[A Case of Long-Term Survival of Breast Cancer with Extra-Regional Lymph Node Metastases].

We present the case of a 65-year-old woman who presented with nipple retraction of her left breast. The patient has a family history of breast cancer. She was diagnosed with bilateral breast cancer with left axillary, cervical, and mediastinal lymph node metastasis(right breast cancer, cT1cN0M0, cStage Ⅰ, Luminal A-like, left breast cancer, cT2N3bM1[LYM], Stage Ⅳ, triple negative type). She was recommended chemotherapy due to her inoperable advanced-stage breast cancer. After 6 courses of administration of AC chemotherapy(doxorubicin and cyclophosphamide)and 5 courses of tri-weekly docetaxel chemotherapy, shrinkage of the primary lesion and disappearance of each swollen lymph node were observed via computed tomography. Surgery was performed 11 weeks post-chemotherapy. Residual lesions, less than 10 mm in size in both the left and right breast masses, were observed. No lymph node metastasis was observed. Four years later, no signs of recurrence have been noted.

[A Case of Triple Negative Breast Cancer with Left Buttock Metastasis].

A female patient in her 50s was diagnosed with triple negative breast cancer in the left breast with a buttock metastasis. After neoadjuvant chemotherapy, the patient underwent surgery on the left breast. As the histopathological findings indicated a residual tumor, she was further treated with capecitabine postoperatively. Twenty months postoperatively, a CT scan revealed a tumor on her left buttock. She was also diagnosed with a relapse of the breast cancer after a core needle biopsy. She was treated with atezolizumab and nab-paclitaxel as first-line therapy for the metastasis and with eriburlin as second- line therapy. As she became uncomfortable sitting owing to the regrowth of the buttock tumor, the left buttock tumor was resected. She has been treated with bevacizumab and paclitaxel for subsequent lung metastases.

Anatomical classification of breast sentinel lymph nodes using computed tomography-lymphography.

To evaluate the anatomical classification and location of breast sentinel lymph nodes, preoperative computed tomography-lymphography examinations were retrospectively reviewed for sentinel lymph nodes in 464 cases clinically diagnosed with node-negative breast cancer between July 2007 and June 2016. Anatomical classification was performed based on the numbers of lymphatic routes and sentinel lymph nodes, the flow direction of lymphatic routes, and the location of sentinel lymph nodes. Of the 464 cases reviewed, anatomical classification could be performed in 434 (93.5 %). The largest number of cases showed single route/single sentinel lymph node (n = 296, 68.2 %), followed by multiple routes/multiple sentinel lymph nodes (n = 59, 13.6 %), single route/multiple sentinel lymph nodes (n = 53, 12.2 %), and multiple routes/single sentinel lymph node (n = 26, 6.0 %). Classification based on the flow direction of lymphatic routes showed that 429 cases (98.8 %) had outward flow on the superficial fascia toward axillary lymph nodes, whereas classification based on the height of sentinel lymph nodes showed that 323 cases (74.4 %) belonged to the upper pectoral group of axillary lymph nodes. There was wide variation in the number of lymphatic routes and their branching patterns and in the number, location, and direction of flow of sentinel lymph nodes. It is clinically very important to preoperatively understand the anatomical morphology of lymphatic routes and sentinel lymph nodes for optimal treatment of breast cancer, and computed tomography-lymphography is suitable for this purpose.

[A Case of a Rupture of the Carotid Artery Caused by the Lenvatinib Medication].

We report a case of a rupture of the common carotid artery caused by the medication of lenvatinib. The patient, 70-yearold female, was referred to our hospital by unresectable papillary thyroid cancer infiltrated the left common carotid artery. Externalbeam radiotherapy and radioiodine therapy were undergone after totalthyroidectomy. After 1 year 7 months from operation, she admitted our hospital due to left shoulder pain and dysphagia caused by the growing left cervical tumor. The medication of lenvatinib was decided after the careful informed consent. Computed tomography on the eighth day of lenvatinib medication showed the existence of air infiltration into the tumor surrounded left common carotid artery. So, a discontinuance of lenvatinib medication was decided immediately. But, on the ninth day, a rupture of the left common carotid artery occurred and on the tenth day, she died. Lenvatinib medication for the patient with the tumor surrounded artery should be decided carefully.

[Tumor Displacement Resulting from Core Needle Biopsy of Breast Cancer - A Case Report].

Tumor cell displacement is occasionally observed in surgical specimens after core needle biopsy. We report a case involving a 58-year-old woman in whom a microlobulated mass was detected on mammography, after which she underwent an ultrasonography- guided core needle biopsy. Thirty-six days later, a new low-echoic lesion was detected on ultrasonography, located from the original mass to the subcutaneous insertion site of the needle biopsy. Fifty days after the biopsy, breast-conserving surgery was performed. Histopathology showed a main tumor containing 2 components, namely invasive carcinoma of no special type, which showed tubule and gland formation, and invasive papillary carcinoma(WHO Classification). The invasive carcinoma with tubule formation was also observed in the adjacent collagen fibers, suggesting tumor displacement in the needle tracks. It has been suggested that malignant cells displaced by core needle biopsy do not survive. However, based on the present case, we recommend ascertaining the absence of extensive tumor displacement using ultrasonography unless all needle tracks are included in the planned resection area.

[The case of a long-surviving patient with breast cancer and brain metastases treated using multidisciplinary therapy].

We present the case of a 55-year-old-woman who was diagnosed with left breast cancer, and underwent a left mastectomy and left axillary lymph node resection. The histopathological examination indicated scirrhous carcinoma and lesser papillotubular carcinoma[estrogen receptor-negative (ER-), progesterone receptor-negative(PgR-), and human epidermal growth factor receptor 2-positive, grade 3 (HER2, 3+)] with lymph node metastases. Adjuvant chemotherapy consisting of epirubicin and cyclophosphamide (EC) followed by paclitaxel was administered. During the therapy, the patient noticed a mass on her left chest wall. It was diagnosed as a locally recurrent tumor. A computed tomography (CT) scan indicated supraclavicular lymph node metastasis. The patient underwent radiotherapy and was administered chemotherapy with TS-1 and trastuzumab. Brain metastases were found 24 months postoperatively, and the patient underwent surgery and wholebrain radiotherapy. After these, systemic capecitabine and trastuzumab chemotherapy was administered. The therapy was subsequently changed to capecitabine and lapatinib. There have been no subsequent metastatic tumors, and good control has been achieved for a long time after the detection of brain metastases.

[Sentinel lymph node biopsy in male breast cancer - a case report].

We report a case of breast cancer in a man who underwent sentinel lymph node biopsy (SLNB). The patient, a 66-year-old man, observed a tumor under his left areola. The elastic hard tumor had a clear border. Ultrasonography revealed a hypoechoic tumor, approximately 18 mm in diameter, in the left subareolar and outer upper region. On fine needle aspiration cytology (FNAC), the tumor was diagnosed as a ductal carcinoma. The patient underwent a mastectomy (Bt) and an axillaryly mph node dissection(Ax)after the SLNB. The SLNB was performed with the blue dye alone. Based on histopathological observations, estrogen receptor (ER)- and progesterone receptor (PgR)-positive invasive micropapillary carcinoma was diagnosed. The human epidermal growth factor receptor 2(HER2) score was 1+, and Ki-67 labeling index was 30%. Lymph node metastasis was not seen in SLNB (0/1) and Ax (0/13). Postoperatively, the patient received oral tamoxifen therapy. There was no evidence of recurrence during the 9-month follow-up. In this case, computed tomographic (CT) lymphography (CTLG) and SLNB were performed successfully, without incident. We recommend SLNB in cases of male breast cancer with clinically negative nodes.

[A case of carcinomatous cardiac tamponade caused by breast cancer treated with instillations of OK-432 and mitomycin C].

The patient was a 36-year-old female who had undergone Auchincloss operation for left breast cancer at another hospital when 29 years old. Three years ago she was transferred from another hospital to our department complaining of dyspnea. Under the diagnosis of cardiac tamponade, we treated her with pericardial drainage and systemic chemotherapy (intravenous dosage of trastuzumab and vinorelbine: VNR), and then pericardial effusion disappeared. Further medical treatment was continued on an outpatient basis. One year later, cardiac tamponade developed again. We performed echo-guided pericardiocentesis and removed 600 mL of bloody effusion. The cytology of the effusion showed class V. Pericardial effusion recurred, so we instilled OK-432 and mitomycin C (MMC) twice. After that the cytology diagnosis became negative, and the heart shadow in chest X-P reduced. The pericardial effusion has never occurred until now. We also gave her systemic chemotherapy (intravenous dosage of trastuzumab)and endocrine therapy (peroral administration of medroxyprogesterone acetate). She made a remarkable recovery with these treatments and could go back to work.

Plasma exchange-based plasma recycling dialysis system as an artificial liver support.

We developed a plasma recycling dialysis (PRD) system based on plasma exchange (PE). In this system, rapid reduction of toxic substances and restitution of deficient essential substances are performed by PE and subsequent blood purification is performed by dialysis between separated plasma recycled over a purification device and the patient's blood across the membrane of a plasma separator. To demonstrate the safety and efficacy of this system, we used a pig model of fulminant hepatic failure (FHF) and anion exchange resin, activated charcoal and hemodialysis for the purification device. FHF was induced by intraportal administration of alpha-amanitine (0.1 mg/kg) and lipopolysaccharides (1 microg/kg) in pigs. Three groups of animals were studied: group 1, diseased controls (N = 4); group 2, PE group (N = 4), 16 h after drug infusion the pigs underwent PE of approximately 1.2 L for 2 h; and group 3, PE + PRD group (N = 4), the pigs underwent PE followed by PRD for 6 h. The hemodynamic status of all animals was stable during the procedure. In group 3, the values of ammonia, total bile acid and total bilirubin continuously decreased and were significantly lower than those of the animals in group 2 24 h after the induction of FHF. The Fischer ratio was significantly higher than in group 2 after 24 h. Group 3 pigs maintained a higher level of consciousness and survived longer than group 2 pigs. Safety of this PE-based PRD system was demonstrated and the removal of toxic substances was significant. This study confirmed the clinical utility of this system as an artificial liver support.

[A case of metastasis to the diaphragm from ascending colon cancer].

We reported a case of metastatic tumor to the diaphragm discovered by rising CEA after operation of ascending colon cancer. A 72-year-old female underwent right hemicolectomy on January 2005. After discharge, she received adjuvant chemotherapy by S-1, but a rise of CEA was shown. Based on exploratory findings, laparotomy was done with the diagnosis of metastasis to the liver(S7). A tumor was present in the right diaphragm, and contacted the liver(S7). Partial resection of the right diaphragm was performed. The removed specimen revealed the same histological findings of the last operated ascending colon. Metastasis to the diaphragm is very rare, especially a solitary one as in this case. Etiologically speaking, the tumor cells might be absorbed or have strayed into peritoneal stomata of the diaphragm.

Plasma exchange-based plasma recycling dialysis system as a potential platform for artificial liver support.

We developed a plasma recycling dialysis (PRD) system based on plasma exchange (PE). In this system, rapid reduction of toxic substances and restitution of deficient essential substances are performed by PE, and subsequent blood purification is performed by dialysis between separated plasma recycled over a purification device and the patient's blood across the membrane of the plasma separator. This study was performed to demonstrate the safety and efficacy of this system. Hyperbilirubinemia was induced by ligating the bile duct in pigs, and 7 days later, only PE for 2 h (group PE) or PE for 2 h followed by PRD for 6 h (group PE + PRD) was performed. The separated plasma was recycled over anion-exchange resin through the extra fiber space of the plasma separator. The safety and efficacy of this system were evaluated based on the values of hemodynamic and laboratory parameters. Transfer from PE to PRD was completed in a few minutes. The hemodynamic status and blood cells counts were stable and hemolysis was not observed during the procedure. In the PE + PRD group, the concentrations of total bile acids continuously decreased (pretreatment, 155.5 +/- 40.6 microM; 2 h [end of PE], 76.1 +/- 14.4 microM; 8 h [end of PRD], 25.8 +/- 9.1 microM) and the value was significantly lower than in the PE group after 6 h. The total bilirubin also continuously decreased during PRD (pretreatment, 55.3 +/- 11.5 microM; 2 h [end of PE], 33.8 +/- 8.4 microM; 8 h [end of PRD], 18.6 +/- 7.7 microM) and was significantly lower than in the PE group after 4 h. No significant change was observed in other laboratory values. This PE-based PRD system allowed a swift transfer from PE to sorbent-based blood purification. The safety of this system was demonstrated and the removal of toxic substances was significant. This study confirmed the clinical utility of this system as a platform for artificial liver support.

Attenuation of graft injury in porcine liver transplantation from non-heart beating donor by FR167653.

BACKGROUND/AIMS: Orthotopic liver transplantation (OLTx) from non-heart beating donor (NHBD) often involves hepatic warm ischemia and reperfusion injury which is triggered by the inflammatory cytokines. This study was carried out to investigate whether a newly synthesized cytokine suppressive anti-inflammatory agent, FR167653, attenuates graft injury in OLTx from NHBD. METHODOLOGY: Porcine OLTx from NHBD was performed. No-heart beating time was scheduled to be 60 minutes. Animals were divided into two groups: no treatment control (CT) group (n=5), and FR167653 treated (FR) group (n=5), in which FR167653 was administered intravenously before the aortic cross clamp in the donor, and before and after the hepatic allograft reperfusion in the recipient continuously. RESULTS: Four out of five pigs died within 24 hours and one on postoperative day 1 from graft liver failure in the CT group, while two pigs died on day 3, and three survived more than 7 days in the FR group (p<0.05). Microcirculatory disturbance was attenuated, liver injury was lessened, and ATP resynthesis was enhanced in the FR group. Additionally, FR167653 inhibited neutrophils infiltration in the liver tissue, and suppressed release of inflammatory cytokines after OLTx from NHBD. CONCLUSIONS: The treatments with FR167653 successfully prevented graft injury after OLTx from NHBD by means of improvement of liver microcirculation, and attenuation of neutrophils activation. The inhibitory effect of FR167653 on the release of inflammatory cytokines played an important role in the liver graft protection.

Synergistic effect of cold and warm ischemia time on postoperative graft outcome in human liver transplantation.

BACKGROUND/AIMS: Prolonged cold ischemia time (CIT) during graft preservation and warm ischemia time (WIT) defined as a rewarming time have been reported to cause postoperative graft dysfunction after orthotopic liver transplantation (OLT). However, a synergistic effect of both CIT and WIT on patients of graft survival has not been confirmed. The aim of this study was to determine whether simultaneously prolonged CIT and WIT was associated with early graft outcome after clinical OLT. METHODOLOGY: Between May 1997 and July 1998, 186 consecutive OLT cases were divided into 4 groups as follows: group A, CIT < or =12 hrs and WIT < or =45 min; group B, CIT >12 hrs and WIT < or =45 min; group C, CIT < or =12 hrs and WIT >45 min; and group D, CIT > 12 hrs and WIT >45 min. Liver graft survival within 90 days of OLT and early postoperative graft function were analyzed. RESULTS: The graft loss rates were 5.4% in group A, 9.8% in group B, 11.1% in group C, and 42.9% in group D. The mean highest aspartate aminotransferase (AST) values after OLT in group D (3352.3+/-569.4 U/L) was significantly higher than those in groups A (1411.7+/-169.2 U/L) and B (1931.3+/-362.6 U/L). CONCLUSIONS: The simultaneously prolonged cold and warm ischemia time significantly caused hepatic allograft injury and failure, suggesting some synergistic effects of CIT and WIT on postoperative graft function.