We conducted a retrospective analysis of clinical features of cases in which cytology revealed ciliated columnar epithelium after an unnoticed tracheal puncture during an ultrasound-guided fine-needle aspiration biopsy (UG-FNAB). A total of 1,042,356 tumors underwent a UG-FNAB at our hospital between January 2005 and June 2022, and ciliated columnar epithelia were observed in 19 cases (0.0018%). We enrolled these 19 tumors in the analysis. One tumor was <5 mm in size ; almost half of the tumors were >10 mm. In only five cases, it was difficult to visualize the inside of the tumor and/or the border of the trachea and tumor by ultrasound, due to calcifications. Final diagnoses were obtained in 12 tumors (seven malignant and five benign). Seven tumors went undiagnosed without repeated UG-FNAB. After the tracheal puncture, there were no subsequent complications and no local recurrence in any of the patients with malignancies. Thus, an unnoticed tracheal puncture might not cause severe complications or local recurrence, but it will decrease the diagnostic yield for cytologic diagnoses. Regardless of the tumor size and ultrasonographic appearance, it is necessary to consider the possibility of a tracheal puncture when cytology for thyroid disease indicates ciliated columnar epithelium.

Sentinel node biopsy for treatment of cN0 early breast cancer has been established and a double method with radioisotope (RI) and dye is recommended. We mainly use RI and Indocyanine Green (ICG) supplementally.

Clinicopathological factors influencing RI-lymph flow to sentinel nodes and prediction of axillary node dissection were evaluated among 207 patients with cN0 breast cancer. RI-lymph flow was calculated by RI-counts per volume in sentinel nodes and the injection site using SPECT-CT ; SIEMENS Symbia Intevo6^®. RI-lymph flow did not always correlate with sentinel node metastasis. It increased in patients with nodal micro-metastasis of diameter ≦2mm, although it decreased in patients with macro-metastasis >2mm, for whom axillary node dissection was considered.

RI-lymph flow decreased in the elderly, especially in menopausal females and in patients with cancer located at the inner-lower quadrant, did not relate to the invasive size of the cancer nor body mass index. In these results, RI-lymph flow was considered to be useful for predicting sentinel node macro-metastasis and surgical conversion to axillary node dissection. That is, they are possible in younger, especially premenopausal females with cancer located in sites other than the inner-lower quadrant and low RI-lymph flow. They are unlikely in the elderly or patients with cancer located in the inner-lower quadrant and high RI-lymph flow.

A 46-year-old man presented to our hospital with bloody sputum that had persisted for two months. Bloody sputum gradually increased, and hemoptysis was present. A chest CT scan showed a nodular shadow with a cavity in the upper lobe of the left lung and swelling of the hilar lymph nodes. The possibility of lung cancer could not be ruled out, so an operation was performed. Yellow-brown cloudy pleural effusion was present in the thoracic cavity, and hypervascularity, white calluses, and reddish-brown spots were diffusely observed in the parietal pleura.

White pleural thickening and numerous nodules were noted on the diaphragmatic surface. Histopathological findings showed eggshell-like structure at the margin of the necrotic tissue within the tumor, and a parasite egg with several nuclei and an acidophilic cytoplasm inside. Westermann paragonimiasis was most suspected by antiparasitic antibody screening test. Combined with histopathological examination and antiparasitic antibody screening test, the case was diagnosed as Paragonimus westermani infection. Although Paragonimus westermani infection is relatively rare, it should be considered as a disease that should be differentiated from pulmonary masses.

Colonobronchial fistula (CBF) can induce severe pneumonia due to inflow of feces via a fistula created between the colon and the bronchus. We report a case of which pneumonia caused by CBF was treated by endobronchial occlusion using Endobronchial Watanabe Spigot (EWS).

The patient was a 75-year-old man who had been on the treatment with percutaneous drainage and antibiotic therapy for left subdiaphragmatic abscess caused by descending colon perforation. During the treatment, the abscess penetrated the diaphragm, forming a pulmonary abscess in the basal segment of the left lung. In addition, the pulmonary abscess ruptured into the bronchi, causing severe pneumonia due to fecal inflow. He developed acute respiratory failure and septic shock. In order to save his life, we performed the resection of the perforated colon, colostomy, and simultaneously EWS occlusion to the responsible bronchi. After the endobronchial occlusion, the fecal inflow disappeared, respiratory condition became stable during surgery and the pneumonia was improved. He was discharged home about 2.5 months after the operation. Endobronchial occlusion using EWS is useful for colonobronchial fistula.

A 75-year-old woman underwent total hysterectomy with bilateral salpingo-oophorectomy for stage IIIa uterine cancer 6 years and 9 months ago. PET-CT and contrast-enhanced MRI revealed diaphragmatic tumors in contact with the inferior vena cava (IVC), which was suspected to be a recurrence of uterine cancer. The IVC was secured after total liver mobilization, and the presence of an enlarged paraesophageal lymph node consistent with metastasis from uterine cancer was confirmed by the frozen section procedure. The diaphragmatic tumors invaded the caudate lobe of the liver ; however, they were safely resected using a combination of Pringle's method and side clamping of the IVC. The final histopathological diagnosis was diaphragmatic metastasis of uterine cancer. Recurrence of uterine cancer is often seen in the lungs, peritoneum, and ovaries, but is extremely rare in the diaphragm and mediastinal lymph nodes. Although the patient underwent R1 resection, the diagnosis was confirmed, and consistency with the previous treatment was maintained. Survival of the patient 55 months after surgery suggests that the multidisciplinary treatment, including surgery, contributed to the improvement in the prognosis.

A 68-year-old woman presented with a self-inflicted neck injury. Abdominal X-ray showed multiple, coincidental, linear shadows indicating that she had swallowed a large number of sewing needles two days before her visit. Abdominal computed tomography (CT) demonstrated multiple, linear shadows in the small intestine and colon, but no evidence of any gastrointestinal perforation. Since there was a high possibility of spontaneous evacuation, the patient was treated conservatively with fasting and laxatives. Seven days later, CT demonstrated that most of the linear shadows had migrated to the colon and had decreased to about half their original number. On day 25, CT demonstrated only one remaining shadow in the transverse colon and two suspected perforations in the ileum and sigmoid colon. On day 28, surgery was performed. The needle in the transverse colon was removed by colonoscopy. Intraoperative fluoroscopy was also used to remove the perforating needle. The patient was then transferred to the psychiatry department 14 days after surgery.

A 46-year-old man presented to our hospital complaining of repeated abdominal pain and fever for the preceding six months. Detailed examinations showed edematous changes of the intestinal wall from the terminal ileum to the ascending colon and stenosis of the terminal ileum. The patient was admitted with a diagnosis of intestinal obstruction, and lower gastrointestinal endoscopy showed only edematous changes of the mucosa from the ileocecal junction to the transverse colon. Because a patency capsule test showed that passage through the terminal ileum was obstructed, severe stenosis was diagnosed, and the decision was made to treat the patient surgically. On intraoperative examination, reddening and hardening of the serosal surface were identified from the ileum to the right transverse colon, which adhered strongly to the retroperitoneal and right abdominal walls. Laparoscopic right hemicolectomy was performed, and the patient was discharged on postoperative Day 7 after an uneventful postoperative course. Postoperative histopathological examination showed no signs suggestive of malignancy or inflammatory bowel disease, and it was thought that repeated ileal diverticulitis had resulted in fibrosis of the subserosal layer, leading to stenosis. Stenosis due to ileal diverticulitis is rare, and this case is reported together with a short discussion of the literature.

A 69-year-old woman experiencing redness and tenderness in her lower right abdomen for one week visited a local doctor who suspected an incarcerated right inguinal hernia and referred her to the Department of Surgery of our hospital. A painful fist-sized red mass extending to the vulva was observed in the lower right abdomen. Contrast-enhanced computed tomography of the abdomen revealed an abscess extending from the right retroperitoneum to the inguinal canal and abdominal wall. The abscess was continuous with the tip of the swollen appendix. She was diagnosed with acute appendicitis that was perforating the abdominal wall. She underwent incision and drainage of the abscess under lumbar anesthesia. Four months later, the patient underwent a lower gastrointestinal endoscopy to rule out any malignancy, followed by a laparoscopic appendectomy. At 1 year and 4 months after the surgery, the patient is doing well. Recently, laparoscopic interval appendectomy (LIA) after conservative treatment has been recognized as a treatment option. We report a rare case of appendicitis perforating the abdominal wall and complicated by an inguinal canal abscess extending to the vulva in which LIA was performed safely and cosmetically after incision and drainage of the abscess.

A 62-year-old woman visited our hospital because of an abdominal mass in the right lower quadrant. Contrast-enhanced computed tomography showed a 14-cm tumor contacting the small intestine and ascending colon. Colonoscopy showed no abnormal findings, and, therefore, no definitive diagnosis was obtained. Since the tumor originated from the transverse colon, right hemicolectomy was performed. Histologically, the tumor was diagnosed as an undifferentiated pleomorphic sarcoma. With no adjuvant therapy, the patient is alive with no signs of recurrence 12 months after surgery. Undifferentiated pleomorphic sarcoma is prevalent in extremity soft tissues, and it is often reported that patients with this disease have a poor prognosis. Since undifferentiated pleomorphic sarcoma of the colon is rare, this case is reported along with a review of the relevant literature.

A 70-year-old man was brought into our hospital because he had a bruise on the back of the head when he had fallen down. A CT scan conducted for swelling and redness of the left buttock revealed buttock abscess along with descending colon cancer and retroperitoneal abscess. He was emergently admitted to our hospital. Colonoscopy showed a type 2 lesion completely encircled the descending colon. The lesion was diagnosed as adenocarcinoma based on a biopsy. As he had a previous history of implantation of the left iliac bone for fracture of the left lower limb, and the retroperitoneal abscess communicated with the left buttock abscess via a defect of the left iliac bone. The abscess disappeared by colostomy and drainage, however, associated resection of the left iliac bone was needed for complete resection of the remnant scar tissue. In order to avoid excessive surgical stress, resection of the scar tissue was limited from the periphery of the primary lesion to the iliac fistula. Despite left hemicolectomy and closure of the stoma, no cancer cells were identified at the surgical margin even by pathological findings. The patient is doing well as of 42 months after the surgery.

An 81-year-old woman underwent a laparoscopic right colectomy for ascending colon cancer, and a 3-cm whitish nodule resembling Yatsugashira Yam was found on the subhepatic surface near the tumor. Preoperative computed tomography showed multiple hepatic cysts as well as a low-density area with slight contrast enhancement in the liver (S5). Since the patient had advanced-stage cancer with perineural invasion, the whitish nodule was considered to be a disseminated nodule of the ascending colon cancer that had invaded the liver, and a partial hepatectomy was performed. The specimen from the liver resection showed a nodule with a thick capsule filled with ocherous gruel material. Pathological examination revealed the ascending colon cancer to be poorly differentiated, SS invasion, and no lymph node metastasis. The whitish nodule was an encapsulated cyst containing necrotic material and cholesterin clefts ; the capsule was composed of hyalinized collagen fibers and elastic fibers with no malignant findings. The nodule was diagnosed as a solitary necrotic nodule of the liver. Solitary necrotic nodules of the liver are rare intrahepatic lesions that are often difficult to pre- and intraoperatively diagnose. To date, 46 such cases have been published. We compiled them and reported them with a review of their clinicopathological features.

A 17-year-old man, who was diagnosed with glycogen storage disease type Ia at the age of two and then had been treated in the Department of Pediatrics in our hospital, was pointed out to have an 8-cm diameter tumor in the liver S6 and multiple nodular lesions in both lobes on CT at the age of 17. A diagnosis of hepatocellular adenoma associated with glycogen storage disease type Ia was most likely. We determined to indicate resection for the S6 lesion in order to avoid risks such as malignant change and rupture. Upon laparotomy, the liver had significantly swollen to show a pattern of fatty liver, and a fist-sized elastic-soft tumor which protruded into inferior surface of the liver was found. Partial hepatic resection was performed. Although he needed two-day postoperative ICU management for strict blood sugar control to treat lactic acidosis or hypoglycemic attack due to glycogen storage disease type Ia, otherwise his postoperative course was uneventful. Histopathological studies revealed no malignant findings that were compatible with hepatocellular adenoma. As of one year and 6 months after the operation, we confirm that the remnant hepatocellular adenoma is enlarging, so that we are proposing him to undergo living donor liver transplant. Treating hepatocellular adenoma associated with glycogen storage disease type Ia, we must select suitable method case by case, by keeping a possibility of liver transplantation in mind and considering a risk of malignant transformation or rupture.

The patient was a 78-year-old man who was diagnosed with multiple hepatocellular carcinomas (HCCs) and was found to have acquired hemophilia A (AHA) on further examination. Immunosuppressive therapy for the AHA was performed prior to surgery and resulted in normalization of the APTT value and negative coagulation factor VIII autoantibodies. Right hepatic lobectomy was necessary for radical resection, and it was performed after embolization of the right branch of the portal vein. He was discharged from the hospital on the 15th day after surgery, and he has been alive for 6 months without recurrence after the operation. His AHA continues to be in remission.

AHA is a disease caused by acquired autoantibodies to coagulation factor VIII due to a breakdown of the immune system caused by autoimmune diseases or malignant tumors. In this case, AHA was diagnosed preoperatively, and liver resection was safely performed after the hemophilia was treated. Surgical resection of malignant tumors when the hemophilia is not diagnosed preoperatively often results in an unfortunate outcome due to uncontrolled bleeding. In the case of preoperative coagulation abnormalities such as a prolonged APTT alone, we should actively consider the presence of AHA.

The patient was an 81-year-old man who presented to our emergency department with jaundice and impaired consciousness. Abdominal ultrasound (US) showed an enlarged gallbladder with a thickened wall and an 11-mm stone inside. Acute cholecystitis (Grade III) was diagnosed, and percutaneous transhepatic gallbladder drainage (PTGBD) was performed. Bleeding in the gallbladder was observed at the time of PTGBD tube insertion, but it stopped spontaneously the next day. On the 22nd day after admission, abdominal US and contrast-enhanced computed tomography (CT) showed a 15-mm gallbladder pseudoaneurysm adjacent to a deep branch of the cholecystic artery near the PTGBD tube insertion site on the luminal side of the gallbladder wall. There was no evidence of extravascular leakage, and the patient's hemodynamics were stable. After antiplatelet agents were stopped, a laparoscopic cholecystectomy was performed on a standby basis. Histopathological findings showed a hematoma and a collapsed arterial wall near the PTGBD tube insertion site. Though a pseudoaneurysm of the gallbladder due to PTGBD tube insertion is rare, this condition should be considered if there is progressive anemia or bloody drainage after PTGBD.

An 85-year-old woman presented with liver dysfunction. Abdominal US showed significant wall thickening accompanied by Rokitansky-Aschoff sinus (RAS) proliferation from the body to the fundus and a 15-mm polyp with a thin stalk in the fundus in the gallbladder. Abdominal contrast-enhanced CT scan showed slight contrast effect in both lesions, but no liver invasion was present. Laparoscopic whole layer cholecystectomy (LWLC) with dissection of No12c lymph node was performed, because a possibility of coexistence of gallbladder cancer could not be ruled out. Pathological examination showed adenocarcinoma in the irregular wall thickening of the body, which partially invaded the subserosa. The final diagnosis was tub1, pT2, pN0, pEM0, pCM0, stage II. The elevated lesion in the fundus was diagnosed as intracholecystic papillary neoplasm (ICPN). No continuity was observed between both lesions. Immunohistochemical analysis of ICPN revealed positive stain for MUC1, MUC5AC and MUC6 but negative for MUC2, suggested mixed gastric type and pancreo-biliary type. The pattern was different from that of gallbladder carcinoma. Ki-67 and p53 were more highly expressed in the cancer lesion than in ICPN.

When a pancreatic cancer patient who has undergone distal gastrectomy requires distal pancreatectomy, a total gastrectomy may be performed due to the risk of ischemia of the remnant stomach. However, patients who have undergone total gastrectomy may have difficulty tolerating postoperative adjuvant chemotherapy, which may interfere with pancreatic cancer treatment. Two cases in which the remnant stomach was safely preserved using intraoperative indocyanine green (ICG) fluorescence and adjuvant chemotherapy was started are presented. Case 1 was a 76-year-old man who underwent distal pancreatectomy for pancreatic cancer after distal gastrectomy for gastric cancer. Intraoperative ICG fluorescence was used to preserve the remaining stomach, and the patient relapsed at 17 months after surgery and is taking postoperative S-1. Case 2 was a 64-year-old man who underwent distal pancreatectomy for pancreatic cancer after distal gastrectomy for a gastric ulcer. Intraoperative ICG fluorescence was used to preserve the remaining stomach, and S-1 was started postoperatively. Eleven months after surgery, the patient relapsed at 11 months and is continuing chemotherapy with a different regimen. Intraoperative ICG fluorescence was useful for safe and reliable remnant stomach preservation and maintenance of tolerability of postoperative adjuvant chemotherapy.

A 71-year-old man presented with a mass in front of the left iliopsoas muscle along with lumber hernia on a lumber MRI examination that was performed for numbness of the left lower extremity. A contrast-enhanced abdominal CT study showed a heterogeneously enhanced mass with a long diameter of 11 cm. The mass extended from the retroperitoneal space to the inguinal canal. The tumor was differentially diagnosed as schwannoma, GIST, and liposarcoma. For the purpose of diagnosis and treatment, the patient underwent en bloc resection of the tumor. The histopathological diagnosis was dedifferentiated liposarcoma. The patient's postoperative course was well and he was discharged on postoperative day 9. However, a local recurrence was found 5 months after the operation, and additional lumpectomy and orchiectomy were performed. The patient underwent cancer genomic profiling tests and MDM2 and CDK4 were amplified.

Retroperitoneal liposarcoma extending deep into the inguinal canal is relatively rare. For inguinal liposarcoma, the best surgical approach is en bloc resection with radical orchiectomy aiming for R0 margin. Cancer genomic profiling tests could guide more precise therapeutic strategies for patients with liposarcoma.

An inguinal hernia containing an ovarian mass is an uncommon occurrence, with only 10 such cases reported in Japan, including our own. Here, we present a case of inguinal hernia accompanied by a prolapsed ovarian mass. A 44-year-old woman was admitted to our hospital with inguinal pain. A cystic mass in the right adnexa of the uterus was identified on contrast-enhanced CT imaging. Following admission and a 5-day course of immunoglobulin administration, laparoscopic inguinal hernia repair and a right adnexectomy were conducted as elective surgeries. This decision was based on the low likelihood of ischemia affecting the hernia contents and the concurrent presence of thrombocytopenia (26×10³/μL) attributed to idiopathic thrombocytopenic purpura. The surgically removed ovarian mass was identified as a cystic mass containing fluid resembling blood and was histologically confirmed to be an endometriotic cyst.