[A Case of Advanced Breast Cancer in Which Mohs' Paste and Systemic Drug Therapy Allowed Local and Disease Control].

Local control of disintegrating advanced breast cancer is often difficult because of the exudate, bleeding, and the foul odor. The current author encountered a case of large breast cancer with ulceration in which drug therapy and local control with Mohs' paste allowed disease control. The patient was a 61-year-old woman. There was a large ulcerated lump in her right breast, and exudate, bleeding, and a foul odor were present. The woman was diagnosed with hormone-sensitive mucinous carcinoma based on a biopsy, and diagnostic imaging revealed axillary lymph node metastasis and multiple metastases in both lungs. Mohs' paste was used locally, and local control was achieved after 1 month. A year and a half after the start of systemic drug therapy, the breast lump disappeared, and lung metastases and lymph node metastasis had almost disappeared. A CR has been maintained 3 years and 5 months later. Mohs' paste was extremely useful in achieving local control of exudation and bleeding from exposed unresected cancer. This was an excellent treatment in the patient's terminal stages and as part of local treatment in combination with systemic drug therapy.

Interleukin-17A derived from mast cells contributes to fibrosis in gastric cancer with peritoneal dissemination.

OBJECTIVES: Interleukin-17A (IL-17A) is pro-inflammatory cytokine and acts as profibrotic factor in the fibrosis of various organs. Fibrosis tumor-like peritoneal dissemination of gastric cancer interferes with drug delivery and immune cell infiltration because of its high internal pressure. In this study, we examined the relationship between IL-17A and tissue fibrosis in peritoneal dissemination and elucidated the mechanism of fibrosis induced by IL-17A using human peritoneal mesothelial cells (HPMCs) and a mouse xenograft model. METHODS: Seventy gastric cancer patients with peritoneal dissemination were evaluated. The correlation between IL-17A and fibrosis was examined by immunofluorescence and immunohistochemistry. A fibrosis tumor model was developed based on subcutaneous transplantation of co-cultured cells (HPMCs and human gastric cancer cell line MKN-45) into the dorsal side of nude mice. Mice were subsequently treated with or without IL-17A. We also examined the effect of IL-17A on HPMCs in vitro. RESULTS: There was a significant correlation between IL-17A expression, the number of mast cell tryptase (MCT)-positive cells, and the degree of fibrosis (r = 0.417, P < 0.01). In the mouse model, IL-17A enhanced tumor progression and fibrosis. HPMCs treated with IL-17A revealed changes to a spindle-like morphology, decreased E-cadherin expression, and increased α-SMA expression through STAT3 phosphorylation. Moreover, HPMCs treated with IL-17A showed increased migration. CONCLUSIONS: IL-17A derived from mast cells contributes to tumor fibrosis in peritoneal dissemination of gastric cancer. Inhibiting degranulation of mast cells might be a promising treatment strategy to control organ fibrosis.

[A Case of HER2-Positive Gastric Cancer with Multiple Lung and Liver Metastases Showing Long-Term Survival].

A male patient in his 70s visited our hospital with a complaint of tarry stool. A detailed examination revealed gastric cancer( pap, tub1, HER2[3+]), with multiple lungs and liver metastases. Chemotherapy with 4 courses of capecitabine, cisplatin, and trastuzumab(Tmab)and 4 courses of weekly paclitaxel(wPTX)plus 3w-Tmab were administered, and CR was achieved. Thereafter, Tmab was administered alone; however, local recurrence of the primary lesion was observed 24 months after diagnosis, and treatment with PTX and Tmab was resumed. After 68 months of diagnosis, the recurrent tumor increased in size. Therapy with nab-PTX plus ramucirumab was initiated, following which, the tumor growth was restricted. Eventually, the patient died of another disease after 6 years and 5 months of diagnosis. Chemotherapy for unresectable advanced/recurrent gastric cancer has a remarkable antitumor effect; however, a complete cure with chemotherapy alone is difficult. Therefore, a multimodal treatment, including chemotherapy, surgical treatment, and radiation therapy, is important.

Established fibrous peritoneal metastasis in an immunocompetent mouse model similar to clinical immune microenvironment of gastric cancer.

BACKGROUND: Peritoneal metastasis (PM) in gastric cancer (GC) is characterized by diffusely infiltrating and proliferating cancer cells accompanied by extensive stromal fibrosis in the peritoneal space. The prognosis of GC with PM is still poor regardless of the various current treatments. In order to elucidate the cause of difficulties in PM treatment, we compared the tumor immune microenvironment (TME) in primary and PM lesions in GC. In addition, a PM model with fibrous stroma was constructed using immunocompetent mice to determine whether its TME was similar to that in patients. METHODS: Immuno-histochemical analyses of infiltrating immune cells were performed in paired primary and PM lesions from 28 patients with GC. A C57BL/6 J mouse model with PM was established using the mouse GC cell line YTN16 either with or without co-inoculation of mouse myofibroblast cell line LmcMF with α-SMA expression. The resected PM from each mouse model was analyzed the immunocompetent cells using immunohistochemistry. RESULTS: The number of CD8+ cells was significantly lower in PM lesions than in primary lesions (P < 0.01). Conversely, the number of CD163+ cells (M2 macrophages) was significantly higher in PM lesions than in primary lesions (P = 0.016). Azan staining revealed that YTN16 and LmcMF co-inoculated tumors were more fibrous than tumor with YTN16 alone (P < 0.05). Co-inoculated fibrous tumor also showed an invasive growth pattern and higher progression than tumor with YTN16 alone (P = 0.045). Additionally, YTN16 and LmcMF co-inoculated tumors showed lower infiltration of CD8+ cells and higher infiltration of M2 macrophages than tumors with YTN16 alone (P < 0.05, P < 0.05). These results indicate that LmcMF plays as cancer-associated fibroblasts (CAFs) by crosstalk with YTN16 and CAFs contribute tumor progression, invasion, fibrosis, and immune suppression. CONCLUSIONS: This model is the first immunocompetent mouse model similar to TME of human clinical PM with fibrosis. By using this model, new treatment strategies for PM, such as anti-CAFs therapies, may be developed.

[Intraductal Papillary Mucinous Carcinoma with Penetration in the Colon and Retrograde Infection-A Case Report].

We report a case of intraductal papillary mucinous carcinoma(IPMC)penetrating the colon in an 82-year-old man. He visited our hospital with left upper abdominal pain. Abdominal CT showed IPMC of the pancreatic tail, measuring 7 cm, with tumor penetration to the colon and retrograde infection. After the antibacterial treatment, we performed distal pancreatectomy with colectomy. Pathological examination showed proliferation of adenocarcinoma of the gastrointestinal tract with penetration to the colon. Severe fibrosis and calcification surrounding the invasive cancer cells suggested a long disease duration. Despite adjuvant chemotherapy, he developed recurrence of peritoneal dissemination after 9 postoperative months, and subsequently, systemic chemotherapy was started. As intraductal papillary mucinous neoplasm(IPMN)might penetrate the adjacent organs, leading to a poor prognosis, even over a prolonged time period, IPMN should be followed-up appropriately and resected soon after the suspicion of malignant transformation.

A child with TSC2/PKD1 contiguous gene deletion syndrome successfully treated with tolvaptan for rapidly enlarging renal cysts.

Tolvaptan, a vasopressin receptor antagonist, has been shown to be effective in the treatment of renal cysts in ADPKD. However, tolvaptan is not indicated for pediatric patients, and reports of its use are rare, making its efficacy and adverse reactions unclear. Herein, we present the case of an 11-year-old girl who had vitiligo from birth. She was diagnosed with West syndrome at 6 months of age and tuberous sclerosis at 2 years of age. At the age of 6 years, an abdominal magnetic resonance imaging (MRI) revealed multiple bilateral renal cysts, and she was diagnosed with ADPKD. Abdominal MRI scans performed at 10 years and 11 years showed rapid renal cyst enlargement, and the renal prognosis was judged to be poor. The patient was treated with tolvaptan to delay cyst exacerbation. There were no apparent adverse events after the initiation of treatment, and the MRI performed 12 months after treatment initiation showed that renal cyst enlargement was suppressed. The results suggest that tolvaptan may be effective in pediatric patients with severe ADPKD who have rapidly enlarging renal cysts, although evaluation of renal cyst enlargement and side effects should be continued.

Splenic injury caused by cardiopulmonary resuscitation in a full stomach with hematoma after hemorrhagic shock due to bleeding duodenal ulcer: A case report.

Background: Cardiopulmonary resuscitation is essential for cardiopulmonary arrest, but complications from chest compressions warrant monitoring. Although rib and sternal fractures are common, abdominal injuries are rare, and splenic injuries are much rarer. Case Presentation: A 74-year-old man was admitted to the emergency room with a hemorrhagic duodenal ulcer. During hospitalization, the patient went into cardiopulmonary arrest due to hemorrhagic shock. Spontaneous circulation returned after 7 min of cardiopulmonary resuscitation. He underwent transcatheter arterial embolization to stop the bleeding from the duodenal ulcer. The next day, a close examination of the patient's progressive anemia revealed splenic injury; transcatheter arterial embolization was performed to save his life. Conclusion: It is important to consider the complication of splenic injury in patients with cardiopulmonary arrest who have undergone appropriate cardiopulmonary resuscitation. A possible mechanism-especially in patients with a full stomach-is the squeezing of the spleen by the diaphragm, abdominal wall, and stomach.

Abdominal internal oblique muscle hematoma of an obese middle-aged man induced by cough.

An obese middle-aged man presented for left abdominal pain. CT scan with contrast medium revealed hematoma in the left abdominal internal oblique muscle.

Robot-assisted low anterior resection for a rectal cancer patient with ileal conduit: A case report.

Surgery for rectal cancer patients with an ileal conduit after total cystectomy is difficult because adhesions in the pelvis and around the ileal conduit are expected. In the present case, we performed robot-assisted low anterior resection of the rectum in a 69-year-old male patient with rectal cancer who underwent ileal conduit diversion after total cystectomy. In this procedure, the port was inserted into the left upper abdomen as a first step, and two additional ports were added on the left side. Low anterior resection was performed using two left hands to create more space in the abdominal cavity for the ileal conduit. We present this minimally invasive robotic procedure that is extremely useful for dissection of adhesions in a narrow pelvic cavity.

Robot-assisted surgery for rectal cancer with solitary sacrococcygeal metastasis after neoadjuvant chemoradiotherapy: A case report.

An 81-year-old man was referred to our hospital for anal bleeding. Colonoscopy revealed a type 3 tumor at the upper rectum and biopsy showed adenocarcinoma. An enhanced circumferential lesion at the upper rectum and a solitary soft-tissue shadow at the fifth sacral vertebra to the coccyx were detected on abdominal magnetic resonance imaging. Fluorodeoxyglucose uptake was observed at the same sites on positron emission tomography. The patient was diagnosed with rectal cancer with isolated sacrococcygeal metastasis and was treated with neoadjuvant chemoradiotherapy followed by robotic surgery. Hartmann's operation was performed in the lithotomy position. The left internal iliac artery and vein were then divided. The internal pudendal artery and vein, the piriformis muscle, and sacrospinous ligament were also divided while preserving the lumbosacral trunk. The scheduled transection line of the sacral surface was fully exposed to prevent massive bleeding during sacrectomy. The dorsal surface of the sacrum was then exposed in the prone position and communicated with the pelvic space. The sacrum was transected at the superior margin of S3 and a specimen was extracted. Pathological findings revealed the infiltration of cancer cells in the sacrococcygeal specimen. The postoperative course was uneventful and the patient was discharged on postoperative day 13.

Segmental arterial mediolysis with a ruptured visceral artery on two consecutive days.

Background: We describe a case of segmental arterial mediolysis in which a vessel ruptured on two consecutive days. Case Presentation: A 69-year-old man presented with sudden-onset abdominal pain. Computed tomography showed a hematoma in the gastric wall. The patient was discharged after the pain was relieved but returned 8 h later with abdominal pain and shock. Repeated computed tomography revealed a massive intra-abdominal hemorrhage without previous aneurysm formation. Emergency angiography and coil embolization were successfully carried out. Segmental arterial mediolysis was diagnosed after irregular vasodilated lesions were observed in multiple arteries. Conclusion: This case suggests that accurately predicting the next vessel rupture is difficult. For patients experiencing intra-abdominal bleeding with segmental arterial mediolysis, we suggest treating only ruptured aneurysms and closely following-up unruptured aneurysms.

Safety and efficacy of cold-water immersion in the treatment of older patients with heat stroke: a case series.

BACKGROUND: Heat stroke treatment focuses on rapid cooling because symptom severity correlates with the duration of hyperthermia (i.e., time during which the core body temperature is sustained above the critical threshold). Several reports have revealed that cold-water immersion is a safe and appropriate therapy for exertional heat stroke in young, otherwise healthy patients. However, few reports have assessed cold-water immersion in older patients. We document three cases of cold-water immersion in older heat stroke patients and evaluate its safety and efficacy. CASE PRESENTATION: Three older patients with severe heat stroke were treated with cold-water immersion. Core body temperatures decreased rapidly, and no complications occurred during the treatment. CONCLUSION: Cold-water immersion can achieve rapid cooling and is effective in treating heat stroke. With special precautions, it can be performed safely for older patients. Further investigation is warranted to establish appropriate cooling methods in older adults.