Case 1, a 73-year-old man who was given a diagnosis of esophageal cancer (cT4N2M0, Stage IV). An endoscopic biopsy specimen revealed squamous cell carcinoma. The patient underwent esophagectomy after two courses of neoadjuvant chemotherapy. Pathological analysis revealed adenosquamous carcinoma and sarcomatoid components. A slight effect of neoadjuvant chemotherapy was observed, with a response of Grade 1a, and the pathological diagnosis was pT3N2M0, Stage III. He died four months after the operation due to metastatic liver cancer. Case 2, a 68-year-old man given a diagnosis of esophageal cancer (cT2N3M0, Stage III). An endoscopic biopsy specimen revealed squamous cell carcinoma, and he underwent esophagectomy after two courses of neoadjuvant chemotherapy. Pathological analysis revealed squamous cell carcinoma and sarcomatoid components. A slight effect of neoadjuvant chemotherapy was observed, with a response of Grade 1a, and the pathological diagnosis was pT1bN0M0, Stage I. There has been no recurrence for four years after the operation. Both clinical tumor responses of our two patients were stable disease, and the pathological responses were Grade 1a. There is no evidence regarding the effectiveness of neoadjuvant chemotherapy for esophageal carcinosarcoma in the literature. In addition, preoperative diagnosis of carcinosarcoma is often difficult. In case the gastrointestinal endoscopy shows unique findings of carcinosarcoma, caution should be exercised to ensure accurate diagnosis. We should collect cases like these to study the effectiveness of neoadjuvant chemotherapy for esophageal carcinosarcoma.

A 72-year-old man was referred to our hospital for examination of anemia. Upper gastrointestinal endoscopy revealed a giant ulcerative lesion in the lesser curvature of the stomach and the pathological diagnosis of the biopsy specimen was poorly differentiated adenocarcinoma. Laboratory data showed prolonged PT-INR and factor VII coagulating activity reduced to 1.7%. We diagnosed advanced gastric cancer with congenital factor VII deficiency and performed total gastrectomy, cholecystectomy and splenectomy with administration of recombinant activated factor VIIa (rFVIIa) just before incision. Additional use of rFVIIa was performed after operation, but was not on the following day. Two days after surgery, bloody drainage was observed and PT-INR prolonged to 5.26. rFVIIa was used for more two days and bleeding became less severe. Fresh frozen plasma (FFP) was also given for three days from the third day after surgery. Thereafter he had no more complications and was discharged. Although the patient underwent an operation with congenital factor VII deficiency, especially with high decrease of factor VII coagulating activity, rFVIIa should be administered considering the risk of postoperative bleeding.

Lymphangioma is a rare malformation which usually occurs in children and of which adult cases are reported less frequently. We herein report an adult case of a 73-year-old woman with a newly developed and growing splenic lymphangioma. CT taken because of suspected pancreatic disease showed no lesion in the spleen. Two years later, CT for lung disease incidentally revealed a unilocular cyst of 19 mm in diameter in the upper pole of the spleen. The lesion gradually enlarged to 50 mm in diameter and became multiple cysts during the follow-up observation period of 3 years and 5 months. Growing splenic lymphangioma was diagnosed and we eventually performed laparoscopic splenectomy for the splenic mass. Cross-sectional view of the spleen showed multiple cystic spaces of various diameters filled with light yellow serous fluid. Histologically, the multiple cysts were lined by flat endothelial cells, and some cysts were filled with eosinophilic serous fluid. Immunohistochemical staining revealed, the flat endothelial cells were negative for CD34, slightly positive for D2-40, positive for CD31 and Prox-1. The final histopathological result was splenic lymphangioma.

A 58-year-old man complaining of lower abdominal distension came to our hospital. Abdominal CT showed massive ascites with partition wall in the abdominal cavity and a 13 cm-sized massive cystic tumor contiguous to the apex of the bladder in the abdominal cavity. The ascites collected by echo-guided puncture was gelatinous. We diagnosed this case as pseudomyxoma peritonei arising from mucinous cyst adenoma of the urachus and surgery was performed. Laparotomy revealed cystic tumor contiguous to the bladder and the navel, and massive yellow jelly-like mucinous materials with a total weight of 4,500 g scattered in the abdominal cavity. The urachal cystic tumor was resected and extensive peritoneum excision with multiple gelatinous materials was done. Then 100 mg of cisplatin was infused into the peritoneal cavity twice postoperatively from the abdominal port. The resected tumor was diagnosed mucinous cyst adenoma of the urachal origin from histopathology and perioperative findings generally. We performed adjuvant chemotherapy, and with no recurrence during over 15 years of follow-up. There are rare cases that obtained long-term survival by postoperative no recurrence with pseudomyxoma peritonei arising from mucinous cyst adenoma of the urachus.

A 75-year-old man presented with pain in the anus. Enhanced abdominal CT revealed an irregular, enhanced lesion of the rectal wall and an abscess in the adjacent mesorectal area. In order to control the focal infection, abscess drainage was performed under spinal anesthesia. We performed intraluminal abscess drainage through the rectal wall due to concerns about the risk of dissemination of rectal cancer. After controlling inflammation, we performed curative resection, including the cicatricial tissue. Histological examination showed no exposure of the tumor. The patient has had no evidence of recurrence of cancer during the 5 years after surgery. Incision and drainage through the perineum carry a risk of dissemination of cancer cells. Performing intraluminal abscess drainage through the rectal wall to control inflammation enabled us to carry out curative resection and a restorative proctocolectomy, while preventing potential dissemination of cancer.

A 78-year-old man was referred to our department with a chief complaint of anal hemorrhage. Laparoscopic abdominoperineal resection was performed for a diagnosis of anorectal malignant melanoma. The tumor had spread from the lower rectum to the perianal skin, and R0 resection was successfully performed. Pathological findings showed that the tumor infiltration had reached the muscularis propria, and three lymph node metastases were found in the para-intestinal lymph nodes. One month after the operation, administration of nivolumab was started at 3 mg/kg because of the appearance of multiple liver metastases and the recurrence of lung metastases. On the day after administration, muscle pain appeared mainly in the proximal muscles of the extremities that was accompanied by strong inflammatory findings. There were no signs of infection, and no specific antibodies for autoimmune disease were detected. Although no improvement was obtained with oral administration of NSAIDs, the symptoms were significantly improved with oral administration of 10 mg of prednisolone. The patient was found to have drug-induced polymyalgia rheumatica due to nivolumab as an immuno-related adverse event. The patient went on to receive three courses nivolumab under good control of the polymyalgia rheumatica with the use of prednisolone. However, the primary disease progressed quickly, and he died 89 days after the first operation. Immune checkpoint inhibitors, including nivolumab, may cause serious adverse events such as autoimmune diseases, so careful observation is required after their administration.

Transesophageal migration of a foreign body into the mediastinum is a rare disease, and can sometimes cause severe complications with a high mortality rate. A mediastinal foreign body should be surgically removed to prevent injury to adjacent critical structures. We report a case of successful thoracoscopic resection of an ingested foreign body with transesophageal migration into the mediastinum. A 55-year-old woman was admitted to our hospital because of chest pain after a meal. Chest CT demonstrated a radiopaque shadow in the upper thoracic esophagus, and accidental foreign body ingestion was diagnosed. Esophagogastroduodenoscopy was performed, but the foreign body was not detected in the esophagus. The foreign body was thought to spontaneously drop with food ingestion and she was followed up 2 months later. Follow-up CT demonstrated that the foreign body was retained and migrated into the mediastinum. The tip of the foreign body was adjacent to the pulmonary artery so we then conducted a thoracoscopic removal of the foreign body. The clinical course was uneventful, and she was discharged on postoperative day 4. A thoracoscopic approach in a prone position may be one of the best surgical approach for a mediastinal foreign body because it is minimally invasive, and it makes it possible to approach the mediastinum directly and safely.