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BACKGROUND: An aberrant biliary duct of segment 5 (B5) is a rare anomaly of the biliary tract. All anatomical anomalies of the biliary tract are risk factors for bile duct injury during surgery. We report a case of cholelithiasis with an aberrant B5 that was detected during a detailed preoperative imaging examination and treated with laparoscopic cholecystectomy. CASE PRESENTATION: A 69-year-old woman was admitted to the emergency room of our hospital with abdominal pain. She was diagnosed with cholelithiasis, and an aberrant B5 branching off the hepatic duct was suggested during preoperative imaging. Laparoscopic cholecystectomy was performed at our surgical department. There were no intra- or postoperative complications, and the patient was discharged on the fourth day after surgery. CONCLUSIONS: Laparoscopic cholecystectomy can be safely performed without intra- or postoperative complications in patients with cholelithiasis and an aberrant B5 if it is accurately diagnosed preoperatively.

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A 67-year-old man with liver and retroperitoneal metastases from a gastrointestinal stromal tumor arising in the jejunum had been administered oral sunitinib for 2 months. He presented to our department with right-sided lower abdominal pain. His general condition was good, with no high-grade fever, and the other vital signs were also stable. Contrast-enhanced computed tomography was promptly performed, and pneumatosis cystoides intestinalis (PCI) was detected in a wide area around the ileocecal lesion. There were no signs of acute abdomen requiring emergency surgery due to conditions such as intestinal perforation, ischemia, or obstruction. Sunitinib was discontinued and the patient was placed on nil orally with intravenous infusion. PCI resolved promptly and the patient was discharged on the 21st day after admission. PCI is a rare side effect of sunitinib with only 8 cases reported previously, which can complicate with acute abdomen or gastrointestinal perforation, in some cases. Thus, the early identification of sunitinib as the cause of PCI is important. Although PCI is a rare adverse effect of sunitinib, clinicians must be aware of it to promptly provide the correct diagnosis and treatment.

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This case involves a 76 year-old woman. A sigmoidectomy was performed for sigmoid colon cancer in August 2006. On histological examination, the cancer was shown to be tub2>tub1>por2, pSE, int, INF b, ly2, v0, pN0, p1 (Douglas), Stage Ⅳ. After surgery, 4 courses of FOLFOX and 8 courses of TS-1 plus CPT-11 were administered after UFT plus LV was performed. Because of suspected recurrence at the anastomotic site, a partial colectomy was performed in September 2010, and TS-1 was started after surgery. In March 2012, the carcinoembryonic antigen level had increased to 13.7 ng/mL. Irregular masses with spicula, 13×15 mm and 19×23 mm on the right and left sides, respectively, were observed on chest computed tomography, and lung metastasis was suspected. Left lower and partial right middle lobectomies were performed. After surgery, the tumor marker levels were normalized. Chemotherapy was not performed. Currently, at 2 years 8 months after resection of the lung metastases, no recurrence was observed. Long-term survival in cases of colon cancer with peritoneal dissemination is rare, but multidisciplinary treatment, including surgical treatment, showed the promising possibility of long-term survival.

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Even though skeletal muscle, making up about 40% of body weight, is the largest organ in the human body, metastasis from malignant lesions is rare. Among reports of metastasis, those involving the iliopsoas muscle are numerous but few reports involve resection. Reported here is one example we experienced where metastasis developed in the iliopsoas muscle following colectomy, resection was then made possible by radiotherapy and chemotherapy. The case involved a 71-year- old male in which a Hartmann procedure was performed for sigmoid colon cancer. The pathology was Type 3 (8 × 7 cm, adenocarcinoma( mod), ss or more, ly1, v1, n0, ow(-), aw or ew(+), stage II). Upon additional sampling, thermal degredation of neoplastic cells was shown and outpatient oral UFT was performed. Five years following surgery, lymphoadenopathy was noted in the area of the left iliac artery upon US and CT. PET showed a probable metastasis to the left iliopsoas muscle. Early esophageal and stomach cancer were diagnosed by GFT. The esophageal cancer was located 30-32 cm from the incisors, unstained, Borrmann type 1, penetrating deeper than the muscularis propria. Biopsy revealed a diagnosis of tubular adenocarcinoma. ESD was performed for the esophageal cancer and one month later, a total gastrectomy D1+ß was performed. During surgery, the iliopsoas muscle tumor was determined to be large and impossible to resect. Radiotherapy of 10MV X-ray, 8 fields, 65-70 Gy/26 times for 6 . 5 weeks was performed for residual tumor but had no effect on tumor size. Fifteen courses of FOLFOX+bevacizumab were then performed. The tumor was markedly reduced in size, unidentifiable upon CT but showed slight uptake on PET and resection of the suspected residual tumor was performed. Histologically, atypical cells were shown in scarred muscle and connective tissue, however, degradation by chemotherapy was high. Residual tumor at resection margins was found, findings consistent with metastasis form sigmoid colon cancer. Taking into account the age and condition of the patient following surgery, chemotherapy was changed to S-1. Currently, 5 months after resection, there has been no recurrence.

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Currently, patients with peritoneal dissemination of gastric cancer must accept a poor prognosis because there is no standard effective therapy. To inhibit peritoneal dissemination it is important to inhibit interactions between extracellular matrices (ECM) and cell surface integrins, which are important for cancer cell adhesion. Although nuclear factor-kappa B (NF-κB) is involved in various processes in cancer progression, its involvement in the expression of integrins has not been elucidated. We used a novel NF-κB inhibitor, dehydroxymethylepoxyquinomicin (DHMEQ), to study whether NF-κB blocks cancer cell adhesion via integrins in a gastric cancer dissemination model in mice and found that DHMEQ is a potent suppressor of cancer cell dissemination. Dehydroxymethylepoxyquinomicin suppressed the NF-κB activity of human gastric cancer cells NUGC-4 and 44As3Luc and blocked the adhesion of cancer cells to ECM when compared with the control. Dehydroxymethylepoxyquinomicin also inhibited expression of integrin (α2, α3, ß1) in in vitro studies. In the in vivo model, we injected 44As3Luc cells pretreated with DHMEQ into the peritoneal cavity of mice and performed peritoneal lavage after the injection of cancer cells. Viable cancer cells in the peritoneal cavities were evaluated sequentially by in vivo imaging. In mice injected with DHMEQ-pretreated cells and lavaged, live cancer cells in the peritoneum were significantly reduced compared with the control, and these mice survived longer. These results indicate that DHMEQ could inhibit cancer cell adhesion to the peritoneum possibly by suppressing integrin expression. Nuclear factor-kappa B inhibition may be a new therapeutic option for suppressing postoperative cancer dissemination.

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INTRODUCTION: The prognosis of type 4 advanced gastric cancer is extremely poor, even the use of multidisciplinary treatment cannot provide satisfactory results. Presented here is a case of highly advanced gastric cancer in which preoperative chemotherapy was effective and resection possible. CASE: A 64-year-old female complained of epigastric distress. Current medical history included: hypertension, hyperlipemia, diabetes, chronic heart disease and development of epigastric distress. Endoscopy was performed upon examination in the Gastroenterology Department. Visual inspection showed a lesion extending from the greater curvature of the fundus to the antrum. Type 4 advanced gastric cancer was strongly suspected. Biopsy samples taken from the antral lesser curvature and from the ulcer border on the upper anterior wall of the body were diagnosed as Group V, adenocarcinoma. Abdominal CT revealed no hepatic mass, but overall thickening of the gastric wall was noticeable and the lymph nodes in the area of the lesser curvature of the stomach and celiac artery were identified. Abdominal ultrasound showed an overall thickening of the gastric wall, and invasion into a portion of the left hepatic lobe and pancreas was suspected. Swelling of the lymph nodes surrounding the stomach was suspected. TREATMENT: Because of gastric cancer with suspected invasion of the left hepatic lobe and pancreas, it was decided to perform preoperative chemotherapy (S-1 + CDDP) and then perform a total gastrectomy. Four courses were performed. RESULTS: Endoscopy revealed no change in the lesion within the stomach. Only scarring in the body and antrum was found, the enlargement was greatly reduced and visual inspection revealed no esophageal infiltration. Biopsy samples were taken from 2 sites, the body center on the lesser curvature side and the greater curvature of the antrum. Scar-like fibrosis was significant and it was not possible to distinguish an increase in poorly differentiated adenocarcinoma. Abdominal CT showed a reduction in gastric wall thickening. These findings showed preoperative chemotherapy to be effective. Following the chemotherapy, a total gastrectomy in addition to splenectomy and cholecystectomy were performed. Histopathological findings showed MLU, type 5, approx. 8.5 × 13 cm, poorly differentiated adenocarcinoma (por 2), INF γ, sci, pT2 (SS), ly2, v0, pN2 (#1: 2/8, #6: 1/6, #11p: 2/5), pPM (-), pDM (-), Stage IIIA. Along with the formation of fibrous scar tissue, an invasive growth of por 2 poorly differentiated adenocarcinoma was found from the submucosal layer to just beneath the serosal layer. Therapeutic effect of the chemotherapy was Grade 2. Post operative S-1 + CDDP was begun but nausea developed and S-1 was reduced. Because of a decrease of neutrophils and nausea, the therapy was changed to UFT. It is currently 6 months after surgery and there are no signs of recurrence. CONCLUSION: Preoperative chemotherapy (S-1 + CDDP) is a therapy which shows promise in reducing tumor size even in highly advanced gastric cancer.

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A case of distant metastasis to mesh-plug prosthesis in gastrointestinal cancer is presented herein. An 88-year-old man had received mesh-plug repair with high ligation for a recurrence of a right inguinal hernia. Six months later, advanced gastric cancer and advanced transverse colon cancer were detected, and therefore a distal gastrectomy and partial colectomy were performed. Two weeks after the operation, the patient complained of right groin tenderness, and the mesh-plug prosthesis was removed to control any infection. A histopathological investigation demonstrated adenocarcinoma in the plug prosthesis. The patient died of carcinomatosis peritonei 45 days after the last operation.

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BACKGROUND AND OBJECTIVES: Superficial spreading type early gastric cancer is characterized by its atypical growth pattern and occasionally indistinct tumor margin. Because it is a rare form of early gastric cancer, the clinicopathological details are not apparent. The aim of this study was to clarify the clinicopathological features of the superficial spreading type of early gastric cancer. METHODS: A retrospective study was conducted in 1,062 surgically resected patients with early gastric cancer. Hospital records were compared between patients with superficial spreading type early gastric cancer and those with more common types of early gastric cancer. RESULTS: Sixty-nine patients (6.9%) had superficial spreading lesions. The male to female ratio was 1.2:1. The most frequent histological type was signet-ring cell carcinoma (32%). The distinguishing histopathological features were submucosal invasion (67%), lymphatic invasion (32%), and lymph node metastasis (30%). There were discrepancies in tumor area between surgical findings and pathological diagnosis in 24 patients (35%) with superficial spreading type. More extensive lymph node dissection was performed and all patients survived in the group with superficial spreading lesions. CONCLUSIONS: The most appropriate treatment for the superficial spreading type of early gastric cancer is wide surgical resection with extensive lymph node dissection.

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