[A Patient with AFP-Producing Gastric Cancer and Stenosis Who Regained Oral Intake Capabilities after T-DXd Treatment].

We present the case of a 55-year-old man with HER2-positive, AFP-producing gastric cancer and multiple liver metastases. The patient consequently underwent 7 courses of SOX plus trastuzumab therapy, 3 courses of weekly PTX plus ramucirumab therapy, and 3 courses of nivolumab therapy, all of which resulted in PD. Obstruction due to tumor growth became noticeable 9 months after the start of the first treatment. Subsequently, the patient experienced malnutrition and systemic edema due to impaired oral intake. However, subsequent trastuzumab deruxtecan(T-DXd)therapy induced remarkable tumor shrinkage. Furthermore, oral intake became possible, and edema started subsiding. Thus, we report the course of a patient with AFP-producing gastric cancer and stenosis who regained oral intake capabilities after T-DXd treatment.

[Transverse Colectomy with D2 Lymph Node Dissection with a Small Incision Using Body Surface 3D-Simulation CT Colonography].

BACKGROUND: Laparoscopic transverse colectomy is technically difficult. In mini-laparotomy surgery, colectomy for midtransverse colon cancer can easily be performed, but exact D2 lymph node dissection is very difficult for a variety of vessels in the transverse colon. Using 3D-CT imaging, we present a case of D2 lymph node dissection where mini-laparotomy transverse colectomy was performedby a small incision similar to that usedin laparoscopic surgery. METHOD: The patient was a 60-yearoldwoman with early transverse colon cancer, which was locatedin the mid-transverse colon. Surgical treatment was plannedfor pT1b(1.5mm)andpVM1 in pathological findings after EMR. Using CT colonography(CTC), the location of the primary tumor was identified. Using simulation CTC(sCTC), composedof CTC and 3D imaging of the arteries andveins, the dominant artery was identified and D2 lymph node dissection was simulated. In addition, body surface 3D imaging and permeable surface 3D imaging of the abdominal trunk were performed. Using body surface 3D-sCTC, composedof sCTC and body surface 3D imaging, the minimum incision to enable D2 lymph node dissection was simulated. RESULT: Using sCTC, it was identified that the dominant artery was the right branch of the middle colic artery(MCA Rt)andthe accompanying vein was branchedfrom the gastrocolic trunk(GCT). D2 lymph node dissection to separate the branching root of MCA Rt and the accompanying vein was simulated. Next, surgical incision was simulated using body surface 3D-sCTC. Because the branching roots of MCA Rt andGCT were locatedabout 5 cm cranial from the upper rim of the navel, a 7 cm upper abdominal midline incision was designed in addition to a 2 cm umbilical incision. Mini-laparotomy transverse colectomy with a 7 cm incision was performedin accordance with the simulation. The operation time was 2 hours and5 1 minutes, andbloodloss was due to occult bleeding. The patient was discharged 7 days after surgery without complications, and the final diagnosis was pT1bN0M0, StageⅠwith no recurrence for 4 years and2 months after surgery. The cranial incision from the upper rim of the navel has shrank about 3 cm, and the umbilical incision is not noticeable. CONCLUSION: D2 lymph node dissection of minilaparotomy transverse colectomy can be a treatment option for early transverse colon cancer through using body surface 3DsCTC.

[Partial Gastrectomy for Elderly Patients with Early-Stage Gastric Cancer].

The aim of this study was to assess the impact of partial gastrectomy on postoperative outcomes in elderly patients with gastric cancer. Sixty -three consecutive elderly patients aged 75 years and older with histologically proven Stage ⅠA gastric adenocarcinoma who underwent partial gastrectomy(PG, n=7)or normal gastrectomy(NG, n=56)were investigated. PG was performed by segmental gastrectomy or local gastrectomy due to poor performance status, severe comorbidities, and social background instead of normal gastrectomy(distal, proximal, and total gastrectomy). Both body mass index(BMI)and body weight changes 12 months postoperatively were significantly higher in those who underwent PG(20.5 kg/m2 vs 18.4 kg/m2, p=0.043; and 96.6% vs 86.4%, p=0.016)despite being statistically similar preoperatively. The 5-year cause-specific survival rate of those who underwent PG was 100% excluding relapse cases. The 5-year overall survival rates were 86% in those who underwent PG and 67%in those who underwent NG, although they differed significantly. Partial gastrectomy may be a valid surgical procedure that may yield better prognosis compared to that with normal gastrectomy for elderly patients with Stage ⅠA gastric cancer.

[D2 Lymph Node Dissection in Mini-Laparotomy Transverse Colectomy Using Non-Contrast Simulation CT Colonography].

BACKGROUND AND PURPOSE: It is reported that simulation computed tomography colonography(S-CTC), which combines CTC and 3-dimensional(3D)vascular imaging, is useful in colorectal cancer surgery. However, it is difficult to create 3D vascular images using non-contrast CT. Laparoscopic transverse colectomy is said to be technically difficult. Mini-laparotomy surgery for mid-transverse colon cancer is quite easy to perform. However, exact D2 lymph node dissection is very difficult. We present a case of D2 lymph node dissection during mini-laparotomy transverse colectomy performed using S-CTC, which involves the creation of 3D vascular images using non-contrast CT. PATIENT AND METHOD: The patient was a 77-year-old man with transverse colon cancer located in the mid-transverse colon, cT2N0M0, Stage Ⅰ. He had coexisting chronic renal failure. Non-contrast CT was performed prior to surgery, and the images were processed using workstation Zaiostation2. RESULTS: Both the artery and the vein created from non-contrast CT could be visualized clearly until the marginal vessels. Using noncontrast S-CTC in combination with CTC and 3D artery imaging, it was identified that the dominant artery was the left branch of the middle colic artery(MCA Lt), while the right branch of the MCA(MCA Rt)and accessory MCA(AMCA)were 10 cm or more apart. The fusion of 3D artery and vein imaging made it evident that the vein accompanying MCA Lt branched from the superior mesenteric vein. Using non-contrast S-CTC, D2 lymph node dissection, dissection of the branching root of MCA Lt and the vein at the same level was simulated. Thus, mini-laparotomy transverse colectomy was performed through a 7 cm incision, in accordance with the simulation. CONCLUSION: Non-contrast S-CTC was useful for performing D2 lymph node dissection during mini-laparotomy transverse colectomy.

[A Case of Rectal Metastasis from Breast Cancer Diagnosed Two Years after Surgery].

We report a case of rectal metastasis from breast cancer.Colorectal metastasis from breast cancer is sometimes difficult to diagnose before surgery.A transanal needle biopsy was thought to be useful for a diagnosis and selection of treatment method.

[Clinical evaluation of eribulin mesylate for the treatment of metastatic breast cancer].

BACKGROUND: Eribulin mesylate, a novel non-taxane inhibitor of microtubule dynamics, results in a significant improvement in the overall survival of heavily pretreated patients with metastatic breast cancer(MBC). In the present study, we aimed to clarify the efficacy and safety of eribulin mesylate for the treatment of MBC. PATIENTS AND METHODS: We examined 18 patients with MBC who received eribulin mesylate in our hospital from October 2011 to May 2013. The patients were assessed for therapeutic response and adverse events with this treatment; in addition, these parameters were assessed in patients undergoing a combination treatment of eribulin mesylate and trastuzumab. RESULTS: The mean age of the patients in this study was 68.7 years(range, 60-85 years). All patients exhibited metastases to lymph nodes and distant sites. The mean number of prior regimens was 4.4(range, 2-9). The mean number of cycles of eribulin mesylate treatment administered was 7.2(range, 2- 17). The objective response rate and clinical benefit rate(PR+long SD)were 33.3%(6/18)and 50.0%(9/18), respectively, and the median progression-free survival was 6 months. The Grade 3/4 adverse events occurring in the patients included neutropenia in 13 patients(72.2%), anemia in 1 patient(5.6%), anorexia in 1 patient(5.6%), stomatitis in 1 patient(5.6%), and peripheral neuropathy in 1 patient(5.6%). However, 3 elderly patients who received the combination treatment of trastuzumab and eribulin mesylate experienced no adverse events. CONCLUSIONS: eribulin mesylate appears to demonstrate an acceptable tumor response in patients with MBC, and it can be safely administered to elderly patients if myelosuppression is carefully managed.

[A case of far advanced-esophageal squamous cell carcinoma successfully treated with docetaxel].

A 65-year-old man with dysphagia and hoarseness was admitted to our hospital. The upper gastrointestinal examinations revealed a tumor in the lower esophagus while the biopsy specimens revealed squamous cell carcinoma. The clinical diagnosis was esophageal cancer(Lt, type 2, cT3N4M0, cStage IVa). The patient underwent neoadjuvant-chemotherapy(5-fluorouracil/cisplatin). After one course, computed tomography(CT)showed rapid growth of the tumor and lymph nodes, resulting in a progressive disease. It was considered unresectable because of the direct invasion of the No. 1 lymph node to the liver. Then, three courses of docetaxel were administered as second-line chemotherapy, and CT revealed the markedly reduced size of the tumor and lymph nodes, resulting in a partial response. The tumor was now thought to be resectable. Subtotal esophagectomy could be performed and the postoperative course was uneventful. Histopathological findings showed no evidence of malignancy at the primary tumor(grade 3), although there were residual atypical keratinocytes in some lymph nodes. The patient is doing well without any signs of recurrence 21 months after the surgery.

Diffusion-weighted MRI as an adjunct to mammography in women under 50 years of age: an initial study.

PURPOSE: To evaluate diffusion-weighted magnetic resonance (DW) imaging as an adjunct to mammography for the detection of small invasive breast cancer. MATERIALS AND METHODS: Institutional review board standards were followed for this retrospective study. We performed both breast DW imaging and mammography on 25 women under 50 years of age with pathologically proven T1 breast cancer and on 21 healthy women under 50 years of age. Four offsite radiologists blind to the clinical information independently interpreted the mammograms and DW images and then classified their confidence level regarding the presence of breast cancer. The composite area under receiver operating characteristic curve (AUC), of mammography alone, DW imaging alone, and the combination of DW imaging and mammography (DWI/Cal) were calculated. RESULTS: The AUC of composite ROC curves of mammography, DW imaging, DWI/Cal combination, was 0.79 (95% CI, 0.72-0.87), 0.86 (95% CI, 0.84-0.87), and 0.96 (95% CI, 0.92-1.00), respectively. CONCLUSION: DW imaging may be a useful adjunct to mammography in the detection of small invasive breast cancer in women under 50 years of age.

A phase 1/11 study of second-line chemotherapy with fractionated docetaxel and nedaplatin for 5-FU/cisplatin-resistant esophageal squamous cell carcinoma.

BACKGROUND/AIMS: There are few second-line regimens available for esophageal cancer. The use of fractionated docetaxel and nedaplatin as second-line chemotherapy was examined in this study. METHODOLOGY: Eligibility criteria were follows: histologically-proven squamous cell carcinoma, surgically unresectable disease, failure to respond to chemotherapy with 5-FU and cisplatin and no more than 2 prior chemotherapy regimens. A total of 12 patients were enrolled in this study. To reduce toxicities, fractionated docetaxel (50 mg/m² in day 1 and 8) and nedaplatin (50 mg/m² in day 8) were administered as second-line chemotherapy. RESULTS: Stable disease (SD) was observed in 4 cases (33%) and the disease control rate was 33%. Regarding toxicities, leukopenia was the most frequently observed (8 cases, 67%); however, there were no cases of grade 4 nonhematological toxicity. The 1-year overall survival was 26.7% and the median survival time was 7.8 months (95% CI=3.328-12.272 months). The 1-year progression-free survival was 0% and the median progression-free time was 2.0 months (95% CI=1.319-2.681). CONCLUSIONS: Combination chemotherapy using fractionated docetaxel and nedaplatin is safe and effective and appears to be a feasible regimen to use as second-line chemotherapy for FP-resistant advanced esophageal squamous cell carcinoma.

COX2 expression predicts resistance to chemoradiotherapy in esophageal squamous cell carcinoma.

PURPOSE: The overexpression of cyclooxygenase (COX)2 is correlated with carcinogenesis, tumor progression, and prognosis, and increased COX2 expression is correlated with radiation resistance. However, no correlation between the COX2 expression and resistance to chemoradiotherapy for esophageal squamous cell carcinoma has been characterized. The purpose of the present study was to evaluate whether COX2 expression is an indicator of resistance to chemoradiotherapy in esophageal squamous cell carcinoma and the feasibility of COX2 as a biomarker for CRT. METHODS: Fifty-eight patients who were diagnosed with esophageal squamous cell carcinoma from biopsy samples were enrolled in the present series. All patients underwent concurrent chemoradiotherapy in a neoadjuvant setting, followed by radical esophagectomy. COX2 expression was evaluated by immunohistochemical staining and statistically compared with the histopathologic findings in surgically resected specimens. RESULTS: The rate of responders was 87% for weak expression of COX2, 62% for moderate expression, and 30% for strong expression, and there was a close correlation between COX2 expression and the response rate (Kendall's τb = 0.396, P = 0.001). In the univariate analysis, negative or weak expression of COX2 was found to correlate significantly with CRT response (odds ratio, 6.296; 95% confidence interval (CI), 1.58-25.096; P = 0.010). In the multivariate analysis, weak expression of COX2 (30% or less) was found to be an independent prognostic factor (odds ratio, 6.534; 95% CI, 1.535-27.803; P = 0.011). CONCLUSIONS: The COX2 expression predicts resistance to chemoradiotherapy in esophageal squamous cell carcinoma, and it also is a feasible biomarker for evaluating the CRT response.

CHAP31 induces apoptosis only via the intrinsic pathway in human esophageal cancer cells.

OBJECTIVE: The antitumor mechanism of histone deacetylase (HDAC) inhibitors differs from conventional antitumor agents. HDAC inhibitors may be effective as novel therapeutic agents for esophageal squamous cell carcinoma (ESCC). This study describes the antiproliferative activity of CHAP31, a novel HDAC inhibitor. Furthermore, the molecular mechanism of CHAP31-induced apoptosis was investigated in ESCC. METHODS/RESULTS: The antitumor activity of CHAP31 was tested in esophageal cancer cell lines (T.Tn and TE2), and potent antitumor activity was observed in vitro and in vivo. In addition, CHAP31 induced apoptosis in esophageal cancer cells. Next, the mechanisms of CHAP31-induced apoptosis were examined using quantitative real-time RT-PCR and Western blotting. No processing of caspase 8 was observed, but CHAP31 induced the cleavage of caspase 9 and up-regulation of the Bax/Bcl-2 protein ratio. CONCLUSION: This study provides new and important information on the potent antitumor activity of CHAP31 and the apoptotic pathway induced by CHAP31 in human esophageal cancer cell lines T.Tn and TE2. In contrast to previous reports showing that apoptosis induced by HDAC inhibitors includes the extrinsic pathway, in our study, apoptosis induced by CHAP31 in the human esophageal cell lines T.Tn and TE2 involved only the intrinsic pathway.

[Effect of practical use of preoperative immunonutrition with impact on prevention of postoperative pneumonia after esophagectomy].

To clarify the clinical benefits of administering immune-enhancing diet, Impact,we examined retrospectively the effect of preoperative immunonutrition with Impact on prevention of postoperative pneumonia after esophagectomy. In 47 patients without preoperative radiotherapy, no patient who preoperatively administered Impact>or=2,250 mL failed to develop pneumonia. The patients whose postoperative hospital stay was more than 30 days were administered Impact

Combined effects of p53 gene therapy and leptomycin B in human esophageal squamous cell carcinoma.

BACKGROUND: p53 gene therapy has been examined in several clinical trials, however, the results of those trials have mostly been unsatisfactory due to the low efficacy of this therapy. Leptomycin B (LMB) is an antibiotic originally isolated from Streptomyces that has the ability to inhibit the export of proteins containing a nuclear export signal from the nucleus to the cytoplasm. Currently, it has been shown that p53 protein has a nuclear export signal. In this study, we assessed whether LMB augments the transduced p53 gene effect. METHODS: Antiproliferative effect of LMB was assessed in human esophageal squamous cancer cell lines. Accumulation of p53 protein into the nucleus by LMB was observed by fluorescence microscopy. The combined effect of p53 and LMB was evaluated in in vitro experiments. RESULTS: LMB induced cell death in a dose-dependent manner and p53 drastically accumulated in the nucleus after LMB treatment. The combinatory treatment of p53 gene and LMB significantly increases the efficiency compared to either agent alone. CONCLUSIONS: Our findings suggest that LMB has a potent ability to augment the effect of the tumor suppressor p53 in esophageal squamous cancer cell lines and that it is a promising component in p53 gene therapy.

Combinatory gene therapy with electrotransfer of midkine promoter-HSV-TK and interleukin-21.

UNLABELLED: We examined the effect of the combination of herpes simplex virus type1-thymidine kinase (HSV-TK)-suicide gene therapy and interleukin-21 (IL-21) immune gene therapy. MATERIALS AND METHODS: To improve tumor specificity and the safety of gene therapy, we designed the suicide gene (HSV-TK) to be driven by midkine (MK) minimal promoter (MKp-TK). Plasmid DNA containing HSV-TK-suicide gene or IL-21 gene was injected into TE2 and Colon26 tumors developed in nude mice and electric pulses were then delivered. RESULTS: Tumors transduced with the MKp-TK gene demonstrated increased sensitivity to ganciclovir (GCV) in vitro and in vivo. MK minimal promoter conferred efficient transcriptional activity to the HSV-TK-suicide gene and in vivo electroporation was an effective method for transducing the MKp-TK gene. IL-21-transduced tumors disappeared completely in syngeneic BALB/c mice. However, the tumors were not suppressed completely in T-cell-depleted nude mice, and antitumor effects were absent in NK-cell-depleted mice. These data suggest that IL-21 induces T- and NK-cell-dependent antitumor effects. Furthermore, the growth of IL-21-producing tumors subsequently transduced with MKp-TK by electroporation was significantly retarded compared with control groups. CONCLUSION: Using the minimal promoter region of MK to drive the HSV-TK gene and in vivo electroporation to transduce IL-21 DNA into the tumors produced an efficient gene therapy with improved safety. To our knowledge, this is the first report of a combination gene therapy using HSV-TK/GCVand IL-21.

[Two cases treated with trastuzumab as primary chemotherapy].

We report two cases treated with primary chemotherapy containing trastuzumab with a review of some important papers. The first patient was a 43-year-old female. A 33-mm left breast invasive ductal carcinoma (ER (-), PgR (-), HER2 3+(IHC) ) with several lymph node metastases in the Ax, Ic and Sc was found. After primary chemotherapy with 6 courses of EC and 4 courses of weekly paclitaxel + trastuzumab, the efficacy for the local tumor was judged as PR. However, brain metastases appeared, so the operation was canceled. Brain metastases were then treated by gamma-knife three times, but systemic chemotherapy was not administered. Eight months later, carcinomatous meningitis appeared. Intrathecal chemotherapy with MTX+Ara-C was started, but the patient died after 20 months from the beginning of the treatment. Local efficacy was judged as CR. The second patient was a 41-year-old female. A 39-mm right breast invasive ductal carcinoma (ER (-), PgR (-), HER2 3+(IHC) ) with two lymph node metastases in the Ax was found. After primary chemotherapy with 6 courses of FEC and 4 courses of weekly paclitaxel + trastuzumab, the efficacy was judged as PR. The operation was scheduled, but he patient wished to continue chemotherapy for cosmetic reasons. Later, because of mild tumor regrowth, we used 2 courses of vinorelbine in combination with trastuzumab. The tumor grew more, so Bp + Ax was done. The woman is alive at this writing with no recurrence.

Analysis of non-genetic risk factors for adverse skin reactions to radiotherapy among 284 breast cancer patients.

OBJECTIVES: We analyzed non-genetic risk factors for adverse skin reactions to irradiation at 4 collaborating Japanese institutions, to design future investigation into genetic risk factors for adverse skin reactions to irradiation in a multicenter setting. METHODS: From April 2001, 284 breast cancer patients, who underwent radiotherapy with breast-conserving surgery, were enrolled from 4 collaborating institutions in Japan. We graded skin reactions according to international scoring systems. Clinical factors were tested against adverse effects. RESULTS: Grade 1+ skin reactions were observed in 261 (92%) of the patients in less than 3 months, 118 (42%) at 3 months, and 29 (10%) at 6 months in the late phase. Univariate analysis of treatment risk factors (such as the use of a multi-leaf colimeter, wedge-filter, or immobilization device) for skin reactions revealed a significant association (p< 0.0001). After a variable selection procedure with logistic regression, the institution, operative procedure, and magnitude of photon energy remained significantly associated with acute skin reactions. Only the institution was an explanatory variable for skin reactions at 3 and 6 months in the final logistic model. CONCLUSION: After stratification, substantial remaining variations in the occurrence of skin reactions of a given level suggested that individual genetic factors contribute markedly to individual radiosensitivity. Analysis of genetic factors associated with adverse effects would be possible by stratifying patients according to institution. Selection of eligible institutions, where appropriate treatment modalities could be performed, would also be possible when planning such a study.

Assessment for diagnosis of lymph node metastasis in esophageal cancer using endoscopic ultrasound elastography.

BACKGROUND: We performed endoscopic ultrasound real-time tissue elastography to more accurately diagnose lymph node metastasis of esophageal cancer. The aim of this study was to evaluate the ability of EUS elastography to distinguish benign from malignant lymph nodes in esophageal cancer patients. METHODS: The present study had two steps. As the first step (study 1), we developed diagnostic criteria for metastatic lymph nodes using elastography and verified the validity of the criteria. Three hundred and twenty-two lymph nodes from 35 patients treated by surgical resection were included in the study. As the second step (study 2), we preoperatively examined the lymph nodes of esophageal cancer patients with EUS elastography and compared its diagnostic performance with that of the conventional B-mode EUS images. A total of 115 lymph nodes from 31 patients were included. RESULTS: In study 1, lymph nodes were considered malignant if 50 % or more of the node appeared blue, or if the peripheral part of the lesion was blue and the central part was red/yellow/green. The sensitivity and specificity of the elastography were 79.7 and 97.6 % with an accuracy of 93.8 %, which was significantly higher than the values for conventional B-mode imaging. In study 2, the sensitivity and specificity of the EUS elastography were 91.2 and 94.5 % with an accuracy of 93.9 %, which was also significantly higher than the values for conventional B-mode EUS imaging. CONCLUSIONS: The present study demonstrated that EUS elastography is useful for diagnosing lymph node metastasis of esophageal cancer.

Proposal for a reclassification of liver based anatomy on portal ramifications.

BACKGROUND: Portal branching patterns that differ from those previously described are occasionally encountered during liver surgery. METHODS: A total of 60 patients with normal intrahepatic venous anatomy underwent helical computed tomography during arterial portography (CTAP). Next, 3 dimensional portograms were reconstructed to verify the locations of the portal veins. Portal branching patterns in the right hemiliver were assessed. RESULTS: In all 60 patients examined, the right anterior portal vein bifurcated into the ventral and dorsal branches. In 42 (70%) of 60 patients, some branches arose from the right posterior portal trunk. Between 1 and 3 branches (mean 2.3 branches per patient) coursed cranially, between 2 and 5 branches (mean 3.2 branches per patient) coursed caudally, and between 1 and 2 branches (mean 1.3 branches per patient) coursed laterally. CONCLUSIONS: We propose that the right liver should be divided into 3 segments, which are designated as the right anterior, middle, and posterior segments.

DNA repair capacity measured by high throughput alkaline comet assays in EBV-transformed cell lines and peripheral blood cells from cancer patients and healthy volunteers.

We collected peripheral blood (PB) from 556 patients with various types of cancer who had undergone radiotherapy and from 81 healthy volunteers. We exposed whole PB and Epstein-Barr virus-transformed lymphoblastoid cell lines (EBLs) derived from the PB mononucleocytes to X-irradiation (5 Gy). Using the alkaline comet assay, we measured the immediate DNA damage and, at 15 min, the % residual damage. In PB, the immediate damage was similar in patients and healthy volunteers while the % residual damage (mean+/-S.D.) was significantly higher in patients with breast (54.3+/-A23.9), cervical (54.7+/-A23.9), head/neck (56.8+/-A24.4), lung (60.1+/-23.5), or esophageal cancers (59.5+/-A33.7) than in healthy donors (42.9+/-19.6) (P<0.05). We did not observe such differences in the EBV-transformed cell lines. Thus, radiation sensitivity of fresh PB cells measured by the alkaline comet assay was related to cancer status.

Primary non-Hodgkin's lymphoma of the breast: report of a case with special reference to 380 cases in the Japanese literature.

A 52-year-old Japanese woman presented with a mass in the left breast. A tumor 2.9 cm in diameter was found in the D area on ultrasonography. An ipsilateral swollen axillary lymph node was detected. Invasion of the tumor to the pectoralis major muscle was seen. Based on a diagnosis of malignant lymphoma by fine needle aspiration cytology, radical mastectomy with ipsilateral axillary lymph node dissection was performed. Malignant diffuse large B-cell type lymphoma was diagnosed histologically according to the World Health Organization classification, and the clinical stage was II E by the Ann Arbor staging system. Four courses of adjuvant chemotherapy with cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) were subsequently performed. The patient is free of recurrence 7 years after surgery. Up to 2002, 380 cases of primary breast non-Hodgkin's lymphoma had been documented in the Japanese literature. When the tumor size was bigger than 4.5 cm, the outcome was poor. Regarding treatment methods, we showed that only enucleation of the tumor is necessary and axillary dissection is not necessary. In our case, we thought that the prognosis was good despite the large tumor and axillary lymph node metastasis, and that we could omit axillary dissection.