We report on a 52-year-old woman with rheumatoid arthritis (RA) who developed methotrexate associated lymphoproliferative disorders (MTX-LPD) in the central nervous system (CNS) in the course of immunosuppressive therapy for RA. The patient was admitted because of monoplegia in her left hand. She had been receiving methotrexate (MTX) for her RA for several years and etanercept had also been introduced because of a worsening of the arthritis six months before admission. Brain MRI revealed multiple lesions with enhancement scattered throughout both hemispheres. 18F-fluorodeoxyglucose-positron emission tomography/computed tomography showed abnormal accumulation suggesting malignancy in the right frontal lobe where abnormal enhancement was observed on the MRI. A brain biopsy was performed at the identified site and it confirmed diffuse large B-cell lymphoma (DLBCL). We therefore diagnosed her as MTX-LPD. According to previous reports, most MTX-LPD cases tend to show regression after the cessation of MTX. However, our case showed no regression and even needed chemotherapy. The patient had a poorer prognosis than previous cases and died 17 months after the onset. Although it is an uncommon complication, particularly in the CNS, MTX-LPD should be considered as a critical differential diagnosis if a patient receiving MTX develops central nervous system lesions. Immediate medical intervention including brain biopsy is required.

A 51-year-old man visited our hospital since he had noticed remarkable increase in size of left scrotal contents. Computed tomography revealed left testicular swelling, retroperitoneal, pelvic and left inguinal lymph nodes. Serum testicular tumor markers (α fetoprotein, β-human chorionic gonadotropin, lactate dehydrogenase) were elevated. Low left orchiectomy was performed due to swelling of the left inguinal lymph node. The excised specimen weighed 3,400g. Pathological findings were non-seminoma. Although there was no operation history of scrotal groin, there was metastasis in the left inguinal lymph node ; therefore, the stage of disease was T2N3M1a. According to the postoperative values of tumor markers, his condition was judged as "good prognosis" in the International Germ Cell Consensus Classification (IGCCC), and he underwent 3 courses of bleomycin, etoposide and cis-platin (BEP) therapy. Although the tumor markers decreased to the normal limit and the size of lymph node was remarkably decreased after 2 courses of BEP therapy, one course of EP therapy was added for further reduction of tumor size. For the residual lymph node metastasis, retroperitoneal lymph node dissection (RPLND) was performed. Then pelvic and left inguinal lymph node dissection was performed at a later date. Pathological findings of excised lymph nodes were only necrotic tissue. He is alive without disease recurrence three years after treatment.

Distant metastasis is rare in patients with non-muscle invasive bladder cancer (NMIBC). We describe two cases of NMIBC with distant metastasis diagnosed in the follow-up period after transurethral resection (TUR), with neither intravesical recurrence nor progression to muscle-invasive disease. Case 1 : A 77-yearold man was referred to our hospital for treatment of a bladder tumor with the complaint of asymptomatic gross hematuria. TUR of the bladder tumor was performed. Pathological examination revealed high grade urothelial carcinoma pT1. Second TUR was performed and pathological examination confirmed high grade urothelial carcinoma pT1 with lymphovascular invasion. The patient received standard BCG therapy and subsequently developed left leg pain and lumbago 10 months after initial diagnosis. Magnetic resonance imaging, computed tomography, and bone scintigraphy demonstrated no local recurrence, but revealed multiple bone and liver metastases. The patient died 15 months after initial diagnosis. Case 2 : A 70-year-old man was referred to our hospital for treatment of an incidental bladder tumor. TUR of the bladder tumor was performed and pathological examination confirmed high grade urothelial carcinoma pT1. Second TUR was performed and pathological examination revealed no residual tumor cells. 18Fflurodeoxyglucose (FDG) positron emission tomography/computed tomography confirmed increasing uptake of 18F-FDG in the retroperitoneal lymph nodes, 18 months after initial diagnosis. The patient underwent laparoscopic lymphadenectomy. Pathological examination demonstrated metastasis of the bladder cancer. Combined chemotherapy was initiated with gemcitabine and cisplatin consecutively. To date the patient survives without progression or new distant metastases after four cycles of chemotherapy.

We report a case of left renal angiomyolipoma extending into the renal vein. A 67-year-old woman showed a left renal tumor which was 6 cm in diameter and had density equal to fat tissue in computed tomography. We suspected liposarcoma and performed radical nephrectomy and resection of thrombus. The pathological diagnosis was angiomyolipoma with no malignancy. To our knowledge, renal angiomyolipoma with tumor thrombus has been reported in 62 cases, and pulmonary embolism developed in 9 of these cases. We conclude that surgical treatment is effective in treating angiomyolipoma with tumor thrombus.

Two cases of breast cancer with bilateral orbital metastases associated with intracranial metastases are presented. Case 1:A 61-year-old woman who was diagnosed with breast cancer 14 years earlier presented with rapid deterioration of visual acuity, eye pain, and limitation of left-sided extraocular motility. Magnetic resonance(MR)images showed an enhanced lesion in the left orbital apex, ethmoid sinus, and right middle fossa. The first gamma knife radiotherapy(35 Gy, 5 Fr)was performed successfully, but was followed by recurrence 18 months later in the right intraorbital, where newly formed iso-intensity masses in the extraconal compartment were found. The second gamma knife radiosurgery was performed for three masses(20 Gy). Case 2:A 35-year-old woman with breast cancer who was diagnosed 22 months earlier was treated for meningeal carcinomatosis by whole-brain radiation(30 Gy, 10 Fr)and intrathecal chemotherapy. Eight months later, swelling in both eyelids and limitation of extraocular motility developed rapidly. MR imaging revealed an infiltrating lesion in the cone with heterogenous signal that was encasing, but not infiltrating the optic nerves. The extraconal lesion extended into the soft tissue of the lower eye lid. She expired one week after diagnosis. With the increasing number of long-term survivors with breast cancer, intraorbital metastases may be found during the course of treatment for intracranial lesions. Understanding the unique clinical presentation and characteristic MR findings of this rare entity are emphasized.

A 94-year-old man, who had been diagnosed with a 5.7 cm renal carcinoma 4 months before and followed up with no therapy, presented with a 3-day history of macrohematuria. Abdominal CT revealed an enlarged right renal tumor, tumoral hemorrhage, and a right retroperitoneal hematoma. Therefore, spontaneous rupture of the renal carcinoma was diagnosed. As his general condition was not serious, he rejected aggressive treatments such as nephrectomy. Instead, he chose treatment with an antineoplastic drug, UFT, which was started orally at a dose of 200mg/day. Under hospitalization, his clinical course was uneventful, and he was discharged 14 days later. Follow-up CT films showed that the size of the tumor gradually decreased. Sixteen months after UFT administration, a CT displayed a right renal tumor with an 86% decrease in size compared with the tumor size when first diagnosed.

Orbital metastasis of gastric cancer occurs very rarely.A 76-year-old woman, who consulted another doctor with the chief complaints of palpitation, shortness of breath, and anorexia 1 month previously, was referred to our clinic for workup and treatment.Workup revealed type III advanced gastric cancer at the lesser curvature of the gastric antrum.Biopsy revealed a diagnosis of poorly differentiated adenocarcinoma.As computed tomography suggested periaortic lymph node metastasis, a diagnosis of T4a(SE)N3aM1(LYM), cStage IV was made.Two weeks later, ptosis was observed in the right eye, and positron emission tomography-computed tomography(PET-CT)revealed metastasis to the right superior rectus muscle.No intracranial tumor progression was observed.The Cyberknife system(20 Gy/1 Fr)was used for treating the orbital tumor. Increased LYM was observed even after 2 courses of S-1 plus oxaliplatin(SOX)therapy.Therefore, weekly combination therapy of paclitaxel and ramucirumab(wPTX plus Rmab)was administered as second-line therapy.No new distal metastasis has been detected in the 10 months since the orbital metastasis development, and the patient is still alive.

We report a case of microangiopathic hemolytic anemia(MHA)caused by metastatic breast cancer treated with weekly paclitaxel. A 58-year-old woman was diagnosed with metastatic breast cancer 2 years earlier. She was treated with various chemotherapy regimens and hormonal therapy, before being switched to fulvestrant 3 months earlier. She presented with severe anemia, and was diagnosed with MHA with bone marrow carcinomatosis following bone marrow biopsy. She was treated with weekly paclitaxel and recovered successfully. A subsequent biopsy showed that the bone marrow carcinomatosis had decreased. MHA due to breast cancer is rare and is associated with poor prognosis; however, rapid initiation of chemotherapy may be effective.

Metaplastic carcinoma is a rare type of breast carcinoma, which tends to be chemo-resistant. We report a case of metaplastic squamous cell carcinoma of the breast diagnosed after neoadjuvant chemotherapy(NAC). A 56-year-old woman was diagnosed as having right-sided breast cancer(invasive ductal carcinoma[IDC], triple negative), cT1cN1M0, stage II A. NAC with 5-fluorouracil, epirubicin, and cyclophosphamide(FEC)followed by docetaxel(DTX)was administered. Tumor progression occurred during both the FEC and DTX regimens. We discontinued NAC and performed breast conserving surgery with axillary lymph node dissection. Histological findings of the resected specimen showed mixed IDC and widely spread squamous metaplasia. Weekly paclitaxel and radiotherapy were administered and the patient is alive with no recurrence 3 years after surgery.

We report a case of a 74-year-old woman with a left breast tumor with skin infiltration. Luminal type breast cancer with lung, bone, and parasternal lymph node metastases was diagnosed. She received paclitaxel and bevacizumab treatment. After chemotherapy, the lung metastasis and parasternal lymph node metastasis had disappeared, and the breast tumor had shrunk. Mastectomy and axillary lymph node dissection were performed. She has been receiving post-operative endocrine therapy. Paclitaxel and bevacizumab combination therapy is one of the useful treatments for metastatic breast cancer with skin infiltration.

An increasing number of patients with lung cancer are undergoing outpatient chemotherapy, and thus, it is very important to maintain the quality of life(QOL)of these patients. Ninjin-Youei-To(TJ-108), a Japanese traditional medicine, has been reported to improve the QOL of patients with advanced cancer. However, the effect of TJ-108 in patients with lung cancer undergoing outpatient chemotherapy is unknown. Therefore, we conducted this study. To investigate factors influencing the QOL of these patients, we administered a QOL questionnaire,"The QOL Questionnaire for Cancer Patients Treated with Anticancer Drugs"(QOL-ACD)to 15 patients with non-small cell lung cancer. Factors related to the overall QOL scores and other categories indicating"activity","physical condition","psychological condition","social relationship", and"face scale" were analyzed. No significant decrease in each of the evaluated factors was observed in this study.

A 51-year-old woman underwent radical operation for a gastric cancer and adjuvant chemotherapy with tegafur, gimeracil, and oteracil potassium. Five and a half years later, screening chest computed tomography(CT)scan showed slight ground glass opacity(GGO)of the both lungs and they were regarded as inflammatory change. Several months later, she experienced a dry cough. CT scan showed aggravation of GGO, and she was refered to our hospital to investigate these lesions 6 years after operation. We performed a wedge resection of right middle lobe. A postoperative pathology revealed metastatic carcinomatous lymphangiosis of gastric cancer. Chemotherapy using capecitabine and oxaliplatin, and then docetaxel was performed and talc pleurodesis was done for the malignant pleural effusion. These treatments did not improve condition, and she died 7 months after lung operation. In conclusion, we need to consider GGO as the possibility of carcinomatous lymphangiosis in case of patient with gastric cancer.

A 73-year-old man was referred to our hospital because of an abnormal shadow on a chest radiography. Chest computed tomography(CT) revealed a 3 cm nodule in the right lower lung lobe, fluorodeoxyglucose-positron emission tomography (FDG-PET) showed abnormal uptake in the tumor with a maximal standardized uptake value (SUV) max of 5.8. Bronchoscopy revealed adenocarcinoma cells. A right lower lobectomy and upper lobe partial resection and ND2a-1 were performed. Histological analysis revealed lung cancer comprising tall columnar cells. Immunohistochemical staining was positive in CDX2, CK20 and CK7. Any primary tumor was not found by postoperative screening. We diagnosed as a pulmonary enteric adenocarcinoma. After 6 months from operation, multiple recurrence was found and the patient died 8 months after operation.

We report a resected case of fetal adenocarcinoma. Fetal adenocarcinoma is a rare type of malignant lung tumor. A 53-year-old man had a 25 mm tumor in the right upper lobe on chest computed tomography. On fluorodeoxyglucose-positron emission tomography( FDG-PET), the tumor showed the accumulation of FDG with a standardized uptake value( SUV) max of 5.63. He underwent bronchoscopic examination, but a diagnosis was not established. We suspected that the tumor was primary lung cancer or metastatic lung tumor of rectal cancer which was resected prior to the treatment for pulmonary lesion. A right upper lobectomy with lymph node dissection was performed and the pathological diagnosis was high-grade fetal adenocarcinoma, stage IB (pT2aN0M0). The patient was treated with postoperative adjuvant chemotherapy. There has been no recurrence after surgery resection for 9 months.

Unilateral absence of a pulmonary artery (UAPA) is a rare congenital cardiovascular malformation and clinical experience of the surgery for this disease are limiting. We report a case of 62-year-old woman of UAPA (absence of left pulmonary artery) underwent a wedge resection of right lung for metastatic lung cancer. The surgery was performed under double lung ventilation because abnormal lung does not contribute to gas exchange. We were able to perform a wedge resection easily by setting the thoracotomy wound right above the tumor in the spine position. In a performing thoracic surgery under double lung ventilation, the position of surgical wound is very important. Therefore, although the diagnosis of this disease is difficult for the rarity and its nonspecific presentation, preoperative diagnosis of UAPA is very important.

A 72-year-old woman with a history of surgery for left breast cancer was found to have sigmoid colon cancer and solitary pulmonary tumor of left upper lobe. We diagnosed adenocarcinoma of the unknown origin by a transbronchial biopsy. We performed left upper segmentectomy and sigmoidectomy. Left pulmonary tumor was diagnosed metastatic lung tumor from breast cancer. A right pulmonary tumor was confirmed by chest computed tomography(CT) after sigmoidectomy. It was also considered to be metastasis from breast cancer and treated with vinorelbine ditartrate. Since no effect was observed by chemotherapy, tumor was surgically removed by wedge resection. Right pulmonary tumor was pathologically diagnosed as metastasis from sigmoid colon cancer. In suspicious case of pulmonary metastases from double cancer, the possibility of different lesions from different primary site should be kept in mind.

The case involved a 44-year-old man who underwent intersphincteric resection and lateral lymph node dissection for rectal cancer. Pathological diagnosis revealed a well-differentiated adenocarcinoma comprising KRAS wild type, and pT2N0M0 (pathological Stage I). CapeOX (capecitabine plus oxaliplatin[L-OHP]), and bevacizumab therapy was initiated because of local recurrence. Although a partial response (PR) was observed, the therapy was terminated after 6 courses because of the development of hand-foot syndrome. FOLFIRI and cetuximab therapy was initiated after cancer recurrence was observed during a follow up. As the therapeutic efficiency is characterized by stability (stable disease: SD), and the tumor reduction effect observed was not sufficient, we performed an abdominoperineal resection to achieve local control. However, a left hydronephrosis occurred due to the pelvic recurrence, necessitating the emergency hospitalization of the patient. Because resistance to L-OHP was not confirmed, mFOLFOX6 and bevacizumab therapy was introduced in hopes of the effect of the former. As Grade 2 allergy (erythema) appeared immediately after the L-OHP was administered during the 3 courses, treatment was discontinued. We the reinitiated the treatment along with the desensitization therapy from the 4 courses. A total of 27 courses of mFOLFOX6 and bevacizumab therapy were administered until the state of disease progression (progression disease: PD) was determined. PR was defined as the best therapeutic efficiency. In some cases, discontinuation of treatment is necessary as observed in the present case due to the onset of L-OHP allergies, even if the overall effect of the treatment is expected to be good. Our case is essentialas it demonstrates the successfulness of desensitization therapy for L-OHP allergies.

A 77-year-old man was diagnosed with ascending colon cancer with synchronous liver metastasis. Per our policy we first only performed a right hemicolectomy (pSSN2H2M0, stage IV). We then planned S-1 and oxaliplatin (SOX) plus bevacizumab (Bmab) chemotherapy as a neoadjuvant for the resection of liver metastasis. After 4 courses, enhanced CT and EOB-MRI findings showed the liver tumor had significantly decreased in size with no side effects, and we performed a partial liver resection for the S7 lesion. Postoperatively, histopathological analysis revealed only a fibrotic lesion and no cancerous cells in the resected specimen, indicating that chemotherapy had downgraded the tumor to Grade 3. Adjuvant chemotherapy was not continued owing to the patient's refusal, but no recurrence was noted 18 months after the second operation. SOX plus Bmab chemotherapy is, therefore, effective in terms of its anti-tumor effects, tolerance, and accessibility. We believe SOX plus Bmab chemotherapy can be considered as an effective option for cases with synchronous liver metastasis of colon cancer as neoadjuvant chemotherapy for interval liver resection.

Patients with metastatic colon cancer can be treated with alternating courses of FOLFOX6 and FOLFIRI in order to reduce their adverse events. We report 2 patients with para-aortic lymph node metastasis treated with 4 courses each of FOLFOX6 and FOLFIRI in combination with bevacizumab, which led to a complete response. Case 1: The patient was a 53-year-old woman with transvers colon cancer tub2 pSS, ly3, v2, n4, H0, P0. Case 2: The patient was a 60-year-old woman with upper rectal cancer tub1 pSS, ly3, v3, n4, H0, P0. The administration of tegafur/uracil plus oral Leucovorin was continued for 6 months. Furthermore, only the administration of oral doxifluridine was continued for 4 years. Complete response has been maintained for over 5 years since resection. Four courses each of FOLFOX6 and FOLFIRI in combination with bevacizumab will not only provide a remission rate of 100% but will also be effective radical therapy for patients with para-aortic lymph node metastasis.