[A Case of Fournier's Gangrene during Second-Line IRIS plus Bevacizumab Chemotherapy for Rectal and Anal Canal Cancer].

A 52-year-old man diagnosed with Stage ⅢA rectal and anal canal cancer underwent abdominal perineal resection using Miles's method. Two years later, local recurrence and lung metastases were detected using contrasted CT imaging. First-line chemotherapy of XELOX was administered for 4 months until the disease progressed and lung metastases developed. After 4 courses of second-line IRIS plus bevacizumab chemotherapy, fever and swelling of the right buttock appeared; he visited and was admitted to our hospital. A CT scan revealed a pelvic abscess which resulted in septic shock. Swelling and pain extended to the right scrotum, and acute necrotizing fasciitis was suspected, and emergency surgery was performed. An incision was made from the right buttock to the right scrotum, bloody purulent drainage with a foul odor was observed, and a diagnosis of Fournier's gangrene was made. Although typical CT findings such as emphysema due to gas-producing bacteria were not observed in this case, early diagnosis and intervention of systemic management including early surgical drainage and operation were effective. For pelvic infections occurring during bevacizumab chemotherapy, Fournier's gangrene should considered for differential diagnosis, even if CT findings are atypical.

[A Case of Superior Vena Cava Syndrome Due to Recurrent Breast Cancer Effectively Treated by Trastuzumab Deruxtecan].

A 64-year-old female underwent Bt+Ax surgery due to ER(-), PR(-), HER2(+), ycT3N1M0, Stage ⅢA right breast cancer. After cancer recured in the chest wall, whole-breast radiation therapy was performed, followed by ddAC, and T- DM1. After 12 courses of T-DM1, CT scan and physical findings showed no evidence of metastases, so chemotherapy was suspended with strict follow-up. Seven months later, a chest wall recurrence with pleural dissemination was found and 9 courses of PER plus HER plus eribulin therapy was administered until disease progression. T-DM1 was re-administered but disease progressed after 2 courses accompanied by SVC syndrome due to 8 cm mediastinal lymph node metastasis which caused respiratory discomfort and face edema. We administered T-DXd and after the first course respiratory symptoms vanished, and after 3 courses lymph node metastasis shrunk extremely in the CT imaging. SVCS is one of the oncologic emergencies, in which palliative radiotherapy may be typically selected for the relief of symptoms, and intravascular stents are used in urgent cases. Surprisingly, we experienced a case of SVC syndrome caused by breast cancer metastasis, effectively treated by T-DXd.

[A Case of an Advanced Intrahepatic Cholangiocarcinoma Effectively Treated by Conversion Surgery after Neoadjuvant Chemotherapy of Gemcitabine, Cisplatin and S-1].

A 61-year-old male suffered from intrahepatic cholangiocarcinoma in S7 lesion(90 mm diameter), diagnosed by hepatic tumor biopsy. As PET-CT showed para-aortic lymph node metastasis(cT3N1M1, cStage ⅣB), and judged to be unresectable, he received neoadjuvant chemotherapy of gemcitabine, cisplatin, and S-1(GCS). After 7 courses of GCS, CT showed partial response of the primary tumor and PET-CT showed decreased accumulation of FDG at para-aortic lymph node. Resectability was reexamined and the patient underwent S7 extended subsegmentectomy as conversion surgery. Furthermore, after the surgery, he received adjuvant chemotherapy of S-1 for 6 months, and he remained relapse-free for the next 2 years. Cholangiocarcinoma is one of the most poorly prognosed type cancer. Conversion surgery for unresectable intrahepatic cholangiocarcinoma is frequently reported, but there are still few reports of GCS as neoadjuvant chemotherapy. Here, we report a case of unresectable intrahepatic cholangiocarcinoma that was successfully treated with GCS and underwent conversion surgery.

[Incidence of Secondary Malignancy of Chronic Myeloid Leukemia during Treatment of Breast Cancer with Hormone Therapy].

It is expected that the number of long-term breast cancer survivors will increase owing to the improvements in chemotherapy and irradiation, while the risk of double cancers, including secondary malignancy, may become an issue. There are many unclear points in the treatment policy with regard to when a secondary malignancy occurs or the primary cancer relapses during the management of a secondary malignancy. A 54-year-old woman who was diagnosed with ER/PgR-positive HER2 negative breast cancer Stage ⅢB received neoadjuvant chemotherapy FEC and docetaxel followed by breast surgery, adjuvant hormone therapy, and radiation therapy. Chronic myeloid leukemia diagnosed by the abnormal findings of leukocytosis and bone marrow aspiration emerged after 3 years of the diagnosis of the first breast cancer. After 3 years of imatinib therapy that achieved a major molecular response(MMR)of CML, a recurrence of sacral metastasis of breast cancer was revealed by MRI. The combination of imatinib and hormone or S-1 chemotherapy could be maintained without serious adverse events after the relapse of the primary cancer.

[A Case of Advanced Esophageal Cancer Discovered Due to Suffocation, Which Was Invasive to the Trachea and Internal Carotid Artery and Treated by Chemotherapy].

A 51-year-old male presented with dyspnea due to upper airway obstruction. We decided to perform a cricothyroidotomy due to difficulty in performing orotracheal intubation. A CT scan revealed a massive tumor infiltrating into the right side of the neck, which penetrated the internal carotid artery. An upper gastrointestinal tract endoscopy was performed, and the patient was diagnosed with advanced esophageal cancer(stage Ⅳ, cT4N4M0). We initiated palliative chemotherapy of FOLFOX as first-line chemotherapy. After the fourth course, the patient was evaluated as having progressive disease(PD)due to regrowth of lymph node metastasis around the lower esophagus. Although we changed the treatment to nivolumab as second-line chemotherapy, there was a gradual exacerbation of airway obstruction, and the head and upper limb edema emerged due to superior vena cava syndrome. After the first course of nivolumab, we diagnosed the patient as having clinically PD. After the first course of docetaxel(DTX)as third-line chemotherapy, he suddenly died of massive hemorrhage caused by the intubation tube on day 136. Airway management is difficult to perform in patients with a poor response to chemotherapy due to obstruction by a tumor. On the other hand, excessive response to chemotherapy is also associated with a risk of massive hemorrhage due to arterial perforation, as observed in this case.

[A Case of Recurrent Premenopausal Hormone Receptor Positive Breast Cancer with Liver, Lung and Bone Metastasis Successfully Treated with Endocrine Therapy].

Here we report a 48-year-old female with recurrent breast cancer. She had received chest muscle-conserving mastectomy and lymph node dissection at another hospital, diagnosed as pStage ⅡB, T2N1M0 premenopausal left endocrine positive/ HER2 negative breast cancer at the age of 45. Although postoperative adjuvant therapy was started with LH-RH agonist plus tamoxifen, and chest radiation, tamoxifen therapy was intolerantly discontinued due to severe adverse events of hot flash after 1 year later. Three years later, she presented with back pain and was referred to our hospital. As PET-CT revealed recurrence of multiple bone and lung metastases and solitary liver metastasis which did not seem to be life-threatening, palliative radiation therapy and endocrine therapy with leuprorelin and anastrozole(LA)were started. Eighteen months later, PET-CT showed complete disappearance of liver and lung metastases and remarkable regression of bone metastases except for the right sciatic bone. LA therapy could be maintained for a total of 30 months until metastatic recurrence on liver and bone emerged. LA endocrine therapy may be effective for patients with premenopausal hormone-positive breast cancer even if the difficult situation such as tamoxifen intolerance.

Evaluation of total and allergen-specific secretory IgA in tears of allergic conjunctival disease patients.

PURPOSE: To investigate the variations in total secretory IgA (sIgA) and house dust mite (HDM)-specific sIgA antibodies in tears of patients with allergic conjunctival disease (ACD). METHODS: The subjects comprised 40 patients (40 eyes) with ACD and 21 healthy individuals as a control. Patients with ACD comprised three groups: 16 patients (16 eyes) with perennial allergic conjunctivitis (PAC group), 11 patients (11 eyes) with atopic keratoconjunctivitis (AKC group), and 13 patients (13 eyes) with vernal keratoconjunctivitis (VKC group). Tear samples were taken by the Schirmer I method using filter paper. Tear samples were eluted and analyzed for total sIgA and HDM-specific sIgA antibodies in tears by enzyme-linked immunosorbent assay. RESULTS: The mean (+/-SD) value of total sIgA in tears in the control, PAC, AKC, and VKC groups was 1446.7 +/- 1220.1, 706.8 +/- 567.2, 440.4 +/- 151.8, and 460.8 +/- 340.6 microg/ml, respectively. Total sIgA values were significantly lower in the VKC group than in the control group. We defined the HDM index as the ratio of HDM-specific sIgA to total sIgA. The HDM index in the VKC (P < 0.001), AKC (P < 0.001), and PAC (P < 0.001) groups was significantly higher compared with those in the control group. CONCLUSIONS: Low levels of total sIgA and high levels of HDM-specific sIgA indicate a local pathogenic factor in ACD.

[Clinical evaluation of a measurement method for secretory IgA in tears].

PURPOSE: To evaluate the efficacy of measurement of secretory IgA (sIgA) in tears with tear sampling methods using filter paper, and to review sIgA measurement method for clinical application. SUBJECTS AND METHODS: Subjects were divided into the following 4 groups: a healthy control group, 29 eyes of 29 subjects; a contact lens group, 15 eyes of 15 subjects; a dry eye group, 13 eyes of 13 subjects; and a herpes group, 6 eyes of 6 subjects. In all subjects the sIgA value in tears was measured. In addition, in eighteen eyes of 18 healthy control individuals, the tear sIgA value was measured three times, morning, noon, and night in one day, and the variation of tear sIgA value was checked. The tears were sampled by the Schirmer 1 method. Schirmer papers were eluted in 200 microl of 0.5 M NaCl and 0.5% Tween 20 in 0.05 M phosphate-buffered solution (pH 7.2). Tear sIgA value was measured by ELISA (enzyme-linked immunosorbent assay). RESULTS: Tear sIgA value was 1249.0+/-1025.0 microg/ ml in the healthy control group; 1057.4+/-1583.3 microg /ml in the contact len groups; 197.8+/-91.3 microg/ml in the dry eye group; and 759.7+/-467.8 microg/ml in the herpes group. There was no significant difference between the healthy control group and the contact lens group, or the control group and the herpes group. There was a significantly (p<0.0001) low value in the dry eye group in comparison with the healthy control group. In the 18 healthy control individuals, there was a tendency for the tear sIgA value collected at noon to be higher. CONCLUSION: Measurment of the changes in tear sIgA values caused by inflammation of the lacrimal gland is useful as a clinical test of lacrimal gland function.