Latissimus dorsi musculocutaneous flap grafting to the infected recipient site in a patient with irradiated locally advanced breast cancer and multiple lung metastases.

BACKGROUND: Musculocutaneous (MC) flaps are more resistant to infection than implants, but no clinical results have been reported so far about the grafting of MC flap to the overtly infected sites. CASE PRESENTATION: A 66-year-old woman had received radiotherapy, a total dose of 50 Gy, to her large mucinous breast cancer to control bleeding from the tumor and was referred to our hospital for further treatment. On her first visit to our hospital, her left breast showed radiation-induced total necrosis with Pseudomonas aeruginosa infection. Removal of the necrotic breast tissue resulted in direct exposure of the left ribs and intercostal muscles with intractable chest pain requiring analgesics. The presence of concomitant life-threatening multiple lung metastases made us change the treatment from letrozole and palbociclib to bevacizumab and paclitaxel, leading to marked regression of the lung metastases. To alleviate her chest pain and get local wound healing, we treated the patient with latissimus dorsi (LD)-MC flap grafting to the exposed chest wall after four months of taxane-containing chemotherapy. The patient has got marked pain relief immediately after the operation. Skin island of the grafted LD-MC flap showed no problems for 4 days just after the operation but gradually turned out to be edematous to ill-colored in the distal part of the skin island. Post-operative clinical outcome suggested that Pseudomonas aeruginosa infection might have had some adverse effect, e.g., microemboli, on MC flap blood flow. Partial necrosis of the LD-MC flap made the patient receive conservative wound management for a very long period of 11 months, finally leading to complete wound healing. After palliative surgery, the patient has been receiving fulvestrant and palbociclib for 14 months and doing well with good control of multiple lung metastases. CONCLUSIONS: Breast surgical oncologists should note that partial flap necrosis can occur when a LD-MC flap is grafted to the infected recipient site and consider the anti-coagulant therapy just after the operation to avoid the adverse effects of the infection.

Confirmed complete response to nivolumab for advanced gastric cancer with peritoneal dissemination: a case report.

BACKGROUND: Recent advances in cancer immunotherapy have been remarkable, with many reports on the clinical effects of immune checkpoint inhibitors. Nivolumab has been covered by the national health insurance in Japan as a third-line agent for advanced and recurrent gastric cancer since September 2017. The objective response rate for nivolumab for gastric cancer is 11.2%. However, patients' quality of life during this treatment has not been examined. Here, we report a case in which multidisciplinary treatment, including with nivolumab, resulted in long-term survival and improved quality of life. CASE PRESENTATION: A 70-year-old Asian woman was referred for surgery for gastric cancer. Postoperative pathological examination revealed peritoneal dissemination, and the patient was diagnosed with stage IV gastric cancer. Therefore, she was treated with S-1 and cisplatin based on negative immunohistochemical staining of resected specimens for human epidermal growth factor receptor 2. However, owing to instability and adverse events, treatment was subsequently changed to S-1 monotherapy. Two years after changing to S-1 monotherapy, she developed recurrence of peritoneal dissemination and was treated with docetaxel. Radiation therapy was also used because the recurrent lesions were local. However, 6 months later, new peritoneal dissemination and lymph node metastasis were observed and nivolumab was started. Subsequent abdominal computed tomography revealed a marked reduction in the disseminated nodules and lymphadenopathy. After 54 cycles of nivolumab, the lesions had disappeared completely. The patient has not developed side effects, including immune-responsive adverse events, has improved quality of life, and is returning to work. She is currently taking nivolumab, and there is no evidence of recurrence approximately 3 years after starting nivolumab. CONCLUSIONS: Nivolumab may have beneficial effects in some patients with advanced or recurrent gastric cancer. Although the prognosis for gastric cancer and peritoneal dissemination is poor, multidisciplinary treatment that includes nivolumab may lead to long-term survival.

Subclinical Needle Tract Seeding by Endoscopic Ultrasound-Guided Fine-Needle Aspiration for Pancreatic Cancer.

A 77-year-old woman with epigastralgia was referred to our hospital. Abdominal computed tomography showed a hypointense mass in the pancreatic tail. Abdominal and endoscopic ultrasonography (EUS) showed a hypo-echoic mass, 25 × 25 mm in size, with pancreatic duct dilatation. EUS-guided fine-needle aspiration (EUS-FNA) was performed to the mass through gastric posterior wall. Pathological examination showed atypical cells growing papillary or tubular fashion, leading to the diagnosis of adenocarcinoma. Under the preoperative diagnosis of T2N0M0 pancreatic cancer, the patient underwent distal pancreatectomy and splenectomy. Macroscopic view of the resected specimen showed a presumed puncture-induced pancreatic pseudocyst adjacent to the pancreas. Pathological examination showed well-differentiated adenocarcinoma and a pseudocyst with presumed migrated atypical cells in the pseudocyst wall. The patient recovered uneventfully and has been on outpatient follow-up with adjuvant TS-1 therapy. Optimal treatment of pancreatic cancer naturally needs preoperative definitive diagnosis more strictly than other solid malignancies due to its much higher operative harm to the patients. EUS-FNA is a safe and effective diagnostic method but needs careful attention to the needle tract seeding.