Two cases of granulomatous mastitis with erythema nodosum are reported.

Case 1 : A 32-year-old woman presented with a painful right breast mass. Antibiotic treatment was ineffective. She was diagnosed as having granulomatous mastitis based on the clinical course. Painful erythema on her lower legs, joint pain, and high fever appeared 24 days after onset. A drug eruption was suspected, but her symptoms did not improve with antibiotic discontinuation. The skin biopsy showed erythema nodosum. The erythema nodosum resolved spontaneously, while the granulomatous mastitis worsened. After she was treated with steroids and drainage, the granulomatous mastitis improved.

Case 2 : A 38-year-old woman presented with a painful left breast mass. Antibiotic treatment was ineffective. The diagnosis on breast biopsy was granulomatous mastitis. Painful erythema appeared on her lower leg 22 days after onset. She was diagnosed with erythema nodosum based on her clinical findings. She followed the same course as case 1, and her granulomatous mastitis improved only with drainage.

Erythema nodosum should be considered when painful erythema appears in patients with granulomatous mastitis.

Acute mastitis includes stagnation mastitis caused due to milk stagnation and suppurative mastitis caused by bacterial infection of the nipple, which is more common during the postpartum period and rarely occurs in atrophied mammary glands of the elderly. Here, we present a case of an elderly patient with noninvasive ductal carcinoma of the breast who presented with acute mastitis. The patient was a 77-year-old woman who visited her previous doctor due to left breast pain and redness and swelling around the nipple areola. She was diagnosed with mastitis and referred to our hospital for a thorough examination after the administration of antimicrobial agents. Redness was observed and an induration was palpable in the EDBC and DCE areas, respectively, of the left breast. The redness disappeared quickly with antimicrobial agents ; however, mammography showed clusters of pleomorphic calcifications in the L-MS/OS and breast ultrasonography revealed an intraductal solid lesion with multiple hyperechoic foci in the left CDE area. Since she was diagnosed with ductal carcinoma with neuroendocrine features based on a core needle biopsy, total mastectomy and sentinel lymph node biopsy were performed. The histopathological diagnosis of the resected specimen was noninvasive ductal carcinoma with neuroendocrine features, which was distributed over an area of approximately 50 mm. Currently, the patient is under postoperative observation without any treatment.

Prophylactic administration of G-CSF is recommended for patients with a high risk of febrile neutropenia during cancer chemotherapy. On the other hand, the G-CSF administration entails a risk of associating aortitis in 0.47-2.7% of G-CSF cases that is recently given an attention. We report a case of aortitis after multiple doses of pegfilgrastim, a long-acting G-CSF, including a review of the literature. The patient was a 53-year-old woman with right breast cancer. She completed 4 courses of dose-dense (dd) EC and 1 course of dd-paclitaxel with pegfilgrastim as neoadjuvant chemotherapy (NAC) without severe adverse events. However, after receiving the second course of dd-paclitaxel with pegfilgrastim, she developed fever and right lower abdominal pain. Two weeks later, the inflammatory response remained, and a CT scan showed inflammation around the aorta, which led to a suspicion of G-CSF-associated aortitis. After symptomatically treated with antipyretic and analgesic drugs and without steroids, her clinical symptoms were improved. Right breast-conserving surgery was then performed due to the evidence of complete response to NAC from a CT scan. After surgery, she no longer had symptoms associated with aortitis, and a follow-up CT scan on postoperative day 42 showed no evidence of aortitis. We must remain alert for possible association of G-CSF-induced aortitis following multiple administrations even after a safe initial one.

A 60-year-old woman had thoracoscopic right upper lobectomy with mediastinal lymph node dissection (ND2a-1) for primary cancer of the right upper lobe of lung (cT1cN0M0 Stage IA3) and was discharged from our hospital on postoperative day 4. However, she was emergently brought into our hospital on postoperative day 12 due to right chest pain with decreased blood pressure. Transthoracic echocardiography revealed a large amount of pericardial effusion. She was diagnosed with cardiac tamponade, and a pericardiocentesis was performed. The aspirated fluid showed features of chyle. She was diagnosed with chylopericardium and was discharged on 23^rd postoperative day. She was readmitted on 37^th postoperative day and was discharged on 54^th postoperative day. In our case, conservative treatments including pericardiocentesis and dietary measures were successful. Even though chylopericardium following lung cancer surgery is an extremely rare complication, it can lead to other life-threatening complications like cardiac tamponade. Therefore, we suggest that the possibility of this complication after lung cancer surgery should be considered.

An 80-year-old woman who had undergone low anterior rectal resection for rectal cancer in 2008 and total aortic arch replacement in April 2018 was detected to have a small lung subpleural nodule in a regular follow-up CT scan. FDG-PET did not show abnormal uptake of FDG in the nodule and it was less than 1 cm in diameter. We thus decided to follow the tumor and 2 months later we found the tumor persisted. For the purpose of diagnosis and local control, surgical resection was performed by video-assisted thoracoscopy in November 2018. The nodule was hard, brittle, white, and was covered by thin inflammatory tissue. Pathological examination revealed the nodule to be a foreign body. The nodule closely resembled bonewax material on inspection, which might have been stayed at the previous cardiovascular surgery.

We report a case of intrathoracic foreign body resembling metastatic lung tumor.

A 78-year-old female patient became aware of a feeling of tightness in her throat in September 2018. After an examination, she was diagnosed with thoracic esophageal cancer (Lt, Type-3, T4bN2M0, Stage IV a). Two courses of 5-FU + cisplatin (FP) therapy were administered as neoadjuvant chemotherapy in December 2018. After the treatment, thoracic esophageal cancer (Lt, Type 5b, cT3N2M0, cStage III) was diagnosed, and in March 2019, the patient underwent right trans-thoraco-abdominal subtotal esophagectomy, two regional + cervical lymph node dissections, and gastric tube reconstruction via the retrosternal route. The patient had been followed up without recurrence until October 2020, when a sudden decrease in visual acuity and the onset of color blindness occurred. Cancer-associated retinopathy (CAR), a form of autoimmune retinopathy, was clinically diagnosed based on a visual field examination, electroretinogram, OCT, and ophthalmoscopic findings. A bronchoscopic biopsy revealed squamous cell carcinoma, and recurrent metastasis was diagnosed, for which the patient received chemoradiation therapy (CRT) consisting of FP and Σ60 Gy/30 Fr. No metastasis was detected by positron emission tomography. The metastasis continued to shrink, and no new recurrences were observed. The patient's visual function improved with shrinkage of the recurrence, and no deterioration in the disease was noted. CAR caused by esophageal cancer is extremely rare. We report a case of esophageal cancer recurrence presented with CAR.

A 75-year-old man was referred to our department after upper gastrointestinal endoscopy to investigate epigastric pain identified type 3 gastric cancer in the lesser curvature of the gastric angle. Computed tomography (CT) did not show any distant metastases, and the diagnosis was cT4aN1M0, cStage III. Resection was attempted, but the tumor was directly invading the head of the pancreas, and since R0 resection could not be performed without pancreaticoduodenectomy (PD), the attempt was abandoned (cT4b (pancreas) N1M0, cStage IVA). It was then decided to administer preoperative chemotherapy, and combination chemotherapy with capecitabine, oxaliplatin, and nivolumab was started. CT after eight courses showed that the primary lesion had contracted dramatically, and there was now a clear margin between the tumor and the head of the pancreas. It was determined that standard R0 resection was now feasible, and laparoscopic distal gastrectomy was performed. The final pathological diagnosis was por2, ypT4a, Ly1a, V1a, pPM0, pDM0, ypN3a, ypStage IIIB, and the histological response to preoperative chemotherapy was assessed as Grade 1a. Whether to perform PD, a highly surgically invasive procedure, for patients with pancreatic invasion of gastric cancer is often the subject of debate, but this case suggests that, with the use of preoperative chemotherapy including nivolumab, one may be able to avoid PD and aim for R0 resection by means of standard surgery.

A 17-year-old man presented with intensifying abdominal pain which occurred on the day before. Abdominal CT findings showed intussusception caused by a mass lesion in the ileocecal region. High-pressure enema performed for diagnosis and therapy was unsuccessful and we could not reduce the intussusception. Therefore, emergency operation was performed. Surgical findings confirmed intussusception in the transverse colon, which was arising from the ascending colon, cecum and ileum. After manual reduction of the intussusception, we could not completely exclude a possibility of malignant tumor. Accordingly, we performed ileocecal resection. Pathological examination revealed that the tumor was pneumatosis cystoides intestinalis (PCI). PCI is a comparatively rare disease that produces a large number of aerobic cyst under the submucosal or subserosal structures of the digestive tract wall. Few studies have reported intussusception with PCI. We report this case with some literature review.

An inflammatory myofibroblastic tumor (IMT) is a tumorous lesion characterized by the proliferation of myofibroblast-like spindle cells in association with severe inflammatory cell infiltration. A 71-year-old man presented with abdominal pain that had continued for 2 months and was referred to our hospital. On abdominal computed tomography, a 30-mm, soft tissue tumor was seen in the ileum with a gradually increasing contrast effect. Intussusception had occurred at the advancing edge of the tumor. On abdominal magnetic resonance imaging, the tumor was hypointense on both T1- and T2-weighted imaging, suggesting that its main component was fibrous. During surgery, a 3-cm-long, small bowel tumor and intussusception were present 70-cm orally from the ileocecal junction, and laparoscopic partial small bowel resection was performed. Histopathologically, proliferation of spindle cells exhibiting little atypism and infiltration by lymphocytes, plasmacytes, eosinophils, and other inflammatory cells with intervening bundles of collagen fibers were evident, and IMT was diagnosed. Since IMT rarely has distant metastasis, it is classified as an intermediate-grade tumor in the WHO classification of soft tissue tumors.

Right-sided colonic volvulus is rare, accounting for 0.4% of all colonic obstructions and 5.9% of all colonic volvulus. The patient was a 25-year-old woman. She had cerebral palsy and scoliosis due to severe neonatal asphyxia, and had undergone fundoplication, gastrostomy, and tracheostomy. She was brought into our hospital with a diagnosis of intestinal obstruction. A blood analysis revealed mild degree of inflammatory reaction. A CT scan showed a dilated colon in the right upper quadrant of abdomen, but the origin of the obstruction was unclear. On the second day of admission, the patient was operated on because of worsening abdominal distention after intestinal tract decompression. Intraoperative findings revealed that the right colon had not been fixed and the ascending colon, twisted 180 degrees, was invaginated into the right upper abdomen. Although there was no necrosis, serosal membrane damage and stasis were observed, and considering the risk of recurrence, the distended portion was resected and reconstructed with a functional end-to-end anastomosis. The postoperative course was good. When the disease affects a patient with cerebral palsy, it is sometimes difficult to make the preoperative diagnosis. However, we should determine whether or not torsion should be repaired within 24 hours after the onset and consider the risk of recurrence when resection of the intestine is considered.

An 82-year-old man underwent ileo-transverse colon anastomosis for cT4b (ureter, iliopsoas) N1bM0 cStage IIIc ascending colon cancer. Postoperatively, the patient was started on CapeOX+Bev as systemic chemotherapy, and the efficacy was judged to be SD. Pathology on the biopsy specimen confirmed MSI-High status, so systemic therapy was switched to pembrolizumab. After 6 courses of pembrolizumab, a CT scan showed that the tumor had shrunk, and the ureteral invasion had disappeared. In the hope of achieving a complete elimination, we then performed a right hemicolectomy and D3 lymph node dissection. Histologically, no residual tumor cells were found in the specimen, and the patient was pathologically CR. No signs of recurrence or metastasis have been observed during one year of ongoing follow-up visits.

A 76-year-old man was referred to our hospital to investigate the cause of bloody stool. On colonoscopy, a type 1 tumor was seen from the dentate line to Herrmann's line, which was malignant on biopsy. No tumor and no erosion were found outside the anal verge and skin. With the diagnosis of anal canal adenocarcinoma (cT2N0M0 cStage I), laparoscopic abdominoperineal resection was performed. The pathological diagnosis was anal canal adenocarcinoma with pagetoid spread. Pagetoid spread was extensively observed on the anal side of the elevated tumors, and the distal margin was only 1.3 mm. The patient was followed up postoperatively and was alive 3 years and 6 months after surgery without recurrence. In this case, no skin lesions were seen before surgery, making preoperative diagnosis difficult. A very rare case of pagetoid spread that has remained recurrence-free for a long period of time without additional resection, despite a small dissection distance, is reported.

A 6-year-old girl was admitted with upper abdominal pain to her local hospital. She was referred to our hospital because abdominal computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) showed cholelithiasis. Limy bile was suspected because the X-ray and CT showed a floating calcified shadow in the right upper abdominal region. On blood tests, hepatobiliary enzyme and CRP levels were within normal ranges. Her pain was easily relieved by an analgesic. ERCP under general anesthesia showed that there was no pancreaticobiliary maljunction, and there was low conjunction of the cystic duct with the common bile duct. There was a cystic duct stone that could not be moved with a guide wire. An attack of biliary colic caused by limy bile and cholecystitis was diagnosed, and laparoscopic cholecystectomy was performed. The neck of the gallbladder had severe inflammation, a finding of chronic cholecystitis. She was discharged on the 4th postoperative day. Limy bile is rare in a child. Thus, this case is reported along with a review of the literature.

An 85-year-old woman was referred to our hospital with a gallbladder tumor. Laboratory studies showed elevated serum levels of AFP 1960 ng/ml and CEA 7.5 ng/ml. Although a histological diagnosis was not obtained, a diagnosis of gallbladder cancer, cT2N0M0 cStage II, was made based on abdominal ultrasonography, CT, and MRI, and cholecystectomy including the gallbladder bed was performed. Histologically, the tumor had a mixture of components of moderately differentiated papillary adenocarcinoma and components similar to hepatocellular carcinoma, and hepatoid adenocarcinoma of the gallbladder was diagnosed. After surgery, the serum AFP and CEA concentrations returned to normal levels. The patient has been doing well without recurrence at 4 months. Hepatoid adenocarcinoma is a rare type of cancer with two characteristics, hepatocellular carcinoma and adenocarcinoma. Hepatoid adenocarcinoma has been reported in various organs, such as the stomach, colon, lung, pancreas, and uterus. However, there have been few examples in the gallbladder. Thus, this case is reported along with a review of the literature.

The patient was a 53-year-old woman. She presented to the obstetrics and gynecology department with bulging and pain in the right inguinal region. Examination results led an inguinal hernia to be suspected and she was referred to our department. An abdominal ultrasonography and a contrast-enhanced CT scan of the abdomen revealed a 3-cm mass with contrast effect in the inguinal region and a continuous cord-like structure extending into the ileocecal area. Laparoscopic surgery with a suspected diagnosis of inguinal hernia or inguinal tumor showed no inguinal hernia, and intraoperative findings by means of the inguinal incision revealed a tumor connected to the round ligament. It was diagnosed as round ligament tumor, and was completely resected. Histopathological examination revealed spindle-shaped, intricate smooth muscle tissue, and we diagnosed it as a round ligament leiomyoma. We have experienced a case of a round ligament leiomyoma that was difficult to differentiate from an inguinal hernia. Leiomyoma of the round ligament is a very rare disease. However, if the lesion is an inguinal mass affecting women with a history of uterine myoma, it should be considered as a differential disease. Laparoscopic surgery appears to be useful for differentiating round ligament leiomyoma from inguinal hernia.

A 34-year-old man with multiple endocrine neoplasia (MEN) 2A presented with recurrence of thyroid medullary carcinoma. A preoperative CT scan revealed a left adrenal mass. ¹²³I-meta-iodobenzylguanidine (MIBG) scintigraphy showed increased accumulation in the left adrenal mass, but no excessive secretion of catecholamines was noted These preoperative findings did not meet the diagnostic criteria for pheochromocytoma. Because the adrenal mass affected the MEN2A patient, it was reasonable to suspect the left adrenal mass as a pheochromocytoma, and an alpha-blocker was administered preoperatively according to the perioperative management of pheochromocytoma. During the operation, the patient's blood pressure elevated due to the surgical maneuver, but antihypertensive treatment by the alpha-blocker was effective, and the operation could be completed safely. Even in pheochromocytoma, endocrine function tests may not demonstrate excessive catecholamine secretion, and perioperative management based on comprehensive clinical findings is important to ensure safe treatment.

The patient was a 69-year-old woman. She was admitted to our hospital due to abdominal distension. CT scan of the abdomen revealed a large mass, measuring 19 cm × 13.5 cm on the left upper quadrant. A retroperitoneal tumor, such as adrenal carcinoma, was suspected. Therefore, a laparotomy was performed. The resected tumor measured 20 cm at the widest diameter. Histopathologic examination revealed hemangiopericytoma-like vessels, and immunostaining was positive for CD34. A solitary fibrous tumor (SFT) arising from the retroperitoneum was the final diagnosis. The patient had an uncomplicated postoperative course and was discharged from the hospital on the seventh postoperative day. The patient has been reviewed periodically as an outpatient. No recurrence has been observed in the 6 years and 3 months since surgery. This case described our experience of a large SFT in the retroperitoneum.

The patient was a 77-year-old man. He presented to the emergency department of another hospital with the chief complaints of dysuria and right lower back pain. He was diagnosed with right inguinal hernia and was referred to our department for treatment. Computed tomography (CT) showed a right inguinal hernia, bladder prolapsed to the right scrotum, and hydronephrosis caused by right ureteral slippage and traction. The ileum also prolapsed into the hernia sac. In this case, we performed transabdominal preperitoneal repair (TAPP) after placing a ureteral stent before the start of surgery. After six months, the patient did not show any hernia recurrence or urinary disorders. Inguinal bladder hernias have been reported to occur in 1-4% of adult inguinal hernias. Inguinal bladder hernias associated with ureteral slippage and hydronephrosis are rare. There have been no reports of TAPP surgery for an inguinal bladder hernia with ureteral slippage ; therefore, we report this case with a review of the available literature.

We performed laparoscopic removal of an infected mesh sheet in a patient who had undergone laparoscopic hernioplasty 6 months previously. Using a laparoscope, we incised the thickened peritoneum to reach the abscess cavity and remove the infected mesh sheet. Although this operation was highly stressful, using a laparoscope, we could completely and safely remove the mesh of the tackers and wash the cavity firmly. The patient had no fever or complications and was discharged three days after the operation.

Laparoscopic removal of an infected mesh sheet is a suitable method for cases of mesh infection after hernioplasty.

An 85-year-old woman with a chief complaint of persistent abdominal pain and vomiting visited a clinic where she underwent computed tomography (CT). A diagnosis of right incarcerated obturator hernia was made, and she was referred to our hospital. The hernia could be easily reduced manually (noninvasively). An immediate CT scan confirmed the hernia reduction and showed no findings suggestive of gastrointestinal perforation or any other conditions. Three days after the hernia reduction, the patient complained of abdominal pain. A CT scan revealed intraperitoneal free gas, which led to a diagnosis of perforation peritonitis. The patient underwent open partial small bowel resection with preperitoneal hernia repair via midline incision using a Direct Kugel Patch with measures taken to prevent wound contamination. Noninvasive reduction of incarcerated obturator hernia has the benefits of avoiding emergency surgery and allowing preoperative detailed evaluation. However, there is always a risk of ischemic perforation of the incarcerated bowel during the reduction. Thus, no consensus has been reached regarding the indication of the noninvasive reduction. Prior to this case report, there have been no documented cases of delayed bowel perforation after noninvasive reduction of incarcerated obturator hernia in the scientific literature. We further discuss this case by reviewing the literature.

A 68-year-old woman was admitted to her family doctor because of increased right lower abdominal and right lower limb pain with gait disturbances. She was suspected of having a pelvic floor hernia on a computed tomography (CT) scan and was referred to our hospital. Abdominal CT revealed prolapse of the small intestine in the right sciatic foramen, and a diagnosis of hernia of the greater sciatic foramen was made. Although there was no evidence of intestinal obstruction, the patient presented with sciatic neuralgia. Therefore, emergency surgery was performed. A right sciatic hernia was observed following laparotomy. The small intestine was reduced. Small-intestinal resection was not performed because there was no evidence of intestinal necrosis. The hernial portal was closed using simple sutures. The day after surgery, the patient's sciatic neuropathy improved with the disappearance of right leg pain. Sciatic hernias are extremely rare, and only 14 cases of small intestinal herniation have been reported thus far, including only four cases of sciatic nerve pain. Here, we report the present case and discuss the relevant literature.