A 60s-year-old Japanese male underwent curative resection for an advanced adenocarcinoma of the esophagogastric junction(Stage III C), followed by adjuvant chemotherapy.Twenty -one months later, he was admitted to our hospital with a complaint of marked decline in activities of daily living(ADL).The patient was diagnosed with pancytopenia, disseminated intravascular coagulation(DIC), multiple lymph node and bone metastases, and bone marrow carcinomatosis.After completing a sufficient informed consent process, he received chemotherapy along with blood transfusion, and then DIC, pancytopenia, and ADL of the patient improved.However, the lack of response of pancytopenia and DIC to transfusion relapsed and his ADL worsened after the second course of chemotherapy.It was difficult to administer additional chemotherapy in the patient and he died 24 months after surgery.There is no established treatment for disseminated carcinomatosis of the bone marrow, and the prognosis of these patients without treatment is reported to be only one month.Our case with prolonged survival following chemotherapy and blood transfusion may support the clinical usefulness of chemotherapy for bone marrow carcinomatosis from esophagogastric junctional carcinoma.

According to the Guidelines for Diagnosis and Treatment of Carcinoma of the Esophagus in Japan, the standard treatment of esophageal cancer with cStage II / III is preoperative chemotherapy and radical resection. But when the tumor has deep ulcer, the perforation of it is sometimes occurred due of the anti-tumor effect and we are forced to change the standard treatment. In this time, we report a case of emergency resection of esophageal cancer which is on the brink of perforation after neoadjuvant chemotherapy. A 62-year-old woman had locally advanced esophageal cancer(cT4N2M0)and performed neoadjuvant chemotherapy(NAC). After 2 courses of NAC, the patient got into critical condition that the esophageal cancer was on the brink of perforation, thus we immediately performed emergency resection of the tumor. Unfortunately, the tumor was not completely resected because of invasion to the Botallo ligament, but we were able to avoid a critical state such as mediastinitis or penetration to the aorta. In multimodality therapy for locally advanced tumor, immediate response to oncologic emergency is significantly required, impacting on the prognosis and quality of life.

Surgery is generally indicated for the treatment of lower lip carcinoma. However, surgery can lead to esthetic as well as functional issues, with disturbances in eating and articulation. If the defect involves less than one-third of the width of the lower lip, primary closure is possible. If the defect is wider, reconstructive local flaps may be necessary for both esthetic and functional recovery. This report describes a case of lower lip verrucous carcinoma in which a tongue flap was used to treat a defect involving more than half the width of the lower lip following resection. The patient was a 91-year-old woman who complained of lower lip discomfort. A biopsy revealed verrucous carcinoma, and we performed resection. After a 3-week waiting period, we performed secondary tongue flap reconstruction. Satisfactory function and cosmetic results were achieved.

A 64-year-old woman visited hospital with a chief complaint of a nodule at the left neck skin. Skin biopsy revealed adenocarcinoma, and the diagnosis was skin metastasis of unknown primary origin. Positron emission tomography and computed tomography showed multiple bone and lymph node metastasis, left breast tumor, bladder tumor, and hydronephrosis. A needle biopsy of breast revealed invasive ductal carcinoma, and transurethral biopsy of bladder revealed adenocarcinoma. The findings were similar to those for the breast and the expression pattern of estrogen-receptor was the same. We diagnosed her with breast cancer and bladder metastasis. We administered systemic chemotherapy, however she died 10 days later. Bladder metastasis of breast cancer is rarely encountered in clinical practice and is often accompanied by life threatening symptoms. Careful histopathological examinations and rapid systemic chemotherapy are significant.

A 46-year-old woman visited our hospital with a chief complaint of a mass in the right breast. Breast ultrasonography revealed a hypoechoic area with an indistinct border on the right breast, and right axillary lymph node swelling. A core needle biopsy revealed invasive ductal carcinoma, and the diagnosis was right breast cancer, cT2N2M0, Stage III A, HER2-enriched type. We administered 4 courses of FEC followed by weekly paclitaxel plus trastuzumab. After the treatment, she had eruption and erythema on the face, precordium and forearm. Though dermatomyositis associated cancer was suspected, a definite diagnosis was not made. However, skin symptoms were improved significantly after mastectomy, suggesting that she had dermatomyositis. For the skin symptom during breast cancer treatment, the examination should be made with the possibility of the adverse effect of chemotherapy and dermatomyositis associated cancer.

A hypervascularized tumor was detected in a 65-year-old man who had underwent a nephrectomy for a right renal cell carcinoma at the age of 55 years. We diagnosed the tumor as a non-functioning pancreatic neuroendocrine tumor or a metastatic tumor from the renal cell carcinoma. We performed distal pancreatectomy with splenectomy and lymph node dissection. The tumor was histopathologically diagnosed as metastatic renal cell carcinoma.

The patient was a 65-year-old man who had been previously diagnosed with chronic hepatitis B, but the patient had discontinued treatment while in his thirties. The patient was admitted to the emergency department after losing consciousness due to abdominal pain. Emergency contrast CT was performed in the shock state, and the diagnosis was hemorrhagic shock due to rupture of hepatocellular carcinoma(HCC). Emergency TAE was performed, and hemostasis was successful due to left hepatic arterial embolism. The tumor was confined to the liver lateral area and it was judged to be resectable curatively, upon state restoration. Ten days after TAE, lateral segmentectomy of the liver was performed. Pathological findings indicated moderately differentiated HCC, mostly necrotic and partially viable. He was discharged on 11POD. On 69POD, the patient reexperienced sudden abdominal pain after lunch. The abdominal pain continued while emergency contrast CT was performed at the time of visit in the shock state. Recurrence of multiple dissemination via high-absorption ascites was found around the largest tumor nest with lower left diaphragm diameter of 15cm, and it was judged that the HCC disseminated recurrence had ruptured. Emergency TAE was performed again, and hemostasis was successful by embolization of the left gastric artery and lower left diaphragm artery. Subsequently, tumor growth slowed after initiating oral administration of sorafenib, and the patient is alive 8 months after re-TAE.

The patient was a 30-year-old man who underwent a medical examination for shortness of breath.An abdominal computed tomography(CT)scan revealed advanced ascending colon cancer with multiple metastases to the liver.We performed a laparoscopic right hemicolectomy first, due to the obstruction.Postoperatively, the patient received capecitabine plus oxaliplatin( CapeOX)chemotherapy.After 10 courses of CapeOX, the multiple liver metastases had reduced remarkably in size. Colectomy of the anastomosis and partial hepatectomy were then performed.Histological examination of the resected tissue revealed no residual cancer cells, suggestive of a pathological complete response.

A 77-year-old female case who underwent laparoscopic distal gastrectomy with D2 dissection, Billroth I reconstruction for gastric cancer. Since the stage was III A, she received an adjuvant chemotherapy with S-1 after surgery. However, about 2 years after surgery, she was referred to our hospital for anorexia and vomiting. As a result of the examination, we diagnosed stenosis due to peritoneal recurrence near the anastomotic site. We performed laparoscopic remnant gastrojejunal bypass (Billroth II method, with Braun anastomosis). A camera port was inserted into a median umbilical incision. Following this, 4 additional ports(1 ports of 12mm in diameter and 3 ports of 5mm in diameter)were inserted under laparoscopic imaging into the right lower, right upper, left upper, and left lower quadrants. We first detached the adhesion considered as the influence of the previous surgery, and the anastomosis of remnant stomach and jejunum and the Braun anastomosis were performed by the linear stapler. The postoperative course was good. She started oral intake from the day after surgery, was discharged on the 6 days after operation, and received chemotherapy promptly. This procedure was effective for recurrent gastric cancer with stenosis which is difficult to resect and it was considered to be a minimally invasive method with a view to initiating chemotherapy early after operation.

A 75-years-old man was diagnosed with a cystic submucosal tumor of the middle body of the stomach and diffuse cystic malformation. Laparoscopic total gastrectomy was performed since a type II c gastric cancer was found at the lower body of the stomach after 1-year follow-up. Histopathological examination revealed mucosal adenocarcinoma with diffuse cystic malformation. Strict observation and appropriate treatment are needed for diffuse cystic malformation because of its significant carcinogenic rate.

The case involved a 67-year-old man. Type 2 gastric cancer in the body of stomach was discovered, and the patient was referred to this department, where distal gastrectomy with Roux-en-Y reconstruction was carried out. The pathological classification was pT2N2H0P0CY0M0, pStage II B, and S-1 administration was started as postoperative adjuvant therapy. After 10 months of administration, a chest computed tomography(CT)scan revealed fine nodular shadows and irregular thickening of the alveolar septa in both lungs, a finding that was judged to be carcinomatous lymphangiosis. CDDP plus CPT- 11 therapy was subsequently started. Chest CT scan after 2 courses of administration showed the disappearance of the carcinomatous lymphangiosis. However, peritoneal metastasis was noted immediately below the abdominal wall. After completing 6courses of administration, the recurrence of peritoneal metastasis disappeared, and the administration of chemotherapy was terminated. There was no subsequent recurrence, and the patient remains alive today, 6years after the surgery. In the present case, the CT scan did not show clear mediastinal or hilar lymph node enlargement, but nodular shadows were noted at the periphery of the lung field, which were thought to be carcinomatous lymphangiosis as a result of haematogenous or anterograde metastasis into the lungs.

A 83-year-old female, with oppression in her chest, was subjected to type 2 advanced gasteric cancer in esophagogastric junction. Examinations revealed Stage III c of cT4, cN2, cM0. For adopting neoadjuvant chemotherapy, S-1 plus CDDP was not on the list, but S-1 plus oxaliplatin (SOX) was, because massive load of infusion along with the chemotherapy was not appropriate for the patient with low cardiac function. After 2 courses of SOX, the primary tumor as well as metastatic lymph nodes were shown with marked reduction in size by CT scan, which enabled total gastrectomy with D2 lymphadenectomy to be performed as a curative resection, leading to patient living with no recurrence more than 3 years. SOX was considered as one of safe neoadjuvant agent for gastric cancer combined with low cardiac function.

A 79-year-old man with cStage II A(T2N1H0P0CYXM0)advanced gastric cancer in angle. Distal gastrectomy was performed and liver metastasis was recognized during the operation. The pathological diagnosis was shown as neuroendocrine carcinoma(NEC). Chemotherapy(S-1/cisplatin[CDDP]: 1 course, etoposide/CDDP: 5 courses)was administered. After chemotherapy, liver metastasis disappeared for 9months.

A 69-year-old woman who was identified the tumor of the pancreas tail by CT scan for postoperative inspection of breast cancer. Pancreas tail cancer with para-aortic lymph node metastases was diagnosed by close inspection. She consulted a different hospital to receive their second opinion. She was diagnosed of sarcoidosis from points with lymphadenopathy in hilar region and para-aorta for 3 years and uveitis. The patient was referred to our institution for treatment. We performed distal pancreatectomy in March, 2014. No.16 lymph nodes were cancer-negative, but lymph nodes around the pancreas were cancer positive. Abdominal CT, 9 months after surgery, showed lymph node swelling. We recommended a definitive diagnosis by EUS-FNA, but she refused the inspection. She was checked by CT scan regularly afterwards and is alive without recurrence 39 months after the operation. Diagnosis for lymph node metastases is difficult for a malignant tumor when the sarcoidosis coexisted.

Recent studies indicated that isolated pulmonary metastases could define a favorable subgroup in metastatic pancreatic cancer. We report a case of isolated pulmonary metastases after curative resection of pancreas head cancer treated with chemotherapy and pulmonary metastasectomy survived for 79 months after recurrence. A 72-year-old male underwent pancreatoduodenectomy for pancreas head cancer. Adjuvant chemotherapy was done with gemcitabine hydrochloride (GEM)for 6 months and then S-1 for 2 months. Twenty-seven months after surgery, 2 small metastatic nodules in the left lung was detected. Chemotherapy with GEM was performed but the lesions grew larger very slowly. A new metastatic nodule was detected in the right lung 40 months after surgery and pleural effusion was detected 52 months after surgery. Then combination chemotherapy with GEM and S-1 was performed for 3 months followed chemotherapy with S-1 alone. Seventytwo months after surgery, chemotherapy with GEM was performed again because of patient's intolerance to S-1. Ninety months after initial surgery, pulmonary metastasectomy of the right lung was performed because of its resistance to chemotherapy. Chemotherapy with GEM was started again 4 months after pulmonary metastasectomy but serum levels of tumor markers remained increase. Combination chemotherapy with GEM and nab-paclitaxel was started 8 months after pulmonary metastasectomy but the patient died 16 months after pulmonary metastasectomy.

We report a case of the pancreas head cancer with peritoneal metastasis, which was resected curatively after chemotherapy. A6 6-year-old male was referred to our hospital for the treatment of biliary stenosis. The serum CA19-9 level was elevated and abdominal CT scan showed stenosis of distal bile duct. By laparotomy, we noticed mass in the head of the pancreas with 8mm of the seeding nodule in a diameter at jejunal mesentery which was diagnosed as adenocarcinoma by intraoperative frozen sections. Therefore, the patient was diagnosed as pancreas head cancer with peritoneal metastasis. After hepaticojejunostomy, we started chemotherapy planning adjuvant surgery if the clinical response was observed. Systemic chemotherapy with gemcitabine and nab-paclitaxel was administrated on days 1, 8 and 15 every 4 weeks. After 5 courses, therapeutic effect was stable disease(SD)in response evaluation criteria in solid tumor(RECIST). All of tumor markers were normalized. Subtotal stomach-preserving pancreatoduodenectomy(SSPPD)was performed 6 months after the initial surgery. Histopathologically, most cancer cells showed degeneration and eliminated in the head of the pancreas. R0 resection was achieved with diagnosis of ypT3, ypN1, pM1(PER), Stage IV . Histological therapeutic effect was Grade III according to the Evans classification. The patient is alive, with no sign of recurrence 8 months after surgery. Adjuvant surgery was suggested to be one of the therapeutic options for pancreatic cancer with peritoneal metastasis.

A 56-year-old man with HCV infection was referred to our hospital for further evaluation and treatment of hepatic tumor. Abdominal enhanced computed tomography demonstrated an S8 hepatic tumor, about 15mm in maximal diameter. The tumor showed enhancement on the arterial phase and washout on equilibrium phase. EOB-MRI scan also showed the hepatic tumor with enhancement in the early phase and washout in the delayed phase. Liver function was normal. Serum AFP and PIVKA- II were normal and CEA and CA19-9 were elevated. However, no other tumor was detected by the colonoscopy, esophagogastroduodenoscopy and PET-CT. Under the diagnosis of HCC, partial hepatectomy was performed. Histologically, the tumor was composed of neoplastic glands with irregularly dilated lumen of adenocarcinoma, resembling ductal plate malformation(DPM). And Von Meyenburg complexes and foci of ordinary intrahepatic cholangiocarcinoma(ICC)were also found. ICC with this histologic features reported as a new subtype of ICCs.

A 67-year-old male was referred to our hospital for further investigation of fecal occult blood. We diagnosed him with rectal cancer with osseous metastasis. Chemo-and radiation therapy were administered following resection of the rectal cancer. There were no other lesions except for the osseous metastasis remaining after these interventions. The osseous lesion was then resected. There have no signs of recurrence for 1 year and 9 months since the last operation. We report a case of successful resection of osseous metastasis from rectal cancer.

The patient was a 70-year-old woman who was diagnosed with obstructive transverse colon cancer suspected of invading the abdominal wall by abdominal CT imaging. Since the preoperative electrocardiogram showed an ischemic change, echocardiography and coronary angiography were performed. We diagnosed chronic heart failure and angina pectoris because echocardiography showed low cardiac function(left ventricular ejection fraction; LVEF 37%)and coronary angiography indicated triple-vessel disease. We firstly performed coronary artery bypass graft surgery following self-expanding metallic stent placement as a bridge to surgery(BTS), because we judged this patient as a perioperative high-risk case. After improvement of cardiac function(LVEF 49%), expanded right hemicolectomy with partial resection of abdominal wall could be performed without perioperative complications. Colonic stenting as a BTS allowed us to treat comorbidities properly, and perform a radical surgery safely for such a high-risk patient.

We report a case of duodenal neuroendocrine tumor(NET)G1 resected by laparoscopic-endoscopic cooperative surgery (LECS). A 78-year-old woman underwent upper gastrointestinal endoscopy, revealing an 8 mm, rising tumor on the anterior wall of the duodenal bulb. The tumor was pathologically diagnosed as a G1 duodenal NET, by biopsy. Endoscopic ultrasonography showed the tumor might invade the submucosal layer. We performed LECS. The endoscopist marked the dissection line around the tumor and penetrated the duodenal wall. The duodenal wall in the excision area around the tumor was dissected using ultrasonically activated scalpel by the laparoscopist. The closure of the defect in the duodenal wall was performed by the laparoscopic hand-suturing technique. The patient was discharged with no complication on postoperative day 8. The horizontal and vertical margins were free of tumor cells. We demonstrated that LECS for NET of the duodenal bulb anterior wall was useful and safe method to enable appropriate surgical margin and minimum intestinal resection.