Hepatocellular Carcinoma Showing Pathological Complete Response to Lenvatinib Monotherapy

A 61-year-old man was referred to our hospital due to the liver dysfunction without hepatitis B or C infection. In addition to the elevated levels of α-fetoprotein (AFP) and protein induced by vitamin K absence or antagonist-II, a large tumor, 10.8 cm in size, and multiple small tumors, up to 1.6 cm in size, in the liver on computed tomography (CT) led to the diagnosis of unresectable advanced hepatocellular carcinoma (HCC). Levatinib monotherapy resulted in complete disappearance of the small liver tumors and marked shrinkage of the largest tumor with complete disappearance of intratumoral enhancement on CT and normalization of serum AFP levels. After 2 months’ cessation of lenvatinib monotherapy due to side effects, the patient underwent residual tumor resection. The pathological findings showed no viable tumor cells, i.e. pathological complete response. The patient was discharged from the hospital on the twelfth day after the operation without any complication. Lenvatinib monotherapy appears to be more effective for HCC than other conventional treatments. In addition, oncologists should take into consideration the possibility of pathological complete response with newly developed anticancer agents including lenvatinib to develop therapeutic strategies to avoid unnecessary overtreatment

Recurrence of Gastric Cancer in the Jejunum Close to the Anastomotic Site after Total Gastrectomy

A 61-year-old man underwent total gastrectomy with esophago-jejunostomy for Borrmann type I gastric cancer. Postoperative intra-abdominal abscess made the patient unable to receive adjuvant chemotherapy. Only 23 weeks after operation, the patient developed melena and anemia, leading to the diagnosis of recurrence in the jejunum close to the anastomotic site. The patient received salvage resection of the recurrence. Pathological study showed that the tumor was composed of atypical cells similar to those of the primary gastric cancer. Normal jejunal mucosa was observed between the esophagus and the recurrent tumor. We judged that exfoliation of the gastric cancer cells caused the recurrence due to both the very short disease-free interval and pathological findings. Surgeons should pay attention to this type of recurrence especially for Borrmann type I gastric cancer. In addition to the adjuvant chemotherapy, gastric irrigation using distilled water during the operation seems to be a feasible measure to prevent this type of recurrence

Pitfall in the Surgical Management of a Shrunken Skin Defect after Neoadjuvant Chemotherapy for Locally Advanced Breast Cancer

A 53-year-old woman with a large, easy-bleeding, and ulcerated breast tumor visited our hospital due to severe anemia. Transfusion and Mohs’ chemosurgery gave the patient marked improvement of her local and general condition. After confirming the human epidermal growth factor receptor type 2 (HER2)-positive breast cancer with no distant metastasis, anti-HER2 agents-containing chemotherapy brought about clinical complete response of the locally advanced breast cancer with a shrunken but still large skin defect. We, therefore, treated the patient with mastectomy and axillary node dissection but failed to directly close the skin even after full skin undermining. We then tried to cover the skin defect using a latissimus dorsi flap, that is, horizontal spindle skin 12 × 6 cm in size, but again failed to fully cover the skin defect. We finally and ostensibly covered the skin defect through an additional skin incision to the recipient skin, but could not get complete wound healing. Pathological study showed a marked collagen fiber around the skin defect and faint viable cancer cells beneath the nipple. The patient required 3 months of wound management for complete wound healing, leading to the application of anti-HER2 agents without anticancer agent to the patient during that time as an adjuvant therapy. Regrowth of her hair once lost by the neoadjuvant chemotherapy (NAC) made the patient refuse the adjuvant anthracycline-containing chemotherapy after wound healing. The patient, therefore, received trastuzumab-emtansine for a year and has been well for 17 months postoperatively. Breast surgeons should note that a skin defect after favorable response to NAC is often surrounded by less stretchable skin due to chemotherapy-induced massive collagen fiber and requires careful preoperative planning for skin closure

A case report of primary pancreatic leiomyosarcoma requiring six additional resections for recurrences

Introduction: Primary pancreatic leiomyosarcoma is extremely rare. We report a case in which six additional resections were required to treat recurrent tumors in a 5-year period following the primary operation. Presentation of case: A 69-year-old man presented with a pancreatic tumor. Abdominal computed tomography scan showed a large heterogeneous mass with a necrotic area arising from the pancreatic body. We performed distal pancreatectomy, splenectomy, and wide resection of the transverse mesocolon. Histopathological examination confirmed the diagnosis of a pancreatic leiomyosarcoma. We repeatedly performed surgery on recurrent tumors. Discussion: Primary pancreatic leiomyosarcoma is considered to be a highly aggressive malignancy. The most effective treatment is complete surgical resection with tumor-free margins. Even when tumors recur, it is possible to improve the prognosis by further resection. Conclusion: Long-term survival is achievable by repeated resection of recurrent tumors. Keywords: Leiomyosarcoma, Pancreas, Recurrence, Metastasis, Disseminatio