A 71-year-old woman underwent right nephrectomy for the treatment of clear cell renal cell carcinoma at the age of 53. After 15 years, surgical removal of a solitary tumor was performed in the right adrenal gland and thyroid gland; both were diagnosed as metastases of renal cell carcinoma. Eighteen years after the initial resection, computed tomography(CT) showed multiple hypervascular tumors spreading across the entire area of the pancreas. She was referred to our hospital, and endoscopic ultrasound-guided fine needle aspiration biopsy(EUS-FNA)revealed that they were metastases from the renal cell carcinoma. Total pancreatectomy and splenectomy were performed, and the patient remains alive and well with no evidence of recurrent disease 7 months after the pancreatectomy. Furthermore, her blood glucose level is well controlled with insulin therapy.

A 72-year-old man received chemoradiotherapy for lung squamous cell carcinoma(T4N2M0, Stage Ⅲb). Nine months after the start of chemoradiotherapy, a 60 mm sized mass was identified in the spleen on abdominal CT. FDG-PET/CT examination revealed abnormal FDG accumulation in the tumor, and no obvious accumulation was observed in other sites. By endoscopic ultrasound-guided fine needle aspiration cytology, the tumor was diagnosed as splenic metastasis from lung cancer. Since the primary lung tumor was well controlled by the chemoradiotherapy and no metastatic lesions were found except in the spleen, laparoscopic excision of the splenic metastasis was planned. Since the tumor was suspected to have infiltrated the tail of the pancreas, laparoscopic distal pancreatectomy and splenectomy were performed. There were no severe postoperative complications. The resected tumor was histopathologically diagnosed as not splenic metastasis, but lymph node metastasis at the splenic hilum from lung cancer invading the pancreas and spleen. Brain metastasis and bone metastasis were observed 3 months postoperatively. He did not undergo any treatments for the metastatic lesions, and he died because of the cancer 11 months after the operation. This case suggests the clinical significance of surgical treatment for distant metastatic lesions from lung cancer.

The patient was a 59-year-old man who was hospitalized with diarrhea and general malaise. Massive ascites and systemic edema were observed upon initial physical examination. Blood test findings showed anemia, hepatic dysfunction, and increased tumor marker levels. Imaging examination revealed the presence of a primary tumor associated with stenosis, extending from the rectosigmoid junction to the upper rectum, multiple liver metastases, and massive ascites. Pathological examination indicated well-differentiated adenocarcinoma. A treatment strategy comprising colostomy and chemotherapy was implemented. Administration of 6 courses of mFOLFOX6 plus panitumumab(Pmab)and 4 courses of FOLFIRI plus Pmab led to marked shrinkage of the primary tumor and liver metastases and disappearance of the ascites. Chemotherapy was discontinued at the request of the patient. The patient developed melena after 2 years. Colonoscopy revealed enlargement of the rectal cancer, and surgical intervention was indicated. We adopted a treatment policy of 2-stage resection, and low anterior resection was performed. The liver was partially resected 3 months later. Hepatic recurrence was observed 9 months after the liver resection, and repeated resection of the liver was performed. An aggressive treatment approach can lead to improved prognosis even in cases involving multiple liver metastases and cancerous ascites.

The survival benefit of adjuvant chemotherapy after resection of liver and pulmonary metastases in colorectal cancer(CRC) remains controversial. We enrolled9 0 CRC patients who underwent hepatic metastasectomy and2 5 CRC patients who underwent pulmonary metastasectomy between April 2005 and March 2017 to clarify the efficacy of adjuvant chemotherapy after hepatic andpulmonary metastasectomy. Forty-two patients receivedad juvant chemotherapy after hepatic metastasectomy, and1 0 patients receivedad juvant chemotherapy after pulmonary metastasectomy. Patients who underwent hepatic metastasectomy andreceivedad juvant chemotherapy hadlonger overall survival(OS)(p=0.043)andrelapse -free survival (RFS)(p=0.043)than those who underwent surgery alone. There were no significant differences in OS(p=0.84)andRFS (p=0.87)between patients receiving adjuvant chemotherapy after pulmonary metastasectomy and those receiving surgery alone. On multivariate analysis, adjuvant chemotherapy was independently associated with favorable OS in patients who underwent hepatic metastasectomy(hazardratio: 0.473, 95% confidence interval: 0.23-0.97, p=0.04). No prognostic factor associatedwith OS andRFS was identifiedin patients undergoing pulmonary metastasectomy. These results suggest that patients who undergo hepatic metastasectomy couldhave an OS andRFS benefit from adjuvant chemotherapy, but those who undergo pulmonary metastasectomy would not.

A 76-year-old woman with lower bile duct carcinoma underwent subtotal stomach-preserving pancreaticoduodenectomy (SSPPD)after percutaneous transhepatic biliary drainages(PTBD). Nine months after the operation, chest computed tomography revealed a mass in the subcutis of the right chest wall, which was a different lesion from that in the PTBD site. The aspiration biopsy cytology and needle biopsy indicated no malignant findings. However, the mass was growing and was suspected to be a metastasis of bile duct cancer. We resected the mass, including portions of the sixth and seventh ribs. The pathological diagnosis was metastasis of bile duct carcinoma. The postoperative course was uneventful. Now, 2 years have passed since the resection of the primary lesion and 9 months since the resection of the chest wall metastasis. Thus far, no manifestations of recurrence have been observed, and the patient has been in a favorable condition. We report this case with a literature review.

A69 -year-old woman was diagnosed as having local advanced breast cancer. She was treated with neoadjuvant chemotherapy( AC followed by paclitaxel)and followed up with left total mastectomy with axillary lymphadenectomy for breast cancer(pT3N1aM0, Stage ⅢA, ER positive, PgR positive, and HER2 negative). She received adjuvant therapy with chest wall irradiation and an aromatase inhibitor. Two years after the mastectomy, mediastinal lymph node and rib metastases and dissemination appeared. We changed the regimen to capecitabine. She continued the capecitabine therapy for 7 years and was found to have multiple lung metastasis. Therefore, we chose eribulin mesylate therapy. Ten days after eribulin mesylate (1.0mg/body)was first administered, she suddenly had difficulty breathing, and chest CT revealed left low lobe atelectasis. The superior mediastinal lymph node had grown rapidly and compressed the left main bronchus and superior vena cava. To reduce the lymph node size, we started radiotherapy(50 Gy/25 Fr)for the superior mediastinal area in addition to the eribulin mesylate therapy. After the radiotherapy, chest CT revealed a remarkable reduction of lymph node size and full pulmonary reexpansion. One year after the radiotherapy, she is continuing treatment without systemic progression.

A 71-year-old man was diagnosed as having Type 2 gastric cancer(tub2, HER2-negative). Abdominal computed tomography( CT)revealed bulky metastatic lymph nodes around the stomach and para-aorta(No. 16a2, b1). Our clinical diagnosis was cT4a(SE)N+M1(PAN), cStage Ⅳb, and SOX therapy was immediately administered. After 3 courses of chemotherapy, the treatment effect was PR, and after 6 courses, the patient was diagnosed with ycT2(MP)N0M0, ycStageⅠB. No Grade 2 or higher adverse events were observed during chemotherapy. At this stage, we determined that radical resection was feasible; thus, distal gastrectomy and D3 dissection(para-aortic lymph node dissection)were performed. No cancer cells were found in the primary lesion on histopathology. The histological response of the primary lesion was Grade 3, and the lymph node was Grade 2b. On follow-up observation, the patient is alive without tumor recurrence at 1 year postoperatively.

The patient was a 67-year-old man. A Type 0-Ⅱa+Ⅱc tumor, 20mm in size was observed in the 1st portion of the duodenum under magnifying endoscopy. Mucosal cancer was suspected and endoscopic resection was performed, with pathological findings as follows: Type 0-Ⅱa+Ⅱc, 19×12 mm, tub1, pT1b(SM2: 700 mm), pUL0, Ly0, V0, pHM0, pVM0. He refused subtotal stomach-preserving pancreaticoduodenectomy(SSPPD)because of the high morbidity and mortality rates. Instead, he underwent only laparoscopic sampling of No. 5, 6, 12b, and 13a lymph nodes, and metastasis in a No. 6 node was pathologically confirmed. He eventually underwent SSPPD with D2, but no metastases were found in other lymph nodes. Pancreaticoduodenectomy is currently considered the best treatment option for complete removal of regional lymph nodes in duodenal cancer despite high morbidity and mortality rates. Further studies are needed to determine the pattern and incidence of lymph node metastasis by location and depth of the primary tumor, to establish optimal treatment guidelines for duodenal cancer.

We experienced a case of multiple esophageal intramural metastasis from adenocarcinoma of the esophagogastric junction. A 58-year-old man was admitted complaining of dysphagia. Upper gastrointestinal endoscopy revealed a type 3 tumor at the esophagogastric junction. Biopsy showed Group 5, poorly differentiated adenocarcinoma. Abdominal CT indicated regional and para-aortic lymph node metastasis. Then the clinical diagnosis was established as Siewert type Ⅲ adenocarcinoma and cT4aN2M1(LYM), cStage Ⅳ. After conducting 4 courses of SP(S-1/cisplatin)therapy, endoscopy showed partial response of the primary tumor and the submucosal nodules in the lower esophagus. We performed lower esophagectomy and total gastrectomy by left thoracotomy and laparotomy. Six esophageal nodules were identified in the lower esophagus, and pathological examination proved the poorly differentiated adenocarcinoma. The esophageal tumors were diagnosed as intramural metastases. The patient showed hepatic and lymphatic recurrence 9 months after surgery, and died 15 months after surgery. Esophageal intramural metastasis from esophagogastric junction adenocarcinoma is relatively rare. We discuss this case along with a review of the literature.

We report a case of ascending colon cancer with hepatic metastases that was treated by CapeOX plus bevacizumab with remarkable efficacy. A 40-year-old female patient presented with a medical history of surgery for resection of right breast cancer4 years ago, left-sided transverse colon 2 years ago, and right ovarian cancer 6 months ago. Follow-up computed tomography(CT)found wall thickening from the ascending colon to cecum. She was diagnosed with an ascending colon cancer by colonoscopy, and underwent right hemicolectomy. One month after the surgery, her serum marker carcinoembryonic antigen(CEA)and carbohydrate antigen 19-9(CA19-9)levels were high. She was diagnosed with unresectable multiple hepatic metastases by CT 2 months after the surgery. Her tumor was epidermal growth factor receptor(EGFR)- positive and wild-type for RAS; she received 4 courses of CapeOX plus bevacizumab. Thereafter, liver metastases were remarkably decreased in size, and she could undergo central bisegmentectomy. Pathology examination revealed no tumor and that the center of the tumor was changed to necrotic tissue and the surrounding area was changed to fibrous tissue and lymphocyte infiltration. The patient is disease-free since the last operation.

The patient was a 76-year-old man who was admitted to our hospital with a diagnosis of ileus. A gallbladder tumor was found incidentally on CT, and it was diagnosed as gallbladder cancer. Enlargement of multiple lymph nodes, including the paraaortic lymph nodes, was observed, and PET-CT further showed FDG uptake in the lymph nodes. Based on these findings, the patient was diagnosed with Stage ⅣB gallbladder cancer with paraaortic lymph node metastases. Since surgical resection was not possible, chemotherapy with gemcitabine and cisplatin(GEM plus CDDP)was started. After completion of 4 courses of GEM plus CDDP, the enlarged lymph nodes were decreased in size on CT, and there was no FDG uptake on PET-CT. These findings indicated downstaging to Stage Ⅱ; thus, conversion surgery with extended cholecystectomy and lymph node dissection was performed. The pathological diagnosis confirmed that the patient had Stage Ⅱ cancer(pT2N0M0). A case of unresectable gallbladder cancer that was treated with GEM plus CDDP and subsequent conversion surgery is reported, along with a literature review.

A female in her 40s underwent surgical resection for rectal cancer, and metastases in the liver, ovaries, and peritoneum in 2 stages. Multiple pulmonary metastases appeared after the second operation, and right lung middle lobectomy and left lung S8 wedge resection were performed sequentially. Because another metastatic lesion in the right lung S7 was located deep in the parenchyma, stereotactic body radiotherapy(SBRT), instead of surgery, was selected for this lesion and a right lung S8 nodule. SBRT was also performed for a new metastatic lesion in the right lung S6. Local relapse of resected or irradiated lesions was not recognized for 53 months after the first pulmonary resection, and no new lesions appeared for 20 months after the last SBRT. SBRT for pulmonary metastases of colorectal cancer can achieve good survival and local control comparable to surgery and has the advantage of safety and respiratory reserve over surgery. The combination of surgical resection and SBRT for multiple pulmonary metastases is especially beneficial for relatively young patients with jobs and/or children, because it enables patients to maintain good quality of life by avoiding systemic chemotherapy accompanied with adverse events.

An 87-year-old male patient was admitted to our hospital with a chief complaint of vomiting. Gastroscopy revealed Type 0-Ⅱc+Ⅱa tumor at the posterior wall in the middle third of the stomach. A biopsy indicated moderately differentiated adenocarcinoma. Abdominal CT revealed no lymph node or distant metastases. The clinical diagnosis was cT2(MP), N0, M0, cStage Ⅰ. Laparoscopic distal gastrectomy with D2 lymphadenectomy was performed. The pathological findings revealed moderately differentiated adenocarcinoma containing synaptophysin, chromogranin A, and CD56-positive tumor cells. He was then diagnosed with adenocarcinoma with neuroendocrine differentiation. The pathological diagnosis was pT2(MP), pN0, M0, pStage ⅠB. MRI revealed multiple liver metastases 5 months postoperatively. S-1 alone chemotherapy was started, and the patient showed partial response(PR)after 3 courses, according to the Response Evaluation Criteria in Solid Tumor (RECIST).

We report an 86-year-old patient successfully treated by multimodality treatment for advanced pancreatic cancer with synchronous multiple liver metastases and liver dysfunction. Systemic chemotherapy(SC)(gemcitabine[GEM]1 g and 5-FU 1 g biweekly)was initiated. Two weeks after, the radiation therapy(55 Gy/25 days)was added. Three weeks after, the short period's high dose hepatic artery infusion(SPHDHAI)(5-FU[1 g]×3 days: 1 day rest: 5-FU[1 g]×3 days)was started. By these treatments, liver dysfunction was completely improved and abdominal pain was disappeared. After 2 times of weekly high dose hepatic artery infusion(WHDHAI)(5-FU 1,500mg), the mixed chemotherapy(MC)(GEM 800 mg[systemic] and 5-FU 1,500 mg hepatic artery infusion:[HAI]biweekly)were started. She could live without admission for about 1 year. About 13 months after lung metastases was appeared and she died about 19 months after first chemotherapy. Our multimodality treatment(systemic and HAI therapy and radiation)was effective for keeping patient quality of life and for improving the survival even if the patient was a very old age and showed liver dysfunction.

We report a case of pancreatic metastasis of pulmonary pleomorphic carcinoma with duodenal invasion after left lower lobectomy. A 65-year-old male underwent left lower lobectomy for left lung cancer in 2016. The final pathological finding was a diagnosis is of pleomorphic carcinoma, pT2bN0M0, stageⅡA. The patient rejected postoperative chemotherapy for 10 months after lung surgery, and he was admitted to our hospital with poor oral intake. CT revealed that the tumor was located in the 2nd part of the duodenum, was about 7 cm in diameter, and was suspected to invade the superior mesenteric vein (SMV). Gastroendoscopy revealed whole-circumference stenosis at the 2nd part of the duodenum. The biopsy was suspicious of duodenal metastasis from pulmonary pleomorphic carcinoma. We scheduled pancreaticoduodenectomy with reconstruction of the portal vein. Regarding the intraoperative findings, the tumor was palpated at the 2nd part of the duodenum, and the tumor invaded the transverse colon and right urinary duct. The SMV had been invaded from the gastro-colic trunk to the root of the ileocolic vein. Therefore, pancreaticoduodenectomy, reconstruction of the portal vein with replacement of the graft of the left external iliac vein, right hemicolectomy, and right ureteral resection were performed. Regarding the pathological findings, the tumor existed in the pancreatic parenchyma and invaded the duodenal mucosa. The tumor cells were similar to those in a previous pulmonary pleomorphic carcinoma. The final pathological diagnosis was pancreatic metastases from pulmonary pleomorphic carcinoma. Surgical reports of metastatic pancreatic tumor have been observed sporadically; however, those reports were of pancreatic metastasis of renal cancer, and there are few reports of resection of pancreatic metastasis. This is a very valuable case of pancreatic metastasis from pulmonary pleomorphic carcinoma that could be resected.

A 60-year-old male undergoing pelvic evisceration with D3 lymph node dissection for pR0 in 2006f or carcinoma of the rectum was diagnosed pathologically with moderately differentiated adenocarcinoma, fStage ⅡA(UICC pT3, pN0, M0). Follow-up CT revealed hypovascular liver tumors with intrahepatic bile duct dilation in the right lobe 8 years after the pelvic evisceration. We conducted right lobe hepatectomy. The resected specimens showed that the tumor extended predominantly along the right intrahepatic bile duct. Histological findings and an immunohistochemical examination of CK7, CK20, and CDX2 revealed metastasis of the rectum cancer. We finally diagnosed him with intrahepatic bile duct metastasis from rectal adenocarcinoma.

A 49-year-old man underwent sigmoidectomy for the diagnosis of type 2 sigmoid cancer. Pathological findings showed a tumor 3.5×4.0cm in size, type 2, pSS, ly2, v1, pN0, cH0, cP0, cM0, pStageⅡ, R0. Asynchronistic metastases to the liver and lungs were subsequently found. Left hepatectomy was performed for 1 liver metastasis, and 4lung metastases were resected through 3 surgeries. A subcutaneous tumor in an abdominal wall scar was also resected in the 4th surgery for metastasis resection. All pathological diagnoses were metastases from sigmoid cancer, and complete curative resection was possible. The final surgery was performed 1 year and 1 month prior, and the patient has now survived without recurrence for 10 years and 2 months after sigmoidectomy. Chemotherapy was not administered during the whole course. This case shows that longterm survival is possible with repeated resection of recurrent metastasis of sigmoid cancer.

A 60s man with a history of laparoscopic distal gastrectomy(LDG)of gastric cancer in January 2015was followed up in an outpatient clinic. He remained healthy without recurrence for about 2 years, but in February 2017, colonoscopy identified an elevated lesion that covered one-third of the circumference in the ascending colon. Biopsy revealed that this lesion had poorly differentiated adenocarcinoma. No other metastatic lesions were noted on thoraco-abdominal CT, and tumor markers were not elevated in a blood test. Right hemicolectomy with D3 nodal dissection was performed on March 2017. Although regional lymph node metastasis was noted during surgery, distant metastasis was not identified. Histological examination revealed that the ascending colon tumor had poorly differentiated adenocarcinoma very similar to that of the primary gastric cancer, and the lesion was diagnosed as metastasis from previous gastric carcinoma. Pathological findings showed pPM0, pDM0, pRM0, pCY0, and definitive surgical treatment was confirmed. However, 2 months after the surgery, ascites caused by peritoneal and bilateral supraclavicular lymph node metastases were detected on CT. He passed away 6months after the last surgery. We report a case of metachronous ascending colon metastasis from gastric cancer that was difficult to preoperatively diagnose.

Several recent case reports have demonstrated long survival cases of advanced gastric cancer(AGC)patients suffering from peritoneal dissemination(PD)treatedwith effective chemotherapy; however, these AGC patients have poor prognosis in general. We report a case of AGC who hadsurvivedPD over 40 months with locoregional therapies. A 58-year-oldmale underwent distal gastrectomy for AGC with localized PD. Although we recommended postoperative chemotherapy, he chose surveillance as his will. Eighteen months postoperatively, CT scan revealedrecurrence of PD, andPET -CT showedonly one site of recurrent nodule. The patient chose locoregional therapy, ie, resection of the recurrent nodule instead of chemotherapy. Pathological exam confirmedthe recurrence of AGC, andabd ominal lavage cytology was classifiedas V. Even after these pathological findings, the patient refused to receive chemotherapy. At 39 months postoperatively, he developed subileus due to multiple recurrence of PD. At 40 months postoperatively, we performedchemotherapy because locoregional therapy was not supposedto be appropriate for these multiple lesions. However, the patient movedto another hospital after 1 course of chemotherapy because of his continuedrefusal to receive chemotherapy.

We report a case of locally advanced colon cancer that directly invaded the rectum wall and uterus resulting in huge mass in the whole pelvis that we could successfully made complete radical resection of the whole tumor without exposing the tumor to the surgical margin after the triplet chemotherapy. The patient was a 57-year-old woman complaining of anus pain, melena, fever, and weight loss. Although swelling of the regional lymph node was observed, no distant metastasis was found resulting in clinical diagnosis of Stage Ⅲb. However, oncologically safe complete resection seemed difficult; thus, chemotherapy( 3 courses of FOLFOX followed by 3 courses of FOLFOXIRI plus bevacizumab)was administered. As a result, significant tumor reduction was observed; therefore, the tumor was completely resected with posterior pelvic exenteration. Final staging was ypT4bypN0M0(ypStage Ⅱ). Eight courses of CapeOX was administered as adjuvant chemotherapy.