[A Case of Recurrent Breast Cancer with Drug-Induced Interstitial Pneumonia Triggered by the Switch from an Original to a Generic Aromatase Inhibitor].

We report the case of a 72-year-old woman who had undergone mastectomy for left breast cancer 9 years ago and had received anastrozole for 6 years after the operation. A year ago, she experienced a breast cancer recurrence in the thoracic wall and lymph nodes and was re-administered anastrozole, leading to a shrinking of the recurrent tumor. After the change from anastrozole to a generic product 2 months ago, she experienced respiratory distress. A CT scan showed bilateral reticular and ground-glass shadows in the lung fields, leading to the diagnosis of interstitial pneumonia, which was treated with steroids. When the generic product was restarted after the symptom had resolved, a recurrence of the lung lesions was observed. Therefore, VATS was performed and a histopathological diagnosis of interstitial pneumonia was posed. We then switched to letrozole, but because of the reappearance of the same lung lesions, the drug was discontinued, and the course was observed. Six months after, the re-expansion of breast cancer metastases was observed. When exemestane was initiated, the lung lesions recurred. The patient's condition improved on a steroid pulse and artificial respiration; however, she died of aspiration pneumonia. We report a case of recurrent breast cancer with drug-induced interstitial pneumonia triggered by the switch from an original to a generic aromatase inhibitor.

Direct hemoperfusion with polymyxin-B-immobilized fiber columns improves septic hypotension and reduces inflammatory mediators in septic patients with colorectal perforation.

PURPOSE: Although some studies have reported favorable effects of direct hemoperfusion with polymyxin-B-immobilized fiber columns (PMX) for the treatment of septic shock, few studies have demonstrated the efficacy of PMX in studies with a uniform case definition and without any other blood purification techniques. MATERIALS AND METHODS: Fifty-two patients with severe sepsis or septic shock secondary to colorectal perforation were treated with PMX. Hemodynamic alterations and plasma concentrations of endotoxin, interleukin (IL)-1beta, IL-1 receptor antagonist (IL-1Ra), IL-6, IL-8, and IL-10 were evaluated following PMX treatment. RESULTS: We observed a significant reduction in plasma endotoxin in the nonsurvivors immediately after PMX treatment compared to before treatment. Systolic blood pressure was markedly increased and circulating levels of IL-1beta, IL-1Ra, and IL-8 were significantly reduced during a 2-h interval of PMX. CONCLUSIONS: Our findings suggested that PMX treatment appears to adsorb endotoxin and also modulates circulating cytokine during a 2-h interval of direct hemoperfusion in septic patients with such condition.

An autopsy case of granulocyte-colony-stimulating-factor-producing extrahepatic bile duct carcinoma.

A 79-year-old man was referred to this department due to the presence of extrahepatic bile duct carcinoma with a tumor at the left chest wall. The lesion was suspected to be a metastasis of bile duct carcinoma to the left wall, however, computed tomography (CT) revealed no regional lymph node or liver metastases. In addition, cytological and pathological examinations did not show malignancy. At the time of admission, the white blood cell count was 21460 cells/muL (neutrophils, 18240 cells/muL) and this elevated to 106040 before death. In addition, serum granulocyte colony-stimulating factor (G-CSF) was elevated. At 28 d after admission, the patient died. An autopsy showed a poorly differentiated adenocarcinoma with sarcomatous change, which had slightly invaded into the pancreas around the bile duct, and was found in the distal bile duct with multiple metastases to the chest wall, lung, kidney, adrenal body, liver, mesentery, vertebra and mediastinal and para-aortic lymph nodes, without locoregional lymph node and liver metastasis. The cancer cells showed positive immunohistochemical staining for anti-G-CSF antibody. This is believed to be the first report of an extrahepatic bile duct carcinoma that produces G-CSF. Since G-CSF-producing carcinoma and sarcomatous change of the biliary tract leads to poor prognosis, early diagnosis and treatment are needed. When infection is ruled out, the G-CSF in serum should be examined. In addition, examinations such as bone scintigraphy and chest CT should also be considered for distant metastasis.

Successful wound management for infected perineum in recurrent rectal cancer by a two-step operation using muscle flaps: a case report.

Perineal wound failure associated with infection is one of the intractable complications after abdominoperineal resection including pelvic exenteration. It is supposed that there is a strong possibility of this complication occurring in patients with infected perineal lesions after radiation therapy. We describe herein a case of a 56-year-old female who received pelvic exenteration for recurrent rectal cancer, the perineal wound of whom was successfully managed by a two-step operation using muscle flaps. The patient had a recurrent tumor in her pelvis after abdominoperineal resection for locally advanced rectal cancer. She had been treated with chemoradiotherapy for the recurrent tumor. The tumor was exposed to the perineum and was associated with bacterial infection. The tumor was curatively resected by total pelvic exenteration. The perineal wound infection was controlled by a lay-open method after reconstruction of the pelvic floor using a rectus abdominis muscle. The perineal wound was secondarily closed using gracilis mycocutaneous flaps 14 days after pelvic exenteration. She was discharged uneventfully 14 days after perineal closure. The strategy in the present report may be a useful option for perineal wound management in patients with a high risk of perineal wound failure due to infection after abdominoperineal resection.

Comparison of the postoperative outcome after a pancreatoduodenectomy using the Billroth I and II type of reconstruction.

BACKGROUND/AIMS: Several types of gastrointestinal reconstruction have been employed after a pancreatoduodenectomy (PD), however, it remains controversial as to which type is the most beneficial. The aim of this study was to investigate the effects of a gastrointestinal reconstruction on the postoperative outcome after PD. METHODOLOGY: The medical records of 68 patients who underwent a PD between 1994 and 2004 were retrospectively reviewed. A total of 28 patients underwent a Billroth I reconstruction while 40 had the Billroth II reconstruction. Both the occurrence of postoperative complications and the nutritional status were compared between the two groups. RESULTS: The patient age, gender, preoperative symptoms, and operation profiles were the same between the two groups. The morbidity and mortality did not differ between the two groups; however, the prevalence of leakage after a hepaticojejunostomy was higher in the Billroth II group than that in the Billroth I group (23% vs. 0%, P = 0.007). All cases of bile leakage were successfully treated by conservative therapy. The day that oral intake was resumed and the length of the hospital stay also did not differ between the two groups. Both groups showed a similar postoperative nutritional status after a PD, as assessed by body weight, the serum albumin and cholesterol concentrations, and the number of lymphocytes. CONCLUSIONS: Bile leakage tends to occur after a PD using a Billroth II reconstruction, however, this can be easily managed by conservative therapy, and it does not influence morbidity, the resumption of oral intake, or the length of hospital stay. Therefore, we could not clearly identify any advantages of one group or another in terms of postoperative complications and the nutrition status after PD. Further investigations from other points of view are therefore necessary to clarify the effect of a gastrointestinal reconstruction after PD.

Radiofrequency ablation with the real-time virtual sonography system for treating hepatocellular carcinoma difficult to detect by ultrasonography.

Radiofrequency ablation has been applied to treat hepatocellular carcinoma, with favorable therapeutic outcomes. Nevertheless, practitioners have approached radiofrequency ablation with some reluctance due to the difficulty of identifying isoechoic tumors and recurrent tumors. The aim of the present study is to investigate the efficacy of Real-time Virtual Sonography to treat hepatocellular carcinoma difficult to detect by conventional ultrasonography. Real-time Virtual Sonography is a system generating multiplanar reconstruction images in real-time using the Hitachi medico EUB-8500 equipped with a probe. The system included following components: 1) digital imaging and communications in medicine (DICOM) data from dynamic CT, 2) a magnetic field generator to match the multiplanar reconstruction image on the monitor and the actual ultrasonography image, 3) the cross section with the tumor displayed as a multiplanar reconstruction image. Total twenty-five nodules of twenty-one patients underwent radiofrequency ablation monitored by Real-time Virtual Sonography. All nodules difficult to detect via conventional ultrasonography were clearly visualized in real-time. The average nodule diameter was 2.4 +/- 1.6 cm, and punctures and coagulation were performed an average of 2.2 and 3 times per session. Dynamic CT after session confirmed effective coagulation of each nodule. In conclusion, this study demonstrates that the present system is capable of effectively and accurately treating tumors difficult to detect by conventional ultrasonography.

Significance of pancreatic exocrine function in the perioperative management of pancreatoduodenectomy.

BACKGROUND/AIMS: The significance of pancreatic exocrine function in the perioperative management of pancreatoduodenectomy (PD) has not been well understood. The aim of this study was to clarify this issue. METHODOLOGY: Clinical records of 60 Japanese patients who underwent PD were reviewed retrospectively. Patients were divided into two groups, normal (n=33) and low (n=27) pancreatic exocrine function, according to the preoperative value of N-benzoyl-L-tyrosyl-p-aminobenzoic acid excretion test (normal value >70%). We compared the perioperative events and nutritional status between the two groups. RESULTS: The preoperative and operative characteristics between the two groups were not significantly different. Postoperative pancreatic juice output from the remnant pancreas during the initial 7 days after PD was greater (1145 +/- 618 vs. 741 +/-612mL, P=0.02), and the prevalence of pancreatic anastomotic leakage was higher (10/23, 30% vs. 1/27, 4%, P=0.008) in the group with normal pancreatic exocrine function than that in the insufficient group. Perioperative body mass index and serum albumin concentration, which reflect the nutritional status of patients, were significantly lower in the group with low pancreatic exocrine function (P=0.007 and 0.04, respectively). CONCLUSIONS: Surgeons should pay more attention to pancreatic anastomotic leakage in patients with normal pancreatic exocrine function after PD. On the other hand, in patients with insufficient exocrine function, perioperative nutritional support should be considered.

Expression of MAGE-A3 in intrahepatic cholangiocarcinoma and its precursor lesions.

MAGE-A3 antigen is known to be neo-expressed in a large proportion of tumors but not detectable in normal tissues, and could be a target antigen recognized by autologous cytotoxic T lymphocytes. In the present study, the expression of MAGE-A3 at protein and mRNA levels was examined in intrahepatic cholangiocarcinoma (ICC) and its precursor lesions. Carcinomatous and dysplastic biliary cells expressed MAGE-A3 in their cytoplasm diffusely, although there was no MAGE-A3 expression in normal and hyperplastic biliary cells. MAGE-A3 was expressed in one of 10 cases (10%) of low-grade dysplasia, four of 13 (31%) cases of high-grade dysplasia/in situ carcinoma, and 32 of 68 invasive ICC cases (47%), respectively. The MAGE-A3 mRNA expression pattern was similar to that of MAGE-A3 protein. The incidence and intensity of MAGE-A3 expression increased along the progression of biliary neoplasia (P < 0.05). There was no correlation between MAGE-3 expression and histological differentiation or anatomical locations of invasive ICC. MAGE-A3 is a promising target molecule for the specific immunotherapy of ICC.

[A case of liver metastatic recurrence of bile duct cancer completely responding to single drug, UFT, chemotherapy].

A 72-year-old man with common bile duct cancer was treated by pylorus preserving pancreatoduodenectomy with D3 lymph node dissection and preventive radiotherapy at hepaticojejunostomy. At 4 months after surgery, CT demonstrated multiple liver metastatic tumors. Single drug chemotherapy, UFT 600 mg, was started. After 6 months, the liver metastatic tumor could not be seen by CT. UFT may be a first candidate for chemotherapy for recurrence of bile duct cancer.

Increasing expression of gastrointestinal phenotypes and p53 along with histologic progression of intraductal papillary neoplasia of the liver.

Intraductal papillary neoplasia of the liver (IPN-L) was recently proposed as the name for intraductal papillary proliferation of neoplastic biliary epithelium with a fine fibrovascular stalk resembling intraductal papillary mucinous neoplasm of the pancreas. We histochemically and immunohistochemically examined IPN-L alone or associated with hepatolithiasis, with an emphasis on the gastrointestinal metaplasia, nuclear p53 expression, and histologic progression. A total of 66 cases of IPN-L were divided into 4 groups: group 1, IPN-L with low-grade dysplasia (13 cases); group 2, IPN-L with high-grade dysplasia (20 cases); group 3, IPN-L lined with carcinoma in situ and no or microinvasion (19 cases); and group 4, group 3 with distinct invasive carcinoma (14 cases). It is suggested that IPN-L progresses from group 1 to group 4. As controls, 20 cases of nonneoplastic intrahepatic large bile ducts and 17 cases of nonpapillary invasive intrahepatic cholangiocarcinoma (ICC) were used. Biliary epithelial hypersecretion of sialomucin rather than sulfomucin was prevalent in IPN-L, and this was associated with the progression of INP-L. Immunohistochemically, cytokeratin (CK) 20 and MUC2, a gastrointestinal marker, were expressed more frequently in IPN-L than in nonneoplastic bile ducts and nonpapillary ICC (P <0.01), and their incidence were significantly increased in parallel with the progression of IPN-L (P < 0.01). In contrast, expression of CK 7, a biliary marker, was decreased in IPN-L compared with nonpapillary ICC. Nuclear p53 immunostaining was detected in 30% of IPN-L as a whole and increased in tandem with the progression of IPN-L (P < 0.01). It is suggested that IPN-L forms a spectrum of biliary epithelial neoplasia with frequent gastrointestinal metaplasia, different from the usual nonpapillary ICC, and shows stepwise progression from the perspective of mucin profile, gastrointestinal metaplasia, and p53 nuclear expression.