[A Case of Chronic Expanding Hematoma of the Lower Abdomen after Reconstruction of Deep Inferior Epigastric Perforator Flap for Breast Cancer].

A 49-year-old woman who had surgery for left breast cancer and subsequently underwent a two-stage deep inferior epigastric perforator(DIEP)flap reconstruction. One month postoperatively, she became aware of abdominal distention and visited a local hospital. CT scan revealed subcutaneous fluid accumulation with capsular formation in the lower abdomen. Imaging findings and physical examination showed no abdominal wall scar hernia. After multiple puncture aspirations, fluid accumulation was observed again, and the possibility of a chronic expanding hematoma was considered. Later, hematoma removal, including the capsules, was performed; pathological findings showed no evidence of malignancy. No fluid retention was observed postoperatively. In cases where imaging evaluation reveals hematoma formation with capsules, hematoma removal, including the capsules, should be performed to avert the possibility of a chronic expanding hematoma.

Axillary management based on American college of surgeons oncology group Z0011 criteria makes it possible to omit intraoperative diagnosis of sentinel lymph nodes in early breast cancer patients.

The ACOSOG Z0011 trial has resulted in the omission of axillary lymph node dissection (ALND) in early breast cancer patients with one or two metastatic sentinel lymph nodes (SLNs). There has been increasing interest in the necessity of intraoperative assessment of SLNs in patients treated based on the Z0011 criteria. We evaluated the utility of intraoperative assessment in these eligible patients. A total of 1396 patients were treated following the Z0011 criteria from April 2012 to December 2019. We examined the proportion and clinicopathological features of patients who underwent ALND due to three or more metastatic SLNs and the sensitivity of intraoperative assessment. Only 16 (1.1%) patients had three or more metastatic SLNs diagnosed by intraoperative assessment, and they immediately underwent ALND. Of the clinicopathological factors, high clinical tumor stage (p = 0.002) and high Ki-67 labeling index value (p = 0.056) were more likely to be associated with the presence of three or more metastatic SLNs. The major independent risk factor for three or more metastatic SLNs was high clinical tumor stage (OR 3.94 [95% CI 1.42-11.0]; p = 0.009). Intraoperative assessment had low sensitivity (70.5%) and a high false-negative rate (29.5%) in detecting SLN metastases. The main finding of our study was the small proportion of patients who required ALND due to three or more metastatic SLNs according to the Z0011 criteria. The Z0011 strategy enables intraoperative assessment of SLNs to be omitted in early breast cancer patients.

[Primary Rhabdomyosarcoma of the Breast in a 16-Year-Old Girl].

We report a case of primary breast rhabdomyosarcoma. A 16-year-old girl noticed tumor of her right breast and consulted a local clinic. From the result of core needle biopsy, breast sarcoma was suspected, so she attended our hospital. Breast ultrasonography showed a mosaic pattern tumor occupying the whole right breast. CT images revealed an axillary node metastasis and no distant organ metastasis. Immunohistochemical staining of the tumor yielded positive results for desmin, MyoD1, and myogenin. Based on reverse transcription polymerase chain reaction(RT-PCR), she was diagnosed as an alveolar rhabdomyosarcoma with PAX3-FKHR(FOXO1)fusion transcripts[t(2;13)(q35;q14)]. She underwent total mastectomy and dissection of axillary lymph nodes. After surgery, the whole-body magnetic resonance imaging(MRI) demonstrated metastases of sacrum and left foot, so she was under systemic chemotherapy.

Prognostic value of tumor cell DNA content determined by flow cytometry using formalin-fixed paraffin-embedded breast cancer tissues.

PURPOSE: The use of formalin-fixed paraffin-embedded (FFPE) tumor tissues in flow cytometry (FCM)-based determination of tumor cell DNA content is more complicated than the use of fresh-frozen tissues. This study aimed to accurately measure tumor cell DNA content from FFPE tissues by separating tumor cells from stromal cells through FCM and investigating its prognostic impact. METHODS: We separately measured the DNA contents of tumor cells and stromal cells by gating with pan-cytokeratin and vimentin (FCMC/V). We evaluated tumor cell DNA contents [DNA index (DI)] of 290 FFPE tumor tissues and classified them into low and high DI groups, using a cutoff DI value determined through an unbiased computational method. RESULTS: The distribution of DI was bimodal, and a cutoff value was determined at a DI of 1.26. The high-DI tumors were associated with aggressive phenotypes and had significantly worse distant recurrence-free intervals (DRFI) than low-DI tumors. Multivariate analysis revealed that lymph node metastasis, Ki67, and DI were independent factors affecting DRFI. Accordingly, patients with low-DI/low-Ki67 tumors had excellent outcomes compared with other tumor types. Multiploid tumors were associated with increased lymphocytic infiltration and aggressive phenotypes. CONCLUSIONS: The DI of FFPE tumors could be precisely determined through FCMC/V. A combination of DI and Ki67 analyses may be able to predict the prognoses of breast cancer patients with greater accuracy.

[A Case of Pure Squamous Cell Carcinoma of the Breast in an Elderly Woman Diagnosed by Cytology].

A n 85-year-old woman presented with a mass in the left breast. A3 7mm lobulated mass including enhancement of a cyst of 37mm was detected by sonography. An axillary lymph node had increased to 16 mm. Atypical cells dyed by light green and orange G were identified by fine needle aspiration and cytology. She was diagnosed with left breast cancer(cT2N1M0, Stage II B), histologically suspected to be squamous cell carcinoma. She underwent a left-breast-conserving surgery and axillary lymph node dissection. On pathology, a cyst of 34×30mm was noted. The tumor grew from inside the cyst to the surround- ing tissue and it had a trend for keratinocytes. Lymph node metastases affected 1/11. By immunostaining, the tumor was found to be ER(+), PgR(-), HER2(-), CK5/6(+), p40(+), mammaglobin(-), and GCDFP15(-). There was no component of ductal carcinoma. She received radiotherapy to the left breast and tamoxifen as an adjuvant therapy. Squamous cell carcinoma of the breast is rare. We encountered a case of pure squamous cell carcinoma of the breast in an elderly woman. We report this case with a discussion of the relevant literature.

[A Case of Concurrent Primary Gastric Malignant T-Cell Lymphoma and Pulmonary Mucosa-Associated Lymphoid Tissue Lymphoma].

A 71-year-old man was admitted to our hospital for epigastric pain. Upper gastrointestinal endoscopy revealed a type 2- like ulcerative lesion in the posterior wall of the upper and middle part of the stomach. Endoscopic biopsies showed malignant T-cell lymphoma histologically. A chest CT scan revealed a nodule in the apex of right lung, suggestive of primary lung cancer. A total gastrectomy with D2 lymphadenectomy and distal pancreatectomy with splenectomy was performed. Seventy-three days after surgery, the patient developed a lung abscess in the middle lobe of the right lung. A wedge-shaped resection of the upper lobe and total resection of the middle lobe of the right lung was performed. Histological examination revealed a primary pulmonary mucosa-associated lymphoid tissue lymphoma in the upper lobe of right lung and an abscess caused by Pseudomonas aeruginosa in the middle lobe of the right lung. Twelve months after surgery the man died of suffocation because of aspiration due to esophageal stenosis caused by progression of metastasis of the paraesophageal lymph node.

[A Case of Granulocyte-Colony Stimulating Factor-Producing Gastric Cancer Successfully Treated with Trastuzumab].

A 68-year-old man diagnosed with type 0-Ⅰgastric cancer by gastrointestinal endoscopy underwent urgent distal gastrectomy due to a perforation during endoscopic submucosal resection. Pathological examination revealed pT3N2M0, pStage ⅢA. TS-1 was administered as adjuvant chemotherapy. Laboratory examinations 10 months after surgery revealed leukocytosis (19,100/mL). Positron emission tomography-CT demonstrated metastases in the bone marrow and ascending colon as well as around the liver. Chemotherapy using nab-PTX had poor efficacy and the leukocytosis worsened. Serum granulocyte- colony stimulating facto (r G-CSF) was high at 1,640 pg/mL, and immunohistochemical staining was positive for G-CSF. Thus, the patient was diagnosed with G-CSF-producing gastric cancer. The tumor was also positive for HER2 antibody by immunohistochemical staining. Combination therapy using TS-1 plus CDDP plus trastuzumab resulted in a good response, and the leukocytosis and elevated serum G-CSF gradually improved. The patient is living 30 months postoperatively and remains on chemotherapy.

[A Case of Gastric Cancer Associated with Membranous Glomerulonephritis].

An 81-year-old woman was admitted for leg edema. She was found to have membranous glomerulonephritis with advanced gastric cancer after renal biopsy and endoscopic examination. Serum albumin was 1.4 g/dL and total protein was 4 g/dL on admission. After albumin was administered, distal gastrectomy was performed. Albumin administration continued post-operatively. The post-operative course was unremarkable and she was discharged on post-operative day 19. Six months after the operation, serum albumin gradually increased and uric protein volume decreased. Possible remission of membranous glomerulonephritis with gastric cancer can be expected after gastrectomy but careful perioperative management is required.

[A Case of Peritoneal Metastasis of Breast Cancer Diagnosed by Laparoscopic-Assisted Right Hemicolectomy].

The patient was an 86-year-old woman. She underwent right breast-conserving surgery and sentinel lymph node biopsy for breast cancer in August 2006. The pathological diagnosis was invasive ductal carcinoma, T1N0M0, Stage Ⅰ, ER (+), PgR (-), HER2 (-). She was treated with tamoxifen for 5 years as adjuvant therapy and showed no signs of recurrence. In November 2014, CA15-3 was elevated and an accumulation of FDG in the right paracolic sulcus was observed on PET-CT. Peritoneal metastasis of breast cancer was suspected, and an operation was performed for a definitive diagnosis. During the operation, the tumor was seen on the paracolic sulcus, and laparoscopic-assisted right hemicolectomy was performed. A poorly differentiated adenocarcinoma was diagnosed by pathological examination, and immunostaining results were as follows: CK7(+), CK20(-), mammaglobin (-), GCDFP-15 (-), ER (-), PgR (-), and HER2 (-). Because there was no original lesion other than the breast cancer, the tumor was diagnosed as a metastasis of breast cancer. The frequency of peritoneal metastasis of breast cancer is low. In this case, pathological diagnosis was necessary for a definitive diagnosis. A change of subtype was also confirmed, and the treatment strategy was decided appropriately. Surgical resection should be considered for peritoneal metastasis of breast cancer when the operation can be performed safely.

[A bridge to surgery for colon cancer obstruction in a very elderly patient - a case report].

A 94-year-old woman with a distended abdomen was transferred to our hospital.Based on the enhanced abdominal computed tomographic (CT) finding, she was diagnosed with colonic obstruction due to sigmoid cancer. Colonoscopy was performed to make definitive and qualitative diagnoses, and to release the stenosis using a self-expanding metallic stent (SEMS). The SEMS was inserted without complication.On the fifth day after the decompression, the patient underwent laparoscope-assisted sigmoidectomy with lymph node resection.Despite the colon obstruction, a primary anastomosis was performed.The operation time was 163 min, and 3 mL of blood was lost.The patient was discharged without complications. We describe the case of a bridge to surgery in a very elderly patient. A bridge to surgery can be an effective option for the treatment of colon obstruction in non-elderly and very elderly patients.

[A case of simultaneous laparoscopic resection of colorectal cancer and a synchronous liver metastasis].

A 39-year-old woman was referred to our hospital with a history of fecal occult blood.She was diagnosed with advanced sigmoid colon cancer.A colonoscopy indicated a stenosis, and an enhanced abdominal computed tomography (CT) scan revealed liver metastasis.The patient was operated on for a total of 337 minutes, and an estimated 35 mL of blood was lost. This is the shortest operating time and lowest amount of blood loss of which we are aware.Although an intra-abdominal abscess occurred, the patient recovered well and was discharged on postoperative day 25.Herein, we describe the case of a patient who underwent simultaneous laparoscopic resection of sigmoid colon cancer and a synchronous liver metastasis.We also review the efficacy of simultaneous laparoscopic resection of colorectal cancer and synchronous liver metastasis in this report.

[A case of neoadjuvant chemotherapy for locally advanced rectal cancer, which had a invasion into the vagina followed by curative resection].

A-64-years-old woman with locally advanced rectal cancer, which had invaded the vagina, was referred to our hospital. She was administered neoadjuvant chemotherapy to reduce the tumor size. After 4 courses of chemotherapy consisting of folinic acid, fluorouracil, and oxaliplatin (mFOLFOX6), an enhanced computed tomography (CT) scan and magnetic resonance imaging (MRI) indicated marked tumor shrinkage. We performed a laparoscopically assisted low anterior resection, which included total mesorectal resection, resection of the vaginal posterior wall, and right lateral lymph node resection. The chemotherapy prevented us from having to create a permanent colostomy. The efficacy of the neoadjuvant chemotherapy was Grade 1b. We experienced a case of neoadjuvant chemotherapy followed by curative resection.

[Cetuximab improved the poor performance status of a colorectal cancer patient].

A 60-year-old man with unresectable colon cancer required treatment for hydronephrosis, acute cholecystitis, and obstructive jaundice before chemotherapy. His performance status (PS) gradually deteriorated to PS 4. Cetuximab monotherapy was initiated instead of intensive chemotherapy. His general condition improved and mFOLFOX7 therapy was then continued in addition to cetuximab. A computed tomography (CT) scan after 6 months of chemotherapy revealed a partial response (PR). Cetuximab monotherapy may contribute to the treatment of patients with a poor PS.

[Six synchronous primary cancers - a case report].

A 60-year-old man presenting with dysphagia was referred to our hospital with a diagnosis of esophageal cancer and gastric cancer. Upper gastrointestinal endoscopy revealed type 2 tumors in the upper thoracic esophagus and in the lesser curvature of the angular incisure, and elevated lesions in the duodenum and in the transverse colon. Laryngoscopy revealed erosion of the right vocal cord. Computed tomography (CT) of the chest revealed a nodule in the middle lobe of the right lung. Laryngomicro surgery was performed for the right vocal cord erosion, and it was diagnosed as carcinoma in situ. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) were performed for the lesions in the duodenum and in the transverse colon, respectively; the lesions were diagnosed as adenocarcinoma in adenoma. After 2 courses of neoadjuvant chemotherapy with the 5-fluorouracil (5-FU), cisplatin, and Adriamycin (FAP) regimen, subtotal esophagectomy with reconstruction of the pedunculated jejunum through the antethoracic route, total gastrectomy, and resection were performed on the right middle lobe of lung. Pathological examination revealed esophageal cancer (fT4N0M0, fStageIII), gastric cancer (ypT3N0M0, pStageIIA), and primary pulmonary adenocarcinoma (pT1bN1M0, pStageIIA). After surgery, the patient was treated with chemoradiotherapy (60 Gy, with 2 courses of 5-FU plus cisplatin [FP]), and 6 months after the operation, he was in good health without recurrence.

[Efficacy and safety of eribulin for metastatic breast cancer patients].

In the EMBRACE trial, eribulin was reported to significantly increase overall survival compared to treatment of the physician 's choice when given to patients with recurrent or metastatic breast cancer who had received prior treatment, including an anthracycline and a taxane. In April 2011, eribulin was approved in Japan for the treatment of inoperable or recurrent breast cancer. In this article, we report on the efficacy and safety of eribulin in cases we encountered. Twenty patients with advanced and recurrent breast cancer were administered eribulin in our hospital during the period from August 2011 to December 2012. The median age was 62 years(range, 42-76 years); 16 patients had the estrogen receptor(ER)(+)/human epidermal growth factor receptor 2(HER2)(-)subtype, whereas 4 patients had the triple-negative subtype. Following recurrence, the median number of chemotherapy regimens was 3(range, 0-5). Regarding the antitumor effects of eribulin, no cases showed complete response(CR), 5 cases showed partial response(PR), and 10 cases showed stable disease(SD); therefore, the response rate(CR+PR)was 25% and the clinical benefit rate(CR+PR+B6-month SD)was 35%. Median progression free survival was 146 days, and median overall survival was 482 days. In terms of adverse events(AEs), observed cases of hematotoxicity were of neutropenia(75%), leucopenia(75%), and anemia(80%). Cases of Grade 3 hematotoxicity or higher were of neutropenia(40%), leucopenia(20%), and febrile neutropenia(1 case, 5%). The observed non-hematotoxic AEs were peripheral neuropathy(30%)and general malaise(35%), although none were of Grade 3 or higher. The therapeutic efficacy of eribulin in the present study was relatively better than that in previous reports(EMBRACE trial, Japan Domestic 221 trial). The frequency of Grade 3 or higher AEs was low, and the drug was well tolerated. We believe that eribulin is a novel drug that provides therapeutic efficacy while maintaining quality of life(QOL).

[Evaluation of laparoscopic hepatectomy for hepatocellular carcinoma with cirrhosis].

Laparoscopic hepatectomy has been reported as a safe and effective approach for the treatment of hepatocellular carcinoma ( HCC). However, few studies have reported survival outcomes after laparoscopic hepatectomy in HCC patients with cirrhosis. In the present study, we evaluated the surgical outcomes and disease-free survival in these cases. Between June 2010 and March 2013, 35 HCC patients with cirrhosis underwent laparoscopic hepatectomy. Operative variables for laparoscopic vs open hepatectomy were as follows: operative times, 268.3 vs 183.3 minutes (p=0.0043); blood loss volume, 151.0 vs 1,106.1 g (p<.001); 1-year disease-free survival rate, 73.1 vs 71.6%; and 2-year disease-free survival rate, 39.9% vs 28.6% (p=0.568), respectively. Laparoscopic hepatectomy is feasible and safe in selected patients with liver cirrhosis, with similar outcomes in disease-free survival when compared with open hepatectomy.

[A case of recurrent duodenal gastrointestinal stromal tumor resistant to imatinib and sunitinib, successfully treated with regorafenib].

Regorafenib is a novel, orally administered multi-kinase inhibitor that has recently been approved for the treatment of recurrent gastrointestinal stromal tumor (GIST). We report a case of successful treatment of recurrent duodenal GIST, which was found to be resistant to imatinib and sunitinib, with regorafenib. A 62-year-old woman underwent a pancreatoduodenectomy for duodenal GIST; after 2 years, a computed tomography (CT) scan detected liver metastases. The patient received imatinib for 6 years, and underwent 2 hepatectomies. Subsequently, she received sunitinib for 10 months; however, CT scans revealed the presence of multiple vertebral metastases. She underwent a laminectomy for the palliative treatment of the vertebral metastases. Upon immunohistochemical examination, the recurrent tumor stained positive for c-kit, confirming the diagnosis for GIST. Consequently, the patient received regorafenib; although the treatment controlled the liver metastases, the vertebral metastases were found to have progressed. She survived for 9 years and 5 months after the initial surgical resection. Regorafenib might be beneficial in the treatment of recurrent GISTs that prove to be resistant to imatinib and sunitinib.

[A case of gastric outlet obstruction and rectal obstruction due to metastases from breast cancer treated by gastroduodenal and colon stenting].

Malignant bowel obstruction often causes oral intake difficulties and decreases quality of life. In Japan, gastroduodenal stenting for malignant gastric outlet obstruction has been covered by health insurance since 2010, while colon stenting has been covered since 2012. Both approaches are useful treatments for malignant bowel obstruction. Here we report the case of a woman with gastric outlet obstruction and rectal obstruction due to breast cancer metastases who was able to eat solid food after duodenal and colon stenting. When choosing whether to perform endoscopic stenting or surgical intervention such as gastrojejunostomy, ileostomy, and colostomy for treating malignant bowel obstruction, it is important to assess the patient's general condition and prognosis as well as the obstruction position.

[A case of colonoscopy release of intussusception due to sigmoid colon cancer].

A 53-year-old woman with recurrent abdominal pain was referred to our hospital. Based on the enhanced abdominal computed tomographic (CT) finding, she was diagnosed with intussusception of the sigmoid colon. Colonoscopy was performed to release the intussusception, and a lead point lesion was detected. An advanced cancer was found in the rectum, which could be pushed back into the sigmoid colon easily using pressurized air. A more-advanced colon cancer was also detected on the oral side of the lesion. The patient was diagnosed with double cancer of the sigmoid colon and was treated with laparoscopic sigmoidectomy with lymph node resection (D3). Preliminary reduction by colonoscopy prior to surgery is an effective option in cases of adult intussusception. Colonoscopy can be used to perform definitive and qualitative diagnoses.

[A case of appendiceal intussusception induced by appendiceal carcinoma].

A 26-year-old man was admitted to hospital because of lower quadrant pain. Colonoscopy showed a polypoid lesion (0- Ip: protruded, pedunculated)in the cecum. Endoscopic biopsy revealed a tubular adenoma with severe atypia. Laparoscopy- assisted ileocecal resection was performed, as the diameter of the tumor made colonoscopic treatment difficult. Appendiceal intussusceptions were found in the excised specimen. The tumor was mucosal in origin. The patient remained cancer-free after the surgery.