, the hernia sac did not reach the scrotum but extended in the cranial and lateral directions after it passed through the external inguinal ring and merged with the subcutaneous tissue on the ventral aspect of the external oblique muscle aponeurosis. We performed hernia repair and orchiectomy. Cryptorchidism is a common congenital abnormality in males ; however, it is rarely observed in adults because most patients undergo surgical treatment at approximately 1-2 years of age. An inguinal hernia associated with cryptorchidism is rare in adults, and its association with Poland syndrome (a rare congenital anomaly) is even rarer.

The patient was a 67-year-old man. He was underweight (the body mass index : 12.09 kg/m²) and had a history of diabetes. In November 2019, he presented with difficulty in swallowing and body weight loss. An esophagogastroduodenoscopy revealed an about 8-cm huge tumor lesion from the middle to lower thoracic esophagus. At the same time, early gastric cancer and advanced sigmoid colon cancer were detected. He was diagnosed with synchronous triple primary cancer comprising esophageal carcinosarcoma, gastric cancer, and sigmoid colon cancer. We selected two-stage operation to safely achieve curative resections for all cancers. In the first stage of the operation, we performed thoracoscopic esophagectomy, laparoscopic total gastrectomy, laparoscopic sigmoidectomy, cervical esophagostomy, and jejunostomy. Thirty-five days later, we reconstructed with the right colon via retrosternal route. The patient had an uncomplicated postoperative course. Histopathological findings showed esophageal carcinosarcoma (pT3N0M0, pStage II), gastric cancer (pT1aN0M0, pStage I a), and sigmoid colon cancer (pT3N1bM0, pStage III b).

We experienced curative resection for rare synchronous triple cancer by using two-stage operation that lessened the surgical stress. The laparoscopic two-stage operation is a useful surgical strategy for high-risk patients.