PMC5216142_01
CT scans taken on admission and after chemotherapy. An abdominal CT scan taken at admission (A) revealed multiple liver tumors and lymph node metastases (arrows). A neck CT scan (B) revealed multiple lymph node metastases (arrows). A chest CT scan (C) revealed osteolytic changes in the thoracic vertebrae (arrow). An abdominal CT scan taken after chemotherapy (D). Liver tumors increased in size (*) and number (+) even after chemotherapy.
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A computed tomography (CT) scan indicated that he had multiple tumors, including one measuring approximately 8 cm in the liver, and multiple lymph node metastases (Fig. 1A and B). The chest CT scan revealed osteolytic legions in the thoracic vertebrae (Fig. 1C), but whole body bone scintigraphy was negative. The multiple liver tumors and metastatic lymph nodes had increased in size and number (Fig. 1D), and his intact PTHrP levels elevated to 87.2pmol/L even after chemotherapy.
Histological examination of the metastatic neck lymph node. Moderately differentiated adenocarcinoma showing a papillotubular structure (A). Immunostaining for CK19 (B) and CA19-9 (C) was positive. Furthermore, tumor cells were positive for PTHrP (D). Magnification, 200x.
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The histological diagnosis of a biopsy specimen from the left neck metastatic lymph node confirmed adenocarcinoma (Fig. 2A). CCC because cytokeratin (CK) 7, CK19 (Fig. 2B), CK20, and CA19-9 (Fig. 2C) were positive, and thyroid transcription factor-1, napsin A, and hepatocyte were negative. CA19-9 positivity indicated that the elevation of serum CA19-9 levels was caused by tumor cell production. In addition, tumor cells from the metastatic lymph node showed positive staining for PTHrP (Fig. 2D).
Clinical course of this case. We focused on the serum calcium levels (closed circles) and inorganic phosphorus levels (open circles). Arrows indicate the administration of zoledronic acid hydrate, gemcitabine, cisplatin, and denosumab. Closed squares indicate the durations for the administration of elcatonin or sodium phosphate. CDDP: cisplatin, Gem: gemcitabine, ZAH: zoledronic acid hydrate
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Because his CCC was inoperable, he received chemotherapy with gemcitabine and cisplatin combined with repeated zoledronic acid hydrate after hydration to improve hypercalcemia during hospitalization (Fig. 3). His serum calcium levels were only transiently reduced by combination therapy of zoledronic acid hydrate, elcatonin (Fig. 3), furosemide, and betamethasone. He was administered 10 mmol sodium phosphate as 310 mg inorganic phosphorus daily (Fig. 3).