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 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.

Past Trends and Future Estimation of Annual Breast Cancer Incidence in Osaka, Japan.

BACKGROUND: Although the breast cancer incidence rate in Japan is lower than in western countries, the age-specific rates have markedly increased in recent years, along with the problems of declining birth rate and an aging population. MATERIALS AND METHODS: We examined past trends of age-specific breast cancer incidence using data from the Osaka Cancer Registry from 1976 to 2010, and estimated future trends until 2025 based on the changes observed and population dynamics using a log linear regression model. RESULTS: The age-specific breast cancer incidence rate has increased consistently from the 1970s, and the rates have caught up with those of Japanese-Americans in the US. Assuming the increasing tendency of age-specific breast cancer incidence to be constant, the average annual incidence of breast cancer will increase 1.7-fold from 2006-2010 to 2021-2025. Furthermore, the number of patients aged 80 years should increase 3.4-fold. CONCLUSIONS: The medical demand for breast cancer care in Japan may increase explosively in the future, particularly among the elderly. We need to prepare for such a future increase in demand for care, although careful monitoring is needed to confirm these results.

[A Case of a Breast Metaplastic Carcinoma with a Giant Cyst].

A 32-year-old woman was admitted to our hospital for a right breast mass. Ultrasonography showed an 8 cm cystic mass with irregular solid components in the C area. CT showed the 8 cm cystic mass in the right breast, and that the chest wall was compressed by the mass. We performed fine needle aspiration(FNA)of this cyst and prepared a cellblock from the intracystic fluid. These cytological findings were malignant. We diagnosed cancer of the right breast and performed mastectomy and axillary node resection. Histologically, this lesion was diagnosed as a mixed metaplastic carcinoma, composed of squamous cell carcinoma, invasive carcinoma of no special type, and spindle cell carcinoma. Immunohistochemically, estrogen receptor, progesterone receptor, and HER2were negative. Adjuvant chemotherapy(FEC followed by triweekly docetaxel)was administered. There have been no signs of recurrence as of 1 year after the operation.

Seasonal variations in breast cancer diagnosis in Osaka, Japan.

To date, seasonal variations in breast cancer diagnosis have been reported in Western countries. In the present study, we calculated the number of breast cancer diagnoses according to season between 1976 and 2005, using data from the Osaka Cancer Registry. In all time periods and all age groups, breast cancer diagnosis showed peaks in early summer and troughs in winter. The number of breast cancer diagnoses in the spring, summer, autumn, and winter were 2,595(26%), 2,739(27%), 2,585(26%), and 2,120(21%)in 1976-1985; 4,219(26%), 4,581(28%), 4,2 62(26%), and 3,466(21%)in 1986-1995; and 6,299(25%), 6,852(28%), 6,368(26%), and 5,335(22%)in 1996-2005, respectively. Most cases were diagnosed because of an awareness of a breast mass. The trend in screening-detected cases differed from the overall trend. As screening becomes more widely adopted, these seasonal variations might change. Careful monitoring is needed to confirm these findings.

[Two cases of radiotherapy-induced sarcoma after breast cancer surgery].

We report 2 cases of radiotherapy-induced sarcoma of the residual breast after breast cancer surgery. In 1 case, the patient was a 64-year-old woman. She underwent breast-conserving surgery and axillary lymph node dissection followed by irradiation to the residual breast in July 2001. A 1.1 × 1.0-cm tumor was noted in the residual breast 7 years 5 months after radiotherapy. An excisional biopsy was performed, and a histological diagnosis of angiosarcoma was made. She died of lung and peritoneal metastases 3 years 2 months after the diagnosis. In the other case, the patient was also 64 years old. She underwent breast-conserving surgery and sentinel lymph node biopsy followed by irradiation to the residual breast in October 2006. A 5.7 × 3.9-cm induration was noted in the residual breast 3 years 5 months after radiotherapy. A core needle biopsy was performed, and a histological diagnosis of sarcoma was made. Mastectomy was performed, and the histological diagnosis was malignant fibrous histiocytoma. She died of chest wall and intrapleural tumor recurrence 3 months after the mastectomy. Although radiotherapy-induced sarcoma is rare, early detection of the tumor in the irradiation area is important, as radiotherapy is often performed for breast cancer patients.

[Locoregional recurrence of HER2-positive breast cancer - treatment after complete remission and long-term clinical benefits].

We report 7 cases of locoregional recurrence in human epidermal growth factor receptor 2 (HER2)-positive breast cancer that we treated. An early complete response (CR) and long-term response was achieved in 5 cases. There were 4 HER2- subtype and 3 Luminal HER2-type cases. Metastasis and recurrence were detected in the residual breast tissue and the supraclavicular, axillary, and parasternal lymph nodes. Chemotherapy consisting of trastuzumab was administered as first-line treatment. A CR was observed 3-4 months after the initiation of therapy in 4 cases, and the time to progression was 27.6- 65.8 months. After achieving a CR, 3 patients terminated treatment and 2 patients continued to take trastuzumab. However, due to adverse effects associated with the chemotherapy, 1 patient changed to endocrine therapy. A second, long-term, CR was achieved in 2 relapsed CR patients by re-challenging with the same chemotherapy regimen. Two patients did not achieve CR and died due to distant metastases. For a better quality of life, it is advisable to continue treatment after a clinical CR for solitary or more complex locoregional recurrences. Following the first-line therapy and a so-called chemoholiday, the patient's disease can be re-challenged using the previously sensitive regimen with careful observation.

[The efficacy of early diagnosis of brain metastasis and systemic treatment after radiotherapy in patients with metastatic breast cancer].

We treated 9 patients diagnosed with brain metastasis from breast cancer. Although 1 patient was initially diagnosed as having Stage IV disease, 5 had Stage I/II early breast cancer. All patients had defined brain metastasis after chemotherapy. Brain metastasis was symptomatic in 7 patients, 4 of whom had brain edema, and asymptomatic in 2 patients. The median survival time from breast cancer metastasis was 23 days for patients who did not receive radiotherapy and 19.6 months for those who received radiotherapy. Among the patients treated with radiotherapy, the median survival time was 4.3 months for patients who did not receive further treatment and 19.7 months for those who received chemotherapy or chemotherapy with trastuzumab. One patient with a solitary brain metastasis underwent stereotactic radiosurgery, and treatment is being continued for 1 of the 2 patients who received systemic therapy after whole-brain radiotherapy and additional stereotactic radiosurgery at recurrence to control brain disease. Systemic treatment after radiotherapy is important for brain metastasis from breast cancer, and early diagnosis of brain metastasis facilitates the use of various available treatments.

[A case of coexisting borderline phyllodes tumor and non-invasive ductal carcinoma].

A 36-year-old woman with benign phyllodes tumor of the left breast had undergone lumpectomy 1 year ago and was admitted to our hospital because of a left breast mass on the operation scar. Ultrasonography showed a 35 mm low-echoic, elliptical mass with a high depth to width( D/W) ratio in the C area and a 10 mm low-echoic, polygonal mass with a high D/W ratio in the E area. Histological examination of an ultrasonography-guided vacuum-assisted biopsy specimen indicated recurrent phyllodes tumor. Since both tumors were assumed to be recurrent phyllodes tumors, quadrantectomy was performed. Finally, the mass in the C area was diagnosed as a recurrent phyllodes tumor and the mass in the E area was diagnosed as a fibroadenoma. A non-invasive ductal carcinoma was incidentally detected between the 2 tumors, and the surgical margin was negative. Radiotherapy was performed on the remnant breast tissue.

[A clinical case of recurrent small intestinal cancer successfully treated with FOLFOX6].

A 73-year-old man was referred to our hospital because of ileus. Enteroscopy revealed severe stenosis in the jejunum. He was diagnosed with small intestinal cancer. Partial resection of the jejunum, partial resection of the transverse colon, and lymphadenectomy were performed. A postoperative pathological examination showed skip metastasis in the jejunum (TNM: Stage IV). Six months later, lung and liver metastases were evident from computed tomography( CT). Nine courses of FOLFOX6 administered once every 2 weeks achieved a partial response. When 9 courses of chemotherapy had been completed, CT showed progressive disease. Subsequently, he has been administered with FOLFIRI in our outpatient clinic.

[A case of liposarcoma of the abdominal wall complicated by thrombocytpenia as a paraneoplastic syndrome].

A 59-year-old woman was admitted to our hospital because of right chest pain. CT scan showed a mass on the right abdominal wall and bilateral pleural effusion. The histological diagnosis following core needle biopsy was undifferentiated sarcoma. The right pleural effusion gradually increased despite negative cytology. Although we planned chemotherapy for the clinically diagnosed pleural invasion, thrombocytopenia as a paraneoplastic syndrome appeared. The minimum thrombocyte count was 4,000/mm3. While transfusion was not effective, per os dexamethasone at 2.0 mg/day kept the thrombocyte count at around 6×10 4/mm3. Anti-thrombocyte antibody was negative. Tumor resection surgery with partial diaphragm resection and 11th and 12th rib resection, and abdominal wall plasty with mesh was performed. The final histological diagnosis was dedifferentiated liposarcoma. The thrombocyte count returned to the normal range just after the operation. However, she died of pleural dissemination, peritoneal dissemination, and local recurrence 69 days after the operation.

[Two cases of stromal sarcoma, so-called malignant fibrous histiocytoma of breast treated with reduction surgery].

CASE 1: A 64-year-old woman with right breast cancer had a partial mastectomy and radiotherapy four years ago was admitted to our hospital because of right breast mass. The vacuum associated biopsy of tumor resulted in breast sarcoma, thus a nipple-spearing mastectomy was performed. The final histological diagnosis was stromal sarcoma, and was identical to histological findings of malignant fibrous histiocytoma. Three months after the operation, a chest wall recurrence appeared. Although tumor resection with latissimus dorsi flap was performed, there were pleural dissemination and malignant pleural effusion. She died six months after the first surgery. CASE 2: A 60-year-old woman was admitted to our hospital because of left breast mass, but she refused a further clinical examination. She readmitted fourteen months later due to a huge sized left breast mass with necrosis and smelling discharge. CT scan showed a huge tumor of left breast and multiple lung metastases. Biopsy of the tumor resulted in breast sarcoma. Total mastectomy with split thickness skin grafting was performed. The final histological diagnosis was identical to the first case. A local recurrence appeared thirty days after the operation, and she died fifty-one days after the operation.

[Postoperative axillary-lymph-node recurrence in breast cancer patients].

We investigated 13 cases of axillary-lymph-node recurrence, who received an operation for an early stage breast cancer. They are the first recurrence of only regional without metastatic disease; the 4 patients, who had sentinel-lymph-node by biopsy at first operation, received an axillary lymph adenectomy, and 5 patients received re-lymph-adectomy after axillary lymph node dissection. The other 4 patients received only systemic therapy. Receptor conversion between primary and lymph-node recurrent site was identified for ER in 2 patients; one showed a lower expression of ER and the other showed for HER2. These led to a change in the subsequent treatment plan; 6 patients had systemic chemotherapy after recurrence, 1 patient had endocrine, 2 patients had trastuzumab and 4 patients continued the same treatment prior to surgery. Ten out of 13 patients were alive without recurrence, and 3 patients were with distant metastasis. However, one of the 3 patients who had a distant metastasis died due to brain and lung metastasis. Axillary node recurrence should be treated with axillary dissection, if possible, and receptor measurement in primary and recurrent site is useful for subsequent treatment.

[A clinical case of the esophagogastric malignancy palliated with covered metallic stent with anti-reflux mechanism].

Esohophageal stents are often used in treating malignant stricture. But, when stents are placed across the esophagogastric junction, they may lead to esophagogastric reflux. We report a case of successfully treated esophagogastric strictures using the new stent with anti-reflux mechanism (long cover type Niti-S™ esophageal stent). A 78-year-old man presenting with severe strictures from the lower esophagus to cardiac part of stomach was histopathologically diagnosed as adenocarcinoma. CT scan images showed multiple liver metastatic tumors. However, he refused chemotherapy. Palliation using long cover type Niti-S™ esophageal stent was performed. No adverse effect was occurred. He started solid meals on the 7th postoperative day. He was thereafter able to ingest solid meals without the symptom of esophgogastric reflux and stenosis until he died of the primary disease two month later.

[A clinical case of lymph node recurrence after resection of gastric cancer successfully treated by combination chemotherapy with irinotecan and cisplatin].

A 60-year-old female who was diagnosed as gastric cancer underwent distal gastrectomy and received adjuvant chemotherapy (S-1 therapy). After 6 months, the tumor marker (CEA) was elevated. CT revealed para-aortic lymph nodes enlargement. Lymph node metastasis was confirmed. The patient was administered combination chemotherapy with irinotecan (CPT-11) and cisplatin (CDDP) Seven months later, CT revealed lymph node metastasis had disappeared. After judgment of complete response (CR), we continued the treatment for 22 months. The patient was followed without any recurrence in May 2010.

[Three cases of breast cancer with skin metastasis after mastectomy treated by radiotherapy].

We reported three cases of patient with triple negative skin metastasis after mastectomy of breast cancer. All three cases had received radiotherapy for skin metastasis. Radiation therapy was effective for recurrent sites, and could improve patient's QOL. After radiotherapy, 2 patients died due to a distant metastasis. Case 1 was resistant to chemotherapy. Case 2 was no indication of chemotherapy because of dementia metastases. Case 3 was the only one continued chemotherapy. It appears that a further consideration was needed for the timing of radiotherapy to be performed among the treatments of locoregional recurrence and distant metastasis of breast cancer.

[Two cases of bronchiolitis obliterans organizing pneumonia (BOOP) induced radiotherapy after surgery of breast cancer].

We report two cases of bronchiolitis obliterans organizing pneumonia (BOOP) induced radiotherapy after surgery of breast cancer. One of the patients was a 58-year-old woman. She underwent a conserving surgery for bilateral breast cancers, and received radiation therapy to the remaining part of bilateral breasts. Two months after the termination of irradiation, cough, fever and general fatigue developed. We clinically diagnosed this case as BOOP after radiation therapy. After initiation of oral steroid therapy, the clinical symptoms and radiographic findings disappeared. Another patient was a 57-year-old woman. She underwent radical mastectomy for right breast cancer. A month after the operation, she suffered from local recurrence, so radiation therapy to the thoracic wall was performed. After irradiation, resection of the thoracic wall lesion was performed because of malignancy from local skin biopsy specimen. Two months after the termination of irradiation, cough, dyspnea and fever developed. We clinically diagnosed this case as radiation-induced BOOP by BAL and TBLB findings. After an initiation of steroid therapy, the clinical symptoms and radiographic findings disappeared. It is important to be aware of BOOP as a complication in the patient who was given radiation after surgery of breast cancer.

[A case of surgical approach to the recurrence of the para-aortic lymph nodes after resection of rectal cancer].

A 63-year-old female diagnosed as rectal cancer underwent low anterior resection and received adjuvant chemotherapy (folinate/tegafur/uracil therapy). After 6 months, lymph node metastasis was confirmed by an elevation of the tumor marker (CEA) and a FDG-PET image. After administration of 37 courses of mFOLFOX6 therapy, surgical excision was performed to the lymph node recurrence, because it was difficult to continue mFOLFOX6 therapy with grade 3 neuropathy. After 8 months from the last operation, no lymph node metastasis was appeared in the para-aortic area.