Chronic lymphocytic leukemia/small lymphocytic lymphoma with t (2;18) (p12;q21) accompanied by a cutaneous nodule with histological features of diffuse large B-cell lymphoma.

A 73-year-old woman presented a 3-year history of indolent enlargement of cutaneous tumor nodules. Peripheral blood flow cytometry revealed thrombocytopenia (platelets; 85,000/µl) and the presence of an abnormal, small B lymphocyte population (CD5+, CD10-, CD20+, CD22+, CD23dim, FMC7+, SmIgλ+, and SmIgκ-; 4,000/µl). Skin biopsy indicated infiltration of CD5+, CD10-, CD20+, BCL2+, BCL6+, and cyclin D1- atypical large B-cells, suggesting diffuse large B-cell lymphoma. Cytogenetic analysis of the peripheral blood revealed a complex karyotype [t (2;18) (p12;q21) and +12]. Fluorescence in situ hybridization detected the presence of BCL2 split signal and the absence of IGH/CCND1 fusion signal. Cervical lymph node biopsy indicated a pseudofollicular pattern. The sequence of immunoglobulin heavy chain variable region from the peripheral blood and the skin tumor contained the same mutated pattern, and therefore, confirmed clonality. Because the patient's clinical course and skin tumor were indolent, the possibility of Richter syndrome was discarded, and the final diagnosis was chronic lymphocytic leukemia/small lymphocytic lymphoma, Rai stage IV and Binet stage C. The patient achieved complete remission after 4 cycles of a fludarabine plus rituximab regimen, without disease progression since >1 year of treatment.

[A Case of Long Survival in Aggressively Growing Small Cell Carcinoma of the Bladder Successfully Treated by Combined Chemotherapy of Methotrexate, Etoposide and Cisplatin].

A 74-year-old man underwent transurethral resection for a bladder tumor (TURBT). The pathological diagnosis was urothelial carcinoma, grade 3 pT2 at least. He desired preservation of the bladder. Thus, MEC (methotrexate 100-150 mg/body (day 1), etoposide 100 mg/m2 (day 2-4), cisplatin 20 mg/m2 (day 2-6)) chemotherapy was administered for 2 courses. The next year, he had a relapse in the bladder, and the pathological diagnosiswasurothelial carcinoma, grade 2 pTa and pTis. He underwent Calmette-Guerin Bacillus (BCG) immunotherapy for 6 courses that resulted in a complete response without recurrence for 6 years. Six months after the latest examination, he complained of difficulty in voiding. An 8 cm tumor in the bladder and enlargement of obturator lymph node were detected. The pathological diagnosis by TURBT was small cell carcinoma. He rejected cystectomy, so we applied MEC therapy again. After 2 courses of MEC therapy, the bladder tumor and lymphadenopathy markedly shrunk in image and almost disappeared subsequently. The patient refused further therapy, but he had been followed without recurrence for 48 monthsafter the chemotherapy.

[A Case of Pancreatic Cancer Associated with Autoimmune Pancreatitis].

A 74-year-old man with IgG4-related cholangitis had been treated with steroids for 1 year. In the outpatient clinic, elevated levels of the tumor marker CA19-9 and serum IgG4 were observed. Abdominal enhanced CT showed a 20mm hypovascular tumor in the pancreatic head. ERCP showed narrowingof the main pancreatic duct in the pancreatic head with slight caudal dilation and stricture of the lower common bile duct. We made a diagnosis of pancreatic cancer, and the patient underwent pancreaticoduodenectomy. Pathological examination of the resected tissue revealed a well-differentiated adenocarcinoma surrounded by autoimmune pancreatitis, characteristic of lymphoplasmacytic sclerosingpancreatitis. He is receiving adjuvant chemotherapy with S-1 in the outpatient clinic.