Changes in Spinal Instability After Conventional Radiotherapy for Painful Vertebral Bone Metastases.

OBJECTIVE: Precise assessment of spinal instability is critical before and after radiotherapy (RT) for evaluating the effectiveness of RT. Therefore, we retrospectively evaluated the efficacy of RT in spinal instability over a period of 6 months after RT, utilizing the spinal instability neoplastic score (SINS) in patients with painful spinal metastasis. We retrospectively evaluated 108 patients who received RT for painful vertebral metastasis in our institution. Mechanical pain at metastatic vertebrae, radiological responses of irradiated vertebrae, and spinal instability were assessed. Follow-up assessments were done at the start of and at intervals of 1, 2, 3, 4, and 6 months after RT, with the pain disappearing in 67%, 85%, 93%, 97%, and 100% of the patients, respectively. The median SINS were 8, 6, 6, 5, 5, and 4 at the beginning and after 1, 2, 3, 4, and 6 months of RT, respectively. Multivariate analysis revealed that posterolateral involvement of spinal elements (PLISE) was the only risk factor for continuous potentially unstable/unstable spine at 1 month. In conclusion, there was improvement of pain, and recalcification results in regaining spinal stability over time after RT although vertebral body collapse and malalignment occur in some irradiated vertebrae. Clinicians should pay attention to PLISE in predicting continuous potentially unstable/unstable spine.

Vertebral body collapse after radiotherapy for spinal metastases.

Spinal metastases are common in patients with advanced stages of cancer and frequently cause vertebral body collapse (VBC). Although conventional radiotherapy (RT) is used for spinal metastases, the rates of occurrence of new VBC and progression of VBC at RT initiation have not been fully investigated. The present retrospective study assessed VBC and its associated risk factors after RT over time and evaluated new VBC and progression of VBC in patients who presented with VBC at RT initiation. The study evaluated 177 patients who received RT for vertebral metastases without paralysis between July 2012 and November 2016. Radiological responses of the irradiated vertebrae were assessed using computed tomography. Follow-up assessments were performed at RT initiation and 1, 2, 3, 4 and 6 months after RT. New VBC occurred in 12% of patients with no prior VBC within 1 month of RT. Multivariate analysis revealed that numeric rating scale (NRS) score (≥4) [relative risk (RR), 27.1; 95% confidence interval (CI), 1.86 to 394.9; P=0.016] was associated with the occurrence of new VBC at the 1 month follow-up time point. VBC progression occurred in 51% of the patients with collapse at RT initiation. Multivariate analysis revealed that bone quality (lytic metastases) (RR, 3.1; 95% CI, 1.28 to 7.70; P=0.013), NRS score (≥4) (RR, 3.0; 95% CI, 1.18 to 7.45; P=0.021) and tumor involvement of posterolateral elements of the spine (RR, 2.7; 95% CI, 1.03 to 7.29; P=0.04) were associated with the progression of VBC at the 1 month follow-up time point. The current study findings suggested that clinicians should pay attention to the factors that predict the occurrence of new VBC and VBC progression to ensure proper evaluation of conservative treatment effectiveness and facilitate the determination of patients who need close monitoring.

Characteristics of Postoperative Patients with Breast Cancer Aged 65 Years and Older.

Objective: This study aimed to compare postoperative patients with breast cancer aged ≥65 years with those aged <65 years and clarify the characteristics of postoperative patients with breast cancer aged ≥65. Methods: In total, 376 patients in whom we were able to evaluate survey items one month after surgery were included in the study. Comorbidity, including diabetes mellitus and hypertension, shoulder range of motion (ROM), upper-limb function, and psychological problems, was evaluated. Results: Hypertension and diabetes mellitus were significantly higher in patients aged ≥65 years (the elderly group) than in those aged <65 years (the non-elderly group) (p < 0.05). Preoperative shoulder flexion ROM was significantly restricted in the elderly group compared with the non-elderly group (p < 0.05). Preoperative shoulder abduction ROM was significantly restricted in the elderly group compared with the non-elderly group (p < 0.05). At one month after surgery, upper-limb function was more impaired in the non-elderly group than in the elderly group (p < 0.05). In both groups, both ROM and upper-limb function were significantly impaired one month after surgery compared with before surgery (p < 0.05). Conclusions: Postoperative patients with breast cancer aged ≥65 years should be careful about risk management and intervention during rehabilitation. Preoperative evaluation of shoulder ROM should be performed because patients aged ≥65 years have limited ROM before surgery.

Cancer Rehabilitation Provided by Designated Cancer Hospitals in Japan: The Current State of Outpatient Setting and Coordination after Discharge.

Objectives: The aim of the present study was to clarify the current state of outpatient cancer rehabilitation and coordination systems provided by designated cancer hospitals in Japan. Methods: A questionnaire was sent to 427 designated cancer hospitals in Japan to investigate the status of outpatient cancer rehabilitation and whether it was sufficiently conducted. The status of regional coordination with post-discharge rehabilitation facilities was surveyed. Results: Responses were received from 235/427 facilities (55.0%). Outpatient cancer rehabilitation was implemented in 92 (39.1% of responding facilities), and of these facilities, 83.7% answered that the provision of rehabilitation was insufficient. The reasons were ineligibility for reimbursement of medical fees, a lack of human resources, a lack of awareness of the need, and a lack of education. Regional coordination was conducted by 39.1% of responding facilities, yet a regional alliance path had been established in only 9.8% of centers. The absence of coordination was associated with large facility size, the absence of physiatrists, and few rehabilitation professionals who had completed the training program; an insufficient framework for regional coordination was also given as a reason. Conclusions: To provide adequate outpatient cancer rehabilitation, sufficient human resources, the reimbursement of medical fees in the outpatient setting, and education and a framework to promote regional coordination are necessary.

Association between Overall Survival and Activities of Daily Living in Patients with Spinal Bone Metastases.

Objective: This study aimed to investigate the association between overall survival (OS) and activities of daily living (ADL) in patients with skeletal-related events. In this study, 265 patients whose clinical parameters were available before radiotherapy were investigated. Methods: Age, sex, ADL, pain, the primary site, spinal level of bone metastases, spinal instability, treatment strategy, including chemotherapy or palliative treatment, and OS were investigated. ADL patients with a Barthel index of ≥90 were classified as the high ADL group, while those with a score < 90 were classified as the low ADL group. For OS, patients surviving ≥160 days were classified as the non-poor prognosis group, and those who survived <160 days were classified as the poor prognosis group. Results: Age, sex, ADL, pain, the primary site, and treatment strategy for OS were different between the two groups (p < 0.1). Logistic regression analysis revealed that ADL, the primary site, and treatment strategy were significant predictors of OS (p < 0.05). High ADL, breast cancer, and chemotherapy had a positive effect on OS. Conclusions: It is suggested that improvements may be obtained by performing rehabilitation interventions to maintain and improve ADL, by constructing a system for monitoring spinal bone metastases with images before ADL decreases, and by performing interventions such as changes in treatment methods such as RT or surgery at appropriate times.

Factors Affecting the Quality of Life of Patients with Painful Spinal Bone Metastases.

This study examined changes in the quality of life (QOL), as well as the factors affecting QOL, among patients with painful spinal bone metastases without paralysis for 1 month after radiotherapy. METHODS: This study included 79 participants (40 male and 39 female; median age, 65 (42-88) years) who had undergone radiotherapy for painful spinal bone metastases without paralysis. Patients' age, sex, activities of daily living (Barthel index), pain, spinal instability (spinal instability neoplastic score [SINS]), and QOL (EORTC QLQ-C30) were investigated. RESULTS: Having an unstable SINS score was a positive factor for global health status (p < 0.05). The improvement in activities of daily living and response to pain were positive factors for physical function (p < 0.05). A positive effect on emotional function was confirmed among female patients (p < 0.05). CONCLUSION: Engaging in rehabilitation along with radiotherapy leads to improvements in QOL for patients with spinal bone metastases.

Factors associated with return to work of breast cancer patients following axillary lymph node dissection.

BACKGROUND: The identification of factors that are related to return to work after surgery for breast cancer could help healthcare professionals accurately identify patients at risk of return to work-related difficulties in order to provide them with appropriate support during breast cancer management. OBJECTIVE: The aim of this study was to identify factors related to return to work in breast cancer patients three months after axillary lymph node dissection. METHODS: Seventy-three women who were working before the surgery were evaluated. Age, body mass index, level of lymph node dissection, marital status, children, co-resident household members, preoperative chemotherapy, postoperative chemotherapy, postoperative hormonal therapy, postoperative radiotherapy, shoulder range of motion, upper limb function (Disabilities of the Arm, Shoulder and Hand; DASH), and work were evaluated. Patients who had returned to work constituted the return to work group, and those who had not returned to work constituted the no return to work group. RESULTS: Of the patients, 36 returned to work at three months. Logistic regression analysis including the five variables showed that shoulder flexion range of motion and DASH were significantly associated with return to work (p < 0.05). CONCLUSIONS: The observation that the symptoms and limitations of upper limb function and shoulder flexion range of motion affect return to work may indicate the importance of postoperative rehabilitation in breast cancer patients following axillary lymph node dissection.

Changes in Physical Function and Effects on QOL in Patients after Pancreatic Cancer Surgery.

This study examined the changes in physical function and quality of life (QOL) of postoperative patients with pancreatic cancer for 3 months after surgery and examined the factors affecting the QOL at the 3 months after surgery. METHODS: This study comprised 32 pancreatic cancer patients who underwent surgery at our hospital. Among these patients, 20 patients for whom data was measured before surgery to 3 months after surgery were selected for statistical analyses: 8 males and 12 females, 69.8 ± 7.4 years. The preoperative and postoperative rehabilitation was given to patients under the guidance of a physiotherapist. Nutritional status, body composition, physical function, gait assessments, and QOL were investigated. RESULTS: Body weight, body fat mass, body fat percentage, body mass index (BMI), and muscle mass significantly decreased 3 months after surgery compared with their respective preoperative values. The mean grip strength at the time of 3 months after the surgery had decreased significantly from 27.3 kg to 24.5 kg. The mean skeletal muscle mass index (SMI) had decreased significantly from 6.3 kg before surgery to 5.9 kg after the surgery. The QOL scores for global health status, physical, and role showed significant decreases 2 weeks after surgery compared with the respective preoperative scores. Significant improvements in these scores were observed 3 months after surgery compared with the respective scores 2 weeks after surgery. Physical function assessments after surgery were associated with QOL 3 months after surgery. CONCLUSION: Recovery of patients after pancreatic cancer surgery in body weight, BMI, body fat percentage, body fat percentage, muscle mass, SMI, and grip strength was not sufficient at the time of 3 months after surgery. It has been observed that physical function of patients has affected the improvement of QOL.

Factors Affecting Participation in Leisure Activities in Patients after Breast Cancer Surgery.

BACKGROUND: The purpose of this study was to investigate the factors related to patient's participation in leisure activity in breast cancer patients with axillary lymph node dissection at 3 months after surgery. METHODS: In total, 160 women who were employed before their surgery were evaluated. Age, body mass index (BMI), employment, level of lymph node dissection, marital status, children, coresident household members, preoperative chemotherapy, postoperative chemotherapy, postoperative hormonal therapy, postoperative radiotherapy, shoulder range of motion test, upper limb function, quality of life, and patient's participation in leisure activity were evaluated. RESULTS: Patients who undertook leisure activities constituted the leisure activity group, and patients who did not constituted the non-leisure activity group. Global health status, emotional function, social function, and dyspnea were significantly different between the leisure activity group and the non-leisure activity group at 3 months after surgery (p < 0.05). Regarding factors that affected participation in leisure activities, logistic regression analysis showed that only participation in leisure activities before surgery was significantly associated with participation in leisure activities at 3 months after surgery (p < 0.05). CONCLUSION: Patients who did not participate in leisure activities prior to surgery were unlikely to participate 3 months after surgery and thus require intervention to encourage their involvement.

The current status of inpatient cancer rehabilitation provided by designated cancer hospitals in Japan.

OBJECTIVE: This survey was conducted to clarify the current status of inpatient cancer rehabilitation provided by designated cancer hospitals in Japan. METHODS: A survey questionnaire was sent to 427 designated cancer hospitals in Japan. Information was sought regarding whether inpatient cancer rehabilitation was provided by the center, and if so, whether respondents regarded such provision as satisfactory. RESULTS: Responses were obtained from 235/427 surveyed institutions (55.0%). Cancer rehabilitation was provided in inpatient settings by 97.4%. Two-thirds of respondents (67.7%) regarded inpatient cancer rehabilitation provision as still inadequate. The primary reasons claimed for this inadequacy were a lack of human resources, a lack of rehabilitation professionals with the requisite knowledge/skills and patients who would benefit from cancer rehabilitation present but not prescribed. The total number of rehabilitation staff was identified as associated factor of inadequate inpatient cancer rehabilitation in multivariate analysis (odds ratio = 0.979, 95% confidence interval = 0.96-1.00, P = 0.009). CONCLUSIONS: In order to provide adequate cancer rehabilitation, a sufficient supply of rehabilitation staff, education and recognition of the need for cancer rehabilitation within oncology units are necessary.

Percutaneous C-Arm Free O-Arm Navigated Biopsy for Spinal Pathologies: A Technical Note.

BACKGROUND: Percutaneous biopsy under computed tomography (CT) guidance is a standard technique to obtain a definitive diagnosis when spinal tumors, metastases or infections are suspected. However, specimens obtained using a needle are sometimes inadequate for correct diagnosis. This report describes a unique biopsy technique which is C-arm free O-arm navigated using microforceps. This has not been previously described as a biopsy procedure. CASE DESCRIPTION: A 74-year-old man with T1 vertebra pathology was referred to our hospital with muscle weakness of the right hand, clumsiness and cervicothoracic pain. CT-guided biopsy was performed, but histopathological diagnosis could not be obtained due to insufficient tissue. The patient then underwent biopsy under O-arm navigation, so we could obtain sufficient tissue and small cell carcinoma was diagnosed on histopathological examination. A patient later received chemotherapy and radiation. CONCLUSIONS: C-arm free O-arm navigated biopsy is an effective technique for obtaining sufficient material from spine pathologies. Tissue from an exact pathological site can be obtained with 3-D images. This new O-arm navigation biopsy may provide an alternative to repeat CT-guided or open biopsy.

Investigation of Factors Affecting Early Quality of Life of Patients after Breast Cancer Surgery.

OBJECTIVE: The purpose of this study was to investigate factors related to early quality of life (QOL) three months after surgery in breast cancer patients with axillary lymph node dissection. METHODS: The subjects of this study were 195 consecutive patients who underwent axillary lymph node dissection for breast cancer. Age, body mass index, level of lymph node dissection, marriage, children, co-resident household members, neoadjuvant chemotherapy, postoperative chemotherapy, postoperative hormonal therapy, postoperative radiotherapy, upper limb function (disabilities of the arm, shoulder, and hand (DASH)), and QOL (European Organization for the Treatment and Research of Cancer Quality of Life Questionnaire (EORTC QLQ-C30)) were evaluated. For each item of the EORTC QLQ-C30, compared with preoperative status and three months after surgery, those who improved or remained unchanged in the three months after surgery were classified as the maintenance and improved groups, and those with worsening status were classified as the worsened group. RESULTS: Age, level of lymph node dissection, DASH, neoadjuvant chemotherapy, postoperative chemotherapy, and postoperative radiotherapy were significantly associated with QOL (p < 0.05). CONCLUSIONS: The early QOL of postoperative patients with breast cancer is affected by multiple factors, such as upper limb function and postoperative chemotherapy, and thus comprehensive intervention is required.

Influence of and Risk Factors for Axillary Web Syndrome Following Surgery for Breast Cancer.

In this study, we examined whether axillary web syndrome (AWS) in patients with breast cancer following axil-lary lymph node dissection affects range of motion (ROM), upper extremity function, and quality of life (QOL). The risk factors for AWS were also evaluated in a total of 238 consecutive breast cancer patients follow-ing axillary lymph node dissection. At 1, 2, and 3 months after surgery, there were no significant differences between the AWS group and the non-AWS group in upper-limb function or QOL. At 2 months after surgery, shoulder flexion and abduction ROM were significantly higher in the AWS group than in the non-AWS group (p < 0.05). Self-training time at home was not significantly different between the groups at 1, 2, or 3 months. Only age was a significant predictor of AWS at 1 month after surgery (p < 0.05). The AWS group in the present study did not have worse results for shoulder joint ROM, upper-limb function, and QOL than the non-AWS group. Younger age should be useful for predicting the development of AWS in the early postoperative period.

Short-Term Impact of Video-Assisted Thoracoscopic Surgery on Lung Function, Physical Function, and Quality of Life.

Background: Video-assisted thoracoscopic surgery (VATS) has been increasingly used as an approach for lung lobectomy. However, the recovery of respiratory and physical function may be insufficient at discharge because the average length of hospital stay is decreasing after surgery. In this study, we investigated the changes in physical function, lung function, and quality of life (QOL) of lung cancer patients after VATS, and factors for QOL were also evaluated. METHODS: The subjects of this study were 41 consecutive patients who underwent video-assisted lung lobectomy for lung cancer. Rehabilitation was performed both before and after surgery. Lung function testing, physical function testing (timed up and go test (TUG) and the 30-s chair-stand test (CS-30)), and QOL (EORTC QLQ-C30) were measured before and 1 week after surgery. RESULTS: Postoperative VC recovered to 76.3% ± 15.6% 1 week after surgery. TUG, CS-30, and QOL were significantly worse after surgery (p < 0.05). Lung function and physical function were found to affect QOL. Postoperative complications included pneumonia in 1 patient. There were no patients who discontinued rehabilitation. CONCLUSION: Our rehabilitation program was safe and useful for patients after VATS.

Risk factors of impairment of shoulder function after axillary dissection for breast cancer.

OBJECTIVES: Postoperative shoulder joint dysfunction has been observed at a certain rate after breast cancer surgery with axillary lymph node dissection. The purposes of this study were to verify the feasibility and effects of home-based exercise using a DVD and clarify the target of intensive intervention with physiotherapy by identifying the factors that cause postoperative shoulder dysfunction. METHODS: The study comprised 237 female patients who underwent breast cancer surgery with axillary lymph node dissection, whose data were acquired until 3 months postoperatively. All patients were instructed to exercise at home using a DVD. Range of motion (ROM) of shoulder flexion and abduction and the disability of the arm, shoulder, and hand (DASH) score were measured before surgery, 1 week and 1, 2, and 3 months after surgery. As factors influencing the recovery of shoulder ROM at 3 months after surgery, the presence or absence of radiation and factors up to 1 month after surgery (age, body mass index, the relationship between operated side and dominant side of the hand, treatment modalities, and complications). RESULTS: Shoulder ROM and DASH scores had gradually recovered from 1 week to 3 months postoperatively. As the results of the multivariate analysis, the factors that were associated with the recovery of ROM of shoulder flexion at 3 months were the side of surgery corresponding to the dominant hand (negative factor) and the presence of paresthesia at 1 week postoperatively (positive factor) (p < 0.05). Radiation therapy and the side of surgery corresponding to the dominant hand were negative factors for the recovery of shoulder abduction (p < 0.01). Regarding the feasibility of the home exercise, 214/229 (93.4%), 172/210 (81.9%), and 139/206 (67.5%) of patients performed exercise at least once a day at 1, 2, and 3 months after surgery, respectively. CONCLUSION: Our result indicated that the side of surgery corresponding to the dominant hand was the inhibiting factor for recovery for both shoulder flexion and abduction at 3 months after surgery. Home-based exercise with DVD was considered feasible. For the verification of this effectiveness, a randomized control study should be planned in the future.

Early response of bone metastases can predict tumor response in patients with non-small-cell lung cancer with bone metastases in the treatment with nivolumab.

The effect of nivolumab and the relation between bone response and tumor control in patients with non-small-cell lung cancer (NSCLC) with bone metastases are not clear. The outcome of nivolumab monotherapy was investigated, and whether the response of bone metastases is useful as an early predictor of tumor control in patients with NSCLC with bone metastases was examined. The participants included 15 patients who received nivolumab monotherapy for NSCLC with bone metastases in our institution between 2015 and 2017. Tumor control was defined using Response Evaluation Criteria in Solid Tumors, version 1.1 (RECIST1.1). Response of bone metastases was assessed by the MD Anderson response criteria (MDA criteria). Responses according to RECIST1.1 and the MDA criteria were classified as responder (complete response or partial response) and non-responder [progressive disease (PD) or stable disease]. Progression-free survival (PFS) was investigated using the Kaplan-Meier method. With RECIST1.1, the overall response rate was 20%. Multivariate analysis showed that the MDA criteria were the only risk factor for patients with PD (RECIST1.1). Median PFS was 1.9 months, with PFS of 20% at 6 months. Univariate analysis showed that being a non-responder according to the MDA criteria was the only risk factor for PFS. In patients who were responders (MDA criteria) within 3 months, PFS was 83 and 50% at 3 and 6 months, respectively, though all non-responder (MDA criteria) patients converted to PD (RECIST1.1) within 3 months. Response according to RECIST1.1 was significantly correlated with response according to the MDA criteria (P<0.05). In patients who were both responders according to RECIST1.1 and the MDA criteria, time to response with the MDA criteria (1.4-2.0 months) was earlier than with RECIST1.1 (2.8-3.0 months) in all patients. In conclusion, application of the MDA criteria within 2 months of nivolumab monotherapy is useful for early prediction of response and prognosis in patients with NSCLC with bone metastases.

Factors Affecting the Discharge Destination of Patients With Spinal Bone Metastases.

OBJECTIVE: To investigate the factors affecting the discharge destination of patients with spinal bone metastases. METHODS: We reviewed the medical records of patients admitted to our institute with a diagnosis of skeletalrelated events secondary to malignant disease. Exclusion criteria comprised decreased cognitive function and hypercalcemia, brain metastasis, peritoneal dissemination, and pleural dissemination. The factors examined included the discharge destination, age, sex, the Barthel Index (BI) at admission and discharge, pain at admission and discharge, number of co-resident household members, length of hospital stay, treatment strategy, spinal instability neoplastic score, vertebral body collapse, spinal level of bone metastases, and motor paralysis. For the discharge destination, patients at discharge were grouped into two categories. The home group included patients discharged to their own homes, and the non-home group included patients discharged to other hospitals. RESULTS: Of 140 patients, the home group comprised 120 patients and the non-home group comprised 20 patients. Activities of daily living (ADL) and pain at rest and during motion improved significantly in the home group, whereas only pain at rest and during motion improved significantly in the non-home group. The results indicated that discharge BI and motor paralysis were the best predictors of the discharge destination; a BI cut-off value of 72.5 predicted discharge to home. CONCLUSION: This study showed that the ADL level on discharge and motor paralysis affected the discharge destination of patients with spinal bone metastases. These results are likely to be helpful in predicting the discharge destination of patients with spinal bone metastases.

Multidisciplinary treatment system for bone metastases for early diagnosis, treatment and prevention of malignant spinal cord compression.

Malignant spinal cord compression (MSCC) is a serious complication of cancers. The present study aimed to establish a multidisciplinary treatment system for urgent magnetic resonance imaging (MRI) and referral to orthopedists in order to prevent neurological deficits caused by MSCC. In the present study, the extent to which this system achieved early diagnosis and treatment and prevented MSCC-caused neurological deficits was examined. The records from patients with neurological deficits caused by MSCC before (between April 2007 and March 2012; group A) and after (between April 2012 and March 2017; group B) the establishment of the multidisciplinary system at the Shikoku Cancer Center (Ehime, Japan) were retrospectively evaluated. The numbers of patients with neurological deficits were 38 and 7 in groups A and B, respectively. All patients received radiotherapy. The incidence of neurological deficits was 13.2 and 3.4% in groups A and B, respectively (P<0.001). The proportion of patients with improvement in the severity of neurological deficits was 5.3 and 28.6% in groups A and B, respectively (P<0.001). The interval between physicians' recognition of a neurological deficit and MRI and the start of treatment, the number of cases, and the severity of neurological deficits were evaluated in groups A and B. The median interval between recognition of a neurological deficit by physicians and MRI was 3 and 0 days in groups A and B, respectively (P<0.001). The median interval between physicians' recognition of a neurological deficit and the start of treatment was 3 and 0 days in groups A and B, respectively (P<0.001). By using a multidisciplinary treatment system, the incidence and severity of neurological deficits following treatment were significantly improved. Therefore, the multidisciplinary treatment system used in the present study may be useful for early diagnosis, treatment and prevention of MSCC in patients with bone metastases.

Rare pancreatic metastasis of undifferentiated pleomorphic sarcoma originating from the pelvis: A case report.

INTRODUCTION: Undifferentiated pleomorphic sarcoma (UPS) is a reclassification of malignant fibrous histiocytoma by the World Health Organization in 2002. UPS, the most common soft tissue sarcoma reported in adults, mostly recurs as lung disease. Pancreatic metastasis of UPS is extremely rare. We present a rare case of pelvic UPS with pancreatic metastasis. PRESENTATION OF CASE: A 69-year-old man was identified as having mediastinal lymphadenopathy on follow-up computed tomography (CT), 2 years after undergoing surgery for gastric adenocarcinoma (pT4aN3M0/IIIC). Subsequent positron emission tomography-CT (PET/CT) indicated pelvic lesions and magnetic resonance imaging (MRI) showed multiple tumors of the left pubis and femur. Histopathology of diagnostic thoracoscopic lymph node dissection and CT-guided needle biopsy of the left pubic lesion showed UPS. Systemic chemotherapy and targeted molecular therapy reduced multiple pelvic and metastatic tumors. Left pubic primary lesion contraction was achieved with intensity-modulated radiation therapy. CT performed 4 years after treatment initiation showed a 40-mm pancreatic head mass. Lesions other than the pancreatic tumor were in remission, and a pancreatoduodenectomy was performed. Histological analysis confirmed pancreatic metastasis of anaplastic pleomorphic sarcoma. DISCUSSION: Reports of pelvic UPS with pancreatic metastasis, as that of the present case, are extremely rare. UPS is malignant potential tumor, and complete excision is the first treatment option, while the usefulness of chemotherapy or radiation therapy remains uncertain. CONCLUSIONS: Complete resection is vital for local control in pancreatic metastasis of UPS. Sites of recurrence are rare; hence, patients must be carefully followed up.

Risk factors for early postoperative psychological problems in breast cancer patients after axillary lymph node dissection.

BACKGROUND: The purpose of this study was to investigate the factors related to early postoperative psychological conditions in breast cancer patients with axillary lymph node dissection 3 months after the surgery. METHODS: The subjects of this study were 200 consecutive patients who underwent axillary lymph node dissection for breast cancer at our hospital. Age, body mass index, surgical side, work, marriage, presence of children, presence of co-resident household members, resection of the pectoralis minor muscle, preoperative chemotherapy, postoperative chemotherapy, postoperative hormonal therapy, postoperative radiotherapy, shoulder range of motion, upper limb function (Disabilities of the Arm, Shoulder and Hand; DASH), and psychological conditions were evaluated. In this study, a Distress and Impact Thermometer was used to classify patients with adjustment disorders, depression, or major depression and suicidal ideation into a group with psychological problems and the remaining patients into a group with no psychological problems. RESULTS: Logistic regression analysis showed that only DASH was statistically significantly associated with psychological conditions (p < 0.05). Using receiver operating characteristic curve analysis, a DASH score of 18 or greater was found to be very specific for predicting psychological conditions. CONCLUSIONS: The observation that somatic symptoms and disability of upper limb function are related to psychological conditions may indicate the importance of postoperative rehabilitation in breast cancer patients with axillary lymph node dissection.