[A Case of Breast Cancer That Developed Pulmonary Tumor Thrombotic Microangiopathy during Adjuvant Chemotherapy].

A 68-year-old woman underwent neoadjuvant chemotherapy for left breast cancer(triple negative type), cT2N3cM0, cStage ⅢC, and Bt+Ax(Ⅲ). The pathological diagnosis was ypT1aN2aM0, ypStage ⅢA, ER-, PgR-, HER2 score 1+, Ki- 67 25%. Adjuvant radiotherapy(50 Gy/25 Fr)was then administered, followed by capecitabine as adjuvant chemotherapy. Dyspnea occurred during administration of capecitabine, and computed tomography(CT)and blood test results suggested drug-induced interstitial pneumonia and disseminated intravascular coagulation(DIC). The patient was admitted, and steroid pulse therapy, anticoagulant therapy, and antibiotics were administered; however, the treatment was ineffective, and she died 3 days after admission. An autopsy provided a final diagnosis of pulmonary tumor thrombotic microangiopathy(PTTM). There is no established treatment for PTTM, and the prognosis is poor even with anticoagulant therapy and chemotherapy. The definitive diagnosis of PTTM is based on pathological findings; however, during respiratory failure, invasive tests such as lung biopsy are not recommended. Therefore, if a significantly worsening respiratory disorder develops, as in this case, chemotherapy should be considered for suspected PTTM.

[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.

[A Case in Which Trastuzumab Combined Chemotherapy Was Effective for Recurrence of Post-Operative Gastric Cancer with Partial HER2 Overexpression].

We report a case in which recurrent partial HER2-positive gastric cancer showed complete clinical response to capecitabine (Cape)/oxaliplatin(L-OHP/OX)(CapeOX)plus trastuzumab(Tmab)combined chemotherapy for 32months. A 65-yearold man underwent distal gastrectomy, D2 lymph node dissection, and Roux-en-Y reconstruction for type 2 gastric cancer of the prepyloric anterior wall in December 2014. Pathological stage was as follows: L, ant, Type 2, 32×22 mm, tub1>tub2> por1, pT2(MP), int>med, INF c>a, Ly1a, V0, pN0, cM0, cH0, cP0, pCY0, pStage I B, pPM0(60mm), pDM0(75mm), pR0. Immunostaining of the tumor indicated overexpression of the HER2 gene in more than 10% of the well differentiated tubular adenocarcinoma(tub1). Nineteen months post-surgery, pancreatic head lymph node metastasis was diagnosed, and we started CapeOX plus Tmab combined chemotherapy. After 19 courses, the metastatic lymph node reduced its size until we could not detect it on CT. We continued treatment for 45 courses(about 32 months). During the courses, there were adverse events such as peripheral neuropathy(Grade 3, CTCAE v5.0), which required interruption of L-OHP, and oral mucosal ulcer (Grade 2).

Impact of the histological phenotype of extrahepatic bile duct carcinoma.

The classification of histological phenotypes was originally conceived for pancreatic intraductal papillary mucinous neoplasms. Recently, it has been introduced for extrahepatic cholangiocarcinoma. The aim of the present study was to clarify the associations between histological phenotype and clinicopathological features of extrahepatic cholangiocarcinoma, using 99 cases of surgically-resected extrahepatic cholangiocarcinoma. All cases were divided into one of two histological phenotypes: Biliary-type (BT; 56 cases, 56.6%) or metaplastic-type (MT; 43 cases, 43.4%). The clinicopathological features were compared between these two phenotypes. BT tumors exhibited significantly poorer differentiation, more frequent lymph node metastasis (BT vs. MT, 42.9 vs. 30.2%; P=0.042), more severe venous invasion (v2-3: BT vs. MT, 64.3 vs. 23.3%; P<0.001), and more severe perineural invasion (ne2-3: BT vs. MT, 78.6 vs. 48.8%, P=0.002). Furthermore, the overall (P=0.015) and disease-free (P=0.003) survival times were significantly decreased in patients with BT vs. MT tumors. In conclusion, extrahepatic cholangiocarcinoma with a BT phenotype has greater malignant potential, and may be an important predictive factor for poor prognosis.

[A Case of Laparoscopic Low Anterior Resection and Adrenalectomy for Rectal Cancer and Adrenal Tumor].

A 70-year-old woman had consulted a doctor at a former clinic because of bloody stool and colonoscopy revealed a type 2 tumor of the rectum. She was referred to our hospital for further examinations and treatment. Preoperative blood examination showed an elevated HbA1c level of 10.2%. Abdominal CT showed a 25mm tumor in the left adrenal gland. The patient was diagnosed with adrenal Cushing's syndrome based on low ACTH levels, disappearance of circadian variation in blood cortisol levels, lack of inhibition by dexamethasone loading, and high urinary cortisol levels. Laparoscopic adrenalectomy for left adrenal tumor and low anterior resection for rectal cancer were performed. The pathological findings were rectal cancer, pap, pT1b(SM), pN0, cM0, fStageⅠof rectal cancer, and adrenal cortical adenoma. The postoperative course was uneventful with steroid replacement therapy. The ileal stoma was closed 4 months after surgery. Surgery in hyperadrenalism requires perioperative steroid replacement therapy because of the risk of postoperative acute adrenal failure. In addition, when diabetes is poorly controlled, we should be careful about risk of leakage and susceptibility to infection.

[A Case of Appendiceal Mucinous Adenocarcinoma Detected with a Bladder Tumor].

A 74-year-oldwoman hadconsultedthe department of urology in our hospital because of microscopic hematuria. Cystoscopy revealeda urinary bladder tumor, suspectedas an adenocarcinoma basedon biopsy. MRI showeda cystic tumor of the appendix with vesical fistula; therefore, she underwent an operation with a diagnosis of appendiceal cancer invading the urinary bladder. During the operation, we found that the appendix sunk into the urinary bladder with right adnexa. Therefore, we performed ileocecal resection, partial resection of the urinary bladder, and right adnexectomy. Macroscopically, the bladder was filled with a large number of mucus lumps. A papillary tumor, 4 cm in size, growing in the lumen of the bladder was detectedat the invasion site. Microscopically, proliferating carcinoma cells in a papillary form were observedin the lumen of the appendix with mucus production, invading the wall of the urinary bladder at the fundus of the appendix. Thus, the patient was diagnosed with mucinous adenocarcinoma of the appendix(V, type 1, 45×30 mm, muc, pT4b[SI, urinary bladder], int, INF c, ly0, v0, pN0, cM0, pStage II ). Primary appendiceal cancer invading the urinary bladder is very rare; herein, we report a rare case of appendiceal mucinous adenocarcinoma detected with a bladder tumor and present a literature review.

[Radical Operation Performed on a Gastric Cancer Patient with Cold Agglutinin Disease - A Case Report].

A 56-year-old man with no abnormalmedicalhistory was admitted to our hospitalfor gastric cancer surgery. The preoperative laboratory tests indicated anemia, hyperbilirubinemia, hemagglutinin reaction, and a markedly high cold agglutinin titer; thus, we diagnosed the patient with cold agglutinin disease(CAD). Although perioperative complications caused by cold stimulation were suspected, we decided that it was possible to perform the operation under robust intraoperative conditions avoiding exposure to cold temperatures, and thus performed the radical operation. Intraoperatively, we performed blood transfusion because the anemia of the patient progressed owing to bleeding; however, no other complications were noted. Postoperatively, the clinical course was good without any complications, and the patient was discharged 13 days after the operation. The present case demonstrated that CAD patients requiring surgery can safely be operated on if their conditions, including perioperative body temperature management, are adequately considered during surgical preparation.

[A Case of Laparoscopic Surgery for Rectal Cancer with Synchronous Lung Metastases after Chemotherapy].

A woman in her 70's presented with the predominant complaint of bloody stools. She was diagnosed with rectal cancer, and bilateral lymph node and pulmonary metastases were detected on computed tomography(CT). The patient was diagnosed with cT3N3M1a, cStage IV disease. After undergoing a colostomy, the patient was treated with S-1 plus oxaliplatin (SOX), and bevacizumab(Bev). A second CT scan obtained after completion of 7 courses of chemotherapy revealed that the lung metastases had significantly reduced or disappeared. Approximately 7 months after initial treatment, the patient underwent a laparoscopic Hartmann procedure to remove the tumor. The patient is currently under observation while being administered postoperative adjuvant chemotherapy as an outpatient in our department. There is currently no evidence of the safety of laparoscopic-assisted rectal cancer surgery for first-time Stage IV cases. However, when tumor regression has been achieved with chemotherapy, it may be an effective option.

[A Case of Long-Term Survival after Surgeries for Gastric Cancer and Metachronous Ovarian Metastasis].

The patient was a 57-year-old woman. In October 2011, she underwent distal gastrectomy, D2 lymphadenectomy, and Roux-en-Y reconstruction for gastric cancer (pT4a, pN3b, Stage ⅢC [JCGC 14th Edition]). She then received S-1 plus CDDP combination therapy and S-1 monotherapy as postoperative adjuvant chemotherapies for 1 year, and was followed up as an outpatient. In April 2013, a significant increase in the CA19-9 level was noted, and CT indicated a right ovarian tumor. Ovarian metastasis from the gastric cancer was diagnosed, and the response to 3 courses of weekly PTX was stable disease. No findings indicated metastasis to other organs. In July 2013, a salpingo-oophorectomy was performed, after which her CA19-9 level returned to the normal range. Follow-up was adopted as the postoperative strategy in part due to the desires of the patient. Presently, 3 years and 6 months after the initial surgery and 1 year and 9 months after the last surgery, no recurrence has been detected. Generally, ovarian metastasis from gastric cancer is considered to be associated with a poor prognosis. However, our patient showed long-term survival after surgeries for gastric cancer and asynchronous ovarian metastasis. Here, we report the details of our case and review the relevant literature.

Invasive micropapillary carcinoma of the extrahepatic bile duct and its malignant potential.

Invasive micropapillary carcinoma (IMPC) was originally described as a distinctive type of invasive carcinoma in the breast, but it has not been recognized as a histological type of the extrahepatic bile duct cancer. The present study demonstrated clinicopathological features and patient prognosis of IMPC. We examined histological reviews of 93 consecutive cases of the extrahepatic bile duct cancer and identified 13 cases which included IMPC component. The component of IMPC ranged from 5 to 60% of the primary tumor tissue, which was mainly detected at the invasive front of the tumor. Of the 13 cases, 12 (92.3%) carcinomas with IMPC showed lymph node metastasis more frequently compared to conventional adenocarcinoma (39.2%, P<0.001). Presence of IMPC component was significantly associated with poor overall survival (P=0.003). In conclusion, extrahepatic bile duct carcinoma with IMPC component showed significant lymphatic invasion, lymph node metastasis, and resulted in poor prognosis.

[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.

[A case of pneumatosis cystoides intestinalis after neoadjuvant chemotherapy for esophageal cancer].

A man in his 60s was diagnosed with esophageal cancer (T3, N0, StageII) and treated with 5-fluorouracil and cisplatin as neoadjuvant chemotherapy (NAC). On day 18 of the second NAC course, the patient developed febrile neutropenia, and a computed tomography (CT) scan showed pneumatosis cystoides intestinalis (PCI) of the ascending and transverse colon, free air around the ascending colon, thickening of the gallbladder wall, pleural effusion, and ascites. Because there were no signs of peritoneal irritation and intestinal perforation was ruled out, conservative treatment was selected. Seven days after PCI was diagnosed, CT showed improvement in PCI and the free air had disappeared, and 26 days after the diagnosis, a subtotal esophagectomy was performed. Observation of the abdomen did not show a thickened wall or stenosis of the ascending or transverse colon. PCI could be treated conservatively, even with free air in the abdominal cavity, by comprehensively assessing not only the imaging but also the physical findings. We were able to perform radical resection of the esophageal cancer without excessive treatment for PCI.

[A case of mixed adenoneuroendocrine carcinoma of the esophagogastric junction treated with neoadjuvant chemotherapy].

We present a case of a 63-year-old man who was admitted to another hospital because of abdominal distension and body weight loss. Gastric endoscopy revealed a type III tumor at the posterior wall of the upper gastric body. The tumor had invaded into the esophagogastric junction. On the basis of the pathology of the biopsy specimen, the tumor was diagnosed as neuroendocrine carcinoma of the esophagogastric junction. Computed tomography (CT) scans showed regional lymph node swelling. Cisplatin( CDDP) +irinotecan( CPT-11) therapy was selected and administered to the patient. After 2 courses, the patient received S-1+CDDP. He was considered to have stable disease. We performed partial resection of the lower esophagus, total gastrectomy, splenectomy, and cholecystectomy. On pathology, the tumor was immunohistochemically positive for chromogranin A, AE1/AE3, neural cell adhesion molecule (NCAM), neuron-specific enolase (NSE), and p53. The Ki-67 index was 80%. The tumor was diagnosed as a mixed adenoneuroendocrine carcinoma (MANEC) of the esophagogastric junction. The patient was treated with S-1 and CDDP. Neuroendocrine cell carcinoma of the esophagogastric junction is rare and usually has a very poor prognosis. We herein report a case of mixed adenoneuroendocrine carcinoma of the esophagogastric junction that was curatively resected and resulted in patient survival without recurrence.