A 75-year-old man who tried enema for persisting constipation had an abrupt onset of abdominal pain and was referred to the hospital. When he was first seen, perforation of the lower digestive tract was diagnosed based on abdominal symptoms and various imaging findings, and an emergency operation was performed. Upon laparotomy, free perforation 2cm in diameter was indentified on the ventral aspect of the sigmoid colon and rectum. Drainage and Hartmann operation were thus done. On the 20^th postoperative day after an uneventful postoperative course, fever developed and persisted thereafter. Despite every close exploration, we could not clarify the origin of the fever and considered it as fever of unknown origin. Venous echography of the lower extremities conducted on the 38^th postoperative day disclosed deep vein thrombosis of the soleal vein. Anticoagulant therapy resulted in disappearance of thrombosis as well as dramatic fall of the fever.
Although deep vein thrombosis can be fatal if pulmonary infarct is once associated, it is a current status where exploration of the presence is barely performed. When we encounter fever of unknown origin, deep vein thrombosis of the lower extremities must be kept in mind as a probable cause.

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We report a case of synchronous quadruple cancers. A 62-year-old man was diagnosed by biopsy as having middle pharyngeal squamous cell carcinoma and cervical lymph nodes metastasis at a local hospital. Synchronous multiple cancers were suspected based on accumulation of FDG-PET in the liver and ascending colon. The patient was referred to our hospital for combined-modality therapy. Detailed examination revealed the diagnosis of quadruple cancers, including middle pharyngeal cancer, early-stage esophageal cancer, early-stage gastric cancer, and advanced colon cancer with liver metastasis. Chemoradiotherapy with cisplatin and 5-fluorouracil was administered as definitive therapy for the esophageal cancer and as neoadjuvant treatment for the pharyngeal cancer. This chemoradiotherapy was followed by left palatine tonsillectomy, left cervical lymphadenectomy, distal gastrectomy, and right hemicolectomy. Subsequently, additional irradiation of the esophagus and right hepatic lobectomy were performed. Four months after the surgery, radiotherapy was administered for local recurrence of the middle pharyngeal cancer and the patient was started on chemotherapy for abdominal lymph node and lung metastases from the colon cancer. Currently, 2 years and 7 months after the surgical resection the patient remains well. Considering confounding factors, the selection of appropriate organs for surgical reconstruction is necessary for the treatment of synchronous multiple cancers.

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