[Occult Breast Carcinoma and Recurrent Tumor in the Breast 14 Years after Axillary Dissection-A Case Report].

We report a patient with occult breast cancer who underwent axillary dissection as primary surgery. The patient, a 68-yearold woman, noticed a tumor measuring approximately 3 cm in diameter, in her left axilla. Biopsy of the axillary tumor revealed adenocarcinoma. Imaging studies did not detect primary lesions in the mammary gland or other organs. The patient was diagnosed with occult breast cancer and underwent axillary dissection but did not desire mastectomy or radiation therapy. The patient was closely observed thereafter. Tamoxifen was prescribed for 5 years but left breast cancer was detected 14 years after the operation. A simple mastectomy was performed. She died of respiratory failure 1 year later. Occult breast cancer may require axillary lymph node dissection and systemic therapy. Breast preservation could be an alternative treatment if followed by adequate systemic therapy and close observation.

[Surgical Resection of a Solitary Pulmonary Nodule in a Patient with Breast Cancer-A Case Report].

Solitary lung tumors after radical surgery for breast cancer often present difficulty in diagnosis and treatment. This report describes the case of a patient with a previous history of radicalsurgery for breast cancer who underwent lung surgery. Solitary pulmonary nodules should be diagnosed in patients with breast cancer, because treatments and prognoses differ between metastatic and primary tumors. At the age of 43 years, this patient underwent surgicaltreatment for breast cancer. Eighteen years later, a solitary mass was observed in the middle lobe of the right lung. Right middle lobectomy was performed using video-assisted thoracic surgery. The diagnosis was primary lung carcinoma. In case of primary lung carcinoma, radical treatment is possible through surgical resection. On the contrary, breast cancer metastasis has been known to have subtypes with characteristics that may often be different from those of the originall esions; therefore, surgicalresection helps in the reevaluation of receptor expression. Thus, early pathological diagnosis using surgical resection is useful for early diagnosis and treatment.

[Analysis of the Risk Factors of Febrile Neutropenia Among 72 Women Receiving FEC in Early Breast Cancer Chemotherapy].

In early breast cancer chemotherapy, it is important to maintain the relative dose intensity(RDI). We retrospectively ana- lyzed the incidence and risk factors of febrile neutropenia(FN)among women receiving FEC(5-fluorouracil 500mg/m2, epirubicin 100mg/m2, and cyclophosphamide 500 mg/m2)chemotherapy. Of 72 patients, 33 patients developed FN and 39 patients did not. Excluding patients in whom the nadir could not be confirmed, we classified a final total of 28 patients into the FN group and 24 into the non-FN group. The number of leukocytes was significantly lower in the FN group(1,500/mL versus 2,146/mL, p=0.05). The reduction rate of leukocytes was also significantly lower in the FN group(74.5%versus 65.0%, p=0.02). In adjuvant FEC chemotherapy, the considerable reduction of leukocytes at nadir is a risk factor of FN. To manage FN appropriately, G-CSF therapy may be considered for these patients.

[Predictors of Overall Survival after Locoregional Breast Cancer Recurrence].

We evaluated prognostic factors of locoregional breast cancer recurrence in 35 patients. The average age at the time of surgery was 58.4 years(range: 32-87 years). Of the 35 patients, 7, 17, and 11 had Stage I , II and III disease, respectively. Immunohistochemically, 25 tumors were ER+, and 10 were ER-, while 6 were HER2+, 27 were HER2-, and 2 had uncertain HER2 statuses. Their median disease-free interval(DFI), which is the intervalbetween initialsurgery and locoregional recurrence, was 29.4 months(range: 1-133 months). After locoregional relapse, 13 patients underwent surgical tumor removal, and 34 received systemic treatment. The median time-to-progression(TTP)after first-line therapy for recurrent breast cancer was 12.7 months(range: 1-185 months), and the median overall survival(OS)was 70.0 months(range: 3-313 months). Univariate analysis showed that disease stage at initial surgery, triple-negative disease, DFI, and TTP significantly affected OS, whereas ER and HER2 status, surgical margin at primary surgery, lymphovascular invasion, irradiation after initial surgery, and resection of the recurrent tumor were not significant factors. Patients with factors that predict worse prognosis after locoregional recurrence should be treated carefully.

[Lung Metastasis of Breast Cancer Five Years after Mastectomy - A Case Report].

The presence of a solitary lung tumor after radical surgery for breast cancer often causes difficulty in the diagnosis and treatment. We report a patient who had previously undergone radical surgery for breast cancer, and who underwent lung surgery. When the patient was 57 years old, she underwent surgical treatment for breast cancer. Six years later, a chest radiograph revealed a solitary mass on the upper lobe of her left lung. A left upper lobectomy was performed, utilizing videoassisted thoracic surgery. The pathological diagnosis, based on hematoxylin and eosin staining, was lung metastasis from breast cancer. The immunohistological findings revealed that the tumor was positive for estrogen receptor, progesterone receptor, and GCDFP-15, and negative for TTF-1 and Napsin A. Although the original breast cancer lesion was positive for the HER2 receptor, the metastatic lung lesion was negative. It has already been reported that the subtypes can change from 1 subtype in the original lesion to another in the metastatic lesion. Adjuvant therapy was administered based on the subtype of the metastatic lesion after the surgery. Therefore, surgical resection is useful for the purpose of reevaluating HER2 receptor status, the results ofwhich can influence the postoperative adjuvant treatment. The patient is now doing well, without any evidence ofrecurrence or metastasis 15 months after surgery.

[Treatment for Elderly Breast Cancer Patients Older than 80 Years].

Breast cancer is the leading form of cancer in women in Japan. Cases of elderly women with breast cancer have been increasing rapidly in Japan due to the increasing age of the population. We examined the clinicopathological features and prognosis of breast cancer patients over 80 years old to define an optimal treatment regimen. From January 2004 to October 2014, 43 primary breast cancer patients underwent surgery at the Chiba Rosai Hospital. The median age was 84 years. On pathological diagnosis, the median tumor diameter was 2.4 cm. The tumors were positive for estrogen and progesterone receptors in 30 and 26 patients, respectively. The median overall survival time was 78 months. Only lymph node metastasis was an important predictor of overall survival. It is important to appropriately treat elderly patients. However, there have been no clinical practice guidelines for the management of breast cancer in elderly individuals because of a lack of clinical trials including elderly patients. Elderly patients have other complications such as cardiovascular disease, diabetes, dementia, and pulmonary emphysema. Therefore, we need to make a clinical decision for each individual patient considering comorbidities, functional status, and clinicopathological characteristics of the tumor.

[Examination of Resection for Pulmonary Tumors after Breast Cancer Surgery].

There are many arguments about whether surgical resection or drug therapy is better for pulmonary metastasis after breast cancer surgery. Here, we examine 9 cases of resection for pulmonary tumors suspected of being metastases from breast cancer, at our institution. The preoperative diagnosis was difficult, with nodules less than 20 mm in all cases. Of the 9 cases, 2 cases were primary lung cancer, 4 cases were metastatic pulmonary tumors, 1 case was comorbid with lung cancer and metastatic pulmonary tumors, and 2 cases were benign pulmonary tumors. The median disease-free interval (DFI) was 6.1 (1.3-8.9) years, and the median survival time was 12.5 (2.3-17.8) years after metastasectomy. There were no changes in the hormone receptors or HER2 status between primary breast tumors and metastases. Both cases of primary lung cancer were Stage ⅠA, and they were treated with radical resection. The 2 benign pulmonary tumors did not receive any unnecessary additional treatment. If a difficult-to-diagnose pulmonary tumor occurs after an operation for breast cancer, a pneumonectomy should be considered, not only for diagnosis but also for treatment.

[A case of liver metastatic recurrence of bile duct cancer completely responding to single-drug S-1 chemotherapy].

A 65-year-old man with common bile duct cancer was treated by pylorus-preserving pancreaticoduodenectomy with D2 lymph node dissection. Three months after surgery, tumor marker was increasing, and CT demonstrated multiple liver metastatic tumors. Single drug chemotherapy with S-1(100 mg/body/day)was administered. After 6 months, the liver metastatic tumors could not be visualized by CT. S-1 may be the chemotherapy of choice for recurrence of bile duct cancer.

Two cases of adenoid cystic carcinoma: preoperative cytological findings were useful in determining treatment strategy.

Adenoid cystic carcinoma (ACC) of the breast is a rare variant of breast malignancy and is known to have an excellent prognosis. We report two cases of ACC diagnosed by preoperative fine-needle aspiration cytology (FNAC), which proved to be very useful in determining the appropriate treatment. The patients were a 57-year-old woman (case 1) and a 71-year-old woman (case 2). On physical examinations and imaging studies both tumors were recognized as lobulated tumors that measured 3.0 x 2.3 cm (case 1) and 3.9 x 3.4 cm (case 2) respectively. FNAC materials showed clusters of malignant cells surrounding globules of mucus, therefore, ACC was diagnosed. Considering the characteristics of ACC, breast-conserving surgeries with axillary dissection and adjuvant radiotherapy were performed instead of primary chemotherapy or mastectomy. Histologically, a distinctive biphasic pattern was observed that consisted of true laminae and pseudocystic spaces. Tumor sizes were 4.0 x 3.3 cm (case 1) and 4.6 x 3.8 cm (case 2), respectively, and surgical margins were negative on microscopic examination. Lymph node metastasis was not present in either case. Even though ACC is very rare, preoperative diagnosis can be made based on its characteristic features. Preoperative diagnosis is extremely useful for determining appropriate treatment.