Clinical effectiveness of microporous polysaccharide hemospheres in mastectomy for patients with breast cancer.

Background: Microporous polysaccharide hemospheres (MPH) are hydrophilic particles administered to reduce the incidence of seroma after mastectomy, but their clinical effectiveness remains controversial. Because a previous randomized, controlled study in a small cohort could not demonstrate the effectiveness of MPH in breast surgery, we evaluated their effectiveness in surgery for breast cancer in a larger cohort. Methods: Medical records of 352 patients who underwent total mastectomy for breast cancer were retrospectively reviewed. Clinical data were compared between 126 patients who received MPH during surgery (MPH group) and 226 who did not (control group) according to surgical procedures. Patients were significantly older in the MPH group than in the control group because of selection bias, but other factors, such as body mass index and number of dissected lymph nodes, did not differ between groups. Results: When analyzed by use of axillary manipulation, the drain placement period and drainage volume were significantly less in the MPH group than in the control group for patients with mastectomy and sentinel lymph node biopsy. Only drainage volume was significantly less in the MPH group for patients with mastectomy and axillary lymph node dissection. The frequency of total postoperative complications, such as seroma requiring puncture, did not differ between groups. Conclusions: Use of MPH may decrease the postoperative drainage volume and drain placement period in mastectomy for patients with breast cancer.

Relationship between Delayed Breast Cancer Diagnosis and Behavioral Economic Factors and Personality Characteristics.

BACKGROUND: Delays in breast cancer diagnosis can allow the disease to progress to an incurable stage. However, factors that cause patients to delay seeking treatment are unclear. In this study, we aimed to identify behavioral economic factors and personality characteristics of patients with breast cancer who had a delayed diagnosis. METHODS: We analyzed questionnaires completed by 41 patients with breast cancer. A delayed diagnosis was defined if the time between the first symptom and the medical visit was more than 6 months. RESULTS: We found 11 patients who had a delayed diagnosis. The significant characteristics associated with patients with breast cancer who had delayed diagnosis were: (i) less experience with breast cancer screening; (ii) progressive disease stage; and (iii) low time and future time preference. We found no significant behavioral economic factors other than time preference, and personality that differed between patients with breast cancer who did and did not have a delayed diagnosis. CONCLUSION: Low time preference rate is a characteristic of patients with breast cancer who had a delayed diagnosis.

Development, implementation, and evaluation of a local community-based ophthalmology sentinel surveillance system in a remote rural area in Japan.

INTRODUCTION: Solid and sensitive infectious disease surveillance systems need to be developed and implemented to prevent and control epidemics. Although statutory national infectious disease surveillance systems have been developed in many countries, some challenges remain, such as their limited timeliness, representativeness, and sensitivity, as well as the fact that they cannot capture all local outbreaks that occur in small communities. To overcome these limitations, local community-based infectious disease surveillance systems that meet local needs and can operate with constrained resources need to be developed, especially in remote and rural low-resource areas. This study aimed to develop, implement, and evaluate a voluntary and unique local community-based ophthalmology sentinel surveillance system in Isa city (OSSS-Isa), a remote rural area in Japan. METHODS: For the development of OSSS-Isa, one hospital in Isa city assumed a leading role and developed a network with all medical institutions - 20 hospitals and clinics in the local community, including two ophthalmology clinics - as sentinel reporting sites. Surveillance was conducted on a weekly basis from Monday to Sunday. The collection, aggregation, and reporting of the surveillance data were implemented promptly on the same day, Monday, using a paper-based form and fax. For the evaluation of OSSS-Isa, the study followed the updated guidelines for evaluating public health surveillance systems proposed by the Centers for Disease Control and Prevention to select the evaluation criteria and develop a questionnaire. The questionnaires were then distributed to 20 hospitals and clinics, with the responses evaluated on a five-point Likert scale. RESULTS: For the implementation of OSSS-Isa, the system issued alerts twice to the networked hospitals and clinics when signs of an increase in the prevalence of a target infectious eye disease appeared in Isa city. After the alerts, the number of cases decreased in the community. Regarding the evaluation survey, physicians from 18 hospitals and clinics responded to the questionnaire (response rate 90%). In contrast to flexibility, more than 75% of the respondents gave high ratings to simplicity, data quality, acceptability, timeliness, and stability in evaluating OSSS-Isa, with the mean score for these evaluation criteria higher than 3.67. CONCLUSION: The present results indicate that OSSS-Isa has high simplicity, data quality, acceptability, timeliness, and stability, which is highly embedded with the local healthcare providers in Isa city. OSSS-Isa contributed to the early and accurate detection of signs of infectious eye disease outbreaks emerging in a small remote rural local community. The success factors seem to include its simple well-designed implementation methods, good external factors, and active human factors suited to the characteristics of the small remote rural community. The OSSS-Isa initiative appears to be a meaningful practical example of successful health advocacy by healthcare providers by developing a system at the local social level while going beyond the boundaries of routine medical practice. If voluntary small-scale surveillance systems can complement statutory large-scale ones and work together locally, nationally, and internationally, it might be possible to detect small, unusual happenings that occur in the community, such as emerging infectious diseases, and thereby help avert global outbreaks.

Metastasis of breast cancer to the right kidney with a tumor thrombus in the inferior vena cava: a case report.

BACKGROUND: It is quite rare for breast cancer to metastasize to the kidney with a tumor thrombus in the inferior vena cava. CASE PRESENTATION: A Japanese woman in her forties was diagnosed with cancer of the left breast and underwent left mastectomy with sentinel lymph node biopsy. The final pathological diagnosis was pT1aN0M0, stage IA (ER positive, PgR positive, HER2 negative). Thirteen years later, she presented for care with the complaint of abdominal pain. By imaging findings, right renal carcinoma with a tumor thrombus in the inferior vena cava and lung metastases was suspected. However, her tumors were refractory to molecular targeted therapy. In addition, CT-guided needle biopsy of the kidney and lung lesions was done and it was revealed that lesions of the left lung and the right kidney was breast cancer metastases (ER positive, PgR positive, HER2 negative). The patient started combination therapy consisting of abemaciclib, tamoxifen and leuprorelin. Six months later, she died from progression of her metastatic disease. CONCLUSIONS: It is sometimes difficult to differentiate between primary renal cancer and kidney metastases from breast cancer on imaging. Renal biopsy is recommended before commencing treatment.

Surgical Resection With Pedicled Rotation Flap for Post-mastectomy Locoregional Breast Cancer Recurrence.

BACKGROUND/AIM: Locoregional recurrence (LRR) of breast cancer is reported to occur at a rate of 5%-15%. Wide excision of LRR is the recommended treatment, which can increase the probability of subsequent local control. Herein, we describe a surgical technique wherein a pedicled skin and subcutaneous flap close the skin defect after resection of a breast cancer LRR without use of a skin graft. PATIENTS AND METHODS: We reviewed four patients who underwent surgical resection using a pedicled rotation flap for chest wall recurrence after mastectomy. RESULTS: The surgical margin was set 2 cm apart from the tumor margin. After resection of tumor from the chest wall, we formed an adjacent pedicled flap and rotated the flap to the skin defect. There were no post-operative complications, including wound necrosis. CONCLUSION: Surgical resection with a pedicled rotation flap for post-mastectomy breast cancer LRR is a highly feasible way to achieve complete resection.

Breast cancer with an intraductal component that was proven genetically to be metastasis of contralateral breast cancer: a case report.

BACKGROUND: When diagnosing patients with bilateral breast cancer, it is challenging to determine the relationship between multiple breast cancer lesions at the individual patient level with certainty. CASE PRESENTATION: A 35-year-old Japanese woman was diagnosed with a left breast cancer. She was previously diagnosed with right pT3N3M0 stage IIIC breast cancer and underwent chemotherapy with targeted therapy, radiotherapy, and endocrine therapy as adjuvant treatment after mastectomy and axillary lymph node dissection. Approximately 2 years after the first surgery, her left breast cancer was preoperatively diagnosed as a contralateral primary breast cancer, and left mastectomy and axillary lymph node dissection were performed. Histopathologically, the tumor was determined to be invasive ductal carcinoma accompanied with several intraductal components. After a second surgery, mutation analysis of her bilateral breast cancer was performed in a clinical study, which revealed that her metachronous bilateral breast tumors had the same GATA3 and CSMD1 mutations. Thus, mutation analysis strongly supported her latter left breast cancer being a metastatic lesion from the former right breast cancer. Some difficulties in diagnosing bilateral breast cancer exist when determining whether they are double primary cancers or represent contralateral breast metastasis. The existence of intraductal components is a critical piece of information for suspecting primary lesions. However, this case demonstrated that metastatic contralateral breast lesions can have intraductal components. CONCLUSION: Herein we report a genetically proven contralateral breast metastasis with some intraductal components.

Primary Tumor Score Based on Tumor Depth and Length Predicts Prognosis in Esophageal Squamous Cell Carcinoma.

AIM: To examine the depth of tumor invasion and tumor length and assess the clinical impact of the primary tumor score (PTS), based on a combination of tumor invasion and tumor length, in patients with esophageal squamous cell carcinoma (ESCC). PATIENTS AND METHODS: A total of 237 patients with ESCC were classified into three PTS groups based on cut-off values for deeper tumor invasion (pT2-T4) and greater tumor length (≥44 mm). A PTS of 2 indicated the presence of both of these abnormalities, 1 indicated one of these abnormalities, and 0 indicated neither abnormality. RESULTS: PTS was significantly positively correlated with depth of tumor invasion, lymph node metastasis, lymphovascular invasion, and stage (all p<0.001). The prognosis differed significantly among the three groups based on PTS (p<0.0001). Multivariate analysis demonstrated that PTS was an independent prognostic factor (p=0.0004). CONCLUSION: PTS has a clinical utility as a prognostic predictor in patients with ESCC.

Expression of SOX9 Is Related to Prognosis in Patients with Oesophageal Squamous Cell Carcinoma.

BACKGROUND: Sex-determining region Y-box 9 (SOX9) is an important transcription factor for the development and differentiation of cells and their organization. In the present study, the clinical significance of SOX9 expression in oesophageal squamous cell carcinoma was examined. MATERIALS AND METHODS: SOX9 expression in surgical specimens of primary tumours were immunohistochemically investigated in 175 patients with oesophageal squamous cell carcinomas. RESULTS: SOX9 was expressed (moderately or strongly) in 62.9% of samples. Expression of SOX9 was significantly positively correlated with depth of invasion, advanced stage, lymphatic and venous invasion, and poor prognosis. Univariate analysis showed that depth of invasion, lymph node metastasis, distant metastasis, stage, lymphatic invasion, venous invasion, and SOX9 expression were prognostic factors. Multivariate analysis indicated that depth of invasion and stage were independent prognostic factors, but SOX9 expression was not. CONCLUSION: SOX9 expression is related to prognosis in patients with oesophageal squamous cell carcinoma, although it is not an independent prognostic factor.

Correlation Between Biomarker Candidate Proteins with the Effect of Neoadjuvant Chemoradiation Therapy on Esophageal Squamous Cell Carcinoma.

BACKGROUND: While chemoradiation therapy (CRT) is one of the most useful treatments for esophageal squamous cell carcinoma (ESCC), it is important to predict response prior to treatment by using markers because some patients respond well and others do not. METHODS: Fifty-nine patients with ESCC were treated with neoadjuvant CRT at the Kagoshima University Hospital. The expression of seven types of biomarker candidate proteins in biopsy specimens of untreated primary tumors was evaluated to determine whether it correlated with response and prognosis. RESULTS: The positive expression rates were 47% for p53, 83% for CDC25B, 68% for 14-3-3sigma, 76% for p53R2, 75% for ERCC1, 32% for Gli-1, and 54% for Nrf2. In terms of histological response, tumor grade of the 59 patients was 48.8% for grade 1 as the non-responder, 29.2% for grade 2, and 22.0% for grade 3 as the responder. CRT was significantly effective in p53(-), p53R2(-), ERCC1(-), and Nrf2(-) tumors, while p53(-), p53R2(-), and ERCC1(-) were factors independently correlated with effective histological response. Their combined expression of two or three negative expressions had 100% effective response and was a significant prognostic factor. CONCLUSION: Our results suggest that two or three negative expressions of p53, p53R2, and ERCC1 in biopsy specimens of primary tumors were associated with a favorable response to CRT for ESCC. Assessment of tumor suppressor and DNA repair protein expressions in biopsy specimens may be useful for the potential utility of CRT therapy for patients with ESCC prior to treatment.

Interactions between inflammatory gene polymorphisms and HTLV-I infection for total death, incidence of cancer, and atherosclerosis-related diseases among the Japanese population.

BACKGROUND: An increased risk of total death owing to human T-lymphotropic virus type-I (HTLV-I) infection has been reported. However, its etiology and protective factors are unclear. Various studies reported fluctuations in immune-inflammatory status among HTLV-I carriers. We conducted a matched cohort study among the general population in an HTLV-I-endemic region of Japan to investigate the interaction between inflammatory gene polymorphisms and HTLV-I infection for total death, incidence of cancer, and atherosclerosis-related diseases. METHOD: We selected 2180 sub-cohort subjects aged 35-69 years from the cohort population, after matching for age, sex, and region with HTLV-I seropositives. They were followed up for a maximum of 10 years. Inflammatory gene polymorphisms were selected from TNF-α, IL-10, and NF-κB1. A Cox proportional hazard model was used to estimate the hazard ratio (HR) and the interaction between gene polymorphisms and HTLV-I for risk of total death and incidence of cancer and atherosclerosis-related diseases. RESULTS: HTLV-I seropositivity rate was 6.4% in the cohort population. The interaction between TNF-α 1031T/C and HTLV-I for atherosclerosis-related disease incidence was statistically significant (p = 0.020). No significant interaction was observed between IL-10 819T/C or NF-κB1 94ATTG ins/del and HTLV-I. An increased HR for total death was observed in the Amami island region, after adjustment of various factors with gene polymorphisms (HR 3.03; 95% confidence interval, 1.18-7.77). CONCLUSION: The present study found the interaction between TNF-α 1031T/C and HTLV-I to be a risk factor for atherosclerosis-related disease. Further follow-up is warranted to investigate protective factors against developing diseases among susceptible HTLV-I carriers.

Role of 18F-FDG-PET/CT in Esophageal Squamous Cell Carcinoma After Neoadjuvant Chemoradiotherapy.

AIM: The aim of this study was to assess the role of 18F-fluorodeoxyglucose positron-emission tomography/computed tomography (FDG-PET/CT) in predicting pathological response and survival in patients with esophageal squamous cell carcinoma (ESCC) treated with neoadjuvant chemoradiotherapy (nCRT). PATIENTS AND METHODS: Thirty patients with advanced ESCC received nCRT followed by surgery, and underwent FDG-PET/CT twice before and after nCRT. We compared the results of FDG-PET/CT with the pathological results and prognosis. RESULTS: Pathological response was found to correlate with the maximum standardised uptake value (SUVmax) after nCRT and the rate of decrease of SUVmax Using univariate analysis, pN, SUVmax after nCRT and the rate of decrease of SUVmax were found to be prognostic factors. Multivariate analysis revealed that only pN was an independent prognostic factor. CONCLUSION: The prediction of pathological response and prognosis using FDG-PET/CT is not as reliable as pathological detection of lymph node metastasis, but could be a useful method contributing to treatment decisions.

Combined fibrinogen and neutrophil-lymphocyte ratio as a prognostic marker of advanced esophageal squamous cell carcinoma.

Patients with advanced esophageal squamous cell carcinoma (ESCC) is received chemoradiotherapy or chemotherapy for clinical management. However, it is difficult to predict tumor response and prognosis using blood markers before starting treatments. The purpose of this study was to investigate the pre-treatment plasma fibrinogen and neutrophil-lymphocyte ratio (NLR) in patients with advanced ESCC treated with chemoradiotherapy or chemotherapy, and to assess the clinical utility of a combined score using these blood markers, named as the F-NLR (fibrinogen and NLR) score, as a predictor of tumor response and prognosis. A total of 98 advanced ESCC patients, treated with chemoradiotherapy or chemotherapy, were classified into three groups: F-NLR score of 2, having both hyperfibrinogenemia (>400 mg/dL) and high NLR (>3.0), score of 1, one of these hematological abnormalities, and score of 0, having neither hyperfibrinogenemia nor high NLR. Fibrinogen and NLR were significantly higher in the progressive disease (PD) group than the non-PD group (P = 0.0419, and P = 0.0001, respectively). A significantly higher F-NLR score was found in the PD group than the non-PD group (P = 0.0140). Overall survival was significantly lower in patients with an F-NLR score of 2 than in those with an F-NLR score of 0 or 1 (P < 0.0001). Multivariate analysis showed that the F-NLR score was one of the independent prognostic factors (P = 0.0081). Our study demonstrates that the F-NLR score is promising as a predictive marker for therapeutic effects and prognosis in patients with advanced ESCC.

As a Novel Prognostic Marker, Cysteine/histidine-rich 1 (CYHR1) is a Therapeutic Target in Patients with Esophageal Squamous Cell Carcinoma.

BACKGROUND: Cysteine/histidine-rich 1 (CYHR1) was first discovered in a yeast two-hybrid screen with murine galectin-3, and no previous reports have described a relationship between the CYHR1 gene and human cancer. The current study evaluated the role and significance of CYHR1 in esophageal cancer. METHODS: The human esophageal squamous cell carcinoma (ESCC) cell line TE-8 and the CYHR1 knock-down cell line TE-8/small interfering (si)-CYHR1 were used for in vitro and in vivo assays. For clinical study, ESCC tissues (n = 104) were used. RESULTS: Compared with parental cells, TE-8/si-CYHR1 cells had suppressed proliferation and invasion activities. In the in vivo assay, the tumors from TE-8 cells treated with si-CYHR1 had abrogated tumorigenicity. In the clinical study, the expression of CYHR1 mRNA was associated with lymph node metastasis and stage and shown to be an independent prognostic factor. CONCLUSIONS: As the findings show, CYHR1 may represent not only a valuable prognostic marker but also a therapeutic target for ESCC patients.

Ferredoxin Reductase Is Useful for Predicting the Effect of Chemoradiation Therapy on Esophageal Squamous Cell Carcinoma.

BACKGROUND: Ferredoxin reductase (Fdxr) is the mitochondrial cytochrome P-450 NADPH reductase. Fdxr overexpression increases the sensitivity of tumor cells to apoptosis in response to chemotherapy through reactive oxygen species (ROS) production. The aim of the present study was to examine the Fdxr expression in esophageal squamous cell carcinoma (ESCC) and determine if the expression is useful for predicting response to chemoradiation therapy (CRT). MATERIALS AND METHODS: Fdxr expression in biopsy specimens from 50 patients before neoadjuvant CRT were immunohistochemically examined. Then, the correlation between Fdxr expression and response to CRT were analyzed. RESULTS: Both clinically and histologically, significant correlations were found between positive Fdxr expression and favorable response to CRT. Furthermore, Fdxr was significantly correlated with postoperative outcomes and was found to be an independent prognostic factor. CONCLUSION: Fdxr expression was found to be closely related to the effect of CRT and could predict the CRT outcome in patients with ESCC.

Analysis of the Fibrinogen and Neutrophil-Lymphocyte Ratio in Esophageal Squamous Cell Carcinoma: A Promising Blood Marker of Tumor Progression and Prognosis.

Esophageal squamous cell carcinoma (ESCC) is one of the most aggressive malignancies in gastrointestinal tract cancers and even patients with early ESCC have a high metastatic potential. Difficulties are associated with clinically predicting tumor progression and prognosis based on conventional tumor markers determined from preoperative blood examinations. The aim of the present study was to measure plasma fibrinogen levels and the neutrophil-lymphocyte ratio (NLR) in blood and compare the clinical impacts of their combined values (fibrinogen and neutrophil-lymphocyte ratio score-F-NLR score) and the modified Glasgow Prognostic Score (mGPS) in patients with ESCC.We classified 238 patients with ESCC based on cut-off values for hyperfibrinogenemia (>400 mg/dL) and high NLR (>3.0) as F-NLR scores of 2 (both of these hematological abnormalities), 1 (one of these abnormalities), or 0 (neither abnormality). We also categorized patients based on cut-off values for high C-reactive protein (CRP) (>0.5 mg/dL) and hypoalbuminemia (<3.8 g/dL) as mGPS of 2 (elevated CRP and hypoalbuminemia), 1 (either elevated CRP or hypoalbuminemia), or 0 (neither elevated CRP nor hypoalbuminemia).The F-NLR score correlated with the depth of tumor invasion, lymph node metastasis, lymphovascular invasion, tumor size, and stage (all P < 0.05). Prognoses among the groups based on the F-NLR score and mGPS significantly differed (all P < 0.001). A multivariate analysis identified the depth of tumor invasion, lymph node metastasis, and F-NLR score as independent prognostic factors (P = 0.002, P = 0.007, and P = 0.037, respectively).The results of the present study showed that the F-NLR score is a promising blood predictor for tumor progression and outcomes in patients with ESCC.

[A Case of Esophageal Cancer in a Patient with CMV Reactivation after Neoadjuvant Chemoradiation Therapy].

A 68-year-old woman was diagnosed with advanced esophageal cancer with lymph node metastasis, for which she received neoadjuvant chemoradiotherapy. During therapy, she had loss of appetite and weight; therefore, we inserted a nasal feeding tube for her nutrition, after which, she gained weight soon. After therapy, she had a high fever with lymphocytopenia and was diagnosed with cytomegalovirus infection because of significantly high CMV antigenemia. Ganciclovir was administered immediately, and she recovered soon. Two months later, we performed esophagectomy, and she recovered without complications. Immediate diagnosis of CMV infection, ganciclovir administration, and nutrition through a feeding tube were useful for the esophageal cancer patient in this report who had immunosuppression and malnutrition during chemoradiation.

[A Case of Concurrent Cancer of the Esophagus and Stomach with Severe Sepsis following Chemotherapy].

A 66-year-old man was diagnosed with synchronous early esophageal cancer and advanced gastric cancer. He received CDDP-based combination chemotherapy (docetaxcel, CDDP, and TS-1). During chemotherapy for gastric cancer, he suddenly developed septic shock, requiring intensive treatment with antibiotics, intravenous immunoglobulin, circulatory and respiratory care, and hemoperfusion with a polymyxin B column. He also had disseminated intravascular coagulation (DIC), complicated by sepsis. Recombinant human soluble thrombomodulin (rTM) was administered to treat DIC. The intensive treatments described above allowed the patient to recover from septic shock and DIC several days later. Early and adequate treatment could be used to rescue a compromised cancer-bearing patient from septic shock following chemotherapy.

Clinical significance of mediastinoscope-assisted transhiatal esophagectomy in patients with esophageal cancer.

PURPOSE: Mediastinoscope-assisted transhiatal esophagectomy (MATHE) is a useful surgical procedure in esophageal cancer patients who have limited indications for transthoracic operations due to preoperative complications. METHODS: In the last 10 years, 63 patients underwent MATHE at our department. We examined the clinical data of these patients and assessed the indications, postoperative outcomes, and prognostic factors of MATHE. RESULTS: The 5-year overall survival (OS) rate was 53.4 %, and disease-free survival (DFS) rate was 66.0 %. Postoperative complications were observed in 22 cases (34.9 %), and recurrent disease occurred in 17 cases (27.0 %). On univariate analyses of OS, location of the tumor, tumor depth, lymph node metastasis, clinical stage, simultaneous resection of other organs, postoperative pneumonia, and blood loss were significant prognostic factors. On multivariate analyses, location of the tumor and lymph node metastasis were independent prognostic factors of OS. On univariate analyses, location of the tumor, tumor depth, lymph node metastasis, clinical stage, and blood loss were significant prognostic factors of DFS, while on multivariate analyses of DFS, lymph node metastasis and blood loss were independent prognostic factors. CONCLUSION: MATHE is a useful procedure for the middle to lower thoracic esophageal cancer patients without clinical lymph node metastasis with serious complications who were unable to undergo thoracotomy.

The translational aspect of complementary and alternative medicine for cancer with particular emphasis on Kampo.

Complementary and alternative medicine (CAM) including Japanese Kampo is known to have anticancer potential. An increasing number of cancer survivors are using CAM for disease prevention, immune system enhancement, and symptom control. Although there have been abundant previous clinical reports regarding CAM, scientific investigations aimed at acquiring quantifiable results in clinical trials, as well as basic research regarding CAM, have only recently been undertaken. Recent studies suggest that CAM enhancement of immune function is related to cytokines. This review provides a translational aspect of CAM, particularly Hozai in Kampo from both scientific and clinical points of view for further development of CAM for cancer treatment.

Present status of endoscopic mastectomy for breast cancer.

Endoscopy is now being used for breast cancer surgery. Though it is used for mastectomy, lymph node dissection, and breast reconstruction, its prime use is for mastectomy. Because an incision can be placed inconspicuously in the axillary site, a relatively large incision can be created. A retractor with an endoscope, CO2, and an abrasion device with the endoscope are used for operation space security. It is extremely rare that an endoscope is used for lymph node dissection. For breast reconstruction, it may be used for latissimus muscle flap making, but an endoscope is rarely used for other reconstructions. Endoscopic mastectomy is limited to certain institutions and practiced hands, and it has not been significantly developed in breast cancer surgery. On the other hand, endoscopic surgery may be used widely in breast reconstruction. With respect to the spread of robotic surgery, many factors remain uncertain.