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An umbilical metastasis from an internal malignancy is called Sister Mary Joseph's nodule(SMJN)and has a poor prognosis. Herein, we report a case of umbilical metastasis of cervical cancer. A woman in her eighties underwent radiation therapy for cervical cancer(cT3bN0M0, cStage ⅢB). Primary tumor shrank after treatment, suggesting that radiation therapy induced complete response. Two years and 9 months after treatment, the patient presented with umbilical pain. A CT scan showed an umbilical mass near the umbilical hernia. PET-CT demonstrated high accumulation of FDG at the mass, which led to suspicion of umbilical metastasis(SMJN). Although she underwent radical surgery, she died from cancer 8 months after surgery.

A 66-year-old woman was referred to the gastroenterology division of our hospital due to elevation of serum CEA level. Contrast-enhanced CT showed a hypovascular tumor at the body of pancreas. She was diagnosed with pancreatic cancer by EUS-FNA. By laparotomy, we found white nodules on mesentery and abdominal wall, which were diagnosed as peritoneal metastasis. After systemic chemotherapy with 9 courses of gemcitabine(GEM)plus nab-paclitaxel(PTX)and 30 courses of mFOLFIRINOX, the tumor had shrunk and serum CA19-9 level were remarkably decreased. Distal pancreatectomy was performed as conversion surgery. Pathological analysis revealed no remnant cancer cells in the primary tumor or the lymph nodes, confirming a pCR. S-1 was started as adjuvant chemotherapy, and she remains alive without recurrence 8 months after surgery.

An 85-year-old woman who visited the hospital with sores on the perianal skin was diagnosed with squamous cell carcinoma of the anal canal(cT3N1aM0, cStage ⅢC). She received chemoradiotherapy(radiation total 54 Gy/30 Fr, mitomycin C/capecitabine). The tumor initially shrank, but regrowth of the primary lesion, extensive perianal skin infiltration, and the appearance of para aortic lymph node metastases was observed 6 months later. Laparoscopic abdominoperineal resection was performed to mitigate strong local symptoms. The perineal defect was repaired with bilateral gluteus maximus flap(V- Y flap). The operation prevented anal pain and improved ADL. The patient is currently undergoing chemotherapy 7 months after surgery. We report the case with a review of the literature in which ADL was improved by salvage surgery for tumor regrowth with severe local symptoms and distant metastases after chemoradiotherapy for squamous cell carcinoma of the anal canal.

A 62-year-old woman was diagnosed with gastric cancer, Type 4, cT4b(LN, mesentery of transverse colon), N1 M1H0P1CY1, cStage ⅣB. S-1 and L-OHP(SOX)were administered for 4 courses and clinical response was SD. She interrupted the treatment because of practicing folk therapy. She had an emergency hospitalization due to pyloric stenosis, vomiting, and an umbilical tumor with pain. She was treated with 1 course of mFOLFOX6(5-FU, L-OHP, l-LV)followed by palliative surgery(laparoscopy assisted distal gastrectomy, Roux-en-Y reconstruction, resection of umbilical tumor, and bypass for transverse colon stenosis due to dissemination). The pathological diagnosis was L, Circ, Type 4, 126×89 mm, por> sig, pT4b(SI, mesentery of transverse colon), pN3a(12/13), H0P1CY1, pStageⅣ, and metastatic umbilical tumor. Following surgery, oral administration of mFOLFOX6 is continued. Umbilical metastasis(Sister Mary Joseph's nodule)is associated with poor prognosis, however, appropriate management including symptom control by palliative surgery and continuation of chemotherapy may lead a better prognosis.

A 52-year-old man underwent total gastrectomy for advanced gastric cancer. The postoperative diagnosis was por1>muc >por2>tub2, pT4a(SE)N3bM0H0P0CY0, pStage ⅢC. He underwent 6 courses of adjuvant chemotherapy with capecitabine plus oxaliplatin. Six months after the surgery, CT showed 2 recurrent lesions: a tumor behind the esophago-jejunal anastomosis and another in the mesentery around the jejuno-jejunal anastomosis. Endoscopy showed intrajejunal invasion. Second-line therapy with paclitaxel and ramucirumab were administered for 3 courses, resulting in rapid progression of the disease. Palliative radiotherapy(39.6 Gy/22 Fr)for both lesions was performed for local control. Sequential administration of nivolumab was started 9 days after terminating radiotherapy. After 6 courses, both tumors markedly reduced PR, and the oral intake of food improved. After 10 courses, there was hyper-progression of the tumor behind the esophago-jejunal anastomosis and shrinkage of the other tumor. Surgery (left upper abdominal exenteration and enucleation of the tumor in the mesentery)was performed to release the jejunal limb obstruction. The tumor behind the esophago-jejunal anastomosis was a poorly differentiated adenocarcinoma, and no viable cancer cells were seen in the tumor in the mesentery. Radiotherapy and immune checkpoint inhibitors may be effective for gastric cancers, although the mechanism of action should be elucidated.

Solitary fibrous tumor (SFT) are relatively rare neoplasms that usually arise in the thoracic cavity in adults. Although many cases of extrathoracic SFT have been recently reported, SFT from the omentum is rare. A 32-year-old woman consulted a gynecologist complaining of irregular vaginal bleeding. Magnetic resonance imaging (MRI) revealed a tumor in the omentum, and the patient was admitted to our department. The patient underwent laparoscopic tumorectomy. The tumor size was 48 × 35 × 30 mm, and grayish-white nodules were observed. Histological examination showed hyperplastic spindle-shaped tumor cells with a pattern-less arrangement. Immunohistochemical staining showed the tumor was positive for CD34 and bcl-2, slightly positive for alpha smooth muscle actin(a-SMA), and negative for S-100 and c-kit. Accordingly, a diagnosis of SFT was made. The patient has not shown any recurrence 12 months after surgery. Most SFTs are benign, although there are some reports of recurring tumors. There are no clear guidelines for the treatment of SFT because of its rarity. Therefore, close long-term follow-up should be performed.

A 70-year-old man presenting with melena was referred to our clinic. A clinical examination revealed a bulky tumor in the lower rectum. After ileostomy, 4 courses of capecitabine plus oxaliplatin (XELOX) therapy were administered as neoadjuvant chemotherapy. Computed tomography (CT) revealed significant reduction of the tumor. Laparoscopic super-low anterior resection with lateral lymph node dissection was performed. The pathological examination revealed no residual cancer cells, and a diagnosis of pathological complete response was made. The patient has been disease-free for 1 year after the operation. Neoadjuvant chemotherapy with XELOX might be promising for patients with locally advanced rectal cancer.

A 60-year-old man showed symptoms associated with pulmonary embolism and anemia in June 2011, and was subsequently diagnosed with stage IV gastric cancer. Following frequent multiple cerebral infarctions and the development of symptoms, the patient was diagnosed with Trousseau syndrome. A total gastrectomy was performed to control bleeding. After the surgery, oral ingestion became possible. The patient was discharged and a hypodermic injection of heparin was given by the home doctor.

Gastrointestinal tract endoscopy revealed the presence of a 5-cm-diameter type 3 tumor in the cardiac portion of the stomach. The tumor was chromogranin positive, and stomach small cell cancer was diagnosed by immunostaining and biopsy pathology. S-1+CDDP therapy was administered as the first-line treatment. A switch to S-1 monotherapy was made after the patient experienced grade 4 hyponatremia. However, following 7 courses of therapy the disease had progressed. Second-line chemotherapy of CPT-11+CDDP was initiated and after 2 courses the disease stabilized.

A 70-year-old male patient underwent right nephrectomy for renal clear cell carcinoma. After 8 years an X-ray showed a nodule on the left lung, and CT scan detected it to be a 15 × 12 mm mass in S1+2 segment of the left lung. CT also detected another 15 × 7 mm mass in the right S3 segment. These lesions had a high FDG accumulation. Pre-operative diagnosis is bilateral pulmonary metastases from renal cell carcinoma, and bilateral lung segmentectomy was performed. Left S1+2 resected tumor was histologically clear cell carcinoma by intra-operative examination, then right S3 segmentectomy was done. And that time, small tumor was found in the middle lung lobe, and a wedge resection was performed. These specimens revealed a primary lung carcinoma of right S3, and tumourlet of middle lobe. It is very rare that three different histlogical types of lung tumor were found.

An 80-year-old woman complaining of a right inguinal induration and pain was performed an inguinal lymph node resection. Histological examination with immnohistochemistry revealed that the lymph node was metastasis of colon carcinoma. With total colonoscopy, she was diagnosed as advanced transvers colon cancer with right inguinal lymph node metastasis. She was performed a right hemi-colectomy. She was dead with peritoneal metastasis of colon cancer 2 years and 1 month later. We report this case that was diagnosed having transverse colon cancer with inguinal lymph node metastasis.

A man in his fifties was referred to our hospital for anorexia and vomiting. Upper gastrointestinal endoscopy showed a gastric cancer (Borrmann Type 3) with pyloric stenosis. We performed gastrojejunostomy to allow oral intake for a tumor invading the pancreas head (cT4bN1H0P0CY1, Stage IV). After the operation, systemic chemotherapy with S-1 (120 mg/m²) was administered from July 2007, which caused grade 3 mucositis oral and drug rash after one week. Then, bi- weekly administration of CPT-11 (60 mg/m²) and CDDP (30 mg/m²) was started from August 2007 as second-line chemotherapy. The treatment was repeated for 14 courses till an allergic reaction happened. A weekly paclitaxel (PTX) therapy (80 mg/m²) was started from January 2009 as third-line. After 6 courses, CT showed that direct invasion to the pancreas was not clear any more, so a distal gastrectomy with D1 lymphadenectomy was performed on August 2009 (ypT3N- 1P0CY0, Stage IIB). The patient received 9 courses of weekly PTX therapy and after that the treatment has been discontinued. Recurrence was not observed for 48 months after an initial treatment.

We report a successful case with irinotecan (CPT-11 60 mg/m2) + cisplatin (CDDP 30 mg/m2) chemotherapy (once in 2 weeks) for recurrent gastric cancer of the remnant stomach. A 77-year-old man was performed a distal gastrectomy for duodenal ulcer 42 years ago. He had a total gastrectomy for gastric cancer of remnant stomach when he was at 73 years old. After the surgery, we treated this patient with S-1 mono-therapy for five courses. However, we finished this treatment for lymph-node metastases. Next we treated him with CPT-11 + CDDP. An abdominal CT revealed a CR after 6 courses. We finished this treatment after 12 courses for anemia (grade 3). After the treatment, the metastatic lymph-nodes appeared in no change. So we considered that CR was continued for 3.5 years.

We report a death case of a man in his sixties with pneumocystis pneumonia during chemotherapy for gastric cancer. He was diagnosed with cStage IIIB (T4a, N2, H0, P0, M0). Because of bulky N2, systemic chemotherapy of S-1 and CDDP was performed from April 2009. But no reductions were noted after 2 courses. We next treated this patient with S-1 and CPT-11. He had also received corticosteroid treatment for nausea. Because of high fever and choke, he came to our hospital at day 12 in 3 courses, and a severe respiratory failure occurred. CT of the chest showed diffuse ground-glass bilateral opacities, and we immediately started a treatment with trimethoprim-sulfamethozazole and corticosteroid for the possibility of pneumocystis pneumonia. We finally deduced pneumocystis pneumonia from markedly elevated serum beta-D-glucan and PCR positive after hospitalization. In spite of early treatments, he died of bacterial pneumonia and gastric cancer. We should be careful of pneumocystis pneumonia during chemotherapy and corticosteroid treatment.

We have a program of strength training for home health care with protein rich supplement just after the training on frail elderly patients. Three cases (80-90 years old) received a new good taste protein rich supplement. They were also frail patients after acute clinical treatments, and were able to go home directly against their physical moving problems for daily life. We performed cardio-pulmonary and swallowing function, energy intake, parameters of muscle strength and the status for daily life before and after the training. Practical results were very different among the patients. But, the status for daily life of all was better than before. It was not clear that the new supplement was effective for the parameters of muscle strength, or not. But a trial for programs with thus foods should be an option for promoting to home health care after hospitalization in frail elderly.

A man in his fifties with rectal cancer underwent low anterior resection in another Hospital in January 2006. He was finally diagnosed with Stage III a (pA, pN1, H0, P0). The patient who had postoperative complication such as ruptured suture left the hospital in May 2006, when he was detected with multiple liver metastases and was referred to our hospital for systemic chemotherapy. Systemic chemotherapy with mFOLFOX6 was performed from May 2006. Grade 3 diarrhea and grade 2 peripheral neuropathy, nausea and vomiting were observed. After 6 courses of mFOLFOX6, MRI revealed metastasis had been disappeared and levels of CEA and CA19-9 were decreased below normal. The treatment has been discontinued. Recurrence was not observed for 30 months.

This case was a male patient, about 50 years old. He received a curative operation for advanced esophageal carcinoma [poorly differentiated squamous cell carcinoma type, Lt, pT3 (pAd) pN3, pstage III] in March 2005. He also received adjuvant chemotherapy of 5-FU plus cisplatin (CDDP). Fourteen months later (May 2006) from surgery, metastases to the left lung and left subclavian lymph nodes were diagnosed, so he received first-line triplet combination chemotherapy (NAF regimen; nedaplatin 60 mg/m2: day 1, adriamycin 50 mg/m2: day 1, 5-FU 700 mg/m2: day 1-5). According to the 9 courses of treatment of this regimen, complete response for these metastases was observed and first-line chemotherapy was finished. However, a severe headache appeared 3 months later, and he had a diagnosis of solitary 5 cm brain metastasis by MRI. Excision of the metastasis was performed with sequential whole-brain radiation therapy (30 Gy). Five months later, diffuse and multiple brain metastases relapsed, and second-line chemotherapy did not respond well, and finally he was died 3 months after palliative care. But, completely controlled metastases (lung and lymph node) by first-line chemotherapy did not relapse again in all his clinical period. If an anticancer therapy goes in complete response in an advanced esophageal carcinoma patient, we should consider about a rare brain metastasis in order to find out as small and solitary state.

A 67-year-old man with intrahepatic cholangiocarcinoma (ICC) underwent an extended right hepatectomy. Approximately, during the next 20 months after the operation, the patient underwent 6 times of radiofrequency ablation for solitary recurrence of ICC. He has survived for 26 months after hepatic resection with PS 0. Radiofrequency ablation for solitary recurrence of ICC may be effective for a good prognosis.