[A Case of Conversion Surgery for Gallbladder Cancer with Para-Aortic Lymph Node Metastasis].

The study presents the case of a 71-year-old woman who visited a nearby hospital for epigastric pain and weight loss. A CT scan showed a mass in the gallbladder, and the CEA level was high, so she was referred to our hospital for further investigation. Abdominal US, CT, and MRI suggested gallbladder cancer with para-aortic metastasis, and the histological findings on the EUS-FNA confirmed the diagnosis. Since surgical resection was not indicated, chemotherapy was performed(gemcitabine plus cisplatin). After 10 courses of chemotherapy, CT and MRI showed downsizing of para-aortic lymph nodes, and no accumulation of FDG was found on FDG-PET. Confirming the downstaging of cancer, conversion surgery, comprising an extended cholecystectomy and a lymph node resection, was performed. The pathological diagnosis showed no lymph node metastasis. No recurrence was observed after 12 months of surgery. Initially, unresectable gallbladder cancer with para-aortic lymph node metastasis was indicated to be compatible with preoperative chemotherapy and conversion surgery.

[A Case of HER2-Positive Unresectable Advanced Gastric Cancer Showing Long-Term Complete Response Treated by Only Chemotherapy].

A 78-year-old man was diagnosed as HER2-positive unresectable advanced gastric cancer(cT4aN3M1[LYM], Stage Ⅳ). After 2 courses of first-line chemotherapy(S-1 plus oxaliplatin plus trastuzumab), PR was achieved. The treatment could not be continued due to adverse events after 5 courses, thus second-line chemotherapy was conducted. Corresponding to the physical condition. The third-line chemotherapy was also introduced. However, we clinically judged PD because of amount of ascites and chemotherapy was terminated. After that, he has survived for more than 2 years without chemotherapy, and endoscopy and CT showed the disappearance of the tumor, metastatic lymph nodes, and ascites at 41 months after diagnosis. Looking back on the changes in tumor markers, it was possible that he had already achieved CR at the first-line chemotherapy.

[A Case of Lymph Nodes Metastases of Gastric Neuroendocrine Carcinoma Treated with Nivolumab and Showing Complete Response].

A 78-year-old man was diagnosed with lymph node metastasis 2 months after surgery for gastric neuroendocrine carcinoma. He received chemotherapy(CDDP plus CPT-11)and showed partial response(PR)after 3 courses of the regimen. Serum CEA increased 5 months after surgery, thus nab-paclitaxel plus ramucirumab was administered. Although the lymph node kept shrinked after 2 courses of the regimen, the lymph node was detected 12 cm of the size in CT after 5 courses of the regimen. He started to receive nivolumab. The lymph nodes showed PR after 4 courses, and complete response after 6 courses of the regimen for 1 year and 4 months until now.

[A Case of Cardiac Tamponade during Multimodal Treatment for Mediastinal Lymph Node Metastasis of Gastric Cancer].

A 52-year-old man underwent total gastrectomy for gastric cancer and chemoradiotherapy for thoracic paraaortic lymph node metastasis. He also underwent esophageal stent implantation for stenosis. He was admitted to our hospital with fever and breathing difficulty and was diagnosed with infectious pericarditis. He showed symptoms of shock due to cardiac tamponade. After pericardial drainage, his vital signs improved. When signs of infection are detected in patients with a history of chemoradiotherapy or stent implantation, we should consider infectious pericarditis due to esophageal pericardial fistula and apply immediate drainage of cardiac tamponade.

Efficacy of Single-incision Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair for Overweight or Obese Patients.

AIM: To evaluate the efficacy of single-incision laparoscopic surgery for totally extraperitoneal repair in overweight or obese patients. MATERIALS AND METHODS: For outcome analyses, patients were subdivided by body mass index (BMI) as normal-weight (18.5≤BMI<25 kg/m), overweight (25≤BMI<30 kg/m) or obese (≥30 kg/m) and compared. RESULTS: In total, 201 patients were divided into a normal-weight group (n=152) and an overweight/obese group (n=49). Median operative time for unilateral hernia was 72 minutes in the normal-weight group and 95 minutes in the overweight/obese group (P<0.05). No significant differences in operative time for bilateral hernia, bleeding volume, peritoneal injury, conversion to a different procedure, postoperative hospital stay, follow-up duration, complications, or recurrence were identified. CONCLUSIONS: Single-incision laparoscopic surgery for totally extraperitoneal repair, which offers good cosmetic outcomes, seems feasible and safe for overweight or obese patients, although the operation takes longer.

Efficacy of single-incision laparoscopic totally extraperitoneal repair for irreducible or incarcerated inguinal hernia.

INTRODUCTION: The aim of this study was to evaluate the efficacy of single-incision laparoscopic surgery for totally extraperitoneal repair (SILS-TEP) of irreducible inguinal hernias and incarcerated inguinal hernias. METHODS: We performed a retrospective analysis of 194 patients, including 16 with irreducible or incarcerated hernia, who had undergone SILS-TEP from May 2016 to December 2017 at Kinki Central Hospital. The outcomes of patients with irreducible or incarcerated hernia and those with reducible hernia were compared. For irreducible or incarcerated hernia, laparoscopic exploration with hernia reduction through an intraumbilical incision was performed. If no bowel resection was needed, one-stage SILS-TEP was performed. If bowel resection was required, two-stage SILS-TEP was performed 2-3 months after the bowel resection. RESULTS: Of the 16 patients, 8 had an irreducible hernia, and 8 had an incarcerated hernia. The eight patients with an incarcerated hernia underwent emergency surgery, and among these patients, two needed single-incision laparoscopic partial resection of the ileum followed by two-stage SILS-TEP. Fourteen patients, excluding the two patients who required single-incision laparoscopic partial resection of the ileum, underwent laparoscopic exploration with hernia reduction followed by one-stage SILS-TEP. Among these 14 patients, one with an irreducible hernia required conversion to Kugel patch repair. The operative outcomes were generally comparable between the two groups. However, the operative time was longer for unilateral hernia, and more seromas were seen in the irreducible or incarcerated group. No other major complications or cases of hernia recurrence were noted in this study. CONCLUSIONS: SILS-TEP, which offers good cosmetic results, can be safely performed for irreducible or incarcerated inguinal hernia.

Learning curve for single-incision laparoscopic totally extraperitoneal inguinal hernia repair.

INTRODUCTION: The learning curve for totally extraperitoneal repair (TEP) is longer and steeper than that for transabdominal preperitoneal repair (TAPP) due to the preperitoneal view to which the surgeon is not accustomed and the limited working space. The aim of this study was to clarify the learning curve for SILS-TEP. METHODS: A retrospective analysis of 80 consecutive patients with unilateral inguinal hernia was performed. All patients underwent elective SILS-TEP performed by a single learning surgeon with a teaching assistant between July 2016 and March 2018 at Kinki Central Hospital. RESULTS: The operative time decreased gradually after 20 cases and stabilized after 40 cases. The first 40 cases were categorized as the learning period group, and the remaining 40 cases were categorized as the experienced period group. More patients received antithrombotic therapy in the experienced period than in the learning period (P < 0.05). The median operative time was 107 and 60 min in the learning period and the experienced period, respectively (P < 0.05). There were no significant differences in blood loss peritoneal injury, conversion to a different procedure, postoperative hospital stay, complications, and recurrence between the two groups. No major complications or hernia recurrence were noted during follow-up. CONCLUSIONS: The learning curve for SILS-TEP might take 40 cases to reduce the operative time. SILS-TEP can be performed safely by a learning surgeon with a teaching assistant.

[A Case of Disseminated Carcinomatosis of the Bone Marrow Developing 15 Months after Gastrectomy].

The patient was a 60-year-old man who underwent distal gastrectomy for gastric cancer. The pathological diagnosis was Stage ⅡB. He received adjuvant chemotherapy(capecitabine plus oxaliplatin: CapeOX)for 6months and the postoperative course was uneventful. One year and 3 months after surgery, he visited the outpatient department for acute lower back pain. Blood tests showed elevated ALP(3,752 U/L), LDH(308 U/L), and CA19-9(69.4 U/mL)levels. Bone scintigraphy showed multiple bone metastases to the femora, ischium, iliac bone, vertebrae, sternum, costae, and scapulae in a super bone scan. The onset of disseminated intravascular coagulation(DIC)was observed later. The patient was diagnosed with disseminated carcinomatosis of the bone marrow. Radiation therapy was performed and anti-RANKL monoclonal antibody was administered for the bone metastases. Recombinant human soluble thrombomodulin was administered for DIC. He received chemotherapy( TS-1 plus cisplatin: SP)but died 4 months after the diagnosis. The prognosis of disseminated carcinomatosis of the bone marrow is extremely poor. We report this case along with a literature review.

Single-incision laparoscopic preperitoneal mesh repair of supra-pubic incisional hernia: A case report.

INTRODUCTION: Repair of supra-pubic incisional hernia is still challenging because of the highest pressure at the lower abdominal wall in the erect position. Recently, laparoscopic preperitoneal mesh repair has been gradually reported. CASE PRESENTATION: A 77-year-old woman underwent single-incision laparoscopic preperitoneal mesh repair under a diagnosis of a supra-pubic incisional hernia, measuring 7 × 4 cm. A single, 2.5-cm, intraumbilical incision was made, followed by creation of the preperitoneal space. Then, the posterior rectus sheath and peritoneum were opened, and laparoscopic exploration was performed. After dissection of the supra-pubic hernia content, the tube for degassing the abdominal cavity was inserted into the abdominal cavity, and the peritoneum and the posterior sheath were closed. The preperitoneal space was dissected gradually, and circular dissection of the hernia sac was performed. The proximal sac (peritoneum) was sutured continuously. A 15 × 10 cm mesh was placed in the preperitoneal space and fixed securely with absorbable tacks at the pubic bone, Cooper's ligament, and the rectus abdominis muscle, respectively. After degassing the preperitoneal space, a second laparoscopic exploration was performed to confirm the secure suture of the peritoneum and no injury of the abdominal organs. At 4-month follow-up, the patient remained well with no signs of recurrence. DISCUSSION: Single-incision laparoscopic preperitoneal mesh repair could minimize the recurrence of supra-umbilical incisional hernia and perioperative complications. CONCLUSION: Single-incision laparoscopic preperitoneal mesh repair, offering good cosmetic results, might be useful for repair of supra-pubic incisional hernia.

Primary splenic malignant lymphoma mimicking metastasis of rectosigmoid cancer: A case report.

INTRODUCTION: Primary splenic malignant lymphoma is quite a rare disease, and its preoperative diagnosis is difficult. CASE PRESENTATION: An 80-year-old man was diagnosed with advanced rectosigmoid cancer with liver and splenic metastases, for which he underwent single-incision laparoscopic high anterior resection for the primary rectosigmoid cancer. After chemotherapy, he underwent laparoscopy-assisted splenectomy and open partial hepatectomy of segment 3 and segment 5/6 of the liver. The resected specimen of the spleen showed primary splenic malignant lymphoma. DISCUSSION: A diagnosis of primary splenic malignant lymphoma seems to be made only occasionally at splenectomy. Patients with primary splenic malignant lymphoma treated by curative resection at an early clinical stage have a more favorable prognosis. Laparoscopy-assisted splenectomy is useful for reducing surgical invasiveness. CONCLUSION: Primary splenic malignant lymphoma should be included among the differential diagnoses of splenic tumors in patients with colorectal cancer with multiple metastases. Curative resection might be a therapeutic option for the treatment of primary splenic malignant lymphoma. Laparoscopy-assisted splenectomy is a useful strategy for reducing surgical invasiveness.

CUBIC pathology: three-dimensional imaging for pathological diagnosis.

The examination of hematoxylin and eosin (H&E)-stained tissues on glass slides by conventional light microscopy is the foundation for histopathological diagnosis. However, this conventional method has some limitations in x-y axes due to its relatively narrow range of observation area and in z-axis due to its two-dimensionality. In this study, we applied a CUBIC pipeline, which is the most powerful tissue-clearing and three-dimensional (3D)-imaging technique, to clinical pathology. CUBIC was applicable to 3D imaging of both normal and abnormal patient-derived, human lung and lymph node tissues. Notably, the combination of deparaffinization and CUBIC enabled 3D imaging of specimens derived from paraffin-embedded tissue blocks, allowing quantitative evaluation of nuclear and structural atypia of an archival malignant lymphoma tissue. Furthermore, to examine whether CUBIC can be applied to practical use in pathological diagnosis, we performed a histopathological screening of a lymph node metastasis based on CUBIC, which successfully improved the sensitivity in detecting minor metastatic carcinoma nodules in lymph nodes. Collectively, our results indicate that CUBIC significantly contributes to retrospective and prospective clinicopathological diagnosis, which might lead to the establishment of a novel field of medical science based on 3D histopathology.

Single-incision laparoscopically assisted appendectomy performed by residents is safe and feasible: A single institution, retrospective case series.

INTRODUCTION: To confirm the safety and feasibility of single-incision laparoscopically assisted appendectomy (SILA) performed by resident doctors. MATERIALS AND METHODS: We retrospectively analyzed 86 consecutive patients who underwent SILA between August 2010 and August 2016 at Kinki Central Hospital. During this period, 9 residents and 6 board-certified attending surgeons performed SILA. Data on the patients' characteristics and perioperative complications were collected from their medical records. RESULTS: Resident doctors operated on 55% (47/86) of patients undergoing SILA. There were no significant differences between the groups with regard to patient characteristics. Mean operative time in the resident and staff surgeon groups was 74 min and 71 min, respectively (p = 0.5). Median blood loss in both the resident and staff surgeon groups was 0 mL (p = 0.3). The rate of conversion to a different operative procedure was 4% (2/47) in the resident group and 3% (1/39) in the staff surgeon group (p = 1). All three above-mentioned procedures, two (4%, 2/47) in the resident group and one (3%, 1/39) in the staff surgeon group, were converted to multi-port laparoscopic appendectomy. The mean postoperative hospital stay was 5 days for both the resident and staff surgeon groups (p = 0.7). Perioperative complications developed in 9% (4/47) of the patients in the resident group and 21% (8/39) of the patients in the staff surgeon group (p = 0.1). CONCLUSIONS: SILA performed by residents under the guidance of a staff surgeon is safe and feasible.

A resected case of medullary carcinoma of the ascending colon followed by infarction of the greater omentum mimicking anastomotic leakage.

INTRODUCTION: Medullary carcinoma is a rare type of colorectal adenocarcinoma, and omental infarction is a rare cause of acute abdomen. PRESENTATION OF CASE: A 72-year-old woman underwent single-incision laparoscopic right hemicolectomy for ascending colon cancer. Pathological examination showed a medullary carcinoma (MC) of T4aN0M0 Stage IIB. Her postoperative course was uneventful, and she was discharged on postoperative day (POD) 6. From POD 7, she suffered from fever, and she returned to the hospital on POD 9. Plain computed tomography showed free air beside the anastomotic site around the elevated density of fat tissue and gallbladder wall thickening with a gallstone. Suspecting anastomotic leakage with acute cholecystitis, probe laparotomy was performed. Intraoperative observation confirmed omental infarction with acute cholecystitis, and no leakage was found at the anastomotic site. Therefore, the necrotic part of the greater omentum was resected, and cholecystectomy was performed. She has remained well, with no evidence of recurrent cancer during the 12 months of follow-up without chemotherapy after the surgery for MC of the ascending colon. DISCUSSION: MC should be distinguished from other more aggressive, non-glandular tumors of the colon because MC appears to have a better survival outcome than undifferentiated colon adenocarcinoma. Omental infarction should be considered in the differential diagnosis of acute abdomen after surgery. CONCLUSION: A rare case of medullary carcinoma of the ascending colon followed by infarction of the greater omentum mimicking anastomotic leakage is presented.

[Eight Cases of Esophagus and Tracheobronchial Stenting for Advanced Esophageal Cancer].

Malignant stricture and fistula of the esophagus and tracheobronchus adversely affect the quality of life(QOL)in patients with advanced esophageal cancer. Stenting is one ofthe therapies available for these patients. We investigated the outcomes ofesophagus and tracheobronchial stenting in our institution. Eight patients with advanced esophageal cancer underwent double stenting from 2010 to 2016. Among them, 4 patients underwent double stenting as planned. One patient underwent an emergency tracheal stenting because ofstenosis ofthe trachea caused by esophageal stenting. Three patients underwent tracheobronchial stenting later on because ofan increase in the tumor size after esophageal stenting. Dysphagia score was improved in 5(67.5%)out ofthe 8 patients. Respiratory symptoms were improved in all patients, and 4 patients(50.0%) were discharged. The median survival time after esophageal stenting was 70.5 days. Esophagus and tracheobronchial stenting for advanced esophageal cancer was useful for the improvement of the QOL.

[A Case of Recurrent Gastric Cancer with Recurrent Celiac Lymph Node Metastasis Successfully Treated with Chemoradiotherapy and CPT-11 plus CDDP Therapy].

Chemotherapy is performed for the recurrence of gastric cancer in many cases. We report a case of recurrent lymph node metastasis successfully treated with chemoradiotherapy and chemotherapy. A man in his 60s underwent total gastrectomy and D2 dissection in 2009. The pathological diagnosis was poorly differentiated adenocarcinoma, T4a, int, INF b, ly2, v2, LN#2: 2/3, #3: 1/4, #7, 8, and 9: 3/4, stage III B. Although we administered S-1/UFT as postoperative adjuvant chemotherapy, a strong rash appeared and the patient ceased chemotherapy. Eight months later, the rash had disappeared. We started chemotherapy with paclitaxel(PAC). CT performed 1 year postoperatively showed celiac lymph node(#9)metastasis. Chemoradiotherapy( RT+PAC)and additional CPT-11(98mg)and CDDP(49mg)treatment were administered. The lymph node (#9)was cicatrized after 8 cycles. Forty-two months after the end of treatment, the patient has had no recurrence. It is thought that chemoradiotherapy is an effective cure for local recurrence of gastric cancer.

Efficacy of endoscopic gastroduodenal stenting for gastric outlet obstruction due to unresectable advanced gastric cancer: a prospective multicenter study.

BACKGROUND AND OBJECTIVES: Gastroduodenal stents for gastric outlet obstruction due to unresectable advanced gastric cancer are increasingly used; however, their effects have not been fully evaluated. METHODS: A multicenter prospective observational study was performed. Patients were eligible if they had stage IV gastric cancer with a gastric outlet obstruction scoring system (GOOSS) score of 0 (no oral intake) or 1 (liquids only). Self-expandable metallic stents were delivered endoscopically. The effects of stents were evaluated. RESULTS: Twenty patients were enrolled and 18 were eligible (15 men, three women; median age, 70 years). Stent placement was successfully performed in all patients, with no complications. After stenting, a GOOSS score of 2 (soft solids only) or 3 (low-residue or full diet) was achieved in 13 (72%) patients. An improvement in the GOOSS score by one or more points was obtained in 16 (94%) patients. The median duration of fasting and hospital stay was 3 (range, 0-9) days and 18 (6-168) days, respectively. Chemotherapy was performed after stenting in 13 (72%) patients. CONCLUSIONS: Gastroduodenal stents are thought to be feasible, safe, and effective for gastric outlet obstruction due to unresectable advanced gastric cancer, with rapid clinical relief and a short hospital stay.

[A case of resection of pancreatic head lymph node metastasis of rectal carcinoid].

An 80-year-old woman was treated with low anterior resection and D3 lymph node dissection for rectal carcinoid in August 2007. Pathological diagnosis was a tumor 23 × 22 mm in size with muscularis propria invasion, ly1, v0, n1 (No. 251[1/12]). Partial hepatectomy was performed for liver metastasis in March 2010 and September 2011. In June 2013, an isolated tumor of 17 mm in diameter was detected between the inferior vena cava and the stomach using abdominal ultrasonography. The tumor was diagnosed as pancreatic head lymph node metastasis using abdominal enhanced computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), and positron emission tomography (PET); fluorodeoxyglucose (FDG) uptake was noted at the site of the tumor, but not at other parts of the body. Curative resection was the chosen treatment option. Open surgery was performed in September 2013, and a tumor 30 mm in diameter located at the ventral side of the inferior vena cava, lateral side of the portal vein, and cranial side of duodenum was resected. No surrounding tissue infiltration was found. Pathological analysis of the resected specimen indicated lymph node metastasis of the rectal carcinoid. The patient has been disease free for 9 months after surgery.

Intraoperative diagnosis using sentinel node biopsy with indocyanine green dye in gastric cancer surgery: an institutional trial by experienced surgeons.

BACKGROUND: Reliable indicators that can intraoperatively determine the absence of nodal metastasis are in great demand to avoid unnecessary lymphadenectomy. However, little has been reported about the intraoperative diagnostic performance of sentinel node (SN) biopsy. METHODS: Sentinel node biopsy by subserosal or submucosal injection of indocyanine green (ICG) was performed in 241 patients with American Joint Committee on Cancer tumor, node, metastasis staging system, 7th edition, clinical T1 (n = 190) and T2 (n = 51) gastric cancer by two experienced surgeons. All nodes that stained green (green node, GN), representing SNs, were excised before gastrectomy and were sliced into 2-mm sections for intraoperative histological examinations with hematoxylin and eosin staining. The sliced GNs were also examined simultaneously by imprint cytology. RESULTS: The GNs were detectable in 240 patients (3.8 ± 2.4 nodes per patient; range 1-17 nodes; median 3 nodes), and the success rate of detection was 99.6 % (240 of 241). Of 240 patients with a successful detection, 29 were found to have lymph node (LN) metastases; 16 were diagnosed with LN metastases in both GNs and non-GNs, 12 in GNs alone, and 1 in non-GNs alone. The false-negative rate based on the SN concept was 3.4 % (1 of 29). However, two patients with cT1 gastric cancer were diagnosed as intraoperative GN negative but were later confirmed as GN positive by histological examinations of paraffin sections. As an intraoperative diagnosis, the false-negative rate was 10.3 % (3 of 29). CONCLUSIONS: Sentinel node biopsy using ICG could be performed intraoperatively within reasonable limits under certain conditions, such as multiplanes for detection, combination use of imprint cytology, and open surgery by experienced surgeons.

[A case of SPT therapy( S-1+CDDP+trastuzumab) was successful for HER2-positive gastric cancer accompanied by distant lymph node metastasis].

A 63-year-old man visited our clinic with a chief complaint of a left axillary mass, and after a series of examinations, gastric cancer was diagnosed. Histopathological examination revealed a human epidermal growth factor receptor (HER)-2- positive( immunohistochemistry[ IHC], 2+; fluorescence in situ hybridization[ FISH], positive) poorly differentiated adenocarcinoma, and SPT therapy( S-1 at 120 mg/m2/day+cisplatin[ CDDP] at 60 mg/m2+trastuzumab at 8 mg/kg) was initiated. The primary lesion and swollen lymph nodes initially decreased markedly in size; however, the lymph node swelling worsened at 186 days( 6.2 months) after the initiation of treatment. Progressive disease( PD) was diagnosed, and SPT therapy was terminated. One cycle of S-1+docetaxel was administered as second-line therapy, but the regimen was changed to docetaxel monotherapy due to adverse effects. After 5 cycles of this treatment, the primary lesion had decreased in size and the lymphadenopathy disappeared. Positron emission tomography( PET)-computed tomography (CT) revealed fluorodeoxyglucose( F18)( FDG) accumulation only in the primary lesion, and therefore, with the patient's informed consent distal gastrectomy was performed approximately 14 months after the first treatment. The postoperative diagnosis was gastric cancer fStage IA (T1a, N0, and M0). Here, we discuss a case of HER2-positive gastric cancer with references. Among the advanced recurrent gastric cancers tested between April 2011 and February 2013, 16.4% (11/67) were HER2-positive.

[Long-term survival after surgical resection of a cancer of unknown primary site-a case report].

We report a case of long-term survival after combination chemotherapy and surgical resection of a cancer of unknown primary site[ CUPs]. A septuagenarian female was identified as having high blood levels of carcinoembryonic antigen (CEA) during follow-up monitoring of asthma. Endoscopy and imaging studies including computed tomography (CT) and positron emission tomography (PET)-CT revealed a malignant lymph node adjacent to the abdominal aorta; however, no other lesion was detected. Therefore, we performed CT-guided biopsy and diagnosed the lesion to be a lymph node metastasis of poorly differentiated adenocarcinoma. As we considered this as a systemic disease, the patient received 2 courses of combination chemotherapy with 5-fluorouracil( 5-FU)/cisplatin( CDDP) and achieved a partial response (PR). Later, the patient received S-1 therapy as second-line chemotherapy and S-1/irinotecan( CPT-11) as third-line chemotherapy in an outpatient clinic. However, the tumor continued to grow, and therefore, we decided to perform surgical resection. Histopathological examination of the resected specimen yielded a diagnosis of metastatic adenocarcinoma of the lymph node. The patient has been well without any signs of recurrence for more than 9 years since surgery. As CUPs is generally associated with poor prognosis, this case raises the possibility that combination therapy might improve convalescence.