[A Case of Cardiodiaphragmatic Corner Lymph Node Recurrence after Surgery for Ascending Colon Cancer].

The case is a female, 50s. She presented to our hospital because of her intestinal obstruction. A CT scan at her visit showed wall thickening of her ascending colon. Colonoscopy revealed type 2 advanced cancer in the ascending colon. The pathological examination was a diagnosis of adenocarcinoma. Laparoscopic right hemicolectomy was performed for cT3N1M0, cStage Ⅲb ascending colon cancer. The pathological result was pT3N1M0, Stage Ⅲb. Contrast-enhanced CT was performed 10 months after the operation. As a result, she was found to have recurrent multiple liver metastases. A laparoscopic partial hepatectomy was performed at the site of recurrence. The pathological result was adenocarcinoma. It was a diagnosis of metastasis recurrence from colorectal cancer. A CT scan 16 months after primary surgery revealed enlarged cardiodiaphragmatic lymph nodes. A PET-CT scan revealed an accumulation of SUVmax 3.0 in the same area. She was diagnosed with lymph node recurrence of colorectal cancer and underwent resection. Histopathological result was adenocarcinoma. It was diagnosed as metastasis from ascending colon cancer.

[A Case of a Malignant Phyllodes Tumor of the Breast with Osteogenic Sarcoma Which Repeated Local Recurrence].

The patient is a 39-year-old woman. At the age of 34, she recognized a 22 mm sized mass in the upper outer quadrant of her right breast, which was diagnosed as a fibroadenoma. 5 years later, the mass increased to 45 mm. We performed lumpectomy which led to a diagnosis of a malignant phyllodes tumor with osteogenic sarcoma. Since the resection margins were positive, we performed mastectomy in addition. Nine months after surgery, a 23 mm large mass appeared on the right fifth costal. Recurrence of malignant phyllodes was suspicious from cytological diagnosis and since thoracoabdominal CT showed no metastasis to other organs, we performed resection. Histological results were the same as the primary tumor. Two months more later, an 11 mm large mass revealed in the right anterior thoracic region. We performed resection again, which showed the same histological features as the primary tumor. Since malignant phyllodes tumors often recur in the early postoperative period, a close follow-up is recommended.

[A Case Performed Mastectomy to Tumor Progression of Breast Cancer Omitting Surgery after Neoadjuvant Chemotherapy].

We report a case performed mastectomy to tumor progression of breast cancer omitting surgery after neoadjuvant chemotherapy. A 62-year-old female patient visited our hospital for left breast tumor. A tumor of the size of 26×24 mm was found at between lower and upper outer quadrant, and we diagnosed it as breast cancer(cT1, cN2, M0, Stage ⅢA, ER positive/HER2 positive). Neoadjuvant chemotherapy by triweekly trastuzumab and weekly paclitaxel followed by EC chemotherapy were performed. However, she rejected surgery after neoadjuvant chemotherapy, and although we consequently restarted a regimen of triweekly trastuzumab which she also refused to continue after 9 cycles. 32 months later, she noticed induration on her left breast, and we diagnosed it as tumor progression of breast cancer. After obtaining informed consent, we performed total mastectomy and axillary lymph node dissection. Histological diagnosis revealed invasive ductal carcinoma, ER negative/HER2 positive, and no axillary lymph node metastasis. So far omission of surgery after neoadjuvant chemotherapy to breast cancer is not defined yet, and we expect early definition of evidence.

[A Case of Stage â £ Breast Cancer Invaded Chest Wall Successfully Resected with Local and Systemic Therapy].

A 54-year-old woman with massive exudates and bleeding in her huge right breast tumor had diagnosed Stage Ⅳ breast cancer, T4cN1M1(PUL, BRA, LYM), with ER positive and HER2 negative subtype confirmed with biological testing. She was treated with stereotactic radio surgery(SRS)for metastatic brain tumors before chemotherapy. Primary systemic chemotherapy, the regimen was EC followed by docetaxel effectively decreased the breast tumor, chest wall invasion, and other metastatic sites. After adding SRS for a new brain tumor lesion, mastectomy with a skin graft and lymphadenectomy were performed. Histological assessment showed free margins, decreased Ki-67 labeling index, ypN0, and histological Grade 1b breast tumor. After the surgery, PMRT and hormonal therapy were applied. The patient remained disease-free after surgery. Locally advanced breast cancer with brain metastasis that could be significantly reduced by sufficient therapeutic dose intensity. Aggressive radiation therapy for brain metastasis may improve local control in patients with Stage Ⅳ breast cancer.

[Disseminated Bone Marrow Carcinomatosis from Colon Cancer-A Case Report].

A 77‒year‒old man came to our hospital with complaints of abdominal pain and difficulty to defecate. Abdominal CT scan showed an abnormal region in the ascending colon, which was suspected to be an ascending colon cancer. D‒dimer was remarkably high, and the platelet count was 63,000/µL; these results suggested disseminated intravascular coagulation caused by tumor activation. After he was admitted, we performed a contrast enhanced CT, and found no signs of remote metastasis. We decided to resect the tumor without colonoscopy examination in order to release the DIC state. After the surgery, the platelet count did not increase, and leukopenia was observed. We conducted a bone marrow biopsy, and made a diagnosis of disseminated carcinomatosis from colon cancer. The patient's condition did not improve, and he died on day 42 after admission. Pathological autopsy was performed and several minimal remote metastases were found throughout the body.

[A Case of Transverse Colon Cancer with Metastatic Recurrence in Bilateral Inguinal Lymph Nodes].

A woman in the 60s. She was referred to our hospital because the fecal occult blood test was positive. Colonoscopy was performed. Cancer is found in the transverse colon. There were no metastases in the lungs and liver. Laparoscopic left hemicolectomy was performed. Histopathological examination was adenocarcinoma(tub1>tub2>muc), pT1b, pN2, ly2, v1, pPM0, pDM0, pRM0, budding(0, Grade 1), fStage Ⅲb. After postoperative adjuvant chemotherapy, she visited an outpatient clinic 8 months after surgery with a complaint of swelling of both inguinal lymph nodes. The swollen inguinal lymph node was relatively soft and there was no evidence of infection. A biopsy of the bilateral lymph nodes was performed. Histopathological examination revealed adenocarcinoma containing mucus components. These findings were consistent with histological findings in transverse colon cancer. Based on these results, we diagnosed metastatic recurrence from transverse colon cancer to both inguinal lymph nodes.

[Primary Biliary Cholangitis Diagnosed with Spontaneous Bacterial Peritonitis after Gastrectomy for Gastric Cancer-A Case Report].

Spontaneous bacterial peritonitis is defined as an ascitic fluid infection without an evident intra-abdominal surgically treatable source. The diagnosis is established by a positive ascitic fluid bacterial culture and an ascitic fluid absolute polymorphonuclear leukocyte(PMN)count≥250 cells/µL. Here we report the case of 81-year-old female patient who was diagnosed with spontaneous bacterial peritonitis after gastrectomy for gastric cancer. The laparoscopic distal gastrectomy and D1+ lymph node dissection were performed for Stage Ⅰ gastric cancer, and the postoperative course was uneventful. The patient presented with abdominal pain and was hospitalized again on the third day from the discharge. Computed tomography showed an accumulation of ascites, and the ascitic fluid polymorphonuclear leukocyte count was 9,973 cells/µL. The patient was diagnosed with spontaneous bacterial peritonitis, and antibacterial agent was performed. Abdominal pain and accumulation of ascites had been improved, and the ascitic fluid polymorphonuclear leukocyte count had decreased clearly. The patient discharged on the 57th day from the operation. Spontaneous bacterial peritonitis after gastrectomy for gastric cancer was rare. We report this rare case, along with a discussion of the literature.

[A Case of Portal Vein Thrombosis Found during Postoperative Adjuvant Chemotherapy(CAPOX)after Laparoscopic Surgery for Rectal Cancer].

Portal vein thrombosis after laparoscopic colorectal cancer surgery is rare and sometimes lethal. We report a case of asymptomatic portal vein thrombosis found during postoperative adjuvant chemotherapy(CAPOX)after laparoscopic surgery for rectal cancer. A male patient in his 60s underwent postoperative adjuvant chemotherapy( CAPOX). The elevation of liver enzyme before the chemotherapy was moderate enough to start. The liver enzyme was increased mildly during the chemotherapy. Computed tomography 27 weeks after the operation revealed the thrombus from the main portal vein to the right branch and posterior branch, and atrophy of the lateral segment with narrowed left branch. Blood flow was confirmed to be maintained by ultrasonic Doppler. We decided to discontinue the chemotherapy and started anticoagulant therapy with Warfarin. Thrombosis was disappeared 2 weeks later, and liver function went back to normal range after 8 weeks. Liver dysfunction during chemotherapy should be noted not only for drug-induced liver damage, but also for the possibility of postoperative asymptomatic portal vein thrombosis.

[Tumor Embolisms from Colon Cancer Detected on Transcatheter Examination-A Case Report].

A 58-year-old woman underwent surgery and systemic chemotherapy(FOLFIRI plus panitumumab)for ascending colon cancer with multiple lymph node and liver metastases; the preoperative Virchow lymph node aspiration cytology showed adenocarcinoma.After 4 courses of chemotherapy, contrast-enhanced CT showed an embolus in the left subclavian vein.An anticoagulation therapy was started, but the embolus tended to increase.Three months later, the patient developed dyspnea and was diagnosed with pulmonary artery thromboembolism and superior vena cava thrombosis.Transcatheter examination was performed because of the anticoagulation-resistant embolism, and the biopsy revealed tumor embolism due to colon cancer.She died of respiratory failure 10 days after the biopsy.The tumor directly infiltrating the vein because of left subclavian lymph node metastases might have resulted from increased tumor emboli.Although cases of tumor emboli infiltrating the veins and developing from lymph node metastases are rare, a transcatheter biopsy may help to detect them.

[Resection of a Desmoid Tumor Originated from Greater Omentum with No History of Open Surgery].

Here we report a case of a 41-year-old male patient who underwent resection of a desmoid tumor originating from the greater omentum with no history of open surgery. An elastic hard mass was palpated in the left upper abdomen, but there were no abnormalities on serum chemical tests, including tumor markers. Computed tomography showed a parenchymal tumor located near the descending colon. Integrated positron-emission tomography and computed tomography revealed moderate accumulation of tracer in the tumor. An intra-abdominal malignant mesenchymoma was suspected and surgery was performed. The tumor was located in the anterior portion of the greater omentum. It partially invaded the diaphragm, and the affected regions were concurrently resected. The resected specimen measured 80 mm at longest diameter. The cut surface was grayish white and parenchymal. The histopathological findings showed the atypical spindle shaped tumor cells grown with collagen fiber progression. Immunohistochemical staining for ß-catenin showed strong staining in the nuclei and cytoplasm of tumor cells. The patient was diagnosed with desmoid tumor originating from the greater omentum. The desmoid tumor with no history of open surgery was rare. We report this rare case, along with a discussion of the literature.

[A Case of Stevens-Johnson Syndrome Induced by Chemotherapy for Metastatic Colon Cancer].

A 78-year-old woman had a semicircular ulcerative lesion of AV 7 cm, as detected using colonoscopy, and pathologic examination based on a biopsy showed well-differentiated adenocarcinoma. On contrast-enhanced CT of the liver, a number of nodular lesions that seemed to be liver metastases were observed. It was decided to administer chemotherapy containing mFOLFOX6 plus panitumumab. Bilateral hemorrhage of the ocular conjunctiva and eyelid edema were observed from the 4th day of chemotherapy. Edema of the lips, epidermolysis, and erythema appeared in addition to vision impairment. We diagnosed her with SJS based on these symptoms. We also administered steroid pulse therapy. Eyelid edema improved, and vision impairment improved 24 hours after the initiation of treatment. For severe cases with visual impairment, systemic administration of corticosteroids is recommended. In this case, administering steroid pulse therapy from an early stage resulted in improvement without sequelae.

[A Case of Nephrotic Syndrome Induced by FOLFIRI plus Ramucirumab for Metastatic Descending Colon Cancer].

We report a case of multiple lung metastases of RAS mutant type descending colon cancer with development of nephrotic syndrome after the introduction of FOLFIRI plus ramucirumab(RAM). A female patient in her 50s underwent adjuvant chemotherapy with capecitabine and oxaliplatin after primary tumor and partial lung resection. For recurrent multiple lung metastases, 4 years of capecitabine and bevacizumab therapy was administered. FOLFIRI plus RAM therapy was introduced because of tumor progression. After treatment, the patient showed increased urine protein content, decreased serum albumin levels, marked hypertension, and increased edema, and was diagnosed with nephrotic syndrome. The patient's condition improved with prednisolone, additional doses of antihypertensive, and diuretics. Even in cases where it is possible to control proteinuria during bevacizumab administration, it is necessary to keep in mind that RAM administration as second-line therapy may cause nephrotic syndrome.

[A Case of Cecal Cancer Complicated with Intussusception Treated Laparoscopically].

A 75-year-old woman presented with the chief complaint of right lower abdominal pain. There was mild tenderness in the lower right abdomen and a mass was palpated. There were no peritoneal irritation symptoms. A CT examination was performed. The ascending colon was invaginated with a part of the cecum and ileum. Wall thickening was observed in the advanced part. Colon cancer was suspected. The preoperative diagnosis was considered to be an intussusception with cecal cancer at the advanced part. A laparoscopic ileocecal resection was performed. The intraoperative findings were as follows. The tumor was invading the ascending colon, but it was possible to restore it by pressing on the developed part with forceps. The pathological diagnosis was Type 2, muc>tub1, pT4aN0M0, pStageⅡb. The postoperative course was good. Water intake was started on the next day, meals were started from the second day, and the patient was discharged on the 9th day after the operation. Cecal cancer complicated with intussusception is a relatively rare disease. We report a case that was laparoscopically operable.

Increase in incidental detection of thyroid cancer in Osaka, Japan.

Using Osaka Cancer Registry data, we examined age-specific and age-adjusted incidence rates of thyroid cancer according to the route of thyroid cancer detection from 1992 to 2012. The detection routes were categorized into "symptomatic" and "incidental detection." Age-specific incidence rates of incidentally-detected thyroid cancer consistently increased during the study period, especially after 2001, for all sex and age groups other than childhood. The rate of symptomatic thyroid cancer did not largely differ among groups. Age-adjusted incidence rates of symptomatic thyroid cancer were around 1.5 and 4.5 per 100 000 among men and women, respectively. The rate of incidentally-detected thyroid cancer increased from 0.1 and 0.1 per 100 000 person-years among men and women in 1992-1994 to 2.0 and 4.9, respectively, in 2010-2012. Age-adjusted mortality rates among both sexes during the study period leveled off. This finding suggests that the thyroid cancer incidence rate in Osaka increased with incidental detection. We need to continue careful monitoring to confirm these findings.

Trends in the clinical stage distribution of breast cancer in Osaka, Japan.

We examined the proportion of screen-detected breast cancer cases and clinical stage distribution by age group among female breast cancer cases in Osaka, Japan using population-based cancer registry from the period 1980 to 2012. The proportion of local cases increased and that of regional cases decreased gradually during the study period. The proportion of distant cases leveled off. The proportion of in situ cases increased rapidly after 2003. This increase was noticeable for women aged 30-39, 40-49, 50-59, and 60-69 years. The proportion of in situ cases for women aged 40-49, 50-59, and 60-69 years reached 15.4, 11.3, and 9.9% in 2010-2012, respectively. Regarding screening status, the proportion of screen-detected cases before 1988 was under 3%. Between 1989 and 2003, it leveled off at around 5%. After 2003, the proportion increased noticeably, and reached 25.4%:34.0% in aged 40-49 years, 32.8% in aged 50-59 years, and 26.7% in aged 60-69 years. The increase in local cases and decrease in regional cases would be due to awareness of breast cancer, probably a result of developments in medical diagnostic technology. On the other hand, the steep increase of in situ cases might be due to screening. We need careful monitoring of the trends in breast cancer incidence by clinical stage.

[A Case of an Elderly with Locoregional Recurrence of ER-Negative HER2-Positive Breast Cancer Successfully Treated with Local Therapy].

An 80-year-old woman who received on anticoagulant therapy for atrial fibrillation was diagnosed with ER-negative HER2-positive breast cancer(cT4bcN1M0, Stage ⅢB). She underwent mastectomy with skin graft and lymphadenectomy, but was evaluated to be too old for standard chemotherapy and HER2-directed therapy. Four months after the operation, she was diagnosed with regional lymph node metastasis and underwent radiotherapy. Moreover, 9 months later, other recurrent sites were revealed in the parasternal lymph node and thoracic wall without distant metastasis. Radiotherapy could be performed around these secondary recurrent sites while avoiding overlap. After 2 years, solitary contralateral axillary lymph node metastasis was diagnosed by PET-CT. She underwent Lt axillary lymphadenectomy. The intrinsic breast cancer subtype did not change. Patient performance status was kept to achieve a good quality of daily life. Eight months later, she diagnosed with primary pancreatic cancer and received 13 cycles of chemotherapy until her death from pancreatic cancer 14 months later. During chemotherapy, no recurrence of breast cancer was observed.

[A Case of Extended Mediastinal and Retroperitoneal Emphysema after Transanal Local Excision of an Early Lower Rectal Adenocarcinoma].

We observed a case of a large collection of mediastinal and retroperitoneal emphysema, which developed after a transanal local excision for an early lower rectal carcinoma and was treated conservatively. An 80's female patient presented with a chief complaint of bowel difficulty, which was diagnosed as mucosal prolapse syndrome with anal sphincter dysfunction. Endoscopic colonoscopy showed full circumferential proliferation of the mucosal membrane including a semicircular protruding lesion, on the upper side of the dentate line. Biopsy revealed findings indicative of an adenocarcinoma(tub1/pap), Group 4. After a sufficient informed consent was taken, a transanal local excision under spinal anesthesia was conducted discontinuously over half of the circumference. The patient underwent partial-thickness excision, partially full-thickness, and the defects are closed as much as possible. A fever of 38 degrees Celsius was recognized on the 1st postoperative day, and a CT scan, on the 2nd postoperative day, showed a large collection of retroperitoneal and mediastinal emphysema tracking upwards to the nasopharynx. Since fever was the only subjective symptom present, antibiotic therapy under fasting was chosen. The mediastinal emphysema had mostly resolved by the 10th postoperative day. Even though standard transanal excision is not a treatment under air supply there is a risk leading mediastinal and retroperitoneal emphysema.

[A Case of Inflammatory Breast Cancer with Very Severe Obesity].

A 39-year-old woman with very sever obesity was admitted to our hospital for a right breast redness and hardness. Her height, weight and BMI were 166 cm, 145 kg and 52.6 kg/m2. Her breast had peau d'orange. CT scan showed swelling of whole right breast and Level I , II lymph node. We performed core needle biopsy and diagnosed as the inflammatory breast cancer with ER and HER2 positive. We introduced chemotherapy(pertuzumab, trastuzumab and paclitaxel)and nutrition counseling in order to reduce her body weight. After 4 courses of chemotherapy, the clinical complete response was obtained and her body weight decreased to 125 kg. We performed mastectomy and axillary node resection and confirmed pathological complete response. Adjuvant chemotherapy(5-FU, epirubicin and cyclophosphamide), adjuvant trastuzumab therapy, postmastectomy radiation therapy and adjuvant hormonal therapy were administered. There have been no signs of recurrence as of 2 years after the operation.

[A Case of HER2-Positive Breast Cancer with Newly Diagnosed Stage IV That Responded to First-Line Pertuzumab and Trastuzumab-Based Therapy].

A 48-year-old woman who observed swelling and erosion in her left breast was diagnosed with locally advanced, ERnegative, HER2-positive breast cancer with de novo liver metastasis, T4cN1M1, Stage IV . She underwent primary systemic therapy with weekly paclitaxel, and pertuzumab and trastuzumab every 3 weeks. The tumor responded remarkably with 57.0% reduction in 5 weeks of treatment. Because of an anaphylactic shock to paclitaxel in day 8, exchanging to eribulin was considered less toxic than taxane, and was continued for 8 cycles until local relapse. The liver metastasis showed 75.4% reduction. The patient received bilateral mastectomy, which resulted in histological response Grade 1b of the left breast and the right breast of DCIS. After the left thoracic radiation, marginal liver metastasis was observed in the S4 segment on PET-CT. Treatment consisted of docetaxel and dual HER2 blockade therapy in 6 more cycles. As a result, complete remission was achieved.

[A Case of Advanced Transverse Colon Cancer with Relapse behind the Rectum after Laparoscopic-Assisted Resection].

A 60's male patient underwent laparoscopic left hemicolectomy with D3 lymph node dissection for transverse colon cancer. Adjuvant chemotherapy with tegafur-uracil and leucovorin was administered.Thirty -four months later, MRI scan revealed a mass with sacrum invasion.Radiation therapy(39 Gy/13 Fr)was performed followed by chemotherapy(modified oxaliplatin, leucovorin, and 5-fluorouracil plus bevacizumab).Two weeks after the completion of radiation therapy, staging laparoscopy and tissue biopsy was performed in the hard tumor, which was located at the caudal end of the incisional scar of the retroperitoneum, in front of the sacrum.The pathological diagnosis revealed metastasis from transverse colon cancer.Radiographic examination showed partial response to radiochemotherapy, and buttock pain decreased.CT review before pain developed showed a small tumor located mainly in the mesorectum slightly adjacent to the sacrum, suggesting the implantation of cancer cells to the stripped plane behind the mesorectum during the surgery.