Preservation of the nipple-areola complex in skin-sparing mastectomy for early breast cancer.

PURPOSE: Skin-sparing mastectomy (SSM) enables a radical cure of breast cancer while overcoming the cosmetic issues related to surgery. We review our experience of performing SSMs and assess whether preservation of the nipple-areola complex (NAC) could have been an option for some patients who underwent SSM. METHODS: The subjects of this retrospective study were women who underwent SSM that utilized four incision types; namely, the so-called tennis racket incision, a periareolar and midaxillary incision, an areola-sparing and midaxillary incision, and a small transverse elliptical incision. We assessed whether preservation of the NAC would have been an option in SSM, based on histologic examination of three serial cut surfaces of the specimen around the nipple, ruling out the option when evidence of the malignant lesion/s was found in at least one of the following locations: in the nipple, within a 1-cm radius from the base of the nipple, or within 1 cm from the surface of the NAC. RESULTS: We performed 193 SSMs. The cumulative 10-year local disease-free survival rate was 98%, with 89% of patients reporting levels of satisfaction with the reconstructed breast, of excellent, very good, or good. We evaluated that 70 of the 193 procedures could have been performed as nipple-sparing mastectomy (NSM). CONCLUSIONS: The outcomes of SSM in this series were excellent and NSM might have been an option for about one-third of the patients.

Clinical comparison of four types of skin incisions for skin-sparing mastectomy and immediate breast reconstruction.

PURPOSE: Skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) has become popular as an effective procedure for patients with early breast cancer. We herein report an overview of the four types of skin incisions used for SSM. METHODS: The records of 111 consecutive breast cancer patients, who received SSM and IBR from 2003 to 2012, were reviewed retrospectively. Four types of skin incisions were used. Type A was the so-called tennis racquet incision, type B was a periareolar incision and mid-axillary incision, type C was the so-called areola-sparing with mid-axillary incision and type D was a small transverse elliptical incision and transverse axillary incision. RESULTS: Twenty-six type A, 59 type B, 20 type C and six type D incisions were made. The average blood loss and average length of the operation during SSM were not significantly different between the four approaches. The average areolar diameter was 35 mm for type A, B and D incisions, and 45 mm for type C. There was a need for postoperative nipple-areolar complex plasty (NAC-P) in 75 % of the cases following type A, B and D incisions, and 35 % of the cases treated using type C incisions. CONCLUSION: The type C incision is superior with regard to the cost and cosmetic outcomes, because fewer of these patients request postoperative NAC-P.

[A case of repeated bone metastases of breast carcinoma successfully treated by S-1 chemotherapy].

We report a case of breast carcinoma with repeated recurrences in the right bone. The recurrent site of the bone was treated by radiation therapy with a total of 3 7. 5 Gy irradiation, and chemotherapy with the CMF regimen. After 2 years, recurrence was suspected in the same region because there was an elevation of the NCC-ST-439 tumor marker. We carried out chemotherapy with S-1 100mg/body/day. The NCC-ST-439 value returned to within the normal range after 3 months' administration of S -1, and continued in the normal value for 20 months.

Intraoperative 99mTc-MIBI-guided detection of ectopic glands in secondary hyperparathyroidism.

99mTc-MIBI-guided detection of abnormal parathyroid glands in primary hyperparathyroidism (1-HPT) has become a popular and effective technique, but its efficacy for detecting the ectopic glands of secondary hyperparathyroidism (2-HPT) is still controversial. Of the 2-HPT cases from 2000 to 2004, 14 ectopic parathyroid glands in 11 patients were resected using intraoperative 99mTc-MIBI scintigraphy. We evaluated and compared the results of radioguided surgery with the preoperative findings from ultrasonography (US), computed tomography (CT), and scintigraphy. The overall results for intraoperative 99mTc-MIBI-guided detection of ectopic parathyroid glands were sensitivity of 100% (14/14) and accuracy of 84.2% (16/19) compared with 42.9% (6/14) and 31.6% (6/19), respectively, for preoperative US and 50.0% (6/12) and 42.9% (6/14), respectively, for preoperative 99mTc-MIBI scintigraphy. Using intraoperative 99mTc-MIBI-guided surgery in cases of 2-HPT will ensure all ectopic parathyroid glands are detected, making the surgery easier to perform and the outcome more successful.

Incidental discovery of follicular lymphoma by sentinel lymph node biopsy and skin-sparing mastectomy for Paget's disease associated with invasive breast cancer.

In breast cancer surgery, establishing a diagnosis other than lymph node metastasis of breast cancer, when performing a sentinel node biopsy in individuals with breast cancer, is rare. Here, we report a case of incidental discovery of follicular lymphoma by sentinel lymph node biopsy for Paget's disease associated with invasive breast cancer. A 60-year-old female initially presented with erosion on her left nipple and was clinically diagnosed with stage IA human epidermal growth factor receptor type 2 (HER2)-positive breast cancer and Paget's disease. Accordingly, skin-sparing mastectomy, sentinel lymph node biopsy, and immediate breast reconstruction were performed. Although an intraoperative pathological examination of frozen sections of lymph nodes presented no evidence of metastasis, it revealed large follicles. Based on immunohistochemistry of the additional lymph nodes, she was diagnosed with follicular lymphoma. Therefore, we initiated chemotherapy for follicular lymphoma followed by trastuzumab. At present, 6 years after the operation for breast cancer, the patient is doing well.

HER-2 protein overexpression in metastatic breast carcinoma found at autopsy.

OBJECTIVE: The overexpression of HER-2 protein has generally been considered to be consistent in primary and metastatic tumor tissues. We evaluated HER-2 protein overexpression levels in 31 autopsied cases. METHODS: Hematoxylin-eosin staining and immunohistological staining Hercep Test II were performed on the primary tumors and the lung, liver, brain and bone metastatic tumors. RESULTS: Nine (29%) of the 31 primary tumors were HER-2 score 3+ and HER-2 score 3+ cases were significantly more frequent in carcinomas of nuclear Grade 3 than in those of Grade 1 or 2. In these 31 patients, the HER-2 status in the primary tumors was consistent with the metastatic foci of the lung, liver, brain and bone in 96% (25 of 26), 91% (21 of 23), 100% (12 of 12) and 85% (11 of 13), respectively. With regard to the nine patients with HER-2 score 3+ primary tumors, the HER-2 status in the primary tumors was consistent with the metastatic foci of the lung, liver, brain and bone in 87% (seven of eight), 78% (seven of nine), 100% (only one) and 33% (one of three), respectively. In 11 (92%) of the 12 patients with brain metastasis, the HER-2 was not overexpressed. CONCLUSIONS: Even in the far-advanced stages of autopsy, HER-2 status of the primary tumors appeared to be maintained especially in the foci of the lung, liver and brain metastases. As there was a high degree of agreement in HER-2 status between the primary tumors and the metastatic foci to the lung, liver and brain, it is considered to be reasonable to treat patients with such metastatic foci based on the HER-2 status of the primary tumors.

Cytological and histological diagnoses of recurrent thyroid carcinoma with monoclonal antibody JT-95, which can detect modified fibronectin.

Although fine needle aspiration (FNA) cytology has increasingly gained importance as a tool in thyroid diagnosis over the recent years, up to 20% of thyroid carcinomas, in particular follicular tumors and follicular variant tumors, are inconclusive by FNA. The monoclonal antibody (MoAb) JT-95 detects the modified fibronectin, expressed in most thyroid carcinomas. Consequently, it has been applied to FNA and tissue section specimens obtained from thyroid tumors during surgery. For FNA specimens of 57 thyroid tumors followed-up for more than 10 years postoperatively and stained with both the Papanicolaou and the immunoperoxidase technique using MoAb JT-95, we retrospectively compared the sensitivity, specificity, and diagnostic accuracy of the two procedures. Histological specimens stained with HE and investigated by JT-95 were also re-evaluated. The pathological results of aspirated specimens, after a change in diagnosis following recurrence, revealed that 43 of 47 malignant lesions were positive, while nine of 10 benign tumors remained unreactive using MoAb JT-95. Sensitivity was 91.4%, specificity 90.0%, and diagnostic accuracy 91.2% by JT-95 cytology. By contrast, sensitivity ascertained by the Papanicolaou technique was 78.1%, specificity 100%, and accuracy 82.4%. Of the six examples that recurred during the 10-12-year follow-up period, tissue sections of all six and aspirated materials of five of the six were stained by JT-95.

Malignant melanoma originating on the female nipple: a case report.

We report a very rare case of malignant melanoma arising on a female nipple. A 42-year-old housewife had suffered from a small dark brown nevus on her left nipple for about thirty years without any changes. Six months before her initial visit it had begun to enlarge and rapidly changed from dark brown to black. A small bleeding ulcer was also present in the center of the lesion. Malignant melanoma rather than mammary Paget's disease was suggested based on its clinical course. Excisional biopsy was performed to differentiate between mammary Paget's disease and malignant melanoma. The histopathological examination revealed malignant melanoma, about 4 mm in thickness. She then underwent wide excision with axillary lymph node dissection. The surgical margin was made in a 3 cm radius around the biopsy site. The excision included nipple, areola, and part of the underlying breast parenchyma, adipose tissue and corresponding superficial layer of fascia. Microscopy showed metastasis in one of 13 axillary lymph nodes. After the operation, the patient received adjuvant DAV-Ferron therapy. In such a case, conserving surgery based on correct diagnosis can achieve a good cosmetic result and optimal tumor control.

Breast metastasis nine years after nephrectomy for renal cell carcinoma: A case report.

INTRODUCTION: The breast is a rare site for metastatic disease. We report a rare case of breast metastasis 9 years after nephrectomy for renal cell carcinoma (RCC) and include a review of the relevant literature. PRESENTATION OF CASE: An 82-year-old woman who developed an RCC underwent left nephrectomy in 2005. In October 2014, computed tomography (CT) revealed a mass of approximately 1cm in the lateral portion of the right breast. Breast ultrasonography (US) revealed a well-circumscribed, hypoechoic mass at the same site. Fine needle aspiration (FNA) was performed, but the sample was inadequate because it did not capture breast duct epithelial cells. In June 2015, follow-up US revealed enlargement of the mass, and core needle biopsy (CNB) was performed to confirm the diagnosis. Histological examination resulted in the diagnosis of breast metastasis from an RCC. The patient underwent surgery for partial mastectomy in November 2015. The patient was asymptomatic and free of detectable disease at 18-month follow-up. DISCUSSION: The diagnosis of breast metastasis by imaging examination is difficult, and the results of FNA examination are often inconclusive because of the absence of breast duct epithelial cells. Only 22 cases of breast metastasis from RCC have been described in the literature. In almost all the reported cases, lumpectomy or partial mastectomy was performed. CONCLUSION: It is important that histological diagnosis be determined by CNB and by other methods if the patient has a history of malignancy, and minimally invasive therapy should be performed in accordance with the prognosis.

Huge cavernous hemangioma arising in a male breast.

We report a rare case of a huge cavernous hemangioma arising in a male breast. A 60-year-old man first noticed 1 x 2 cm elastic hard nodule just below his right nipple ten years previously. It enlarged 5 x 5 cm over six years. When he came to our clinic, it was size of child head (510 mm in circumference),was an elastic hard with a rather smooth surface, and firmly fixed to the chest wall. Magnetic resonance imaging (MRI) and multidetectocomputed tomography (MDCT)showed a large mass infiltrating into the chest wall. Fine needle aspiration cytology (FNA) and core needle biopsy (CNB) failed to obtain proper material except for old bloody fluid or necrotic connective tissue, precluding a correct diagnosis preoperatively. Mastectomy with partial resection of the chest wall was subsequently performed. Histologically, it was found to be a cavernous hemangioma without cellular atypia. In such a case, complete excision is recommended to exclude the possibility of an underlying malignant lesion.

Breast cancer screening and the changing population pyramid of Japan.

BACKGROUND: Breast cancer has been the most prevalent cancer in Japan since the 1990s. The mortality from breast cancer is increasing in Japan, whereas in other industrialized countries it has been decreasing since 1990. On the other hand, Japan faces unparalleled growth in its aging population. The aim of this study was to report the mammography screening among Japanese women and the related upcoming changes in the population pyramid of Japan. DATA SOURCES AND METHODS: The reference data for our study were obtained from the Center for Cancer Control and Information Services, Japan Ministry of Internal Affairs and Communications, Ministry of Health, Labour and Welfare, the Japanese Cancer Society, and the National Institute of Population and Social Security. The survey data were obtained from breast cancer and mammography screenings in the Tokyo Prefecture in 2008. The following parameters were analyzed: annual breast cancer incidence, current screening rates, average life-span, and predicted demographic statistics. RESULTS: Our results showed that breast cancer incidence and mortality have been increasing annually in Japan. The average age of breast cancer patients increased to 58.40 years in 2010. The incidence of breast cancer in women aged 65 years and older increased from 25.3 to 32.9 % in the last 10 years and is expected to continue to increase in the future. The check-up rate was 16.0-20.0 % for women aged 65-74 years and 43.0-46.0 % for women aged 40-54 years. According to our questionnaire survey, concerns about breast cancer and mammography screening were high in the young and low in the elderly women. The Japanese population aged 65 years and older was 30,740 (24.1 %) in 2012 and is estimated to increase by 40 % over the next 20 years despite Japan's declining population size. CONCLUSION: Breast cancer incidence has increased in Japan, even among patients aged 65 years and older. Breast cancer has become increasingly prevalent in older Japanese women. As the population pyramid of Japan changes, women aged 65 years and older, who think that there is no longer need to receive mammography screening and are not educated regarding self-examinations, should be encouraged to receive regular check-ups for breast cancer.

Immunological assessment of cryotherapy in breast cancer patients.

BACKGROUND: In murine studies, cryotherapy has induced antitumor immune responses associated with the rejection of tumors. However, the effects of freezing-induced immunomodulation in breast cancer (BC) patients remain unclear. MATERIALS AND METHODS: Ten BC patients were prospectively divided into two groups: 1) cryotherapy followed by surgical excision and 2) surgical excision-alone. The cytokine profiles of plasma and peripheral blood mononuclear cells (PBMCs) were analyzed using flow cytometry following in vitro stimulation with the 30-mer MUC1 peptide. RESULTS: No differences in the percentages of interferon-γ (IFN-γ)-producing cluster of differentiation (CD)4(+) or CD8(+) T cells and the plasma levels of IFN-γ, interleukin-1ß (IL-1ß), IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12p70, tumor necrosis factor-α (TNF-α) and TNF-ß were observed between these 2 groups, and PBMCs were not significantly altered. CONCLUSION: Alternations to the type 1 and 2 helper cytokine profiles were not detected in vitro in BC patients treated with cryotherapy-alone.

An Extracellular Matrix Molecule, Secreted by the Epithelial-Mesenchymal Transition is Associated With Lymph Node Metastasis of Thyroid Papillary Carcinoma.

BACKGROUND: Papillary thyroid carcinoma often has lymph node metastasis, compared with follicular thyroid carcinoma. The study showed that epithelial-mesenchymal transition occurs in carcinoma cells during the first stage of metastasis, where some extracellular matrix molecules are secreted in large quantities. Sialic acid carried by fibronectin as the antigen of the monoclonal antibody (MoAb) JT-95, was detected in 90% of papillary thyroid carcinoma cases, and in a few follicular thyroid carcinomas, in the extracellular matrix of thyroid carcinoma cells. OBJECTIVES: The current study was conducted to investigate the association between increasing the number of extracellular matrix molecules, fibronectin, and lymph node metastasis. We also co-cultured a thyroid carcinoma cell line and lymphocyte cell line, with and without MoAb JT-95, in order to investigate the mechanism of cell to cell interaction. PATIENTS AND METHODS: Immunostaining with JT-95 was performed in 45 papillary thyroid carcinoma cases, and 20 follicular type tumors, to investigate the association between the quantity of fibronectin expression and the frequency of lymph node metastasis. The thyroid carcinoma cell line (SW1736), which secreted fibronectin, and the B cell-lymphoma cell line (Daudi), which held integrin on the cell surface, were co-cultured to observe the adhesion of cells to each other. The SW1736 cell line, pretreated with JT-95, was also co-cultured with the Daudi cell line. RESULTS: There were 39 cases with lymph node metastasis in 59 malignant tumors, and 0 cases in 6 benign follicular type tumors. The staining scores by JT-95 of the 39 tumors with lymph node metastasis were 5+ in eight cases and 6+ in 31 cases. On the other hand, the scores of 20 malignant tumors without lymph node metastasis were < 4+ in all of the cases. In the co-cultured assay, numerous adhesions were observed between the SW1736 and Daudi cells. In contrast, the inhibition of adherences was observed in proportion to the concentrations of JT-95. CONCLUSIONS: Increased fibronectin expression in thyroid malignancies is correlated with lymph node metastasis.

Chest wall reconstruction using Gore-Tex® dual mesh.

PURPOSE: This study aimed to evaluate the clinical outcomes of chest wall reconstruction using a relatively new expanded polytetrafluoroethylene prosthesis Gore-Tex(®) dual mesh. METHODS: We reviewed charts of 11 patients who underwent bony chest wall resection from April 2006 to January 2011. RESULTS: Six patients underwent three ribs resection, three patients underwent two ribs resection, and the other two patients underwent sternal resection. Of six patients after three ribs resection, three underwent reconstruction using 2 mm Gore-Tex(®) dual mesh, one using Gore-Tex(®), one using Bard composite E/X, and the remaining one used no prosthesis. Three patients who underwent two ribs resection underwent no chest wall reconstruction using prosthesis. Two patients who underwent sternal resection underwent chest wall reconstruction using dual mesh with or without a vascularized musculocutaneous pedicle flap. Immediate postoperative extubation was performed in all patients, except one who was extubated the following day. No postoperative deaths or cases with paradoxical respiration occurred. CONCLUSION: Chest wall reconstruction using Gore-Tex(®) dual mesh demonstrated acceptable durability.

Anomalous systemic arterial supply to the basal segments of the lung with three aberrant arteries.

We report a case of anomalous systemic arterial supply with three aberrant arteries supplying the basal segments of the right lung. There is no published report of a patient of anomalous systemic arterial supply to the basal segments with three aberrant arteries. Transverse computed tomography (CT) showed one aberrant artery in the right lower lobe, and preoperative three-dimensional CT showed three aberrant arteries, which provided detailed information and assisted in the thoracoscopic surgery. The patient underwent a complete thoracoscopic right lower lobectomy.

Vascularized rib support for chest wall reconstruction using Gore-Tex dual mesh after wide sternochondral resection.

Only a few reports describe chest wall reconstruction after sternal resection using Gore-Tex dual mesh, and very few reports describe the use of a vascularized rib to support the thoracic cage. We present a case of a breast cancer patient who underwent anterior chest wall resection for recurrent sternal cancer. Her sternoclavicular joints bilaterally and lower sternum were divided using an electric saw. The bony chest wall was reconstructed using Gore-Tex dual mesh, and a vascularized rib was used to bridge the space between the clavicular heads to support the thoracic cage. The patient's postoperative course was uneventful, without complications, such as paradoxical respiration or pneumonia.

The expression of sialic fibronectin correlates with lymph node metastasis of thyroid malignant neoplasmas.

BACKGROUND: Papillary thyroid carcinoma (PTC) is often accompanied by lymph node metastasis (LNM), compared with follicular thyroid carcinoma (FTC). Sialic acid is carried by fibronectin (sFN) as the antigen of monoclonal antibody (MoAb) JT-95 detected in 90% of PTC, and a few cases of FTC. PATIENTS AND METHODS: JT-95 staining was performed in 9 PTC and 20 follicular type tumors to investigate the relationship between the expression of sFN and the frequency of LNM. RESULTS: There were 11 cases with LNM from 23 malignant tumors, and no cases of LNM from 6 benign follicular type tumors. The staining scores by JT-95 of the 11 tumors with LNM were 5+ in 4 cases, and 6+ in 7 cases. On the other hand, the scores of 12 malignant tumors without LNM were <4+ in all cases. CONCLUSION: An increase of sFN expression in thyroid malignancies is correlated with LNM.

Thoracoscopic surgery for pulmonary metastases after chemotherapy using a tailor-made virtual lung.

PURPOSE: Details with regard to the standard criteria for a therapeutic metastasectomy and the use of video-assisted thoracic surgery (VATS) remain elusive. To evaluate the feasibility of VATS using a tailor-made virtual lung for patients with pulmonary metastases after chemotherapy, we reviewed the following cases. METHODS: Clinical data from October 2006 to April 2010 were obtained from patients who received chemotherapy before a pulmonary metastasectomy (lobectomy or segmentectomy). VATS was the primarily selected surgical approach except for treating hilar lesions. A lobectomy was performed when the metastasis was greater than 3.0 cm in diameter or located deeply in the lobe. Tailor-made virtual lungs were created using three-dimensional multidetector computed tomography before lobectomy on a routine basis. The virtual lung consisted of three-dimensional pulmonary vessels, a tracheobronchial tree, pulmonary parenchyma, and tumors. RESULTS: Twelve operations, consisting of 1 segmentectomy, 10 lobectomies, and 1 wedge bronchoplasty upper lobectomy, were performed on 11 patients during the study period. VATS was completed in 10 of these 12 operations. The mean operative time for the lobectomies was 257 min, and the mean operative bleeding volume was 215 ml. Two cases experienced postoperative transient atrial fibrillation, and no mortalities associated with these operations were reported. CONCLUSION: VATS was performed safely in instances of metastasectomy after chemotherapy, and the tailor-made virtual lung assisted in lung orientation during the operation.

Three-dimensional computed tomography for lung cancer in a patient with three right vein ostia.

Some variations in pulmonary vein anatomy can have serious consequences in patients undergoing lung surgery, but clinicians rarely encounter patients with these variations. We report here a thoracoscopic lobectomy for right lung cancer in a patient with three right vein ostia. Preoperative review of three-dimensional 64-row multidetector computed tomography (3D-MDCT) of the patient showed a variation that was not confirmed in transverse plane computed tomography films. However, the variant anomaly was confirmed during thoracoscopic right lower lobectomy. The postoperative course was uneventful, and the patient was discharged on postoperative day 10. Preoperative 3D-MDCT of the pulmonary vein produced a precise preoperative simulation for the surgeon and clearly showed the orientation of the patient's vascular variant during surgery. This imaging technology contributes to safer thoracic surgery, especially thoracoscopic surgery.

Thoracoscopic lobectomy for treating cancer in a patient with an unusual vein anomaly.

Various anatomical variants in pulmonary veins can have a serious effect on patients undergoing lung surgery. We present a case of a patient with an unusual pulmonary vein variation. Preoperative review of the patient's three-dimensional 64-row multidetector computed tomography imaging allowed us precise simulation and good orientation of the patient's vascular variant anatomy during surgery. Upper lobectomy through thoracoscopic approach was performed successfully in the case where the middle lobe vein might have been divided without preoperative anatomical evaluation by 3D CT images.