A 51-year-old male was admitted in June 2001, due to hemosputum, cough, hemo-stool and an abnormal shadow on a chest roentgenogram. Laboratory results showed severe anemia with hemoglobin of 4.0 g/dl (13.6 < normal range < 16.8 g/dl) and hematocrit of 16.0 % (40 < normal range < 48 %). The patient's chest X-ray demonstrated a huge mass lesion in the left upper lung field (Figure ). Computed tomography (CT) of the chest showed a mass shadow, measuring 7.0 × 7.0 cm in size in the left upper lobe (S1+2
) without any invasion of the surrounding tissue such as the vessels, plexus or thoracic wall and with no mediastinal lymph node swelling. Abdominal CT revealed a huge mass, measuring 12.7 × 7.5 cm in size in the small intestine. Prior to performing any treatment for the presumed lung cancer, we tried to stop the continuous bleeding from tumor in the small intestine. As a result, we performed an emergency operation. The tumor was observed in the jejunum at a location about 30 cm from the ligament of Treitz on the anal side and a 25 cm length of the jejunum, including the tumor, was thus resected. Six days later, the patient experienced sudden chest pain, dyspnoea and hemoptysis. The patient's chest X ray showed the left lung mass shadow to have rapidly increased in size, while the broncho-fiberscopy findings showed bleeding from the left upper bronchus and an obstruction of the left lower bronchus due to coagulation. Hemothorax due to a rupture of the lung induced by the rapid growth of the tumor was found after an emergency thoracotmy. The tumor was so large that it was difficult to approach the interlobular pulmonary artery. Therefore, a left pneumonectomy with mediastinal lymph nodal dissection was performed. Thereafter, intraoperative intrapleural hypotonic cisplatin treatment [6
] was performed because some tumor cells were suspected to exist in the pleural cavity due to the rupture of the tumor. A histological examination revealed pure giant cell carcinoma containing no sarcomatoid component, similar to that found in the small intestine (Figure ). As a result, we diagnosed the patient to have stage IV disease (pathological stage T2N0M1) according to the TNM classification [1
]. The patient had an uneventful recovery without any complications. However, about 4 months after the first operation, the patient was diagnosed to have a recurrence at another site in the small intestine and spleen by abdominal CT. The patient received 2 cycles of chemotherapy (cisplatin 40 mg/m2
+ gemcitabine 800 mg/m2
+ vinorelbine 20 mg/m2
), at days 1 and 8, and thereafter every 4 weeks). The splenic metastases increased in size while the size of the tumor in the small intestine decreased. At this time, no recurrence site except for those in the small intestine and spleen were found, therefore, to avoid the risk of bleeding either from tumors in the small intestine or a rupture of spleen in the future, surgical treatment consisting of a partial resection of the small intestine and a splenectomy was performed. The intestinal tumor was found in the jejunum at a location about 10 cm from the ligament of Treitz on the anal side and a total 20 cm length of the jejunum, including the tumor, was resected. A pathological examination revealed a proliferation of pure giant cell carcinoma with extensive necrosis both in the small intestine and the spleen, thus suggesting the chemotherapy to be effective in the both organs. Thereafter, the patient received 2 additional cycles of this triplet chemotherapy. The patient experienced neither any hematological nor severe non-hematological adverse events. About 6 months later, metastases in multiple abdominal lymph nodes were found (Figure ). The patient was started on chemotherapy (carboplatin AUC = 2 + paclitaxel 60 mg/m2
, on days 1 and 8, and thereafter every 3 weeks). After receiving a total of 10 cycles of chemotherapy on an outpatient basis, abdominal CT showed the chemotherapeutic effect to be a complete response (Figure ), without any severe hematological or non-hematological adverse events. At present, the patient has survived for about 3-years since the first operation and a complete response has been maintained for 15 months.
Posterior-anterior view of a chest X-ray film demonstrated a huge mass shadow in the left upper lung field.
Pathological findings of the left lung. The section consists of a diffuse proliferation of atypical, giant and bizarre cells (arrowhead). No sarcomatoid component is seen.
Computerised tomographic scan before and after treatment. A) Abdominal CT showed multiple lymph node swelling, suggesting the presence of metastases (arrowhead). B) Abdominal CT showed the lymph nodes metastases to have completely disappeared.