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.
1) 伊那中央病院外科 症例は 63 歳の男性で,腹痛,一過性の意識消失を認め受診した.受診時ショック状態であり,上腹部に 圧痛を認めた.血液検査では貧血と血小板減少,腹部 CT では腹腔内にやや density の高い多量の腹水貯留 を認め,腹腔内に右胃大網動脈から連続して 75×45×36 mm 大の囊状に拡張した造影剤貯留を認めた.右胃 大網動脈瘤破裂による腹腔内出血,出血性ショックと診断し,緊急手術を施行した.手術では多量の腹腔 内出血と右胃大網動脈に拍動性の動脈瘤を認めた.動脈瘤壁は破綻し,動脈瘤破裂の所見であった.右胃 大網動脈根部を露出し結紮切離,大網とともに動脈瘤を摘出した.ショックを呈した胃大網動脈瘤破裂は まれであるが,救命のためには迅速な診断と治療が求められる.胃大網動脈瘤破裂につき,その疫学,診 断および治療につき報告する. キーワード:胃大網動脈瘤,破裂,ショック はじめに 胃大網動脈瘤はまれな疾患であるが 1 ) ,動脈瘤破裂を来した場合には,救命のため迅速な診断と治療が 必要である.我々は,右胃大網動脈瘤破裂によりショックを来し,手術により治療しえた 1 例を経験した ため報告する. 症 例 患者:63 歳,男性 主訴:腹痛 既往歴:慢性 C 型肝炎でフォローを受けていたが,腹部画像検査でこれまで異常を指摘されたことはな かった.腹部外傷歴や高血圧の既往はなかった. 現病歴:2013 年 9 月中旬,前日の夕に腹痛を認めていたが,一時的に腹痛は改善したため経過を見てい た.翌日夕に腹痛が突如として再燃,同時に一過性に意識レベルの低下と冷汗の出現を認めたため当院へ 救急搬送された. 身体所見:身長 175.0 cm,体重 58.6 kg,体温 37.1°C,心拍数 92 回/分,血圧 75/44 mmHg,呼吸数 18 回/分,SpO 2 96%(room air) ,意識は清,腹部は膨隆していた.上腹部に圧痛を認めたが,腹膜刺激症状は 認めなかった. 血液検査所見:RBC 248×10 4 /μl,Hb 8.1 g/dl,Plt 7.3×10 4 /μl,TP 4.7 g/dl,Alb 2.6 g/dl と貧血と血小板低 〈2015 年 6 月 24 日受理〉別刷請求先:芳澤 淳一 〒 399-8695 北安曇郡池田町大字池田 3207-1 北アルプス医療センターあづみ病院 外科 日本消化器外科学会雑誌.2015;48(11):897-903
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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