Breast cancer dermal lymphatic invasion recurrence and contralateral axillary lymph nodes metastasis after complete response to neoadjuvant therapy: A case report.

INTRODUCTION AND IMPORTANCE: Non-luminal type breast cancer patients with pathological complete response (pCR) by neoadjuvant chemotherapy (NAC) usually have a good prognosis, but occasionally recurrence occurs. CASE PRESENTATION: A 61-year-old woman was diagnosed with breast cancer T2N2aM0 stage IIIA and its intrinsic type was non-luminal type. After NAC, the patient achieved pCR and underwent breast-conserving surgery and axillary lymph node dissection (ALND). Radiotherapy and trastuzumab of one-year duration was added. However, six years and two months later, local recurrence and contralateral axillary lymph node (CLALN) metastasis were identified. After resection, anti-human epidermal growth factor receptor 2 (HER-2) therapy was done, however, six months after operation, purpura was observed on the right chest and tended to increase. One and a half years after re-operation, dermal lymphatic invasion (DLI) recurrence without clinical inflammatory signs was diagnosed. A skin resection was performed >1.5 cm away from the purpura, and the surgical margins were negative but four months later, a recurrence re-emerged. CLINICAL DISCUSSION: CLALN metastasis is considered distant metastasis based on the current TNM classification. However, as previous ALND or radiotherapy can change lymphatic flow, the resulting CLALN may not be distant metastasis. DLI recurrence without clinical inflammatory signs is likely to be resistant to anti-HER2 even in non-luminal type, and even a 2-cm margin for skin surgical lines may result in positive margins. CONCLUSION: There are cases where CLALN after ALND should also be considered possible metastasis. In DLI recurrence, the skin excision margin line should be set very generously.

Ten-year follow up of cosmetic outcome, overall survival, and disease-free survival in endoscope-assisted partial mastectomy with filling of dead space using absorbable mesh for stage ≤ IIA breast cancer: comparison with conventional conservative method.

BACKGROUND: Data on long-term cosmetic outcome, overall survival, and disease-free survival of endoscope-assisted partial mastectomy (EAPM) for breast cancer are scarce. Thus, we examined these outcomes after a 10-year follow-up period, and compared with conventional conservative method (CCM). PATIENTS AND METHODS: Data on 257 patients with stage ≤ IIA breast cancer who underwent CCM (n = 125) or EAPM (n = 132) were analyzed. Cosmetic outcome at 2, 5, and 10 years was evaluated by 5 criteria (breast retraction assessment, nipple deviation, atrophy, skin change, scar). For overall mortality, breast cancer-specific mortality, and recurrence, the risk by operation method was tested by Cox proportional hazard models. RESULTS: EAPM performed significantly better than CCM in terms of cosmetic outcomes for location B at 2, 5, and 10 year-follow ups. As for cosmetic outcomes by individual criteria, EAPM had significantly higher proportions of satisfactory results for scar across all follow-up periods, and atrophy at 2-year and 10-year follow-up. There were no significant differences in terms of overall mortality, breast cancer-specific mortality, and recurrence between EAPM and CCM. The rates of patients who experienced local recurrence were similar between CCM and EAPM. CONCLUSION: EAPM is better than CCM in terms of long-term cosmetic outcome, especially for location B. As a surgical treatment for breast cancer, EAPM is comparable to CCM in terms of mortality and recurrence.

A case of intrathyroid parathyroid tumor that was difficult to diagnose by ultrasonography.

BACKGROUND: With advances in diagnostic imaging such as ultrasonography (US), computed tomography (CT), and 99mTc-MIBI-sestamibi (MIBI) scintigraphy, localized diagnosis of hyperparathyroidism (pHPT) has become possible with considerable accuracy. However, even with the use of these imaging techniques, since intrathyroid parathyroid tumors exist as a mass within the thyroid, it is often difficult to distinguish from thyroid masses. Although there have been various reports on US images of intraparathyroid tumors, we experienced a case with US images that were distinct from previous reports. Herein we present a case of an intrathyroid parathyroid adenoma (IPA) that was difficult to diagnose, with a main focus on US images. CASE PRESENTATION: A 53-year-old man with a diagnosis of hyperparathyroidism was referred to our department in December 2018. Ultrasonography revealed a tumor that was located in the inferior pole of the right lobe of the thyroid gland and no parathyroid mass was observed. The tumor had an irregular round shape and showed heterogeneous hyperechogenicity with a defined margin, but within it, there were a few irregular and hypoechogenic area with unclear margins, while the tumor had a mosaic appearance at first glance. Although 99mTc-MIBI scintigraphy showed accumulation at the same location in delayed phase, it was difficult to determine the presence of a parathyroid tumor on the image. The patient underwent an operation on April 2019 and the tumor could not be identified on both naked eye and palpation. We used US intraoperatively to define the location and resected the tumor. A parathyroid adenoma was diagnosed by frozen section and the final diagnosis was an intrathyroid parathyroid adenoma. CONCLUSION: We experienced an IPA presenting an US image that was atypical and has previously not been reported. IPA has no established US image to confirm the diagnosis and even with the use of other imaging techniques, a definitive diagnosis often cannot be established. Thus, our recommendation based on the current situation is that operation with intraoperative diagnosis using frozen section should be conducted if hypercalcemia and high I-PTH are observed and when localization sites in MIBI and US coincide.

Comparison of the indocyanine green dye method versus the combined method of indigo carmine blue dye with indocyanine green fluorescence imaging for sentinel lymph node biopsy in breast conservative therapy for stage ≤IIA breast cancer.

BACKGROUND: Fluorescence imaging (FI) is one of the methods to identify sentinel lymph nodes (SLNs). However, the procedure is technically complicated and requires procedural skills, as SLN biopsy must be conducted in dim light conditions. As an improved version of this method, we introduced a combined method (Combined mixed dye and fluorescence; CMF) consisting of indigo carmine blue dye and FI. The direct visualization of SLNs under shadowless surgical light conditions is facilitated by the addition of the blue dye. We compared the SLN detection rates of CMF with that of the indocyanine green (ICG) dye method (ICG-D). METHODS: A total of 202 patients with stage ≤IIA breast cancer who underwent breast conservative therapy with separate incision from January 2004 to February 2017 were reviewed. Details of the two methods are as follows: (1) ICG-D: 10 mg of ICG was used and the green-stained SLNs were resected via a 3-4 cm axillary incision; (2) CMF: A combination of 5 mg of ICG and 4-8 mg of indigo carmine was used. After a 1.5-2 cm incision was made near the point of disappearance of the fluorescence using Photodynamic Eye (PDE), the blue-stained SLNs were resected under shadowless surgical light conditions. RESULTS: There were 92 ICG-D and 110 CMF cases. CMF resulted in a significantly higher SLN detection rate than ICG-D (96.4% vs. 83.7%; p = 0.003). This difference was particularly notable in those aged ≥60 years (98.3% vs. 74.3%) and individuals with body mass index (BMI) ≥25 kg/m2 (90.3% vs. 58.3%). CONCLUSION: CMF is an effective method to identify SLNs which is safe and efficient. CMF achieves a high SLN identification rate and most of this procedure is feasible under shadowless surgical light conditions. CMF can reliably perform SLN biopsy even in those aged ≥60 years and individuals with BMI ≥ 25 kg/m2.

An accessory thyroid gland that presented tumor-like images.

A 26-year-old woman presented with right breast pain and itching. Incidentally, a firm, non-tender, movable mass (3 cm in diameter) located in the lower right part of the neck was identified by palpation. Ultrasonography revealed a clearly demarcated dumbbell-shaped mass with homogenous hypo- (cranial side) and hyper-echogenicity (caudal side) compared with the thyroid gland. Computed tomography scan and magnetic resonance imaging presented images that were different from thyroid gland substance. The right thyroid lobe was strongly compressed by the mass. Hyperparathyroidism was ruled out by laboratory testing. The patient solicited resection of the mass despite recommendations for core needle biopsy, and it was removed surgically. The mass was surrounded by a thin capsule and was not connected with the thyroid gland. Pathological examinations revealed normal thyroid gland tissue. The final diagnosis was an accessory thyroid gland. Accessory thyroid glands should be considered as a possible diagnosis when nodules around the main thyroid gland are encountered.

Comparison between endoscope-assisted partial mastectomy with filling of dead space using absorbable mesh and conventional conservative method on cosmetic outcome in patients with stage I or II breast cancer.

BACKGROUND: Studies comparing cosmetic outcome between conventional conservative method (CCM) and endoscope-assisted partial mastectomy (EAPM) are scarce. PATIENTS AND METHODS: A total of 111 patients with stage I or II breast cancer who underwent CCM (n=51) or EAPM (n=60) were reviewed. Evaluation of cosmetic outcome consisted of a 3-level scoring method; breast retraction assessment (0-2), nipple deviation (0-2), atrophy (0-2), skin change (0-2), and scar (0-2). Total scores ≥7 were considered satisfactory. Score 2 was considered satisfactory for analysis by each scoring criterion. RESULTS: EAPM had a higher rate of satisfactory results compared with CCM (71.7% vs. 52.9%; P=0.042), particularly for atrophy (55.0% vs. 29.4%; P=0.007), and scar (55.0% vs. 31.4%; P=0.012) and for location B (70.0% vs. 12.5%; P=0.025). CONCLUSIONS: EAPM is superior to CCM for postoperative cosmetic outcome with respect to atrophy, scar, and lower tumor location.

A case of solitary intraductal papilloma of the breast coexisting with ductal carcinoma in situ (DCIS).

A 54-year-old woman was referred to this institution because of spontaneous bloody discharge from the nipple of her left breast in July 2003. Physical examination revealed no mass, but minimal pressure on the mammary gland exuded a bloody discharge from the nipple. No lymph node swelling was recognized in the axillary or subclavicular regions. Mammography and magnetic resonance imaging revealed mastopathy. Ultrasonography on the immersion method demonstrated a dilated duct with an irregular, solid, hypoechoic mass immediately behind the nipple. Fine-needle aspiration cytology showed the mass to be an intraductal tumor. Carcinoembryonic antigen (CEA) concentration of the nipple discharge was 400 ng/ml. Preoperatively, she was diagnosed as intraductal solitary papilloma, and endoscope-assisted microdochectomy was carried out under general anesthesia. The tumor was 10.5-10.6 mm in diameter and had developed from the posterior wall of the duct adjacent to the nipple. The tumor contained a small solid area in which a two-cell layer of epithelium was missing, and thus solitary papilloma coexisting with ductal carcinoma in situ (DCIS) was diagnosed. Solitary intraductal papilloma coexisting with carcinoma is rare; cases of DCIS are exceptionally rare. Follow-up for 3 years has revealed no evidence of recurrence.

Parathyroid adenoma without hyperparathyroidism.

A 45-year-old female patient was admitted to our hospital presenting with a right anterior cervical tumor that was elastic, hard, painless and 3.5 x 3.5 cm in size. Laboratory data including serum calcium level, thyroid and parathyroid hormonal functions revealed no abnormalities. Further examination, consisting of computed tomography (CT), magnetic resonance imaging (MRI), ultrasonography (US) and radioisotope (RI)-imaging demonstrated that it was a solid tumor located behind the right thyroid lobe. The tumor, whose origin was unclear, was successfully removed with right thyroid lobectomy. Macroscopically, it appeared as reddish solid tumor consisting of small cystic lesions storing chocolate-colored mucous. Immunohistology confirmed that there was proliferation of chief cells with positive parathyroid hormone (PTH) staining. Thus the tumor was diagnosed as parathyroid adenoma despite a lack of clinical evidence for hyperparathyroidism. The reason for the lack of clinical features of hyperparathyroidism in this adenoma still remains unclear, however, there might be inactivation of hormone excretion, possibly due to insufficiency of blood supply. This was a very rare case of parathyroid adenoma exhibiting no clinical evidence of hyperparathyroidism.

The correlation of microsatellite instability and tumor-infiltrating lymphocytes in hereditary non-polyposis colorectal cancer (HNPCC) and sporadic colorectal cancers: the significance of different types of lymphocyte infiltration.

BACKGROUND: Tumor-infiltrating lymphocytes (TIL) are strictly divided into two categories: those lymphocytes in stroma and those in between cancer cells. However, there has been no fully adequate comparison of these two categories, especially analysis in relation to microsatellite instability (MSI). METHODS: The materials were derived from patients with colorectal cancer who underwent surgery in Jichi Medical School and Omiya Medical Center. There were 19 hereditary non-polyposis colorectal cancer (HNPCC) patients who were compatible with Japanese criteria A and 106 patients with sporadic colorectal cancer (sCRC) in either Dukes B or C stage. As microsatellite markers, the global standard five markers were selected. Immunohistochemical analysis was performed using the anti-CD3, -CD4, -CD8 and -S-100 antibodies and the results were evaluated according to the degree of infiltration, which was classified into three grades. RESULTS: As for stroma-infiltrating lymphocytes (SIL) in sCRCs, severe infiltration was observed in 20% of high microsatellite instability (MSI-H) patients and 12.8% of low microsatellite instability (MSI-L)/stable microsatellite (MSS) patients without a statistically significant difference. In contrast, severe infiltration of intra-tumor cell-infiltrating lymphocytes (ITCIL) was observed in 41.7% of MSI-H sCRC patients and 4.3% of MSI-L/MSS patients. Thus, there was a close correlation between ITCIL severity and increased microsatellite instability (P < 0.001). In examination of ITCIL, patients with severe infiltration tended to show a better survival rate than those with moderate or mild infiltration. CONCLUSIONS: The present study suggests that different factors are involved in the infiltration of SIL and ITCIL. Although there were no statistically significant differences, the cumulative survival rates tended to be higher in severe ITCIL cases than in those with moderate and poor ITCIL (P < 0.09). We suggest that there might be a possibility of ITCIL having a role for a better prognosis after colorectal cancer surgery, which is closely related to MSI.