Oncoplastic breast surgery to prevent "Bird's beak" deformity in the breast: a comparative retrospective study.

PURPOSES: Breast deformity occurring in the lower pole after breast conserving surgery (BCS) is known as bird's beak (BB) deformity. This retrospective study evaluated the outcomes in breasts reconstructed with a conventional closing procedure (CCP) and a downward-moving procedure (DMP), respectively, after BCS. METHODS: In CCP, the inferomedial and inferolateral portions of breast tissues were reapproximated toward the midline after wide excision to repair the breast defect. In DMP, the retro-areolar breast tissue was detached from the nipple-areolar complex after wide excision, and the upper pole breast tissue was moved downward to refill the breast defect. RESULTS: CCP was performed in 20 patients (Group A), and DMP was performed in 28 patients (Group B). Although retraction of the lower part of the breast was postoperatively observed in 13 (72%) of 18 patients from Group A, it was observed in 7 (28%) of 25 patients in Group B (p < 0.05). The downward pointing of the nipple was observed in 8 (44%) of 18 patients from Group A and in 4 (16%) of 25 patients in Group B (p < 0.05). CONCLUSIONS: DMP is more useful for preventing BB deformity than CCP.

[A Case of Intussusception Caused by Cancer of the Sigmoid Colon in an Adult].

A 55-year-old man complaining of difficulty in defecation was referred to our hospital. A digital examination and abdominal CT led to a diagnosis of intussusception due to tumor of the sigmoid colon. The intussusception was successful reduced by enema. Following colonoscopy and abdominal enhanced CT, a sigmoid colon cancer(cT3, cN1b, cM0, cStage Ⅲb)was detected. A laparoscopic sigmoidectomy and lymph node dissection were performed on 23 days after the hospitalization. Postoperative course was uneventful. Preoperative reduction of the intussusception in this case enabled us to perform an elective surgery. We report this case with a review of the relevant literature.

Roles of the hexosamine biosynthetic pathway and pentose phosphate pathway in bile acid-induced cancer development.

Esophageal squamous cell carcinomas (ESCCs) as well as adenocarcinomas (EACs) were developed in rat duodenal contents reflux models (reflux model). The present study aimed to shed light on the mechanism by which bile acid stimulation causes cancer onset and progression. Metabolomics analyses were performed on samples of neoplastic and nonneoplastic tissues from reflux models, and K14D, cultivated from a nonmetastatic, primary ESCC, and ESCC-DR, established from a metastatic thoracic lesion. ESCC-DRtca2M was prepared by treating ESCC-DR cells with taurocholic acid (TCA) to accelerate cancer progression. The lines were subjected to comprehensive genomic analyses. In addition, protein expression levels of glucose-6-phosphate dehydrogenase (G6PD), nuclear factor kappa B (NF-κB) (p65) and O-linked N-Acetylglucosamine (O-GlcNAc) were compared among lines. Cancers developed in the reflux models exhibited greater hexosamine biosynthesis pathway (HBP) activation compared with the nonneoplastic tissues. Expression of O-GlcNAc transferase (OGT) increased considerably in both ESCC and EAC compared with nonneoplastic squamous epithelium. Conversely, cell line-based experiments revealed the greater activation of the pentose phosphate pathway (PPP) at higher degrees of malignancy. G6PD overexpression in response to TCA exposure was observed. Both NF-κB (p65) and O-GlcNAc were expressed more highly in ESCC-DRtca2M than in the other cell lines. Moreover, ESCC-DRtca2M cells had additional chromosomal abnormalities in excess of ESCC-DR cells. Overall, glucose metabolism was upregulated in both esophageal cancer tissue and cell lines. While bile acids are not mutagenic, chronic exposure seems to trigger NF-κB(p65) activation, potentially inducing genetic mutations as well as facilitating carcinogenesis and cancer progression. Glucose metabolism was upregulated in both esophageal cancer tissue and cell lines, and the HBP was activated in the former. The cell line-based experiments demonstrated upregulation of the pentose phosphate pathway (PPP) at higher degrees of malignancy. While bile acids are not mutagenic, chronic exposure seems to trigger G6PD overexpression and NF-κB (p65) activation, potentially inducing genetic mutations as well as facilitating carcinogenesis and cancer progression.

Effect of Oral Branched-Chain Amino Acids and Glutamine Supplementation on Skeletal Muscle Atrophy After Total Gastrectomy in Rat Model.

BACKGROUND: Sarcopenia is closely related to short-term outcomes of surgery and long-term prognosis. After gastrectomy, a decrease in muscle strength occurs because of insufficient nutrient intake and disturbed digestive function. Branched-chain amino acids (BCAAs) and glutamine (Gln) play vital roles in the signaling pathways regulating protein synthesis and protein degradation. In this study, we investigated the effects of BCAA and Gln supplementation alone or in combination on skeletal muscle atrophy after total gastrectomy in a rat model. METHODS: Male Wistar rats were divided into five groups: (1) sham operation (n = 8); (2) total gastrectomized rats (TG [control group], n = 16); (3) TG with BCAA (TG-B, n = 16); (4) TG with Gln (TG-G, n = 16); and (5) TG with BCAA and Gln (TG-BG, n = 16). In all groups, body weight, muscle weight, and marker for muscle metabolism were examined. RESULTS: Weight gain was significantly greater in the TG-BG group (130.5%) than in the TG group (108.1%) at 15 wk (P < 0.05). The gastrocnemius muscle weight was significantly higher for TG-BG (2.84 g) than for TG (2.44 g) at 15 wk (P < 0.05). Western blotting indicated that atrogin-1 and MuRF1 levels were lower in the TG-BG group than in the TG group but were not suppressed in the TG-B or TG-G group. CONCLUSIONS: In a rodent sarcopenia model induced by TG, the administration of BCAA in combination with Gln more effectively inhibited muscle atrophy than the administration of BCAA or Gln alone.

[A Case of Peritoneal Mesothelioma Diagnosed by Ileus].

The present case involved a man aged about 70 years. He visited our hospital with the main complaint of abdominal pain. We diagnosed him with intestinal obstruction, and we decided to perform surgery. White knot sections were spread inside the abdominal cavity, and the small intestine appeared as a single block. This block was resected and examined for peritoneal mesothelioma. Peritoneal mesothelioma is thought to have incubation period of 20-25 years after exposure to asbestos, and the number of affected patients will increase in the future. In some cases, peritoneal mesothelioma occurs only in the peritoneum; therefore, diagnosis often becomes difficult. Once intestinal obstruction occurs, administering chemotherapy is difficult. Therefore, early diagnosis is thought to be very important.

[Laparoscopic Surgery for an Intussusception Caused by Rectosigmoid Colon Cancer after Pre-Operative Reduction by Transanal Insertion of a Circular Sizer - A Case Report].

An octogenarian man complaining of bloody stool was referred to our hospital. A digital examination, abdominal enhanced CT and endoscopy led to a diagnosis of intussusception due to rectosigmoid colon cancer, but he was not suffering from bowel obstruction. An elective laparoscopic Hartmann's operation was performed after reduction by transanal insertion of a circular sizer. It may be difficult to reduce an intussusception induced by rectal cancer. We report this case with a review of the relevant literature.

[A case of advanced esophageal cancer with direct bronchial invasion successfully treated by multidisciplinary therapy].

A 66-year-old man with advanced esophageal cancer (staging Mt, 6.0 cm, cT3N0M0, cStage II) was administered neoadjuvant chemotherapy (NAC: 5-fluorouracil and cisplatin). As the tumor continued to grow after one course of NAC, video-assisted thoracoscopic surgery(VATS) was used to perform an esophagectomy along with 3-field lymph node dissection and retrosternal route reconstruction using a gastric tube. The second course of NAC was not administered. Intraoperative findings showed the direct invasion of the primary esophageal cancer into the membranous portion of the left bronchus. The maximum possible tumor tissue was resected and removed. The tumor tissue was exposed extensively to the surface of the esophageal adventitia and a residual tumor at the surface of the left bronchus was suspected. It was diagnosed as CT-pT4 (left bronchus), N0, M0, CT-pStage III. Subsequently, we administered chemoradiotherapy consisting of weekly low-dose docetaxel with radiation for the residual tumor (60 Gy/30 Fr). The patient is still alive 40 months after surgery without any signs of recurrence.

Periarterial or perivenous invasion is an independent indicator of lymph node metastasis in invasive breast carcinoma of no special type.

Pathological diagnosis of breast cancer often includes cases of lymph node metastases without lymphatic or lymphovascular invasion by the primary tumor. In this study, to resolve this discrepancy, we designed a sensitive method to detect lymphatic invasion and correlate it with lymph node metastasis. Elastica van Gieson (EVG) staining and D2-40 immunohistochemistry revealed the abundant distribution of lymphatic vessels around blood vessels in the mammary tissue in close proximity to the elastic fibers around the arteries and veins. Based on the histological location of the blood and lymphatic vessels, we hypothesized that, in breast cancer, perivascular invasion is similar to lymphatic invasion and correlates with the presence of lymph node metastasis. Using EVG staining, perivascular invasion was histologically classified into periarterial invasion (periA), perivenous invasion (periV), and periarterial or perivenous invasion (periA/V). We tested our method and compared it to other methods commonly used for identifying lymphatic invasion in 105 patients with invasive breast carcinoma of no special type (IBC-NST) who received minimal preoperative therapy. The correlation between perivascular invasion and lymph node metastasis in these patients was statistically analyzed, including findings related to lymphatic invasion, such as retractile artifacts and perineural invasion. PeriA, periV, and periA/V showed significant correlations with lymph node metastasis. PeriA/V had high sensitivity and negative predictive value. The odds ratio (OR) for periV was significantly high in the univariate analysis, while the ORs for periA/V, retraction artifacts, and perineural invasion were significantly high in both the univariate and multivariate analyses. In particular, periA/V revealed a strong correlation with lymph node metastasis (OR: 61.8). These findings indicate that the IBC-NST periA/V ratio is a sensitive pointer of lymphatic invasion and could be an independent and reliable indicator of lymph node metastasis.

[Our experience with panitumumab used for patients with metastatic colorectal cancer].

We report having treated patients with metastatic colorectal cancer with panitumumab in our department. Ten patients were treated. The mean age was 65. 7 years-old with 7 males and 3 females. Seven patients were treated with only panitumumab, and three patients were treated with panitumumab and another drug. The median number of infusions was 8 times. In the 9 cases that could be evaluated, the disease control rate was 66. 6%. Skin toxicity was observed in all patients. A low serum magnesium value of grade 3 was observed in one patient. We consider that treatment with panitumumab for patients with metastatic colorectal cancer was a safe option.

Conservative axillary surgery is emerging in the surgical management of breast cancer.

Axillary lymph node dissection (ALND) has been the standard axillary treatment for breast cancer for a long time. However, ALND is associated with postoperative morbidities, including local sensory dysfunction, reduced shoulder mobility and most notably arm lymphedema. Recently, ALND can be avoided not only in clinically node-negative (cN0) patients with negative sentinel lymph nodes (SLNs), but also in patients with less than 3 positive SLNs receiving breast radiation, axillary radiation, or a combination of the two. Moreover, SLN biopsy has been adopted for use in clinically node-positive (cN +) patients presenting as cN0 after neoadjuvant chemotherapy (NAC); ALND may be avoided in cN + patients who convert to SLN-negative following NAC. Patients who undergo SLN biopsy alone have less postsurgical morbidities than those who undergo ALND. Nevertheless, ALND is still required in a select group of patients. A variety of conservative approaches to ALND have been developed to spare arm lymphatics to minimize arm lymphedema. These conservative procedures seem to decrease the incidence of lymphedema without increasing axillary recurrence. In the era of effective multimodality therapy, full conventional ALND removing all microscopic axillary disease may now be unnecessary in both cN0 patients and cN + patients. Regardless, emerging procedures for ALND should still be considered as investigational approaches, as further studies with longer follow-up are necessary to determine the safety of conservative ALND to spare arm lymphatics.

The involvement of axillary reverse mapping nodes in patients with node-positive breast cancer.

INTRODUCTION: Axillary reverse mapping (ARM) procedure is useful in reducing lymphedema. However, concerns regarding oncologic safety have limited the adoption of the ARM procedure. This study aimed to evaluate the involvement of ARM nodes in node-positive breast cancer patients. MATERIALS AND METHODS: Two hundred twenty-three node-positive patients were enrolled in this study: 90 were clinically node-negative, but had one or more positive sentinel lymph nodes (SLNs) (SLN-positive group); 68 were clinicopathologically node-positive (CpN-positive group); and 65 had confirmed nodal involvement and received neoadjuvant chemotherapy (NAC) (NAC group). All patients underwent axillary lymph node dissection with fluorescent ARM. RESULTS: ARM nodes were involved in 33 (36.7%) patients of the SLN-group. Residual ARM nodes after SLN biopsy were involved in 11 patients (12.2%), including 5 patients (19.2%) with crossover type nodes and 6 patients (9.4%) with non-crossover type nodes. However, the difference in involvement rates between the two types was not high enough to be significant. Of these 11 patients, moreover, four patients had three or more than 3 involved SLNs. On the other hand, the involvement rate of ARM nodes in the NAC group was significantly lower than that of the CpN-positive group (35.4% vs. 64.7%: p < 0.01). Despite lower involvement, the risk of metastases in the ARM nodes was still too high to spare ARM nodes in both the NAC group and CpN-positive group. CONCLUSIONS: Suspicious or involved ARM nodes should be removed even when detected in ARM procedure, particularly in NAC-group and CpN-positive-group patients.

Conservative Axillary Surgery May Prevent Arm Lymphedema without Increasing Axillary Recurrence in the Surgical Management of Breast Cancer.

Axillary lymph node dissection (ALND) has been associated with postoperative morbidities, including arm lymphedema, shoulder dysfunction, and paresthesia. Sentinel lymph node (SLN) biopsy emerged as a method to assess axillary nodal status and possibly obviate the need for ALND in patients with clinically node-negative (cN0) breast cancer. The majority of breast cancer patients are eligible for SLN biopsy only, so ALND can be avoided. However, there are subsets of patients in whom ALND cannot be eliminated. ALND is still needed in patients with three or more positive SLNs or those with gross extranodal or matted nodal disease. Moreover, ALND has conventionally been performed to establish local control in clinically node-positive (cN+) patients with a heavy axillary tumor burden. The sole method to avoid ALND is through neoadjuvant chemotherapy (NAC). Recently, various forms of conservative axillary surgery have been developed in order to minimize arm lymphedema without increasing axillary recurrence. In the era of effective multimodality therapy, conventional ALND may not be necessary in either cN0 or cN+ patients. Further studies with a longer follow-up period are needed to determine the safety of conservative axillary surgery.

Axillary Reverse Mapping in Clinically Node-Positive Breast Cancer Patients.

BACKGROUND: Axillary reverse mapping (ARM) nodes are involved in a significant proportion of clinically node-positive (cN+) breast cancer patients. However, neoadjuvant chemotherapy (NAC) is effective at decreasing the incidence of nodal metastases in cN+ patients. PATIENTS AND METHODS: One hundred forty-five cN+ patients with confirmed nodal involvement on ultrasound-guided fine needle aspiration cytology were enrolled in this study: one group underwent axillary lymph node dissection (ALND) without NAC (upfront surgery group), and the other group underwent ALND following NAC (NAC group). The patients underwent 18F-FDG-positron emission tomography/computed tomography (18F-FDG-PET/CT) before surgery, as well as an ARM procedure during ALND. RESULTS: the rates of involvement of ARM nodes in the NAC group were significantly lower than those of the upfront surgery group (36.6% vs. 62.2%, p < 0.01). Notably, involvement was significantly decreased after NAC in non-luminal-type tumors as compared to the luminal-type (18.4% vs. 48.5%: p < 0.01). Moreover, there was a significant difference in ARM node involvement after NAC between patients with or without axillary uptake of 18F-FDG (61.5% vs. 32.5%: p < 0.01). CONCLUSIONS: NAC significantly decreased the risk of ARM node metastases in cN+ patients, but 18F-FDG-PET/CT was not suitable to detect residual metastatic disease of the axilla after NAC.

Mild nonocclusive mesenteric ischemia associated with syncope.

Nonocclusive mesenteric ischemia (NOMI) is a life-threatening disease caused by a reduction in mesenteric blood supply without vascular occlusion. Early diagnosis of NOMI is often difficult because there are no specific findings suggesting NOMI. Here, we report a rare case of a very elderly patient with mild NOMI caused by dehydration due to short-term reduced oral intake and associated with syncope. A 90-year-old man was admitted to our hospital with syncope and melena. The syncope was thought to be caused by orthostatic hypotension due to dehydration owing to reduced oral intake for approximately 24 h. Abdominal computed tomography (CT) revealed marked bowel wall thickening with mesenteric stranding in the ileum and ascending colon, dilated small intestine with thinned bowel wall, collapsed superior mesenteric vein, hemorrhagic ascites, and absence of obvious vascular occlusion in the mesenteric vessels. Abdominal symptoms, laboratory abnormalities, and CT findings improved gradually with the correction of dehydration. Therefore, we diagnosed our patient with mild NOMI. NOMI can be associated with syncope and can occur even with dehydration due to short-term reduced oral intake. When examining elderly patients with hypovolemic signs, such as syncope, who exhibit abdominal symptoms, clinicians must keep in mind the possibility of NOMI.

Temporary spontaneous regression of male breast cancer: a case report.

BACKGROUND: Spontaneous regression (SR) of a malignant tumor is the partial or complete disappearance of primary or metastatic tumor tissue in the absence of treatment, which can be temporary or permanent. Here, we report an extremely rare case of male breast cancer that exhibited temporary SR followed by reappearance 8 months after tumor disappearance. CASE PRESENTATION: A 70-year-old man presented at our hospital with a primary complaint of pain and a lump in his left breast. Ultrasonography revealed a hypoechoic lesion measuring 12 mm × 10 mm × 8 mm. Fine-needle aspiration cytology revealed numerous necrotic and degenerated cells and few sheet-like clusters of atypical ductal epithelial cells. The atypical cells had mildly enlarged nuclei with nucleoli, were focally overlapped and formed tubular patterns. The cytological diagnosis indicated a suspicion of malignancy. Core needle biopsy (CNB) revealed necrotic and degenerated cells with microcalcification. The pathological diagnosis was indeterminate because there was no area of viable atypical cells. An excisional biopsy of the left breast lesion was scheduled one month later. However, it was difficult to detect the tumor during physical examination and ultrasonography performed 1 month after the patient's first visit. The operation was canceled, and the patient received follow-up observation. After 8 months of follow-up, ultrasonography and computed tomography (CT) revealed reappearance of a 0.6-cm-diameter breast tumor in the same place. CNB was performed again and revealed invasive ductal carcinoma. A total mastectomy with sentinel lymph node biopsy was performed 13 months after the first tumor disappeared. Histopathological examination revealed invasive cribriform carcinoma without sentinel lymph node metastasis. The patient did not have any complications, and adjuvant therapy with tamoxifen was started. The patient was alive without recurrence 7 months after surgery. CONCLUSIONS: Temporary SR followed by tumor reappearance can occur in breast cancer cases, and it is important to follow patients even if their breast tumor has seemingly disappeared. When breast tumors disappear without treatment, clinicians must be aware of the possibility of SR of cancer and should follow the patient for early detection of tumor reappearance.

Rapid preparation of fluorescent 9-anthrylmethyl esters for fatty acid analysis of small amount of triacylglycerols.

This paper proposes a one-step method for preparation of fluorescent 9-anthrylmethyl esters from triacylglycerols (TAG) ranging in amount from 0.1 to 5 microg. It involves base-catalyzed transesterification using potassium 9-anthracenemethoxide, prepared by proton exchange between 9-anthracenemethanol and potassium tert-butoxide. Transesterification for 10 min at room temperature gave the fatty acid 9-anthrylmethyl esters in nearly maximal yields (82-85%). The products could be analyzed by reversed-phase HPLC without purification. Excellent linear relationships were observed for standard curves of 10-250 pmol of TAG standards (16:0, 19:0, 18:2 and 22:6), and differences in the slopes were less than 5% among the standards. Almost consistent compositions of the esters were observed for the products formed from 0.5 to 5 microg or less of fish oils TAG, and they were similar to those obtained by HPLC of ordinary multi-step synthesis products and by GLC of methyl esters. The present method is a great improvement of derivatization time, and is powerful for fatty acid analysis of small amounts of natural TAG.

Thoracoscopic Surgery in a Patient with Multiple Esophageal Carcinomas after Surgery for Esophageal Achalasia.

We present a case in which we used a thoracoscopic approach for resection of multiple esophageal carcinomas diagnosed 33 years after surgery for esophageal achalasia. A 68-year-old Japanese man had been diagnosed with esophageal achalasia and underwent surgical treatment 33 years earlier. He was examined at our hospital for annual routine checkup in which upper gastrointestinal endoscopy showed a "0-IIb+IIa" lesion in the middle esophagus. Iodine staining revealed multiple irregularly shaped iodine-unstained areas, the diagnosis of which was esophageal carcinoma. Thoracoscopic subtotal esophagectomy was performed. Esophageal carcinoma may occur many years after surgery for esophageal achalasia, even if the passage symptoms have improved. So, long-term periodic follow-up is necessary for detection of carcinoma at an earlier stage.

Preparation of ethyl magnesium bromide for regiospecific analysis of triacylglycerols.

This paper presents a procedure for preparation of a Grignard reagent, ethyl magnesium bromide, used for partial deacylation of triacylglycerols (TAG) in their regiospecific analysis. Magnesium turnings were reacted with ethereal solution of bromoethane in a screw-capped test tube to synthesize 2 mL of 1 M ethyl magnesium bromide. Continuously stirred with a vortex mixer, the reaction smoothly proceeded at room temperature. Regiospecific analysis of 1,3-distearoyl-2-oleoylglycerol using this product showed that fatty acid compositions of the sn-1(3) and sn-2 positions were contaminated by less than 2 mol% of fatty acids migrated from isomeric positions. The analyses of lard and cod liver/mackerel oil TAG showed typical distribution patterns of 16:0, 22:5n-3 and 22:6n-3 in pig and fish depot TAG. These results confirmed the view that the freshly prepared reagent is usable for regiospecific analysis of TAG.