BackgroundGastric hepatoid adenocarcinoma (GHAC) is an atypical form of gastric cancer (GC) that has similar tissue morphology to hepatocellular carcinoma and frequently produces alpha-fetoprotein. We present an exceedingly rare case of GHAC resulting in a spontaneous gastric perforation.Case presentationA 61-year-old man presented at our institution complaining of abdominal and back pain. A computed tomography scan revealed a spontaneous gastric perforation with a solitary liver tumor and lymph node swelling. Following a diagnosis of advanced-stage GC with a gastric perforation, perforative peritonitis, multiple lymph node metastases, and a solitary metastasis of the lateral segment of the liver, the patient underwent distal gastrectomy. Histopathology of the resected specimen revealed that the tumor cells were arranged in a hepatoid pattern. On immunohistochemical staining, the tumor cells were positive for alpha-fetoprotein and Sal-like protein 4. Thus, the patient was diagnosed with GHAC. Hepatic resection of the solitary liver metastasis was performed. However, recurrence occurred and the patient achieved complete response following tegafur/gimeracil/oteracil-based chemotherapy.ConclusionsGHAC is a highly malignant histological subtype of GC. We reported on an extremely rare case of GHAC resulting in a spontaneous gastric perforation and reviewed the literature, including epidemiological data, treatment regimens, and the association between GHAC and alpha-fetoprotein-producing GC.

BackgroundSolitary metastasis of a malignancy to the spleen is rare, particularly for gastric cancer. Only a few case reports have documented isolated splenic metastasis from early gastric cancer. We describe a case of splenic metastasis from early gastric cancer.Case presentationA 60-year-old man underwent a distal gastrectomy for early gastric cancer. It infiltrated the submucosa with pathological nodal involvement (pT1bN2M0, stage IIB). One year after the gastrectomy, an abdominal computed tomography scan showed a low-density lesion, 17 mm in diameter, at the upper pole of the spleen. Positron emission tomography/computed tomography showed focal accumulation of fluorine-18 fluorodeoxyglucose in the spleen without extrasplenic tumor dissemination or metastasis. We diagnosed splenic metastasis of gastric cancer, and performed a splenectomy. Histological examination confirmed moderately differentiated tubular adenocarcinoma and poorly differentiated adenocarcinoma (solid type) that was consistent with the features of the primary gastric cancer. The splenic tumor was pathologically and immunohistochemically diagnosed as a metastasis from the gastric carcinoma. More than 18 months after the splenectomy, the patient has had no evidence of recurrent gastric cancer.ConclusionWhen solitary metastasis to the spleen is suspected during the postoperative follow-up of a patient with gastric cancer, a splenectomy is a potentially effective treatment.

Background A horseshoe kidney is a congenital malformation involving the fusion of the bilateral kidneys and is often accompanied by anomalies of the ureteropelvic and vascular systems. When performing resection of colorectal cancer in a patient with horseshoe kidney, damage to the ureter or excessive renal arteries should be avoided. To achieve this purpose, comprehensive preoperative anatomical assessments and surgical planning are important. Here, we report a case of a laparoscopic abdominal perineal rectal resection for lower rectal cancer with a horseshoe kidney. Case presentation A 79-year-old woman presented with bloody stool and was diagnosed with advanced lower rectal cancer, immediately above the rectal dentate line, without metastasis. A preoperative computed tomography (CT) scan revealed a horseshoe kidney, while a three-dimensional CT (3D-CT) angiography revealed aberrant excess renal artery from the aorta to the renal isthmus. The left ureter ran in front of the isthmus of the horseshoe kidney and presented calculus formation. Laparoscopic abdominal perineal rectal resection was performed with D3 lymph node dissection. During the operation, we mobilized the sigmoid colon mesentery via a medial approach and preserved the left ureter, the left gonadal vessels, and the hypogastric nerve plexus in the retroperitoneum in front of the horseshoe kidney. Conclusions We report a rare case of rectal cancer surgery in a patient with a horseshoe kidney. We discuss the anatomical peculiarities of a horseshoe kidney, such as excess renal arteries, inferior vena cava, ureter, gonadal vessels, and nerves, that should be preserved according to the literature. We suggest that preoperative 3D-CT angiography is both useful for revealing the relationship between the vascular system and a horseshoe kidney and helpful when performing laparoscopic surgery for a left-sided colon and rectal cancer to avoid intraoperative injury.

BackgroundMediastinal lymph node metastases occasionally occur in patients of advanced gastric cancer of the cardia with esophageal invasion, but they rarely occur in patients with gastric cancer of other sites. This report describes a case of a solitary metastasis to t a superior mediastinal lymph node after distal gastrectomy for gastric cancer of the antrum.Case presentationA 70-year-old man underwent curative distal gastrectomy for advanced gastric cancer of the antrum (pT2pN2M0, stage IIB). Postoperatively, he underwent adjuvant chemotherapy with S-1 (100 mg/day). Although the serum levels of his tumor markers increased after surgery, computed tomography scans did not detect evidence of early recurrence in the superior mediastinum. However, a 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) scan showed accumulation of fluorodeoxyglucose in the upper mediastinum with no evidence of recurrence elsewhere. Therefore, a solitary superior mediastinal lymph node was suspected to have a metastatic lesion derived from the gastric cancer. The patient underwent tumor resection right mini-thoracotomy two years and three months following gastrectomy. A pathological examination demonstrated moderately differentiated adenocarcinoma, confirming that it was a metastatic adenocarcinoma from the gastric cancer. The patient developed recurrences in the superior mediastinum and several right costa six months following the second surgery. He was treated with chemotherapy, but he died 18 months after the second operation.ConclusionWe present a rare case of a solitary metastasis to a superior mediastinal lymph node after distal gastrectomy for gastric cancer. An FDG-PET scan is useful for the diagnosis of mediastinal lymph node metastasis in gastric cancer. Metastasis to the superior mediastinal lymph nodes from gastric cancer in sites other than the cardia suggests systemic expansion of gastric cancer, and therefore, even a solitary metastasis may be related to a poor prognosis.

Background: Gastric perforation is a relatively rare complication of gastric cancer. Malignant gastric perforation is often a manifestation of advanced cancer with serosal invasion and lymph node metastasis; thus, gastric cancer rarely perforates at an early stage. Herein, we describe a case of gastric perforation, which was treated conservatively; later, the patient was diagnosed with an extremely rare early-stage gastric cancer and underwent radical surgery in two stages. Case presentation: An 81-year-old woman was referred to our hospital for breathlessness. Abdominal contrast-enhanced computed tomography (CT) revealed gastric perforation and perforated peritonitis. She was hospitalized, and conservative treatment was initiated; upper gastrointestinal endoscopy was performed on the 14th day after admission. Gastric ulcer scars were observed in the anterior wall of the stomach; biopsy from around the ulcer showed group V (moderately-well differentiated adenocarcinoma). She was diagnosed with gastric perforation due to early gastric cancer. Abdominal CT revealed no findings suggestive of liver, lung, or para-aortic lymph node metastasis, and a radical gastrectomy with lymph node dissection was performed 32 days after onset. Microscopic findings revealed that the cancer cells proliferated to the regenerated mucosa of ulcer scars and infiltrated into scar tissue equivalent to submucosal tissue (T1b). The gastric cancer was staged as T1bN0M0, stage IA. The patient has been reported healthy without any evidence of gastric cancer recurrence for the past 48 months. Conclusions: Treatment of gastric cancer perforation includes first-stage surgery and second-stage surgery after conservative therapy and closure of the omental patch or perforation site. Ensuring a balance between lifesaving and curability, while selecting surgical methods is necessary. Depending on the patient's general condition and degree of peritonitis, curatively resectable perforated gastric cancer, including early-stage gastric cancer, should be treated conservatively as in our case, or minimally invasively with an omental patch or perforation closure as surgery for gastric perforation. After evaluation of the patient's general condition and adequate assessment of the extent and progression of the gastric cancer, a two-stage gastrectomy with lymph node dissection was suitable and achieved an improved general condition, which may lead to a highly curative surgery and improve prognosis.

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Background: Gastrointestinal stromal tumor (GIST) is a mesenchymal tumor originating in the wall of the gastrointestinal tract, and 20-30% of these tumors originate from the small intestine. The clinical manifestations of GIST of the small intestine generally include a palpable mass, distention, and abdominal pain and sometimes include acute abdomen due to ileus, bleeding, perforation, and intussusception at onset. Here, we describe a rare case of a pedunculated GIST of the small intestine complicated by torsion.Case presentation: A 69-year-old woman was referred for lower abdominal pain. Abdominal contrast-enhanced computed tomography showed a 73×62×57-mm tumor in the pelvic cavity with an enhanced margin and reduced contrast effect inside of it. T2-weighted magnetic resonance imaging showed a hyperintense, demarcated, lobulated tumor. The diffusion-weighted image showed hyperintensity, and the apparent diffusion coefficient value revealed diffusion restriction, indicating malignancy. T1-weighted images showed a low intensity tumor; contrast-enhanced images showed hypointensity inside of the tumor and slight hyperintensity around its edges. It was presumed that the tumor had caused hemorrhagic infarction. Emergency laparotomy was performed, and the pedunculated tumor was found to be twisted 360 degrees clockwise at the pedicle with hemorrhage and necrosis due to torsion. We performed partial resection of the small intestine including the tumor. Histopathology revealed tightly arranged spindle-shaped cells with hemorrhage, congestion, and inflammatory cell infiltration. Immunohistochemical staining showed positivity for CD34, CD117, and DOG1.Conclusions: The present report describes a very rare case in which pedicle torsion of an extra luminal expanding GIST of small intestine, although there were some reports of small intestine volvulus caused by GIST of small intestine as a rare condition. The torsion of pedunculated GIST of small intestine should be recognized as an emergency condition of GIST, and we report that characteristic findings of this condition were acquired with CT and MRI which was possibility useful for the diagnosis.