[A Case of Cystic Cervical Lymph Node Metastasis of HPV-positive Tonsil Cancer, Being Discriminated as the Branchiogenic Carcinoma].

In recent years, human papillomavirus (HPV)-positive oropharyngeal carcinomas have been increasing. The first manifestation of these tumors is frequently as cystic metastasis to cervical lymph nodes that may precede recognition of the primary tumor, so, they often result in misdiagnosis as branchial cleft cysts. We report a case of cystic cervical lymph node metastasis of HPV-positive tonsil cancer. The patient was a 70-years-old man who noticed a mass on his left neck. The tumor was large and soft, and it was diagnosed as benign in fine-needle aspiration cytology. We diagnosed the tumor as a branchial cleft cyst and undertook surgery. The histopathological diagnosis was squamous cell carcinoma arising from a branchiogenic cyst. However, because it did not satisfy the diagnostic criteria, we diagnosed the tumor as an unknown primary tumor. One year later, left tonsil cancer was suspected based on PET-CT imaging and a left tonsillectomy was undertaken, whereafter tonsil cancer was found. In p16 immunostaining, it was positive in both cystic mass and tonsil. The cervical mass was cystic lymph node metastasis of HPV-positive tonsil cancer. It is important to investigate the oropharynx, when we found cystic cervical mass, because HPV-positive oropharyngeal carcinoma frequently results in cystic neck metastasis.

Oncocytic Carcinoma of the Submandibular Gland: A Case Report.

Oncocytic carcinoma (OC) of the submandibular gland is extremely rare. A 76-year-old man complained of a painless tumor of the right neck. Ultrasonography demonstrated swelling in the lymph nodes of the neck, and fine-needle aspiration cytology of a node showed metastatic carcinoma with oncocytic features. Radical surgery revealed infiltrating carcinoma of the right submandibular gland with lymph node metastases (19/23). Tumor cells showed less atypia and had abundant eosinophilic cytoplasm, which stained deep blue with phosphotungstic acid-hematoxylin stain. The cells were immunohistochemically positive for cytokeratin 7 but negative for p63 and SOX10. We diagnosed the tumor as OC. Chemoradiotherapy was performed after surgery. The patient showed no sign of recurrence until 42 months after the operation, when lymph node swelling was detected in the mediastinum by computed tomography scanning. With no further treatment, the patient is alive with lymph node swellings in the mediastinum and pulmonary hilum 80 months after surgery.

[A Case of Advanced Gastric Cancer with Synchronous Liver Metastases Treated with Combination Therapy].

A 66-year-old woman was admitted to our hospital because of epigastralgia, and she was diagnosed with a type 2 tumor at the antrum of the stomach. Pathological examination suggested a moderately differentiated adenocarcinoma with negative staining for HER2 on immunohistochemistry. Abdominal CT showed gastric wall thickening and enlarged lymph nodes. Although the clinical finding was Stage ⅢB(T4aN2M0), a liver metastasis (S2) was found during the operation. We performed distal gastrectomy with D2 lymph node dissection and partial hepatic resection in December 2010. A post-operative pathological diagnosis of gastric cancer, pT4aN2M1, pStage Ⅳ, was made. Although adjuvant chemotherapy of S-1 was administered, CT revealed a liver metastasis in S3 5 months after the operation, and the patient underwent transcatheter arterial chemoembolization (TACE) followed by a regimen of S-1 plus CPT-11. After 3 courses of this regimen, grade 2 anorexia was observed, and the treatment schedule was changed to a regimen of capecitabine plus cisplatin (XP). After 7 courses of this regimen, CT revealed multiple liver metastases in S2, S3, and S8, and the treatment schedule was changed to several other chemotherapy regimens. However, liver metastases continued to grow, and the patient died 51 months after surgery. Although the prognosis of gastric cancer with synchronous liver metastases is very poor, it is possible to prolong survival with multimodal therapy.

[A case of liver and bone metastasis from gastrointestinal stromal tumor treated using imatinib].

A 71-year-old man with an unspecified gastric tumor had undergone gastrectomy 15 years previously, and in 2012, positron emission tomography-computed tomography(PET-CT)showed the presence of a bulky tumor located in the right hepatic liver and multiple bone metastases. Although it was unclear whether the tumor was primary or metastatic, liver biopsy was performed. Immunostaining revealed that the lesions were positive for c-kit, and therefore, these lesions were diagnosed as liver and bone metastases from gastric gastrointestinal stromal tumor(GIST). Chemotherapy with imatinib was initiated. PET-CT performed after 3 months revealed a marked decrease in fluorodeoxyglucose(FDG)accumulation. The patient is alive at present with no recurrence.

[A case of advanced gastric cancer with portal vein thrombus leading to liver metastases].

A 68-year-old man presenting with anorexia was admitted to our hospital; he was diagnosed with pyloric stenosis arising from a type 3 tumor in the antrum of the stomach. Pathological examination revealed a poorly differentiated adenocarcinoma; immunohistochemical staining tested positive for alpha fetoprotein(AFP), and negative for human epidermal growth factor receptor 2(HER2). Abdominal computed tomography (CT) showed a portal vein thrombus and enlarged lymph nodes. Since the clinical finding was Stage IV(T4aN3M1), curative surgery was ruled out. Following stent placement for food intake, TS-1 plus cisplatin (CDDP) neoadjuvant chemotherapy was initiated. TS-1(80 mg/m² / day) was administered orally for 2 weeks followed by a drug-free 1-week period, and CDDP (60 mg/m²) was administered intravenously on day-1 as 1 course. After 5 courses of this regimen, lymph nodes were reduced in size and the portal vein thrombus disappeared. However, grade 4 thrombocytopenia was observed, and the treatment schedule was modified to include several other chemotherapies. Two years after the initiation of chemotherapy, liver metastasis was detected via elevated AFP. The patient died 27 months after initial treatment. Although the prognosis for gastric cancer with portal vein thrombus is very poor, it is possible to prolong survival with multimodality therapy.

Segmental muscular defects of the intestine: a possible cause of spontaneous perforation of the bowel in adults.

Idiopathic intestinal perforation has been described as spontaneous bowel perforation; only a few cases of the condition have been reported in adults. We conducted a histologic analysis of 7 adult cases of spontaneous intestinal perforation (mean patient age, 63.3 [range, 44-89] years; male-to-female ratio, 1:1.3), which revealed some previously unreported findings. None of the patients had congenital disease. All patients presented with acute abdomen, and intestinal perforations were detected during laparotomy. Perforations, ranging in diameter from a pinpoint size to 3 cm, developed in the colon and small bowel in 4 and 3 cases, respectively. One patient had 2 perforations. Histologic examinations revealed segmental muscularis propria defects around the perforation sites. The extent and degree of the muscular defect varied from case to case; however, all lesions included full-thickness muscular defects. No significant infiltration of inflammatory cells was observed associated with the defects. The mucosa and muscularis mucosa were maintained normally, except in 1 hemorrhagic case. Reparative changes such as granulation were not found; however, short spindle cells or fibroblasts occasionally proliferated around the edges of the disrupted muscularis propria. In 1 case, a muscular defect was also observed in an area far from the perforation site. These findings closely resemble those of neonatal intestine with spontaneous perforation. Etiology of segmental muscular defects in adults is unclear. It may be focal congenital anomaly. In any case, the segmental muscular defects can explain bowel wall weakening, and it can be a major cause of spontaneous perforation of the adult bowel.

[A case of multiple liver metastases after resection of gastrointestinal stromal tumor of the small intestine that was successfully treated with imatinib mesylate].

A 73-year-old man was found to have an intestinal tumor, approximately 10 cm in diameter, on computed tomography (CT). In September 2001, he underwent partial resection of the jejunum with partial colectomy and left nephrectomy. Pathological examination showed 2 mitoses per 50 high-power fields, and immunohistochemical analysis showed positive staining for c-kit. Based on the above findings, the tumor was diagnosed as a high-risk malignant gastrointestinal stromal tumor( GIST) of the small intestine; the patient was followed up and no adjuvant therapy was administered. In October 2005, an abdominal CT scan revealed 2 tumors with diameters of 21 and 28 mm in the S8 and S7 region of the liver, respectively, and the patient was diagnosed with liver metastases from GIST. After obtaining adequate informed consent, chemotherapy with imatinib (400 mg/day) was initiated. Although the patient experienced partial response (PR) 2 months after the treatment, grade 3 neutropenia and general fatigue were observed. Therefore, the treatment schedule was changed to 1 week of therapy, followed by 1 week of rest. At present, at 91 months after the diagnosis of liver metastases, the patient shows no signs of recurrence. Therefore, it is important that adjuvant chemotherapy should be considered for the treatment of patients with high-risk malignant GIST.

[A case of jejunum cancer diagnosed by anemia].

The patient was an 85-year-old woman who was referred to a nearby clinic complaining of shortness of breath. Blood test showed anemia, and she was referred to our hospital for identification of the source of bleeding. Upper and lower endoscopy were performed and revealed no abnormalities. Computed tomography (CT) was performed and showed a >7- cm thickening in the wall of her small intestine. The presence of small bowel cancer was suspected. Oral double-balloon endoscopy was performed and showed a near-circumferential ulcerative lesion in the jejunum that was causing small bowel stenosis. A biopsy yielded a diagnosis of signet-ring cell carcinoma. We performed a partial resection of the patient's jejunum. The histopathological diagnosis of the resected specimen (according to the Union for International Cancer Control [UICC]TNM Classification of Malignant Tumours, seventh edition) was poorly differentiated adenocarcinoma, signet-ring cell carcinoma, mucinous carcinoma, T2 (MP), N0, H0, P0, stage I. 7 months after surgery, the patient is alive without recurrence. The incidence of small intestinal cancer is generally reported to be 1% to 2% of all gastrointestinal malignancies. We report a rare case in which cancer of the small intestine was identified during investigation of anemia.

[A case of small-sized lung cancer complicated by sarcoidosis].

A woman in her seventies presented with bilateral hilar and mediastinal lymphadenopathy with high fluorodeoxyglucose (FDG) uptake by positron emission tomography (PET)-computed tomography (CT), small lung nodules, and uveitis. Mediastinoscopic biopsy yielded a histological finding of epithelioid granuloma and a diagnosis of sarcoidosis. A nodule, 1 cm in diameter, in the right middle lobe with moderate FDG uptake was deemed to be a sarcoidosis lesion. Steroid therapy for uveitis resulted in shrinkage of the hilar and mediastinal lymph nodes; however, 1 year later the nodule in the right middle lobe had enlarged to 2 cm in diameter. Right middle lobectomy was performed, and a histological diagnosis of lung squamous cell carcinoma was made. Six months later, right pretracheal lymphadenopathy with high FDG uptake was noted and was proved to be a metastatic squamous cell carcinoma by endobronchial ultrasound-guided transbronchial needle aspiration( EBUS-TBNA). After 7 courses of chemotherapy with docetaxel, the target lesion shrank and its abnormal FDG uptake disappeared. Small-sized lung cancer could be missed when complicated by sarcoidosis because the latter produces a background of multiple lesions, so careful diagnostic imaging and follow-up should be performed in patients diagnosed as having sarcoidosis.

[A long-term survival case of biliary tract cancer treated with multimodality therapy].

A 64-year-old man with obstructive jaundice underwent percutaneous transhepatic biliary drainage, and bile cytology diagnosed adenocarcinoma. The operation ended with exploratory laparotomy because of severe cirrhosis, and thus, S-1 therapy was started after radiation therapy (50 Gy) with an endoscopic retrograde biliary drainage (ERBD) tube. After 37 months, an abdominal computed tomography(CT) scan detected dilation of the intrahepatic biliary tract without recurrence, and we therefore detained a biliary expandable metallic stent instead of the causal obstruction of the ERBD tube. Subsequent CT scan and upper gastrointestinal endoscopy detected stenosis and a thickened wall of the duodenum because of recurrence, and thus, we detained a duodenal stent and started gemcitabine therapy. The patient is alive 70 months after the initial consultation. We report herein a long-term survival case of biliary tract cancer treated with multimodality therapy.

[Liver damage detected after a hepatectomy for liver metastasis after 12 courses of mFOLFOX6 therapy as an adjuvant chemotherapy for colorectal cancer].

The FOLFOX regimen is approved as an adjuvant therapy for colon cancer in Japan. We report a case of pathological damage in the resected non-cancerous liver after 12 courses of mFOLFOX6 therapy as an adjuvant therapy for stage IIIb colon cancer. A 45-year-old man underwent laparoscopic right hemicolectomy for ascending colon cancer. After completing 12 courses of adjuvant mFOLFOX6 therapy, this patient exhibited liver metastasis. Lateral segment resection was performed, and pathological examination of the resected specimen revealed irregular sinusoidal dilatation and cell apoptosis in the non-tumorous part of the liver. This was probably due to the effects of mFOLFOX6. We stress that when resectable liver metastasis is found after 12 courses of FOLFOX as an adjuvant therapy for colon cancer, careful attention should be paid during surgery and during postsurgical management because there may be damage in the remnant liver.

[A case of liver metastases from gastric cancer successfully treated with weekly paclitaxel chemotherapy].

A 63-year-old woman underwent distal gastrectomy for gastric cancer (P+, CY+, Stage IV) in February 2011. About 3 months after surgery, abdominal computed tomography(CT) examination revealed solitary liver metastasis. Systemic chemotherapy was started using a regimen of S-1/cisplatin(CDDP). After 2 courses, an adverse reaction of grade 3 neutropenia occurred, although liver metastasis regression was confirmed. Weekly paclitaxel (PTX)was selected as the second -line chemotherapy. After 3 courses, imaging indicated complete regression of the liver metastasis. No adverse events occurred following 5 courses of weekly PTX. No recurrence was noted at a post-surgical follow-up of 15 months. We experienced a case of liver metastasis that was successfully treated with S-1/CDDP and weekly PTX chemotherapy.

[A case of diffuse pneumonic type of mucinous adenocarcinoma treated with reduction surgery].

A female never-smoker in her 60s presented with persistent productive cough. Chest radiography and computed tomography revealed widespread consolidation in the basal area of her left lung lower lobe. She received antibiotics and steroid therapy. Nevertheless, consolidation extended over the left lower lobe, and multiple nodular shadows appeared in both the lungs until a histological diagnosis of adenocarcinoma was obtained with lung wedge resection biopsy. Left lower lobectomy was performed as a tumor reduction surgery to palliate dyspnea due to massive sputum. The duration of decreased sputum production was short, and the lesion spread rapidly over the residual lung, resulting in death due to respiratory failure 8 months after her first visit. The histological diagnosis was diffuse pneumonic type of invasive mucinous adenocarcinoma with lepidic, acinar, and solid growth patterns (formerly mucinous bronchioloalveolar cell carcinoma). Mucous sputum containing tumor cells tends to spread aerogenously to other lobes and both lungs, and thus, disease control is difficult. Although there are some case reports of successful treatment with oral epidermal growth factor receptor tyrosine kinase inhibitors or pemetrexed, an effective therapeutic strategy for this type of lung cancer has not been established.

[A case of rapidly progressing retroperitoneal differentiation type liposarcoma].

A 75-year-old man visited our hospital in August 2011 due to general malaise and loss of appetite. Abdominal computed tomography scan showed a retroperitoneal tumor. Therefore, we performed resection of the retroperitoneal tumor, pancreas tail, and spleen. The pathological diagnosis was dedifferentiation-type liposarcoma with invasion of pancreas. Abdominal computed tomography scan 2 months after the operation showed peritoneal dissemination and multiple liver metastasis. The patient selected the best supportive care. An effective cure for dedifferentiation-type liposarcoma, besides surgical resection, is not yet established. Therefore, complete resection is important. Moreover, since the rate of recurrence is high, the development of an effective systemic chemotherapy is desired.

[A case of primary splenic malignant lymphoma associated with gastric cancer].

The patient was an 85-year-old woman with a chief complaint of anemia and epigastralgia. She was diagnosed with type 4 gastric cancer(por) located in the upper-third of the stomach by gastrointestinal endoscopy in April 2011. Computed tomography scan revealed no distant metastases, but a tumor measuring about 4 cm in diameter was detected in the spleen. We performed total gastrectomy with D2 lymph node dissection and splenectomy in June 2011. The postoperative pathological finding of the gastric cancer was pT4aN3aM1P0CY1H0, p-Stage IV(Japanese Classification of Gastric Carcinoma, 14th Edition). Histological examination of the splenic tumor revealed a follicular-type malignant lymphoma. At present, our patient is being treated with S-1 monotherapy in the outpatient clinic and shows no signs of recurrence. However, it is important that the patient is followed-up carefully because peritoneal lavage cytology was positive and the relapse rate of follicular lymphoma is comparatively high.

[A case of adenocarcinoma of the esophagogastric junction successfully treated with chemoradiation therapy].

The patient was an 80-year-old female with chief complaint of anemia. She was diagnosed as a type 3 gastric cancer (por/tub2) of the esophagogastric junction by gastrointestinal endoscopy in November 2010. CT scan revealed no distant metastasis and we diagnosed as c-stage II B (T4aN0M0). However, severe COPD was detected by the respiratory function test. Considering her age and respiratory function, we decided that total gastrectomy under general anesthesia was difficult. She was treated with radiation( 50.4 Gy/28 Fr) and the combination chemotherapy of S-1( 80 mg/m², day 1-21) plus low-dose CDDP (6 mg/m², day 1-5, 8-12, 15-19) during her hospitalization, and treated with S-1 mono-therapy as an outpatient. The tumor was reduced and the hemorrhage was not seen though the response was SD. Moreover, she did not experience any adverse event of grade 3 or more. The chemoradiation therapy appears to be effective for patients of adenocarcinoma of the esophagogastric junction.

[A case of unresectable mediastinal carcinoma obtaining clinical complete response after sequential chemoradiotherapy].

A man in his sixties was pointed out a solitary anterior mediastinal tumor 3 cm in diameter by CT scan with a complaint of chest compression, which grew 7 cm in diameter involving right subclavian and common carotic arteries and left innominate vein and superior vena cava 2 months later. FDG-PET/CT showed a high abnormal uptake only in the mediastinal tumor. A histological diagnosis of mediastinal poorly differentiated carcinoma or mediastinal lymph node metastasis of unknown origin was made by medistinoscopic biopsy. After 4 courses of chemotherapy with carboplatin and paclitaxel, the tumor was markedly decreased but was judged as unresectable because of residual involvement of great vessels. Addition of 60 Gy of radiotherapy targeted for the tumor resulted in further decrease in diameter of the tumor in CT scan and disappearance of abnormal uptake of the tumor in FDG-PET/CT thus regarded as clinical complete response. Since then, a disease free status has been maintained for 16 months.

[A case report of huge abdominal recurrent tumor of small intestinal GIST after 15 years from the operation with primary lesion].

A man in his 60s was given an emergency operation 15 years ago for abdominal bleeding. His tumor of small intestine was resected and diagnosed as small intestinal leiomyosarcoma. He came to our hospital because of his abdominal masses 15 years after the initial operation. CT scan showed a 15 cm-sized solid and cystic tumor in the pelvic cavity. The tumor was diagnosed as GIST by PET-CT and MRI. The tumor was resected, and pathological findings led to the diagnosis of GIST with this tumor. Previous tumor cells were slightly-positive for kit immunohistological examination, but did not resemble this tumor cells morphologically. So genetic tests were performed and revealed two tumors had same mutations of c- kit. Finally, we could diagnose the tumor was recurrent metastases of small intestinal GIST 15 years after the initial surgery. kit mutation analysis was useful for a diagnosis of recurrences and predictions of the clinical response to imatinib in GISTs.

[A case of liver tumor diagnosed 5 years after gastrectomy against gastric cancer].

A-62-year-old man with gastric cancer underwent gastrectomy 5 years ago, and an abdominal computed tomography scan detected a 15 mm early enhanced lesion located liver (S8) in 2008. Although primary or metastatic were unclear, we underwent partial hepatectomy( S8) as it was an isolated liver tumor. Pathological finding showed adenocarcinoma, and immunostaining was negative for cytokeratin (CK) 7 and positive for CK20 which was the same in primary gastric cancer, so it was diagnosed liver metastasis of gastric cancer. The patient was living at the time, but he passed away 24 months after hepatectomy. We report herein the case of resectable case of liver tumor 5 years after gastrectomy against gastric cancer.

[Two cases of lung cancer patients with postoperative brain metastases obtaining long-term survival after gamma knife radiosurgery].

We report two cases of lung cancer patients with postoperative solitary brain metastases obtaining long-term survival after gamma knife stereotactic radiosurgery. Both were seventies men and had good performance status without active extracranial disease. In one case, an asymptomatic metastatic brain tumor 1.8 cm in maximum diameter appeared one year and two months after the operation and was irradiated with gamma knife resulting in complete local control for seven years. He is alive with solitary lung metastasis in good performance status. In the other case, gamma knife was employed for a metastatic brain tumor 2.7 cm in maximum diameter that appeared nine months after the operation accompanying incomplete left hemiplegia. Six months later, the tumor was enlarged and gamma knife was repeated, but the tumor growth could not be suppressed. Following deterioration of hemiplegia and appearance of convulsion, he died of neurological disorder three years and two months after the onset of brain metastasis. Gamma knife stereotactic radiosurgery for metastatic brain tumors is less invasive and a repeatable technique, and is expected to provide a good local control and a survival benefit for appropriately selected patients.