In general, when perforating peritonitis is diagnosed, colorectal cancer is not very often determined to be the cause. If perforation of the lower gastrointestinal tract is suspected based on symptoms and abdominal findings, the patient's general condition should be assessed. After diagnosing colorectal cancer perforation, the site of perforation and degree of peritonitis/contamination should be determined, and then the treatment strategy should be decided based on these findings and the general condition of the patient. In recent years, although the survival rate has increased due to progress in intensive care management, the acute phase mortality rate in emergency surgery is still higher than that in elective colorectal surgery. On the other hand, if the patient's general condition is good and the patient is judged to be able to tolerate extensive surgery, radical surgery for cancer should be considered. Surgery that prioritizes life-saving for peritonitis and surgery that performs radical surgery including resection of multiple organs for cure of cancer require conflicting surgical strategies. It is necessary to consider the patient's background and general and intraoperative condition, and then perform the optimal surgical procedure that satisfies both surgical strategies.

We retrospectively reviewed 49 elderly patients with breast cancer aged 75 years or older, who underwent surgery under local infiltration anesthesia due to underlying diseases and other reasons.

The median age of the included patients was 85 years (75-94 years), and the surgical procedures performed included partial mastectomy in 49 cases and total mastectomy in two cases. The median operation time was 42 min (22-103 min), and the amount of intraoperative bleeding was small in all the cases. Postoperative complications occurred in only six cases (12.2%) with mild seromas. Whole breast radiotherapy was performed in only eight patients (17.0% of 47 partially resected breasts), and drug therapy included hormone therapy in 28 patients and none in 21 patients.

Local Recurrence recurrence of the local region was observed in 4 of 51 cases, of all 4 cases did not receive either irradiation norhormone therapy. Further, there was no distant recurrence or death from primary disease. Compared with 390 patients aged 75 years or older who underwent general anesthesia during the same period, the overall survival rate was poor. However, there was no difference in the breast cancer-specific survival rate. Therefore, primary lesion resection under local infiltration anesthesia is an important treatment option for the increasing number of elderly patients with breast cancer.

Purpose : Partial-breast irradiation (PBI) is an alternative to whole-breast irradiation (WBI) for breast-conserving therapy. Although several randomized controlled trials demonstrated that PBI showed an equivalent efficacy to WBI, limited data are available for Japanese patients. This study was made to clarify the usefulness of PBI.

Methods : Patients aged ≥40 years, with a maximum tumor diameter of ≤3.0 cm, and with sentinel nodes negative for metastases underwent PBI using multicatheter interstitial brachytherapy (MIB) delivering 32 Gy in 8 fractions. Oncological and cosmetic outcomes were evaluated.

Results : Between 2008 and 2020, a total of 657 patients underwent MIB-PBI. The median age and follow-up time were 57 years and 6.1 years, respectively. Ipsilateral breast tumor recurrence (IBTR) was observed in 23 patients (3.5%). The 5-year cumulating incidence of IBTR, relapse-free interval, and overall survival were 2.2%, 96.6%, and 99.7%, respectively. Cosmetic results could be assessed in 172 patients with a minimum follow-up period of 5 years, and excellent or good outcomes with the Harvard cosmesis score and the Breast Cancer Conservative Treatment cosmetic results (BCCT.core) software were observed in 155 patients (90.1%) and 143 patients (83.1%), respectively.

Conclusions : Although this study was a retrospective registry trial from a single institution, MIB-PBI had an acceptable clinical efficacy for local control and long-term cosmetic outcomes in Japanese patients.

(Background) Since the cosmetic evaluation method in breast-conserving surgery objectively evaluates the laterality of the breast, the patient's subjective evaluation has not been heard, which may reduce patient satisfaction.

(Purpose) To investigate what patients value in breast-conserving surgery.

(Subjects and methods) Among the post-breast-conserving surgery patients attending our hospital, we have conducted a questionnaire survey asking ; how much the patient cares about each item in the evaluation method of the Sawai group, whether the patient wears a bra before and after surgery, whether the patient has breast symptoms after surgery, and how much the patient cares about the position of the scar, the shape of the breast, and patient satisfaction.

(Results) Each item included in the Sawai method was not given much importance, and the number of bra wearers decreased after surgery. Fifty-two-point-nine percent of the patients bought new underwears, and 41.2% had breast symptoms, after surgery, 54.9% answered that they were not particular about the scar or the shape of the breast as long as there was no pain or discomfort, and 62.7 % answered that they were satisfied or somewhat satisfied with their postoperative breasts.

(Conclusion) To increase patient satisfaction, it is important to question the patient about what she thinks important in addition to appearance, and to discuss with the patient about the location of the surgical scar and method of mammoplasty before surgery.

A 47-year-old woman was found to have a 4-cm-diameter mass that was palpable at the outer area in the right breast. The mass has been present since adolescence and has shrunk slightly. Mammary gland echography revealed a lobulated multinodular mass, and the echo density of the tumor distal to the nipple was lower than that of other areas. Breast contrast-enhanced MRI revealed an early enhancement in the tumor distal to the nipple. Based on a needle biopsy, the patient was diagnosed with phyllodes tumor with low-grade ductal carcinoma in situ (DCIS). Since the tumor extended to the subareolar area, breast-concerving surgery with resection of the areola tissue directly above the tumor were performed. The pathological diagnosis was fibroadenoma phyllodes with invasive ductal carcinoma and adenomyoepithelioma. The intraductal components similar to a low-grade DCIS extended into the fissure of the phyllodes-like foliate structure and formed an infiltrated area, partly extending outside the tumor. The resected margins were negative. Postoperative whole-breast irradiation was also performed.

In this case, while the fibroadenoma changed over the long-term course, phyllodes-like foliate structure, epithelial cancerization, and myoepithelial proliferation were noted in the interstitium. This case provides an interesting insight on the histogenesis of fibroadenoma and phyllodes.

A 56-year-old woman who was diagnosed with right breast cancer underwent total mastectomy along with sentinel lymph node biopsy. Pathological diagnosis included invasive ductal carcinoma (papillotubular), NG3, ER(-), PgR(-), Ki-67=20%, HER2(-) ; pT1b (9 mm), pN0, M0 ; Stage I, with an adjacent adenomyoepithelioma. The patient was followed up without adjuvant therapy. Four years after the operation, computed tomography (CT) scan showed a lobular and multinodular tumor in Segment 6 of the right lung. Four months later, a thoracoscopic right lower lobectomy of the lung was performed at another hospital, where a tumor with proliferating myoepithelial cells was detected. Pathological review led to the diagnosis of malignant adenomyoepithelioma. It was noted that both the ductal and myoepithelial components were malignant, measuring approximately 20 mm. Four courses of epirubicin cyclophosphamide (EC), followed by 12 courses of weekly paclitaxel (weekly PTX) were administered as postoperative adjuvant chemotherapy. Following this treatment, the patient developed multiple distant metastases in the brain, lung, liver, and kidney. The patient's general condition deteriorated due to progression of the distant metastases. The patient is currently undergoing follow-up with best supportive care and Palliative care at home.

Here, we report a case in which cancer multi-gene panel testing contributed to treatment. The patient was a 59-year-old woman. She was referred to our hospital for suspected left breast cancer with skin invasion. The right breast presented with invasive ductal carcinoma cT1N1M0 stage IIA (Luminal HER) and the left one with invasive ductal carcinoma cT4N3M0 stage IIIC (Luminal). The patient was treated with combination chemotherapy (docetaxel+pertuzumab+trastuzumab), and surgery was performed after tumor shrinkage was observed. Postoperatively, the patient was administered with adjuvant chemotherapy and endocrine therapy according to the subtype. One year postoperatively, treatment was switched due to the recurrence of bone metastases in the cervical and thoracic spine, followed by liver metastasis after 6 months. Liver biopsy was performed to reconfirm the subtype, and treatment was switched again. The patient was treated successfully, although adverse events rendered the continuation of treatment difficult after approximately 6 months. Therefore, cancer multi-gene panel testing (FoundationOne^®) was performed, and a germline mutation in the BRCA2 gene was confirmed. We strongly recommend the inclusion of multi-gene panel testing in cancer management, as it may offer new treatment opportunities.

A mediastinal ganglioneuroma is a ganglion-derived, benign tumor that usually occurs in children and young abults aged ≤20 years and is often asymptomatic when discovered. The case of a preschool child with a symptomatic, massive, posterior mediastinal ganglioneuroma is presented. A 5-year-old girl was brought to a local clinic with coughing and fever. Imaging showed a 10-cm, clearly defined tumor in the right posterior mediastinum. Computed tomography, magnetic resonance imaging, and positron emission tomography findings were suggestive of a benign neurogenic tumor, and the symptoms were considered to be due to compression by the tumor. Thoracoscopic-assisted total resection was conducted, and ganglioneuroma was diagnosed. Three years later, there has been no sign of recurrence. Although symptomatic mediastinal ganglioneuroma discovered in young childhood is a comparatively rare disease, it should be considered in the differential diagnosis.

Thymoma arisen in the lung is extremely rare and only few cases have been reported so far. Primary intrapulmonary thymoma is difficult to be differentiated from other pulmonary tumors based on imaging studies. Surgical resection of the tumor with pathological diagnosis is useful for making the definite diagnosis. This paper deals with a case of a patient who developed pulmonary adenocarcinoma while she had been followed for multiple nodules : which were eventually diagnosed as thymomas after upper lobectomy of the right lung.

A 71-year-old woman who had been followed for bilateral multiple pulmonary nodules underwent resection with biopsy of a nodule 20 years earlier which was diagnosed as benign nodule. An irregular shaped shadow situating in the right upper lobe and showing an increasing tendency was detected and was diagnosed as pulmonary adenocarcinoma by CT-guided lung biopsy. We performed thoracoscopic right upper lobectomy and pathologically diagnosed as moderately differentiated adenocarcinoma pT1bN0M0 Stage I A2. Two solid nodules were present in the right upper lobe which were diagnosed as intrapulmonary thymoma (type A). Its morphological characteristics were same as those seen in the former specimen taken 20 years earlier. There were no tumor shadows suggestive of thymoma in the thymus, so that we diagnosed the case as multiple thymomas which might have arisen in the lung.

A 53-year-old man presented with vagueness and was diagnosed with Barrett's esophagus and Barrett's adenocarcinoma by an upper gastrointestinal endoscopy. After close examination, he was clinically diagnosed as having Barrett's adenocarcinoma, AeLt, cT1b, cN0, cM0, cStage I. No lymph node and distant metastases were seen. We planned a two-stage operation because of his risk factors including obesity (BMI 34), chronic renal failure (Cre 3.98 mg/dl, eGFR 14 ml/min) and type 2 diabetes (HbA1c 6.9%). The first-stage operation was consisted of robot-assisted subtotal esophagectomy, gastrostomy, and cervical esophagostomy. One month after the first-stage operation, a robot-assisted gastric tube creation, and reconstruction via the retrosternal route with cervical anastomosis and enterostomy were performed as the second-stage operation. We drained anastomotic leakage, and then he was discharged from the hospital on the 30th postoperative day. We report a case of a high-risk obese patient with esophageal cancer who was safely operated on by using the two-stage robot-assisted surgery.

A 64-year-old man was diagnosed with Borrmann type 2 adenocarcinoma at the posterior wall of the gastric fundus. In addition to the primary tumor, CT showed another tumor of 20 mm in the pancreatic tail, which was suspected to be a primary cancer, endocrine tumor, or solid pseudopapillary neoplasm based on radiological examinations. Total gastrectomy with simultaneous distal pancreatectomy and splenectomy was performed under the diagnosis of gastric cancer and splenic tumor. However, histopathological examination showed that the pancreatic tumor had similar immunostaining features (CK20 and CK7-positive, CA19-9-negative) as the primary gastric cancer and another metastatic tumor in the spleen. The final diagnosis was Stage IV gastric cancer with synchronous metastases to the pancreas and spleen. After adjuvant chemotherapy, the patient has remained free of recurrence for 5 years. Since there are few case reports of simultaneous resection for gastric cancer with synchronous multi-organ metastases, this report implies that a radical surgical procedure might be a feasible option in selected cases even with synchronous multi-organ metastases.

A 62-year-old woman had received pylorus-preserving gastrectomy for early gastric cancer. She was admitted to our hospital because of abdominal pain and nausea. Computed tomogram showed small bowel obstruction due to a low-density mass containing air bubbles, characteristic of gastrolithiasis. Although an ileus tube was inserted and dissolution of the gastrolithiasis by Coca-Cola^® was carried out, the obstruction did not improve. She underwent single-port laparoscopic surgery. The gastrolithiasis of about 40 mm diameter was blocking the small intestine at about 30 cm from the ileocolic valve, and the distended part was extracted from the abdominal cavity. An incision of the small bowel was made, and the stone was removed. Finally, the incisional site was closed. Although she had prolonged high fever postoperatively, she improved with administration of antibiotics. She was discharged 29 days after the operation. On analysis of the components of the stone, 98% of it was tannic acid, and a diagnosis of gastrolithiasis was confirmed. After pyloric-preserving gastrectomy, the frequency of gastrolithiasis is higher than that after distal gastrectomy. If gastrolithiasis remains in the stomach, endoscopic extraction, dissolution therapy by Coca·Cola^® or surgical treatment should be tried. In rare cases, gastrolithiasis could cause intestinal obstruction. Since dissolution therapy for a stone in the small intestine is rarely effective, surgical treatment should be considered at an early stage.

Jejunal diverticulum is rare. It is often asymptomatic, but sometimes presents with symptoms such as diverticulitis. When it causes abdominal abscess or peritonitis due to penetration or perforation of jejunal diverticulitis, surgical therapy is selected in many cases and there are few cases treated conservatively. We have experienced a case of abdominal abscess caused by jejunal diverticulitis treated conservatively.

A 70-year-old woman presented to our hospital with fever and left lower quadrant abdominal pain. An abdominal CT scan revealed multiple jejunal diverticula, mild degree of thickening wall and a jejunal diverticulum with enhancement effect. We identified fluid retention with air and the increased CT value of panniculitis in the mesentery which was adjacent to the diverticulum. We diagnosed the case as abdominal abscess and localized peritonitis due to penetrated jejunal diverticulitis. Since her general condition was stable and the abdominal symptom was localized, we selected conservative therapy and she made a good recovery. From our experience as well as previous reports, we can afford to select conservative therapy if the correct diagnosis of penetrated jejunal diverticulitis is made early after the onset of the disease and patient's general condition is stable.

A 67-year-old woman was admitted with abdominal pain. Laboratory data on admission showed a high inflammatory response. CT showed wall thickness of the appendix with a poor contrast-enhanced, 4-cm mass at the apex and right hydronephrosis. She was diagnosed as having an appendiceal tumor and right hydronephrosis associated with ureteral stenosis. Colonoscopy showed no apparent mass at the orifice of the appendix. Because an appendiceal malignancy could not be completely excluded, ileocecal resection with D3 lymph node dissection was performed. The tumor showed inflammatory cell infiltration consisting mainly of foamy histiocytes and xanthogranulomatous inflammatory lesions composed of granulation tissue. The tumor was finally diagnosed as xanthogranulomatous appendicitis. Although there are many reports of xanthogranulomatous change occurring in the gallbladder and kidneys, such change in the appendix is rare. Therefore, this case of xanthogranulomatous appendicitis that was difficult to differentiate from an appendiceal tumor is reported.

A 14-year-old girl presented to our hospital with lower abdominal pain and fever since 2 days. She was diagnosed with acute appendicitis on abdominal contrast-enhanced computed tomography (CT) and underwent appendectomy. Over the fourth postoperative day, her fever symptoms and inflammation did not improve, and abdominal CT revealed a surgical site abscess and thrombosis of the superior mesenteric vein ; therefore, she was started on 10,000 units of heparin. The CT scan at the initial visit was reviewed, and it was found that the thrombus had already formed in the superior mesenteric vein. On postoperative day-10, CT showed that the thrombus had spread to the left portal vein, but blood tests revealed no abnormal liver function. On postoperative day-13, heparin was switched to rivaroxaban (RVX). No change in thrombosis or any symptoms was observed, and the patient was discharged while continuing RVX on postoperative day-26. Six months after the surgery, RVX was discontinued and follow-up was continued.

A 74-year-old woman had a history of right femoral hernioplasty with mesh implantation almost 9 years earlier. More than 4 years earlier, she underwent laparoscopic right hemicolectomy (D3 dissection) for cecal cancer, pStage IIIb, followed by postoperative adjuvant chemotherapy. One year earlier, abdominal CT showed a mass in the right inguinal region, which gradually increased in size. Three months earlier, right inguinal pain appeared, and PET-CT showed FDG accumulation in the same area. Suspecting recurrence of cecal cancer, laparoscopic anterior right inguinal mass resection was performed. There was a 40-mm mass located in the abdominal wall near the center of the mesh. There were no findings of intraperitoneal dissemination. Histopathologically, it was a well to moderately differentiated tubular adenocarcinoma, suggesting recurrence of cecal cancer. The tumor adhered to the mesh from the abdominal wall side, and it was considered to be a hematogenous metastasis rather than a peritoneal metastasis. It also appeared that the mesh may have been involved in the recurrence of the resected cecal cancer 4 years after its placement.

The case was a 66-year-old woman. During treatment for ulcerative colitis, she developed fever and was diagnosed with diverticulitis of the sigmoid colon and abscess formation by CT. She occasionally had symptoms such as fever and abdominal pain and had to undergo fasting treatment. On preoperative CT, diverticulitis of the sigmoid colon, abscess formation, and suspected left ovarian penetration were diagnosed. Intraoperative findings showed an abscess and fistula formation between the sigmoid colon and left ovary, so laparoscopy-assisted resection of the sigmoid and left ovary was performed. A rare case that developed diverticulitis of the sigmoid colon penetrating to the ovary is presented along with a review of the relevant literature.

Here, we report two cases of pancreatic trauma type IIIb.

A 22-year-old man presented with abdominal pain following a personal watercraft accident. Abdominal computed tomography (CT) revealed a pancreatic injury. Endoscopic retrograde pancreatography (ERP) showed complete disruption of the main pancreatic duct (MPD) in the body, which could not be managed by ERP-guided stenting of the distal duct. Surgical management was opted, and he was discharged on day 8 without any complications.

A 12-year-old boy presented with abdominal pain 2 days after being injured by an elbow strike in a handball game. Abdominal CT scan revealed pancreatic injury without pancreas-serosa rupture. ERP revealed complete disruption of the MPD in the body, which was successfully managed by ERP-guided stenting of the distal duct. Non-surgical management was opted in this case, and patient was discharged on day 15 without any complications.

Non-surgical management, including endoscopic stenting procedures, may be a less invasive and effective treatment option for selected patients with higher-grade pancreatic injuries.

A 37-year-old man was presented with seizures and loss of consciousness. Morning hypoglycemia was observed, and since contrast-enhanced computed tomography showed a clearly demarcated, hypervascular tumor in the pancreatic head and boby, insulinoma was diagnosed. Surgery was scheduled, but because the patient also had neurofibromatosis type 1, there were multiple other nodules in the pancreas, and these had to be distinguished intraoperatively to enable total resection of the insulinoma. Partial pancreatectomy was conducted with the use of preoperative selective arterial calcium injection, intraoperative ultrasound, rapid intraoperative pathological diagnosis, and intraoperative blood insulin measurement during rapid calcium infusion. Three years postoperatively, there has been no sign of recurrence.

A 52-year-old woman who had been diagnosed with neurofibromatosis type 1 underwent surgery for left breast cancer 6 years earlier. A CT scan taken one year after the surgery disclosed a left retroperitoneal tumor, but we decided to follow it under a diagnosis of retroperitoneal neurofibroma because she had not clinical symptoms and hypertension. Thereafter the left retroperitoneal tumor gradually enlarged to 70 mm in diameter on CT taken 6 months earlier. At that time, we considered a possibility of pheochromocytoma, and with close exploration, the diagnosis of left pheochromocytoma was made. After doxazocin was gradually increased the dose to 14 mg/day, laparoscopic left adrenalectomy was performed. We have experienced a case of neurofibromatosis type 1 with breast cancer operated on, in which during follow-up period after breast cancer surgery a retroperitoneal tumor was detected and diagnosed as pheochromocytoma by close exploration done several years later. Neurofibromatosis type 1 can be associated with a variety of tumorous lesion and it is important to perform screening tests for pheochromocytoma if necessary and not to overlook it.

The patient was a 60-year-old female, height, 159 cm ; weight, 100 kg ; body mass index, 40 kg/m². She had undergone mesh repair for an umbilical hernia 9 years ago. She was brought to our hospital with an emergency because of abdominal pain that had not improved since the previous night. Computed tomography revealed a 14×10-cm incarcerated abdominal wall scar hernia with free air near the small intestine, and emergency surgery was performed. Necrosis of the small intestine with a 1-cm perforation was observed, and resection was performed. The hernia was repaired by removing the mesh using the components separation technique. On postoperative days 14 and 18, the patient experienced hemorrhagic shock due to massive subcutaneous bleeding and emergency surgery was performed. The patient was managed with a ventilator, renal failure requiring hemodialysis, and antibiotic-induced agranulocytosis ; however, she was discharged from the hospital on day 77. The patient had a fever prior to rebleeding, which may have been triggered due to infection. Patients with obesity require adequate hemostasis and infection control because of their fragile tissue and extensive dissection.

A 56-year-old male patient visited urology department of the hemodialysis clinic because of discomfort and bulging in the left inguinal region for several months. He was referred to our hospital with a diagnosis of left inguinal hernia. In consideration of future kidney transplantation, the urologist requested a surgical procedure that does not use a mesh. While the Shouldice procedure has a reported recurrence rate of 1.15% and is a tissue-to-tissue herniorrhaphy procedure recommended by international guidelines, it is rarely performed in Japan. In fact, a search of the Japan Medical Abstracts Society for the keyword ‘Shouldice procedure' (excluding conference proceedings) yielded only six results. Following are the steps different in the Shouldice method compared to other conventional methods : (1) the cremaster muscle is dissected in the inguinal canal, and the lateral segment is wrapped around the spermatic cord to “externalize the internal inguinal ring,” (2) the posterior inguinal canal wall is incised and the preperitoneal space is fully dissected, and (3) the rectus abdominus muscle and internal abdominal oblique muscle are used for repair with four layers of sutures. In this report, we describe a rare case in which the Shouldice method, which is very rare in Japan, was used as a tissue suture method without a mesh.

A 70-year-old man was admitted to our hospital with coccygeal pain and anal discomfort. A painful mass was palpated on the right hip, and a computed tomography scan revealed a 90×75-mm multilocular cyst in the presacral space and a right hip abscess. We diagnosed an infected presacral cystic tumor with perianal abscess and performed incisional drainage of the abscess. However, due to recurrence of fever and pain, we performed the tumor resection using the transsacral approach with removal of the coccygeal bone at postoperative day-15. Histopathologically, the patient was diagnosed with an epidermoid cyst without malignancy.

The presacral space is known to be the origin of various tumors that develop from embryonic structures. These tumors are at risk of infection and malignant transformation ; therefore, complete resection is recommended. There is no indication for a surgical procedure or approach, but in our case, a large presacral epidermoid cyst with infection was resected using a transsacral approach.