Evaluation of additional gastrectomy after noncurative endoscopic submucosal dissection for early gastric cancer.

BACKGROUND: Performing additional surgery after noncurative endoscopic submucosal dissection (ESD) for early gastric cancer is controversial. Our aims are to clarify the risk factors for lymph node metastasis (LNM) and local residual cancer (RC) after noncurative ESD and to determine recommendations for additional treatment. METHODS: Of the 1483 patients who underwent ESD for early gastric cancer between January 2012 and April 2020, we retrospectively analyzed 151 patients diagnosed as having a lesion not meeting the curative criteria after ESD. Of these patients, 100 underwent additional gastrectomy, and 51 were observed without surgery. RESULTS: Surgical specimens showed LNM in 14 patients (14.0%) and local RC in 7 (7.0%). However, 81 patients (81.0%) had neither of these malignancies. Multivariate analysis revealed that a positive lymphatic invasion (P = 0.035) and an undifferentiated type (P = 0.047) were independent risk factors for LNM, whereas a positive horizontal margin (P = 0.010) was an independent risk factor for local RC. Furthermore, the prevalence of LNM was significantly higher in patients with both positive lymphatic and vascular invasions. In the additional gastrectomy group, 3 patients (3.0%) had recurrences, and 2 patients (2.0%) who had distant recurrences died of gastric cancer. In the observation group, recurrence was observed in 3 patients (5.9%). One patient (2.0%) who had liver metastasis died of gastric cancer. Of the 2 patients (3.9%) who had local recurrences, one underwent additional ESD, and the other without additional ESD died of other disease. The 5-year overall survival rates in the additional gastrectomy and observation groups were 87.4% and 73.8%, respectively (log-rank test, P = 0.008). CONCLUSION: Following noncurative ESD for early gastric cancer, we recommend an additional gastrectomy with lymph node dissection for patients with lymphovascular invasion and/or undifferentiated type. Careful follow-ups without additional surgery may be acceptable for patients with advanced age, severe comorbidity, or no lymphovascular invasion.

[Application of Bevacizumab beyond Progressive Disease in Patients with Lung Cancer Recurrence after Surgery].

BACKGROUND: The benefits of continuing bevacizumab (BEV) beyond progressive disease (PD) in patients with non-small cell lung cancer (NSCLC) remain unclear. We present our experience of continuing chemotherapy with BEV in patients with recurrent NSCLC after surgery. PATIENTS: From January 2010 to December 2016, chemotherapy with BEV was continued beyond PD in 20 patients. These patients included 10 men and 10 women, and their mean age at surgery was 71±10 years. Recurrence was observed at 630±460 days after surgery. RESULTS: The average number of protocols with BEV was 3±1 (1-6). The presented side effects were acceptable. Eight patients died of cancer. The 5-year survival rates after surgery, recurrence, and initiation of BEV were 78.8%, 50.1%, and 34.3%, respectively, and the median survival times were 2,465, 2,017, and 1,120 days, respectively. CONCLUSION: The majority of patients with operable NSCLC had a good performance status. We could detect recurrence early on, before the symptoms appeared, by regular examination. Therefore, these patients had an advantage in that more chemotherapeutic regimens could be administered to them and their prognosis could be improved by the continuation of BEV beyond over PD.

Efficacy and safety of low-dose capecitabine plus docetaxel versus single-agent docetaxel in patients with anthracycline-pretreated HER2-negative metastatic breast cancer: results from the randomized phase III JO21095 trial.

PURPOSE: The randomized phase III JO21095 trial compared the efficacy and safety of low-dose capecitabine plus docetaxel combination therapy (XT) versus single-agent administration of docetaxel in anthracycline-pretreated HER2-negative metastatic breast cancer. METHODS: Patients were randomized to either low-dose XT (capecitabine 825 mg/m2 twice daily, days 1-14; docetaxel 60 mg/m2, day 1 every 3 weeks) or docetaxel (70 mg/m2, day 1 every 3 weeks). The primary objective was to demonstrate superior progression-free survival (PFS) with low-dose XT versus single-agent docetaxel. Overall survival (OS) and safety were secondary endpoints. RESULTS: In total, 162 patients were treated. Median PFS was 10.5 months with low-dose XT and 9.8 months with single-agent docetaxel (hazard ratio [HR] 0.62 [95% confidence interval (CI) 0.40-0.97]; p = 0.03). The OS HR was 0.89 (95% CI 0.52-1.53; p = 0.68). Grade ≥3 treatment-related toxicities occurred in 74% of XT-treated patients and 76% of docetaxel-treated patients. The main differences in grade ≥3 treatment-related toxicities were hand-foot syndrome (7.3% of XT-treated patients vs 0% receiving docetaxel), fatigue/malaise (2.4 vs 10.0%), and peripheral edema (1.2 vs 7.5%). Dose modifications were required in 100% of low-dose XT and 49% of docetaxel patients. Toxicity-related treatment discontinuations occurred in 18 and 33%, respectively. CONCLUSION: The improved PFS with low-dose XT versus docetaxel alone is consistent with higher-dose XT phase III experience, but the safety profile was more favorable and manageable.

Circulating tumor cells as a prognostic marker for efficacy in the randomized phase III JO21095 trial in Japanese patients with HER2-negative metastatic breast cancer.

PURPOSE: Prognostic effects of circulating tumor cells (CTCs) have been reported in metastatic breast cancer (MBC). However, few phase III trials have investigated the potential role of CTCs in treatment selection. We explored potential relationships between CTCs, efficacy, and differential treatment effects. METHODS: Patients with HER2-negative MBC were randomized to receive either concurrent capecitabine plus docetaxel (XT) or sequential single-agent docetaxel followed by single-agent capecitabine at progression (T â†’ X). Blood samples were collected at baseline, on day 1 of cycles 2 and 3, and at progression. CTCs were counted using the CellSearch® System. The relationship between baseline CTC count and outcomes was investigated using a pre-defined threshold of 2 CTCs/7.5 mL. RESULTS: At screening, 44% of the 148 enrolled patients had positive CTC score. In multivariate analyses of pooled treatment arms, positive baseline CTC and triple-negative disease were strongly associated with worse progression-free survival (PFS) and overall survival (OS). Patients with positive CTC score at the baseline had worse OS, irrespective of change in CTC (decreased versus remaining positive) at cycle 2. The prognostic effect of baseline CTC count on OS appeared slightly less pronounced in XT-treated pts. compared with T â†’ X. CONCLUSIONS: A baseline CTC count ≥2 CTCs/7.5 mL was associated with worse prognosis. However, some improvement in PFS and OS was shown with concurrent XT, thus baseline CTC could be a predictive marker. As the current trial was not designed to evaluate a change in chemotherapy according to on-treatment CTC changes, prospective investigation is required.

Clinically node-negative invasive lobular carcinoma of the breast showing multiple lymph node metastases.

A 73-year-old woman was pointed out of her right breast tumor on screening computed tomography (CT). Mammography showed distortion of the mammary gland and skin retraction. Ultrasound (US) showed an irregular tumor with hyperechoic haloes adjacent to the anterior tumor borders. Neither lymphadenopathy nor image findings suggesting lymph node metastasis were detected on US and CT. Core needle biopsy pathologically showed the tumor to be invasive lobular carcinoma. Under the preoperative diagnosis of node-negative breast cancer, the patient underwent mastectomy and sentinel node biopsy. Due to no sentinel node detection, a small but hard lymph node was identified and submitted for frozen section as a sampling node. After confirming the lymph node metastasis on frozen section, axillary lymph node dissection revealed 12 lymph node metastases. Postoperative pathological study showed cancer cell infiltration to the dermis near the nipple-areolar complex. In addition, immmunostaining showed the tumor to have low proliferative biology, i.e., Ki-67 labelling index of 10%. Breast surgeons should note that indolent invasive lobular carcinoma with cancer cell infiltration to the skin near the nipple-areolar complex can have multiple lymph node metastases even though showing neither lymphadenopathy nor image findings suggesting lymph node metastasis.

Intracystic gastrointestinal stromal tumor developed in the round ligament of the liver.

A 44-year-old woman was referred to our hospital for the examination and treatment of a presumed gallbladder tumor. Both ultrasound and computed tomography showed an intracystic tumor but failed to point out the discontinuity between the cystic lesion and the gallbladder. Magnetic resonance imaging, however, could clearly depict the presumed intracystic tumor and the discontinuity between the gallbladder and the target lesion. Both contents of the gallbladder and the cystic lesion showed hypo and hyper intense patterns, though both with slightly different intensities, on T1- and T2-weighted images, respectively. Under the preoperative diagnosis of early gallbladder cancer despite these image findings, laparoscopic cholecystectomy was attempted to the patient. Laparoscopic observation, however, revealed that the target lesion was not continuous with the gallbladder and was located in the round ligament of the liver. Intraoperative findings led us to do cholecystectomy and resection of the adjacent cystic tumor. The intracystic tumor was 3 cm in size and had minute solid component inside the cyst wall. Pathological study of the presumed gallbladder cancer showed epithelioid cells and spindle cells growing in sheet like and storiform fashions, respectively. Cystic walls mainly consisted of hypo cellular fibrous components. Immunohistochemical staining of the tumor was positive for CD117 and negative both for desmin and S100, leading to the diagnosis of gastrointestinal stromal tumor. MIB-1 labelling index of the gastrointestinal stromal tumor was 8%. The patient recovered uneventfully and has been well without any recurrences for 3 months.

Successful endoscopic treatment of a huge trichobezoar in a 10-year-old girl.

A 10-year-old girl was admitted to our hospital due to acute pancreatitis. Computed tomography showed an intra-gastric mass containing multiple small air bubbles. Ultrasound showed a well-circumscribed large oval mass with a broad acoustic shadow. Endoscopy revealed a huge trichobezoar with many movable hairs, being judged by the cause of acute pancreatitis. Due to the parents' strong preference not to leave any surgical scars on their daughter, the patient underwent endoscopic treatment. The trichobezoar grasped with a snare was too large to pass through the esophageal-gastric junction. In addition, the outer layer of the trichobezoar was too hard to be cut with conventional endoscopic devices but was successfully cut with a FlushKnife. The content of the trichobezoar was much softer than its hard surface but needed appropriate counter-traction to be torn off the tissue. Two alligator forceps via a dual-channel multi-bending scope were able to give sufficient counter-traction to the inner tissue of the trichobezoar, successfully removing the trichobezoar through piece-by-piece tearing off. All the endoscopic procedures took seven hours for the complete trichobezoar removal. The total weight of the dissected mass was 180 g. The girl resumed eating on the next day and was discharged on the third day. Physicians should note that a medical team with full endoscopic expertise can remove huge trichobezoars using a FlushKnife, a dual-channel multi-bending scope, and two alligator forcepses.

Focal coagulative necrosis of the liver in a patient with sustained virologic response to anti-hepatitis C virus therapy.

A 69-year-old woman with chronic hepatitis C virus (HCV) infection was referred to our hospital due to liver enzyme abnormalities. Four years after anti-HCV therapy, the patient with sustained virologic response and no clinical symptoms developed an oval hepatic mass with mixed high and low internal echoes near the portal vein on ultrasound. Magnetic resonance imaging (MRI) of the liver lesion showed a slightly hypo intense pattern on T1-weighted images, a hyper intense pattern both on T2- and diffusion-weighted images, a slight rim enhancement pattern with no intra-lesional enhancement up to the late phase, and a very low intense pattern on hepatobiliary phase images. Positron emission tomography/computed tomography (PET / CT) showed no areas of avid radiotracer uptake in the liver. No tumor markers showed abnormally high values. All these images and laboratory findings led us to the assessment of the liver lesion as a non-neoplastic disorder. However, due to the patient's strong preference to get both definitive diagnosis and cure of the lesion, the patient underwent laparoscopic partial hepatectomy. Pathological study showed 2 necrotic areas surrounded by multiple lymph follicles, epithelioid cells, lymphocytes, collagen fibers, and plasma cells, leading to the diagnosis of focal coagulative necrosis of the liver (FCNL). Physicians should note that FCNL can occur without any symptoms and can be diagnosed at least as a non-neoplastic disorder with combined MRI and PET/CT analysis.

Eosinophilic variant of chromophobe renal cell carcinoma metastasizing to the liver: Diagnostic pitfall.

An 82-year-old man developed a hypervascular renal tumor, 2 cm in size, and multiple liver tumors. Liver tumors had obscured tumor margins on ultrasonography. Positron emission tomography/computed tomography (PET/CT) showed no areas of avid radiotracer uptake in the liver. Routine pathological examination failed to demonstrate tumor cells in 9 tissue samples obtained from repeated core needle biopsies. Even a frozen section of the liver segment 8 tumor further failed to prove malignant cells, and an additive frozen section of the liver section 2 tumor finally proved atypical cells growing in tubular and solid fashions with eosinophilic cytoplasm. Tumors showed expansive growth patterns, were in direct contact with normal liver cells, had abundant micro-vessels, had only sparse hyalinized septa, and had no pale cells. Immunostaining revealed the tumor cells to be positive for CD10, CD117, and E-cadherin and negative for CK7, and PAX8, leading to the diagnosis of metastatic chromophobe renal cell carcinoma (chRCC) in the liver. Arginase-1 immunostaining clearly demarcated the boundary between the chRCC cells and normal hepatic cells. Diagnostic physicians should note that chRCCs are of low-grade malignancy despite their abundant intra-tumoral blood flow and can often pose imaging and pathologic diagnostic difficulties.

A Metastatic Breast Tumor of an Appendiceal Signet Ring Cell Carcinoma.

A 54-year-old woman with pseudomyxoma peritonei from an appendiceal signet ring cell carcinoma was referred to our hospital. Right massive effusion with cytology-proven malignant cells was controlled with thoracentesis. Pathological study after intraperitoneal (IP) chemotherapy, hyperthermic IP chemotherapy, and cytoreductive surgery showed no malignant cells in the abdomen except for the appendix and greater omentum. Although the patient noticed a right breast mass, mammography (MMG) showed no abnormality. Ultrasonography showed right breast masses consisting of hypo- and hyper-echoic areas without clear tumor margins. Magnetic resonance imaging (MRI) with contrast medium showed multiple lesions showing persistent enhancement pattern. Pathological study of the vacuum-assisted biopsy specimen showed signet ring cells growing in diffuse, trabecular, and linear fashions, leading to the diagnosis of metastatic breast tumors from the appendiceal signet ring cell carcinoma. Positron emission tomography (PET)/computed tomography (CT) showed no fluorodeoxyglucose uptake in the breasts. The patient was treated with simple mastectomy for local control. Pathological study of the resected breast showed predominant localization of the metastatic breast tumors deep in the mammary gland and lymphovascular invasion. Metastatic breast tumors from appendiceal signet ring cell carcinomas are extremely rare and can sometimes be difficult to detect with MMG and PET/CT. General surgeon should note that appendiceal signet ring cell carcinomas can metastasize to the breast, presumably through lymphatic permeation from malignant pleural effusion, without abnormal MMG and PET/CT findings.

A presumed pathological complete response of ruptured hepatocellular carcinoma showing retained intratumoral blood flow after trans-arterial chemo-embolization.

A 74-year-old women with abdominal pain emergently visited our hospital in a shock status. After hemodynamics stabilization with intravenous fluid/albumin administration and blood transfusion, image evaluation showed perihepatic presumed blood retention and an intrahepatic large tumor. Angiography showed a tumor stain in the liver and no active leakage of the contrast medium from the tumor. These findings led to the diagnosis of ruptured hepatocellular carcinoma (HCC) without active bleeding. The patient, therefore, was treated not with trans-arterial embolization (TAE) but with trans-arterial chemo-embolization (TACE) using 10 mg of epirubicin. Post-TACE images showed marked tumor shrinkage with retained intratumoral blood flow. Under the tentative diagnosis of shrunken but viable HCC, the patient underwent laparoscopic segmentectomy for the HCC. Postoperative pathological study showed coagulative and lytic necrosis, intratumoral bleeding, hemosiderin deposits, massive collagen fiber, infiltration of inflammatory cells, and no viable cancer cells in the resected tumor. These pathological findings highly suggested that chemotherapeutic effect of epirubicin had brought about complete cancer cell death in the area not affected by TAE. Physicians should treat the patients with ruptured HCC, especially when showing stable hemodynamics, not by TAE but by TACE for better clinical outcome. Oncologists should further note that a complete pathological response of HCC could be observed even in cases of retained intratumoral blood flow.

Well-Differentiated Adenocarcinoma Spreading Widely in the Gastric Submucosa.

A 56-year-old woman was referred to our hospital due to dry mouth. Diagnostic upper gastrointestinal endoscopy showed slightly elevated lesions both on the anterior wall and lesser curvature in the upper part of the stomach. Biopsy-proven tuble-forming atypical cells in the two lesions led us to treat the presumed early gastric cancers with endoscopic submucosal dissection (ESD). Pathological examination of the ESD specimen showed well-differentiated malignant cells spreading widely in the submucosa with positive lateral and deep margins. On retrospective image re-evaluation after ESD, we noticed the correlation between the presumed early gastric cancers and the multiple submucosal cyst-like lesions in the gastric wall on computed tomography. Under the tentative diagnosis of gastric cancers originating not from orthotopic gastric mucosa but from submucosal ectopic gastric gland, the patient underwent laparoscopic total gastrectomy and regional lymph node dissection, revealing the tumor infiltration to the serosa and regional lymph node swelling. Postoperative pathological evaluation showed lymph node metastases, multiple submucosal cyst-like lesions lined with a single layer of presumably benign epithelium, papillary adenocarcinoma cells in the submucosa, and tubular adenocarcinoma cells both in the mucosal and subserosal regions. The patient was discharged on the postoperative 7th day without any events and completed adjuvant chemotherapy on an outpatient basis. General surgeons should note that cyst-like lesion(s) in the gastric wall might be a predictor of extensive submucosal cancer cell spreading even in a case of well-differentiated gastric adenocarcinoma.

Latissimus dorsi musculocutaneous flap grafting to the infected recipient site in a patient with irradiated locally advanced breast cancer and multiple lung metastases.

BACKGROUND: Musculocutaneous (MC) flaps are more resistant to infection than implants, but no clinical results have been reported so far about the grafting of MC flap to the overtly infected sites. CASE PRESENTATION: A 66-year-old woman had received radiotherapy, a total dose of 50 Gy, to her large mucinous breast cancer to control bleeding from the tumor and was referred to our hospital for further treatment. On her first visit to our hospital, her left breast showed radiation-induced total necrosis with Pseudomonas aeruginosa infection. Removal of the necrotic breast tissue resulted in direct exposure of the left ribs and intercostal muscles with intractable chest pain requiring analgesics. The presence of concomitant life-threatening multiple lung metastases made us change the treatment from letrozole and palbociclib to bevacizumab and paclitaxel, leading to marked regression of the lung metastases. To alleviate her chest pain and get local wound healing, we treated the patient with latissimus dorsi (LD)-MC flap grafting to the exposed chest wall after four months of taxane-containing chemotherapy. The patient has got marked pain relief immediately after the operation. Skin island of the grafted LD-MC flap showed no problems for 4 days just after the operation but gradually turned out to be edematous to ill-colored in the distal part of the skin island. Post-operative clinical outcome suggested that Pseudomonas aeruginosa infection might have had some adverse effect, e.g., microemboli, on MC flap blood flow. Partial necrosis of the LD-MC flap made the patient receive conservative wound management for a very long period of 11 months, finally leading to complete wound healing. After palliative surgery, the patient has been receiving fulvestrant and palbociclib for 14 months and doing well with good control of multiple lung metastases. CONCLUSIONS: Breast surgical oncologists should note that partial flap necrosis can occur when a LD-MC flap is grafted to the infected recipient site and consider the anti-coagulant therapy just after the operation to avoid the adverse effects of the infection.

Epithelioid Hemangioendothelioma of the Liver Showing Spontaneous Complete Regression after the Cessation of Methotrexate Intake.

A 71-year-old man with slight fever and dull abdominal pain was referred to our hospital. He had been receiving methotrexate (MTX) to treat his rheumatoid arthritis for more than 6 years but stopped taking MTX after admission due to the rapid aggravation of his liver function. Computed tomography (CT) showed multiple liver lesions with late enhancement, highly suggesting them to be cholangiocarcinomas. Tumor marker levels were normal except for a slightly elevated PIVKA-II level, i.e., 45 mAU/mL (range 0-40 mAU/mL). We did a biopsy to the largest lesion and endoscopic biliary drainage to make a definitive diagnosis of the hepatic lesions and treat jaundice, respectively. Pathological study showed round, polygonal, and spindle-shaped epithelial atypical cells growing in a sarcomatoid fashion. Atypical cells were positive for CD31, CD34, vimentin, and TFE3, and some of them had intracellular vacuoles, leading to the diagnosis of epithelioid hemangioendothelioma (EHE) of the liver. The patient got well 4 weeks after the endoscopic biliary drainage. CTs showed marked regression of the EHE lesions 3 months after biliary drainage and complete regression in 12 months. The patient further developed Hodgkin lymphoma in the para-aortic lymph nodes 23 months after the biliary drainage and is now under chemotherapy for the malignant lymphoma. We, however, have not detected any EHE lesions in the liver or distant organs for at least 16 months after the confirmation of complete regression of the EHE lesions. Oncologists should note the spontaneous regression of the EHE and investigate the correlation between MTX cessation and EHE regression.

Ipsilateral breast tumor recurrence (IBTR) in patients with operable breast cancer who undergo breast-conserving treatment after receiving neoadjuvant chemotherapy: risk factors of IBTR and validation of the MD Anderson Prognostic Index.

BACKGROUND: There is limited information about the risk factors for ipsilateral breast tumor recurrence (IBTR) after patients undergo breast-conserving surgery plus radiotherapy (breast-conserving treatment [BCT]) subsequent to neoadjuvant chemotherapy (NAC). The objective of the current study was to analyze these risk factors. METHODS: The authors collected data from 375 patients who underwent BCT and received NAC and analyzed the risk of IBTR associated with undergoing BCT after NAC. The usefulness of the MD Anderson Prognostic Index (MDAPI) for IBTR also was validated using the current data set. RESULTS: The median follow-up was 47.8 months, and the 4-year IBTR-free survival rate was 95.6%. Multivariate analysis demonstrated that estrogen receptor (ER) status and multifocality of the residual tumor were associated significantly with IBTR-free survival. In addition, patients who had ER-positive and human epidermal growth factor 2 (HER2)-negative tumors did not develop IBTR during the observation period. Although prognostic stratification according to MDAPI was relatively good for the prediction of IBTR in the study patients, the IBTR rate in the high-risk group was not very high and was lower than that in the intermediate-risk group. Multivariate analyses demonstrated that IBTR was an independent predictive factor for overall survival. CONCLUSIONS: ER status and multifocality of the residual tumor after NAC were independent predictors of IBTR after BCT. The MDAPI was barely adaptable to the study patients in terms of predicting IBTR. Patients with ER-positive and HER2-negative tumors had a favorable prognosis, whereas patients who developed IBTR after NAC had significantly worse overall survival. The authors propose a new IBTR prognostic index using the 2 factors that were identified as predictive of IBTR: ER status and multifocality of the residual tumor.

[The importance of p53 and ras mutation as predictive markers for adjuvant chemotherapy in non-small-cell lung cancer].

OBJECTIVE: A previous large, randomized, control trial(JBR.10)revealed that adjuvant chemotherapy with cisplatin(CDDP) and vinorelbine(VNR)was effective for non-small-cell lung cancer(NSCLC). It was also reported that adjuvant chemotherapy was not effective for p53-negative or K-ras mutation-positive patients. To clarify whether p53 and ras statuses are true predictive markers for chemotherapy with cisplatin, chemosensitivity was examined using an in vitro drug sensitivity assay. MATERIALS AND METHODS: Surgically resected fresh tumor specimens obtained from 27 patients at our institute with NSCLC were used for this study. Histoculture Drug Response Assay(HDRA)was applied to evaluate the chemosensitivity of CDDP and VNR in these specimens. p53 expression was evaluated by immunohistochemistry, and K-ras mutation by direct sequencing. RESULT: Four of the 27 patients were positive for K-ras mutation. The inhibition rate of CDDP was 54±5% for K-ras mutation positive-patients, and 50±13% for negative-patients. There was no significant difference between these two groups. p53 overexpression was observed in 14 patients, but not in 13 patients. The inhibition rate of CDDP was 50±12% for p53- overexpressed patients, and 50±12% for patients not overexpressed. The inhibition rate of VNR was 36±17% for p53- overexpressed patients, and 33±14%for patients not overexpressed. As for 8 adenocarcinoma patients, the inhibition rate of CDDP of p53-overexpressed patients(59±8%)was significantly(p=0. 018)higher than that of patients not overexpressed (45±9%). p53 overexpression may be a predictive marker for chemotherapy using CDDP in lung adenocarcinoma. CONCLUSION: p53 overexpression may be a possible predictive marker for adjuvant chemotherapy using CDDP in NSCLC.

Prolonged Large Seroma Formation after Breast-Conserving Therapy.

A 78-year-old obese woman with breast cancer underwent breast-conserving surgery and axillary lymph node dissection. Due to the prior exposure to long-term taxan chemotherapy for her recurrent gastric cancer, the patient did not undergo adjuvant chemotherapy and began to receive radiotherapy to both the conserved breast and supraclavicular region on the 39th day after operation. Two aspiration therapies were done to the enlarging seroma only at the initial phase of the radiotherapy. No further aspiration therapies were done to the seroma during and after radiotherapy for more than 3 months despite the undoubtable seroma formation. High degree of tension due to large seroma formation, extended from the axilla to deep into the breast parenchyma, made the patient request us to heal the long-lasting seroma. Five aspiration therapies and one simultaneous minocycline intrathecal injection therapy did not bring about wound healing. To heal the persistent seroma, capsulectomy was done to the encapsulated lesion 7 months after the operation. Resected capsule was 110 × 45 mm in size and had smooth inner surface. Pathological study showed the seroma capsule mainly consisting of fibrous tissue with some inflammatory changes. Postoperative course was uneventful, and wound healing was promptly obtained after capsulectomy. Breast surgeons and radiation oncologists should note this type of unfavorable radiation-induced adverse event after breast-conserving therapy.

Successful Enucleation of Intra-Nipple Recurrence of Breast Cancer.

A 36-year-old unmarried woman had undergone nipple-preserving mastectomy and immediate breast reconstruction using extended latissimus dorsi muscle flap for her left breast cancer. During adjuvant endocrine therapy, the patient sometimes developed faint bloody nipple discharge with negative cytological results. More than 9 years after operation, the patient developed left nipple swelling with evident bloody nipple discharge. A small tissue, spouted from the single duct orifice of the nipple by manual compression, showed atypical cells growing in papillary fashion, leading to the diagnosis of intra-nipple recurrence. Based on both the strong request from the patient and high probability of noninvasive nature of the recurrent cancer, we tried to enucleate the intra-nipple recurrence. In the operation, we first threaded the nipple skin at the affected duct orifice of the nipple, second incised the nipple with horizontal skin incision between the bilateral edges of the left areola via a small spindle skin resection just around the affected duct orifice, third threaded the intact lateral nipple skin for countertraction, and finally enucleated the intra-nipple recurrence. After completely enucleating the recurrent focus without any macroscopic cancer residuals in the nipple, we reproduced the nipple into the original shape, resulting in excellent cosmesis without any nipple necrosis. Histological study showed the intra-nipple recurrence to be noninvasive papillary cancer. Approximately a quarter of the main tumor and a small part of one ductal spread focus were pathologically exposed but were present without any missing boarders, suggesting complete resection of the intra-nipple recurrence. This is the first case of intra-nipple recurrence of breast cancer successfully enucleated without any complications.

Unilateral Axillary Lymphadenopathy due to Toxoplasmosis: A Ubiquitous Infectious Disease Important for Differential Diagnosis of Solid Malignancies.

A 30-year-old woman was pointed out for her right axillary lymphadenopathy in a medical checkup. Ultrasonography showed two swollen lymph nodes and the presence of lymph node hilum with a convex shape in the larger lymph node. Under the tentative diagnosis of lymphadenitis, the patient was initially treated with antibiotic therapy, leading to no improvement in her lymphadenopathy for 1 month. Positron emission tomography after antibiotic therapy showed a maximum standardized uptake value of 7.0 in the swollen lymph nodes without any other avidities. Neither mammography nor ultrasonography showed any abnormalities in the breasts. The serum IL-2R level was within the normal range. Despite the lack of malignant cells in the aspiration biopsy cytology specimen, the patient received lymph node excisional biopsy to avoid undertreatment. A postoperative pathological study showed a swollen lymph node with preserved lymph node structure, follicular hyperplasia, and lymphoid hyperplasia. The irregularly dilated germinal center had microglanulomas, tingible body macrophages, enlarged aggregation of monocytoid B cells with neutrophil interminglement, and no giant cells, leading to the diagnosis of toxoplasmosis. A detailed interview after the lymph node biopsy revealed that she did not have any cats but had chickens and had her right forearm a little injured by the roof edge of a chicken coop 5 weeks before the medical checkup. Postoperative serologic testing to further confirm the toxoplasma infection showed elevated IgG and IgM antibody levels. Oncologists and infectious disease specialists should note this type of transmission of toxoplasma gondii and unilateral lymphadenopathy as an important clinical manifestation of toxoplasmosis.

Nipple Preservation through Partial Nipple Incision and Partial Areola Resection for a Breast Cancer Adjacent to the Nipple-Areolar Complex.

A 45-year-old woman with a tumor just beneath the left areola was referred to our hospital. Magnetic resonance imaging (MRI) findings made us perform a core needle biopsy of the tumor, leading to the diagnosis of invasive lobular carcinoma (cT1N0M0). MRI also depicted three daughter nodules located medially to the main tumor in a linear fashion. Patient's strong request for nipple preservation made us try to resect the breast cancer in a manner to possibly preserve the nipple-areolar complex. First, to resect the target four tumors, medial horizontal skin incision at the nipple level and subsequent lower semicircular peri-areolar incision were done to the left breast. Second, small skin resection in a triangle shape and a radial fashion from the nipple bottom, i.e., orthogonal skin resection to the peri-areolar incision, was done to the areola just above the main tumor. Third, the triangle resection line was extended to the center of the parietal part of the nipple via a longitudinal skin incision on the lateral side of the nipple. Intra-nipple tissue adjacent to the sub-areolar tumor was resected as much as possible. Partially resected areola and partially incised nipple were sutured into the original shape. Pathological study showed invasive lobular carcinoma with lymphovascular invasion and widespread, i.e., total size of 60 mm, noninvasive lobular carcinoma and negative surgical margins in the nipple-areolar complex. The patient was discharged on the second day after operation, developed temporary superficial partial dermal necrosis of the nipple-areolar complex, and received adjuvant endocrine therapy, i.e., tamoxifen and luteinizing hormone-releasing hormone agonist scheduled for 10 years, and normofractionated radiotherapy to the conserved breast after full wound healing of the nipple-areolar complex.