[Permissibility of Stoma Closure Surgery in Patients with Colorectal Cancer Who Underwent Primary Tumor Resection Including in Cancer-Bearing Conditions]

From 2006 to 2021, 27 patients who underwent stoma construction during colorectal cancer resection followed by stoma closure were grouped into 2 groups: Group A(7 patients with cancer)and Group B(20 patients without cancer). The male- to-female ratio were 6:1 for Group A and 13:7 for Group B. The average ages were 63.7 and 65.0 years, respectively. The ratios(Group A:Group B)of the causes for stoma construction were 5:13 for bowel obstruction due to colorectal cancer, 2:2 for abdominal wall invasion/dissemination and 0:5 for covering stoma. The causes of non-curative resection for Group A were peritoneal dissemination(4 patients), liver metastasis(1 patient), bladder infiltration(1 patient), and periaortic lymph node metastasis(1 patient). For Groups A and B, Hartmann surgery was performed in 4 and 10, colectomy and stoma construction in 3 and 5, and low anterior resection and covering stoma in 0 and 5 patients, respectively. The median time to stoma closure was 10 months for Group A and 6 months for Group B(p<0.05). There was no case of anastomotic leakage and 1 case of anastomotic stenosis(case not treated with anticancer drugs). No patient died of cancer within 1 year after stoma closure(median survival time after stoma closure was >26.0 months for Group A). Although stoma closure in patients with cancer was significantly delayed compared with patients without cancer, it was performed safely.

[A 10-Year Survivor with Multidisciplinary Treatment for Pancreatic Carcinoma That Recurred 17 Months after Pancreatoduodenectomy]

Postoperative recurrence of invasive pancreatic ductal carcinoma(PC)has a poor prognosis. We experienced a case of PC that relapsed 17 months after pancreaticoduodenectomy(PD)and survived for more than 10 years after PD. A 51-year-old man underwent PD in December 2011(pT3pN1bM0, pStage Ⅱb). Gemcitabine(GEM)16 cycles were performed as postoperative adjuvant chemotherapy, and a 1 cm nodule was found in the liver on abdominal CT scan, and partial liver resection was performed. After that, adjuvant chemotherapy with S-1 was performed for 12 months. Abdominal CT scan revealed abdominal lymph node metastasis, and radiation therapy(39.6 Gy)was requested from another hospital. Then, the combination therapy of 5-FU/l-LV plus L-OHP(or CPT-11)was started in September 2014. To date, a total of 131 cycles of chemotherapy have been given. 10 years and 5 months after pancreaticoduodenectomy and 9 years after hepatectomy, although recurrence around the superior mesenteric artery plexus was observed, outpatient visits are continued.

[Clinicopathological Examination of Resected Case of Primary Duodenal Cancer at Our Hospital]

Primary duodenal cancer is a rare disease. We examined 8 resected cases of duodenal cancer at our hospital from June 2003 to February 2022. Patients with resected duodenal cancer had an average age of 69.3 years(45-84 years), with a male-female ratio of 3 : 5. Of the 8 cases, 6 cases were adenocarcinomas and 2 were neuroendocrine carcinomas. Among those with adenocarcinomas, 3 cases were Stage Ⅰ, while Stage ⅡA, ⅢA, and ⅢB accounted for one case each(UICC 8th edition). Five patients underwent a pancreaticoduodenectomy(PD), while 1 underwent partial duodenal resection. Except for 1 case of Stage ⅢB(death from tumor recurrence in 1 year), tumor recurrence was not observed in the 5 remaining cases(survival period; >1 month to >97 months). The patient with a pT3pN1M0, Stage Ⅲ neuroendocrine carcinoma underwent a partial duodenal resection due to poor cardiac and renal function. Meanwhile, the patient with a pT4pN0M0, Stage Ⅲ neuroendocrine carcinoma underwent a PD. The survival time was 123 months for the former(death from other diseases, no tumor recurrence)and 7 months for the latter(death from recurrence).

[Function of the Puborectalis Muscle in Patients with or without Fecal Incontinence Three Years after Low Anterior Resection for Lower Rectal Cancer]

To clarify the function of the puborectalis muscle(PM)in fecal incontinence(FI)prevention after low anterior resection (LAR)for lower rectal cancer(LRC), PM function at 3 years after LAR was studied. A total of 29 patients aged 40-79 years (19 men and 10 women, mean age: 63.9 years)who underwent LAR for LRC were enrolled in the present study. Based on the presence of postoperative FI, these patients were divided into 2 groups[group A: patients with FI(n=13), 11 men and 2 women aged 43-75 years(mean age: 64.8 years)and group B: patients without FI(continence, n=16), 8 men and 8 women aged 41-79 years(mean age: 62.9 years)]. These groups were compared with group C of control subjects[n=38; 28 men and 10 women aged 42-76 years(mean age: 64.5 years)]. Magnetic stimulation at the S2-4 sacral levels has been shown to activate the sacral motor nerve(SMN)root of the cauda equina. SMN latency(SMNL)was determined on the right, left, and posterior sides of the upper anal canal. FI after LAR was also evaluated using the Wexner score(WS), with a score of 8 or more being associated with FI according to our data. All patients had pathological Stage Ⅰ disease(19 patients: T1, N0, M0; 10 patients: T2, N0, M0). Group A had a larger proportion of men than group B(p<0.1). The distance of anastomosis from the anal verge(DAAV)was significantly shorter in group A(2.2±1.2 cm)than in group B(4.6 ±1.3 cm)(p<0.001). Regarding WS of group A, 23.1% patients had a score of 8-10(mean: 9.0), 53.8% of 11-15 (mean: 13.4), and 30.7% of 16-20(mean: 17.0). All patients in group A(WS: 8 or more)were incontinent. In contrast, all patients in groups B(WS: 0)and C(WS: 0)were continent. Patients with preoperative defecation ability(WS: 0)were also continent. As for SMNL on the right(9 o'clock), left(15 o'clock), and posterior(18 o'clock)sides of the PM located in the upper anal canal, conduction delay was significantly longer in group A(8.4±0.6 ms, 8.2±1.9 ms, and 8.3±0.9 ms, respectively)than in groups B(4.4±0.5 ms, 4.3±0.7 ms, and 4.4±0.9 ms, respectively)and C(4.1±0.5 ms, 4.0±0.5 ms, and 4.2±0.7 ms, respectively)(p<0.001, all). FI after LAR with a short DAAV, especially in men, may cause PM dysfunction due to operative damage of the SMN.

[Long-Term Survival of Patient Having Advanced Esophageal Cancer with Cirrhosis after Overcoming Anastomotic Leakage, Purulent Osteomyelitis, Cervical Lymph Node Recurrence, and Systemic Edema-A Surgical Case]

We report the surgical case of advanced esophageal cancer with cirrhosis in a patient who has been cancer-free for 6 years after overcoming anastomotic leakage, purulent osteomyelitis, cervical lymph node recurrence, and systemic edema. A 69-year-old woman visited our hospital and presented with the complaint of a food sticking sensation. Endoscopic findings showed a type 3 tumor in the middle thoracic esophagus. Esophagectomy was subsequently performed. Histopathological findings revealed poorly differentiated squamous cell carcinoma, Mt, 17×15 mm, type 3, pT3, pIM0, pPM0, pDM0, pRM0, pN2(7/18), pStage Ⅲ, and liver cirrhosis(F4, A1-2). Postoperative suture failure was observed; however, it conservatively improved in approximately 2 months. The patient had lower back pain since approximately 6 weeks after the surgery, and she was diagnosed with purulent spondylitis and was administered antibiotics. The patient was subsequently discharged 67 days after the surgery. One course of 5-FU+CDDP was administered as postoperative adjuvant chemotherapy. However, renal function deteriorated, and chemotherapy was discontinued. Four months after the surgery, cervical echography revealed recurrence in the left cervical lymph node, and docetaxel(DTX)was administered. Five DTX doses were administered, because of which the left cervical lymph nodes markedly shrunk. Moreover, the sixth dose of DTX resulted in febrile neutropenia and a large amount of abdominal pleural effusion. Consequently, the patient was hospitalized. Tolvaptan treatment was extremely effective, and the thoracic ascites disappeared. Esophageal cancer has not recurred, and the patient is being observed at an outpatient clinic 6 years after the surgery.

[A Long-Term Recurrence-Free Survivor after Resection for Hepatopulmonary Metastases found within One Year after Rectal Cancer Surgery]

We observed a case of long-term survival without recurrence following hepatectomy and lung resection in a patient with hepatopulmonary metastases, which appeared 7 months after rectal cancer surgery. We report the case of a 68-year-old man whose chief complaint was anal pain. The patient was referred to our hospital because of a suspected rectal cancer. He was diagnosed with rectal cancer without distant metastasis, and abdominoperineal excision was then performed. Histopathological findings revealed Rb, type 2, 85×60 mm, tub 2, ly1, v1, pPM0, pDM0, pRM0, pT3(A), pN0(0/27), cM0, and pStage Ⅱa. Seven months after the surgery, abdominal computed tomography(CT)revealed a 3 cm nodule in segment 7 of the liver. In addition, chest CT detected a 2 mm nodule in segment 3 of the upper lobe of the left lung. Hepatectomy was immediately performed, whereas lung nodules were to be followed up. Three months later, chest CT showed that the lung nodules had increased in size(approximately 5 mm); therefore, the patient was diagnosed with lung metastasis, and thoracoscopic partial lung resection was performed. The histopathological findings of the hepatic tumor and lung tumor were similar to those of rectal cancer. The postoperative course was good, and the patient has been alive without recurrence for 8 years since the final surgery(lung resection)without postoperative adjuvant chemotherapy.

[Relationships Gastric Stasis in the Remnant Stomach and Interdigestive Migrating Motor Complex in Patients after Pylorus-Preserving Gastrectomy for Early Gastric Cancer]

The demerit of pylorus-preserving gastrectomy(PPG)is the postprandial abdominal fullness(PAF)with gastric stasis in the remnant stomach(GSRS). We investigated the relationship between clinical findings and GSRS, and between GSRS and interdigestive migrating motor complex(IMMC)in PPG patients. A total of 30 patients(17 men and 13 women, mean age of 62.3 years)after PPG for early gastric cancer(Billroth Ⅰ)were divided into 2 groups(group A; 18 patients with GSRS, group B; 12 patients without GSRS). The relationship between GSRS including clinical findings and IMMC was studied from 1.5 to 3 years after operation. A catheter equipped with a micro-tip force transducer was inserted transnassally into the remnant stomach and duodenum in a supine position, and the IMMC was studied. All patients were Stage ⅠA(mucosal cancer, no lymph node metastasis, no distant metastasis). The remnant stomach was 1/3 compared with stomach size before operation. The length of the antral cuff in group A(1.5±0.2 cm)was significantly shorter than group B(3.2±0.3 cm)(p =0.0004). Appetite was significantly recognized in group B compared with group A(p=0.0067). PAF was significantly recognized in group A compared with group B(p=0.0001). Reflux esophagitis was found in group A more than group B. Early dumping syndroms did not found significant differences in both groups. In endoscopic esophagogastric finding of the remnant stomch, gastritis with GSRS was significantly found in group A compared with group B(p=0.0001). The IMMC was significantly recognized in group B compared with group A(p<0.0001). The occurrence of the PAF due to the GSRS may be caused by abscens of the IMMC.

[Role of Pudendal Sensory Nerve in Patients with or without Fecal Incontinence after Low Anterior Resection for Lower Rectal Cancer]

To clarify the pudendal sensory nerve(PSN)play in preventing fecal incontinence(FI)after low anterior resection(LAR) for lower rectal cancer, the PSN function was studied at 6 months after LAR. A total of 36 patients aged 42.0 to 79.0 years (23 males and 13 females with a mean age of 62.0 years)who underwent LAR for laparoscopic radical cystectomy(LRC) were enrolled in the present study. Based on postoperative F1, these patients were divided into 2 groups[group A; patients with FI(n=12), group B; patients without FI(continence, n=24)]. These were compared with group C(n=32, control subjects, 18 males and 14 females aged 40.0 to 76.0 years with a mean age of 61.8 years). Anal mucosal electric sensitivity (AMES)threshold was measured [at the upper 1 cm oral side from dentate line(DL); a, DL; b, and lower zones 1 cm anal side from DL; c]. FI after LAR was also evaluated by the Wexner score(WS). All patients were pathological Stage Ⅰ(25 patients: T1, N0, M0; 11 patients: T2, N0, M0). Group A had a significantly larger proportion of males than group B(p< 0.05). The distance of anastomosis from anal verge(DAAV)in group A(2.4±1.8 cm)was significantly shorter than in group B(4.4±0.9 cm)(p<0.001). WS from 6 to 10 comprised 25.0% of group A, 11 to 15 comprised 50.0%, and 16 to 20 comprised 25.0%. All patients in group A(WS; 8 or more)were incontinent. In contrast, all patients in group B(WS; 0) and C(WS; 0)were continent. Patients in pre-operative defecation(WS; 0)were also continent. On the AMES(a, b, c), sensitivity of patients in group A(6.4±1.1, 5.1±0.5, 4.9±0.6 mA)was significantly higher than in groups B(2.6±0.5, 2.4 ±0.4, 2.5±0.6 mA)and C(2.3±0.4, 2.1±0.4, 2.3±0.5 mA)at all zones(p<0.001). FI after LAR with a short DAAV, especially male, may be PSN dysfunction due to operative damage of PSN.

[Function of Pudendal Motor Nerve in Patients with or Without Fecal Incontinence after Low Anterior Resection for Lower Rectal Cancer]

To clarify the pudendal motor nerve(PMN)play in preventing fecal incontinence(FI)after low anterior resection(LAR) for lower rectal cancer, the PMN function was studied at early postoperative period after LAR. A total of 30 patients aged 43 to 78 years (21 men and 9 women with a mean age of 62.4 years) who underwent LAR for LRC were enrolled in the present study. Based on postoperative FI, these patients were divided into 2 groups(group A: patients with FI[n=10], group B: patients without FI[continence, n=20]). These were compared with group C(n=28, control subjects, 18 men and 10 women aged 46 to 76 years with a mean age of 60.2 years). Magnetic stimulation at the S2-4 sacral levels has been shown to activate the PMN root of the cauda equina. PMN latency(PMNL)at posterior sides of the anal canal was studied. FI after LAR was also evaluated by the Wexner score(WS). All patients were pathological Stage Ⅰ(20 patients: T1, N0, M0; 10 patients: T2, N0, M0). Group A had a significantly larger proportion of men than group B(p<0.05). The distance of anastomosis from anal verge(DAAV)in group A(2.4±1.7 cm)was significantly shorter than in group B(4.4±0.9 cm)(p< 0.001). WS from 8 to 10(mean: 9.25)comprised 20.0% of group A, 11 to 15(mean: 13.5)50.0%, and 16 to 20(mean: 18.5)comprised 30.0%. All patients in group A(WS: 8 or more)were incontinent. In contrast, all patients in group B(WS: 0)and C(WS: 0)were continent. Patients in pre-operative defecation(WS: 0)were also continent. As for PMNL, the conduction delay in group A(7.9±0.9 ms)was significantly longer than in groups B(4.1±0.6 ms)and C(3.9±0.3 ms) (p<0.001, respectively). FI after LAR with a short DAAV may be EAS dysfunction due to damage of PMN.

Granulomatous cholangitis mimicking hilar cholangiocarcinoma: a case report

Background

Hilar biliary stricture caused by isolated fungal infections in immunocompetent patients are considered to be extremely rare and difficult to the diagnose from the outset.

Case presentation

We report a unique case of granulomatous cholangitis based on isolated biliary fungal infection manifesting as obstructive jaundice and mimicking hilar cholangiocarcinoma in an immunocompetent woman. A 67-year-old Japanese woman was referred to our hospital for obstructive jaundice. She had been followed up for hypochondroplasia by the referring physician. Her total bilirubin level was 5.4 mg/dL. Viral hepatitis screening was found to be negative, and serum IgG4 was within normal limits; however, her CA19-9 level was high. Abdominal computed tomography revealed dilatation of the intrahepatic bile ducts. Abdominal echogram detected a solid mass in the hilar bile duct. Her magnetic resonance cholangiopancreatography has also revealed an abrupt stenosis of the primary biliary confluence with upstream dilatation of the intrahepatic bile ducts. Endoscopic nasobiliary drainage was then performed to improve the obstructive jaundice. Although biliary cytology did not reveal malignant findings, the bile duct in the hilum showed severe stenosis, and hilar cholangiocarcinoma could not be completely excluded. The patient had a developmental disorder based on chondrodystrophy. To avoid excessive surgical stress, such as hepatic lobectomy, we performed resection of the extrahepatic bile duct and Roux-en-Y hepaticojejunostomy reconstruction. Intraoperative frozen sections of the resection margins were determined to be negative for tumor. The resected specimen showed multiple strictures inside the common bile duct, numerous calculi in the lumen, and little free space. The final pathological diagnosis was granulomatous cholangitis due to fungal infection. The patient’s postoperative course was deemed uneventful. She was discharged from our hospital 23 days after surgery without antifungal treatment.

Conclusions

For a unique case of granulomatous cholangitis based on isolated biliary fungal infection mimicking hilar cholangiocarcinoma, we were able to avoid excessive invasion and performed appropriate surgical management.

[Phyllodes Tumor of the Breast Occurring near Postoperative Fibroadenoma Scar-A Case Report]

We report the case of a phyllodes tumor of the breast occurring near a postoperative scar of fibroadenoma of the breast. The patient was a 41-year-old female who had a lump in the left breast, and underwent surgical resection of the tumor 5 years ago at another hospital.The pathological diagnosis of the tumor was fibroadenoma, and surgical margin was negative. The patient underwent ultrasonography every year at the treatment hospital.Five years later, the patient noticed a tumor in her left breast and visited our hospital.The tumor was 30mm in diameter and situated near the postoperative scar.A core needle biopsy for breast tumor led to the diagnosis of a phyllodes tumor.Surgical resection was performed with 5mm margins, and pathological analysis of the surgical specimen revealed a benign phyllodes tumor.The surgical margins were not involved.One year and 6 months after surgery, no metastases or recurrence were reported.

[Breast Papilloma with Rapid Growth Difficult to Distinguish from Carcinoma-A Case Report]

We report a case of papilloma of the breast with rapid growth in a 39-year-old female who had a lump in the left breast. The follow-up for the breast tumor was performed at another hospital.Three years after her first visit, 3 tumors measuring 1.8 cm, 0.5 cm, and 0.3 cm in diameter were detected. The patient visited our hospital to diagnose these tumors. We performed core needle biopsy for the tumor, and the pathological diagnosis was benign papilloma.After 1 year, the tumor grew to 3.0 cm in diameter, and we repeated the core needle biopsy. The pathological diagnosis remained as benign papilloma; however, the ultrasonography and MRI results showed that the tumor was malignant.Surgical resection was performed for the tumors, and pathological analysis of the surgical specimen revealed 3 benign papillomas with no involvement of the surgical margin.Six years after surgery, no recurrence was reported.

[Long-Term Survival by Multidisciplinary Treatments in a Non-Curative Resected Case of Rectal Mucinous Carcinoma Occurring 20 Years after Surgery for Rectal Carcinoma]

We reported the long-term survival ofa patient who underwent multidisciplinary treatments for non-curative resected rectal mucinous carcinoma that occurred 20 years after rectal carcinoma surgery. A 69-year-old man who had undergone a lower anterior resection for rectal cancer diagnosed approximately 20 years prior was referred to our hospital with a diagnosis ofrectal cancer. The tumor was detected near the rectal anastomosis ofthe previous surgery. Histopathologic study ofthe biopsy specimen revealed mucinous carcinoma. We performed a Miles operation in July 2010. The pathological findings were mucinous carcinoma, pT4b(small intestine), pN0, pPM1, pDM0, pRM1. Two months after surgery, chemotherapy comprising mFOLFOX6 plus Pmab was started and 12 courses oftreatment were administrated. Then, UFT was orally administrated. The pelvic tumor gradually increased to 9 cm in diameter. Radiation therapy was performed from May 2013 but was not effective. The histopathologic findings of a CT-guided biopsy revealed mucin only. We administered oral S-1, but his serum CEA level increased to 30.7 ng/mL and skin invasion of the tumor was observed; therefore, we performed tumor reduction surgery through an incision from the perineum in July 2015. After surgery, regorafenib was administered. The serum CEA value was normalized, but repeated urinary tract infection, gradually deteriorated renal function, and local cancer progression were observed. Administration of regorafenib continued in an outpatient setting for approximately 2 years and 4 months. The patient was admitted to the hospital because his general condition deteriorated in February 2018 and he died in March 2018. We experienced a case that survived for more than 5 years and 6 months after the pelvic recurrence of the rectal mucinous carcinoma.

[The Diagnostic Problem of Automated Breast Volume Scanner(ABUS)for a Breast Cancer Patient with Dementia-A Case Report]

The patient was an 84-year-old woman.She had presented with a mass on her right breast.Mammography revealed an illdefined mass.Handheld ultrasonography(HHUS)revealed a low echoic mass, 25mm in diameter, on the AC area of her right breast.An automated breast volume scanner(ABUS)was not useful for detecting the lesion because the patient had dementia and restless body movements.A core needle biopsy for breast tumor led to a diagnosis of invasive ductal carcinoma, which was positive for estrogen and progesterone receptors, and negative for HER2/neu.The Ki-67-positive cell index was 70%.We examined her whole body and made a diagnosis of T2N0M0, StageⅡA.She underwent a muscle-preserving mastectomy plus sentinel lymph node biopsy.The pathological diagnosis from the resected surgical specimen was invasive ductal carcinoma, positive for estrogen and progesterone receptors, and negative for HER2/neu.The Ki-67-positive cell index was 70%.The surgical margins were negative for malignancy, and no metastasis was observed in the sentinel lymph node.She was given endocrine as adjuvant therapies.Three years after the surgery, she was well without metastases.Patients with dementia could not use ABUS.HHUS will be useful for these patients.

[A Case of Synchronous Bilateral Breast Cancer in an Elderly Patient]

We encountered a case of synchronous bilateral breast cancer in an elderly patient. A 75-year-old woman visited our hospital because she was identified with an abnormality on mammography during breast cancer screening. An elastic hard tumor 2.0 cm in diameter was detected in the A area of her right breast. Mammography showed an irregular tumor shadow with spicula in the right breast and micro-calcifications in her left breast. Ultrasonography showed a low echoic lesion 20mm in size in the A area of her right breast and a low echoic area 5mm in size in her left breast. Histological examination of core needle biopsy specimens revealed invasive ductal carcinoma in both breasts. Synchronous bilateral breast cancer was diagnosed. Bilateral muscle-preserving mastectomy with sentinel lymph node biopsy was performed. Postoperative histology revealed bilateral invasive ductal carcinoma without lymph node metastasis that was positive for ER and PgR, was negative for HER2, and had a Ki-67-positive cell index of 20% in the right breast(T1N0M0, Stage Ⅰ), and that was positive for ER, was negative for PgR and HER2, and had a Ki-67-positive cell index of 5% in the left breast(T1N0M0, Stage Ⅰ). The surgical margins were negative. She was administered endocrine therapy as adjuvant therapy for 5 years after the surgery. Eight years after the surgery, she was well without metastasis.

[A Case of Sentinel Lymph Node Biopsy for Breast Cancer in an Elderly Man]

A 75-year-old man noted an elastic hard tumor under his left areola.Mammography showed a microlobulated mass, so he was diagnosed with category Ⅳ breast cancer.Ultrasonography showed a circular hypo-echoic mass that was 21mm in diameter with a moderately indistinct border.Based on core needle biopsy, the tumor was diagnosed as invasive ductal carcinoma.We performed a whole-body check-up, and he was diagnosed with T1N0M0, StageⅠ breast cancer.The patient underwent mastectomy and sentinel lymph node biopsy.The pathological diagnosis based on the resected surgical specimen was invasive ductal carcinoma, positive for ER and negative for PgR and HER2/neu protein expression, and the Ki-67 positive cell index was 20%.The surgical margins were negative, and there was no metastasis in the sentinel lymph nodes.He was administered endocrine therapy as adjuvant therapy.Two years after the surgery, he remains well without metastases.

[The Diagnostic Problem of the Automated Breast Volume Scanner(ABUS) for Paget Disease-A Case Report]

The patient, a 41-year-old woman, presented with an elastic soft tumor on her left breast. Sore skin was observed on the left nipple and areola. Mammography revealed poor extension at the left nipple surrounding skin. A hand-held ultrasonography( HHUS)device and automated breast volume scanner(ABUS)did not detect the thickening of the skin. Surgical biopsy was performed. The skin lesion was diagnosed as Paget disease. We examined her whole body and made a diagnosis of Tis N0 M0, stage 0. The patient underwent a mastectomy and sentinel lymph node biopsy. The pathological diagnosis on the basis of the resected surgical specimen was invasive ductal carcinoma, negative for ER and PgR, and positive for HER2/neu protein expression, and the Ki-67-positive cell index was 30%. The surgical margins were negative, and no metastasis was found in the sentinel lymph node. She was given trastuzumab as adjuvant therapy. Two years after the surgery, she was well without recurrence.

[Primary Undifferentiated Pleomorphic Sarcoma of the Ileum-A Case Report]

Undifferentiated pleomorphic sarcoma(UPS)of the small intestine is extremely rare and has a poor prognosis. We encountered a case of primary UPS of the ileum without metastatic lesions. The patient was a 44-year-old man who presented with the chief complaint of lower abdominal pain for 9 months. He also presented with anemia, hypoproteinemia, and a lower abdominal tumor about 10 cm in size. Abdominal CT with cystography showed an irregular solid tumor with compression of the cystic bladder. Based on a presumptive diagnosis of the retroperitoneal tumor, he underwent laparotomy. An irregular tumor, 9×8×5 cm in size, was observed in the ileum approximately 60 cm from the terminal ileum. There were no lymph node, peritoneal, or liver metastases. Partial excision of 30 cm of the ileum from 50 cm to 80 cm at the terminal ileum was performed. The final histological diagnosis was primary UPS(storiform pattern with fibroblast-like spindle cells). The patient was not administered adjuvant chemotherapy and was discharged on postoperative day 10. He is currently well without any evidence of recurrence for 2 years after the surgery.

[Neuroendocrine Carcinoma of the Breast Encountered in the General Hospital without the Breast Department-A Case Report]

Neuroendocrine carcinoma(NEC)is a rare disease. We report a case of NEC encountered in the general hospital without a breast department. The patient was a 69-year-old woman. She had received breast cancer screening and a mass on her left breast was found. Mammography revealed an ill-defined mass. Ultrasonography showed a low echoic mass, 11mm in diameter, on the A area of her left breast. A core needle biopsy of the breast tumor(A area)led to a diagnosis of an invasive ductal carcinoma, positive for estrogen receptor and progesterone receptor, but negative for HER2/neu. The Ki-67 positive cell index was 5%. We then examined her whole body and diagnosed her with T1N0M0, Stage Ⅰ. She underwent muscle-preserving mastectomy plus sentinel lymph node biopsy. The pathological diagnosis from the resected surgical specimen was invasive ductal carcinoma(NEC), positive for estrogen receptor and progesterone receptor, but negative for HER2/neu. The Ki-67 positive cell index was 5%. The surgical margins were negative, and no metastasis was found in the sentinel lymph node. She was administered endocrine therapy as adjuvant therapy. Two years postoperatively, she was well without metastases.

[Postprandial Abdominal Fullness after Pylorus-Preserving Gastrectomy for Early Gastric Cancer]

To clarify the basis for postprandial abdominal fullness(PAF)in patients after pylorus-preserving gastrectomy(PPG), the authors investigated the relationship of PAF with postgastrectomy disorder(PGD)and gastric emptying function(GEF)in PPG patients. A total of 22 patients(14 men and 8 women, average age 64.8 years)were divided into 2 groups[Group A, PAF-positive(n=12); Group B, PAF-negative(n=10)]at 1 year after PPG for early gastric cancer. The relationships of PAF with PGD and GEF were examined. Length of the antral cuff(LAC)was significantly shorter in group A than in group B(p< 0.05). Appetite and food consumption per meal were significantly greater in group B than in group A(p<0.05 and p<0.01, respectively). Symptomatic reflux esophagitis(RE), early dumping syndrome, decreased percent body weight before illness, endoscopic RE, and endoscopic gastritis in the remnant stomach were more common in group A than in group B. Gastric stasis in the remnant stomach was significantly more common in group A than in group B(p=0.0071). GEF for solid food [time to 50%residual rate in the remnant stomach(minutes)and residual rate at 120 minutes in the remnant stomach(%)] in group A was significantly delayed compared with that in group B(p<0.001). Patients with PAF showed shorter LAC, delayed GEF for solid food, and worse postoperative quality of life(QOL), compared with those without PAF.

[Treatment Experience of Palbociclib as a New Checkpoint Inhibitor]

We encountered a case of multiple metastases from breast cancer. The patient was administered palbociclib, which was a new checkpoint inhibitor. The patient received various chemotherapies and endocrine therapies. We observed episode of care, a harm phenomenon, and tolerability. We did not recognize adverse events more severe than Grade 3 during the 6 weeks after initiating palbociclib therapy. Diagnostic imaging showed that the metastatic lesions maintained stable disease during the 6 weeks after initiating palbociclib therapy. This case suggested that palbociclib therapy is useful for patients with metastatic breast cancer.

[Study of the Therapeutic Effect and Neutrophil Lymphocyte Ratio in Breast Cancer Patients Who Received Eribulin]

BACKGROUND

The neutrophil lymphocyte ratio is reported to be a poor prognostic factor in each carcinoma, and the possibility of predicting the therapeutic effect of chemotherapy, for example, is being studied. In this study, we measured the NLR before and after administration of eribulin and the NLR before and after the final administration in breast cancer patients and examined the relationship with the therapeutic effect.

METHODS

Eleven primary breast cancer patients were examined after eribulin was administered; PD was confirmed eventually, and administration was discontinued. The NLR was determined before the first administration of eribulin and 7 days after the administration; the NLR before the final administration and after the last administration were each tested with p<0.05 as the significance level and using the t test.

RESULTS

The average value of NLR before initial administration was 4.07±2.11, and the average value after 7 days of administration was 2.47±1.97. The NLR before initial administration tended to be higher, and a significant difference was observed(p<0.05). The average NLR value before the final administration was 4.02±2.04, and the average value of the NLR after the final administration was 3.19 ±1.76, showing no significant difference(p=0.27, NS).

[Diagnosis of a Non-Invasive Ductal Carcinoma, Assisted by Long-Term Follow-Up of Spontaneous Nipple Discharge - A Case Report]

We report a case of a non-invasive ductal carcinoma revealed on long-term follow-up of spontaneous nipple discharge. The patient, a 36-year-old woman, had noticed spontaneous nipple discharge from both breasts over a 3-year period. Mammography and ultrasonography did not reveal any lesions in the breasts. The nipple discharge from her left breast stopped 36 months after initial clinical assessment. However, the nipple discharges from her right breast transformed into a bloody discharge from a single duct. Ultrasonography showed a tumor, 6mm in diameter, in the upper-outer quadrant of her right breast. A core needle biopsy for breast tumor led to a pathological diagnosis of non-invasive ductal carcinoma. We conducted a whole-body clinical examination but no metastatic lesions were detected. Subsequently, we performed breastconserving surgery and sentinel lymph node biopsy. The pathological diagnosis was non-invasive ductal carcinoma in situ. The tumor was positive for estrogen and progesterone receptors, but negative for HER2/neu. The Ki-67 labeling index was 5%. The surgical margin was negative. We diagnosed the tumor as TisN0M0=Stage 0. Endocrine therapy comprising tamoxifen (20mg/day)was initiated. Four years after surgery, she was well without any metastases.

[Successful Breast Conserving Surgery for Simultaneous and Ipsilateral Multiple Breast Carcinomas of Young Patient - A Case Report]

We report a case of a simultaneous and ipsilateral multiple breast carcinoma.The patient was 35-year-old woman.She was noticed a breast lump on her right breast, and visited our hospital.Mammography showed a tumor accompanied by spiculation on her right breast.Ultrasonography revealed 2 tumors with irregular margins, 23mm in diameter and 12mm in diameter, and were observed on C area of her right breast.The continuity of the 2 tumors was not clear.Core needle biopsies for each breast tumors led to a diagnosis.The pathological diagnosis was invasive ductal carcinoma.We checked up whole body. There was no metastatic lesion.We performed breast conserving surgery and sentinel node biopsy.The pathological diagnosis was invasive ductal carcinoma, positive for estrogen receptor and progesterone receptor, negative for HER2/neu.The Ki-67 positive cell index was 30%.The surgical margin was negative.We diagnosed T2N0M0=Stage II A.She was started the endocrine therapy by LH-RH agonist and tamoxifen.Four years after surgery, she was well without metastases.

[Asynchronous Bilateral Neuroendocrine Breast Carcinoma - A Case Report]

We report a case of asynchronous bilateral neuroendocrine breast carcinoma. The patient was a 49-year-old woman presenting with a bloody nipple discharge from the right breast. We suspected intraductal papilloma and performed a microdochectomy. A pathological analysis of the resected specimen confirmed the diagnosis as neuroendocrine carcinoma. The tumor was positive for estrogen receptor, progesterone receptor, chromogranin A, and synaptophysin, but negative for the HER2/neu marker. The Ki-67 labeling-index was 40%. As the tumor margin was positive, breast-conserving surgery plus level II axillary lymph node dissection was performed. After surgery, radiotherapy(total dose of 50 Gy)was administered for treating residual breast involvement. Adjuvant hormonal therapy was performed for 5 years. Ten years after surgery, ultrasonography revealed a 12mm irregular hypoechoic mass in the left breast. The mass was diagnosed as a solid tubular carcinoma based on core needle biopsy findings. Subsequently, we performed breast-conserving surgery. The pathological diagnosis was a neuroendocrine carcinoma, and the tumor was positive for estrogen receptor, progesterone receptor, chromogranin A, synaptophysin, and CD56, but negative for the HER2/neu marker. The Ki-67 labeling-index was 50%. We report our experiences with a rare case of asynchronous bilateral neuroendocrine breast carcinoma. In this case, ultrasonography was a useful modality for detecting both the lesions.

[A Case of Local Recurrence of Descending Colon Cancer with Ileus Obstruction and Lung, Liver and Brain Metastasis]

We report a 50-year-old man with local recurrence of descending colon cancer with ileus obstruction and brain metastasis, 2 years 6 months after initial resection due to perforation of descending colon cancer(Hartmann procedure, D2 lymph node resection, Stage II, tub2). He complained of left upper abdominal pain and abdominal fullness. He also complained of paresis of the right upper extremity and of experiencing convulsions 1 month before admission. He was diagnosed with local recurrence of descending colon cancer, based on findings of contrast radiography and the presence of colonic fiber. We subsequently performed transanal decompression as a bridge to surgery and performed partial resection of the local recurrence in the anastomosis at the descending colon and ileum involved with the cancer 2 weeks after decompression. In addition, multiple lung and liver metastases, and solitary brain metastasis(2.5 cm in size located in the left side of the parietal region) were detected by cerebral plain computed tomography. However, he refused both chemotherapy after surgery, as well as further surgery and/or radiation therapy for the brain metastasis. He desired to return to his home as soon as possible. In order to improve his quality of life(QOL), in-home treatment involving the best supportive care(BSC)conservative therapiesincluding, anticonvulsant and anti-intracranial hypertension drugs-were administered to prevent brain metastasis symptoms, such as paresis of the right upper extremities and convulsions. He was discharged from our hospital 14 days after surgery. Regrettably, he died due to bronchial asthma 75 days after palliative surgery in his home.

[Two Cases of Neuroendocrine Carcinoma of the Non-Ampullary Duodenum]

Here we report 2 cases of neuroendocrine carcinoma(NEC)of the non-ampullary duodenum which is extremely rare neoplasm. Case 1: A 76-year-old man had a type 2 duodenal carcinoma with a 3 cm-sized lymph node metastasis. Duodenal resection with subpyloric lymph nodes dissection and Roux-en-Y reconstruction were performed. The histopathological diagnosis was NEC of the duodenal bulb after surgery(pT3pN1M0, stage III A, UICC 7th edition). The patient died of chronic heart failure 10 years and 3 months after the surgery. Case 2: A 45-year-old woman had a type 2 duodenal NEC of the second part of the duodenum. A subtotal stomach-preserving pancreatoduodenectomy was performed with lymph node dissection.(pT4pN0M0, stage II B, UICC 7th edition). The patient died of recurrence 7 months after the surgery.

[A Case of a Long-Term Survivor Who Underwent Surgical Intervention for Hepatocellular Carcinoma Combined with Tumor Thrombus in the Main Trunkof the Portal Vein]

We reported a patient survived more than 7years after undergoing hepatectomy accompanied by tumor thrombectomy in the main trunk of the portal vein after preoperative hepatic arterial chemotherapy for hepatocellular carcinoma combined with tumor thrombus in the main portal vein. A 58-year-old man underwent hepatic arterial infusion therapy with 5-fluorouracil( 5-FU)plus cisplatin(CDDP)for 6 weeks for a solitary 7cm nodule of hepatocellular carcinoma on the liver(S6) with tumor thrombus in the main portal vein. Although hepatic arterial infusion therapy was effective and the tumor shrank markedly, the tumor thrombus of the main portal vein still existed and the existence of portal hypertension was predicted from lower platelet values. Therefore, we performed hepatectomy accompanied by tumor thrombectomy in the main portal vein. Four months after surgery, staining of a single tumor was observed in the residual liver by contrast computed tomography (CT)and Lipiodol-TAI was performed. There was no recurrence of cancer for about 4 years, when a single recurrent lesion was found in the liver caudate lobe and a single lung metastatic lesion was also found in the left lower lobe section. We performed hepatectomy of the caudate lobe, and furthermore, we performed the left basilar segmentectomy. After these operations, the patient remained cancer free and died suddenly of another disease 7years after the first treatment for the hepatoma.

[A Case of Transduodenal Ampullectomy for an Ampullary Neoplasm Coexisting with Gastric and Colon Cancer]

We present here a case of transduodenal ampullectomy for an ampullary neoplasm coexisting with gastric and colon cancer. The patient was a 72-year-old man who was referred to our hospital with a positive fecal blood test. Colonoscopy revealed advanced cancer in the descending colon. As part of the preoperative examination, for the colonic cancer, upper gastrointestinal endoscopy was performed. Endoscopy showed a 2 cm elevated lesion(0'-II a type)with subserosalinfil tration on the small curvature side of the upper part of the stomach, and a 2 cm elevated lesion on the papilla of Vater. Histopathological examination showed that the former was a well differentiated tubular adenocarcinoma and the latter was a villous tubular adenoma with severe atypia. First, laparoscopic colectomy for advanced descending colon cancer was performed. Totalgastrectomy with Roux-en-Y reconstruction, cholecystectomy, and transduodenal ampullectomy for the ampullary neoplasm 21 days after the first surgery. The patient was discharged without any complications, such as postoperative suture failure. According to pathological tissue diagnosis, the degrees of progress of the colorectal cancer and the gastric cancer were pT2(MP)and pT1b(SM2), respectively, and there was no lymph node metastasis. The duodenal papillary tumor was a tubular villous adenoma(high grade). Local excision of the papilla is minimally invasive, leaves easy-to-secure stumps, and has less risk of complications such as bleeding and pancreatitis. Taking into account the balance with coexisting gastrointestinal cancer treatment, local excision of the papilla in this case was considered to be an appropriate treatment.

[Long-Term Effect of Fulvestrant for Locally Advanced Breast Cancer in an Elderly Patient - A Case Report]

We report an elderly patient with locally advanced breast cancer who received long-term fulvestrant therapy.The patient was a 75-year-old woman who presented with a right breast lump.She noticed the tumor 4 years and 6 months ago, but she had not visited any hospital.However, her daughter brought her to our hospital.The tumor was 73mm in diameter.A core needle biopsy for breast tumor led to a diagnosis of an invasive ductal carcinoma, positive for estrogen receptor(ER)and progesterone receptor(PgR), and negative for HER2/neu.The Ki-67 positive cell index was 20%.We performed a whole- body checkup, and confirmed the diagnosis as T4cN1M0, Stage III B.She initiated endocrine therapy by letrozole(2.5 mg/ day).After 1 year and 6months, tumor marker levels increased.We changed the endocrine therapy to fulvestrant(500mg/ month).For the next 2 years and 6 months, this therapy was effective.Her axillary lymph node metastases disappeared and tumor size decreased(60%).She underwent muscle-preserving mastectomy plus axillary lymph node dissection.The pathological diagnosis from the resected surgical specimen was confirmed as invasive ductal carcinoma, positive for ER and PgR, and negative for HER2/neu protein expression.The surgical margins were negative, and there was no metastasis in the lymph nodes.She was administered adjuvant endocrine therapy.Four years after surgery, she was well without metastasis.

[A Case of Advanced Breast Cancer with Liver Metastasis Successfully Treated with Multi-Disciplinary]

We report a case of advanced breast cancer with liver metastasis(T2N1M1, Stage IV )achieving a significant improvement of QOL by multi-disciplinary therapy. The patient was 37-year-old woman who had breast lump and axillary lymph nodes swelling with liver metastasis. A core needle biopsy for breast tumor led to a diagnosis of an invasive ductal carcinoma, negative for estrogen receptor and progesterone receptor, and positive for HER2/neu protein expression. The Ki-67 positive cell index was 40%. She received 16 courses of DOC plus HER plus PER(docetaxel 75mg/m / 2, trastuzumab 6 mg/kg, pertu- zumab 450mg/body, and received 4 courses of EC(epirubicin 90mg/m / 2, cyclophosphamide 600 mg/m2). The breast lesion and liver metastatic lesion disappeared after chemotherapy. We checked up whole body. There was no metastatic lesion. Therefore, we diagnosed a clinical complete response. We performed muscle preserving mastectomy and axillary lymph nodes dissection. The pathological diagnosis from resected specimens were pathological complete response. The surgical margin was negative. She was started the endocrine therapy by tamoxifen(20mg/day). Three years after surgery, she was well without metastases. Multi-disciplinary therapy can improve patient QOL and the clinical outcomes in Stage IV advanced breast cancer.

[Synchronous and Unilateral Breast Cancers(Invasive Lobular Carcinoma and Non-Invasive Ductal Carcinoma) - A Case Report]

We report a case of synchronous and unilateral breast cancers in a 51-year-old female.A focal asymmetric right breast density was detected on breast cancer screening mammography.Ultrasonography showed a low echoic mass, 9mm in diameter, in the B area, and a second low echoic mass in the CD area of her right breast.A core needle biopsy of the B area mass led to a diagnosis of an invasive lobular carcinoma, positive for estrogen receptor(ER)and progesterone receptor(PgR), and negative for HER2/neu.One -percent of the tumor cells were Ki-67 positive.Her preoperative diagnosis was Stage I (T1N0M0).She underwent muscle-preserving mastectomy plus sentinel lymph node biopsy.The pathological diagnosis from the resected surgical specimen was invasive lobular carcinoma(B area), positive for ER, and negative for PgR and HER2/neu protein expression.From this, she was additionally diagnosed with non-invasive ductal carcinoma(CD area)that was posi- tive for ER, and negative for PgR and HER2/neu protein expression.The surgical margins were negative, and there were no sentinel lymph node metastases.These tumors were independent.She was given adjuvant endocrine therapy.Two years and 6 months after surgery, the patient was doing well and without metastases.

[A Case of Neuroendocrine Ductal Carcinoma In Situ of the Breast Detected as an Intra-Cystic Tumor Using Ultrasonography]

We report a case of neuroendocrine ductal carcinoma in situ of the breast. The tumor was shown to be an intra-cystic tumor on performing ultrasonography. The patient was a 40-year-old woman. Amorphous calcifications were detected on her right breast on performing mammography during breast cancer screening. Ultrasonography indicated that the tumor was 9mm in diameter, and displayed features of an intra-cystic tumor. A vacuum-assisted core needle biopsy for breast tumor led to a diagnosis. The pathological diagnosis was mastopathy. We could not rule out malignancy of the tumor. Subsequently, we performed surgical resection with 5mm margins. The pathological diagnosis was intra-cystic neuroendocrine carcinoma in situ, positive for estrogen receptor and progesterone receptor, and negative for HER2/neu. The Ki-67 positive cell index was 5%. The surgical margin was negative. We performed a whole-body checkup, and confirmed a diagnosis of TisN0M0, Stage 0. She was initiated endocrine therapy with tamoxifen(20mg/day). Four years after surgery, she was well without metastases.

[A Case of Metastases to the Bone, Skin, and Ovary from Gastric Cancer Occurring More Than Eight Years after Distal Gastrectomy]

We report a 72-year-old woman with rare metastases of gastric cancer to the bone, skin, and ovary occurring more than 8 years after distal gastrectomy, which were subsequently effectively controlled. Histopathological diagnosis revealed signetring cell carcinoma, and the comprehensive findings were pT4a, pN3, ly2, v0, and Stage III c. The adjuvant chemotherapy of S- 1 plus cisplatin(CDDP)was switched to S-1monotherapy for 4 years and then to tegafur/uracil(UFT)for an additional year. Eight years after the operation, I-CTP and alkaline phosphatase(ALP)levels were elevated, and bone scintigraphy revealed bone metastasis. The patient's ALP levels, which had increased to 6,617 U/L, remarkably decreased to 359 U/L 17 months after treatment with zoledronic acid. About 9 years after the operation, a 2cm subcutaneous node was seen on the patient's scalp, and a biopsy was performed. Histologically, the node was confirmed as a signet-ring cell carcinoma. S-1 therapy was initiated, and the node disappeared within 8 months. About 10 years after the gastrectomy, abdominal computed tomography( CT)scans indicated a tumor sized 11×10 cm in the pelvis, and a biopsy was performed. Histologically, the tumor was a signet-ring cell carcinoma appearing as an ovarian metastasis of gastric cancer. Ovariectomy was performed. Peritoneal dissemination was not detected. The patient was treated with S-1 plus oxaliplatin and zoledronic acid, and continues to remain in good condition 9 months after the ovariectomy.

[Indoleamine 2,3-Dioxygenase Activity during Fulvestrant Therapy for Aromatase Inhibitor Resistant Metastatic Breast Cancer]

We evaluated the clinical significance of indoleamine 2,3-dioxygenase(IDO)for breast cancer patients between different clinical stages and patient ages. IDO activity was measured by the tryptophan(Trp)/kynurenine(Kyn)ratio. Trp and Kyn levels were measured using high performance liquid chromatography(HPLC). Serum Trp/Kyn levels in Stage IV breast cancer patients were lower than in patients at other stages. Serum Trp/Kyn levels of breast cancer patients over the age of 70 years were lower than in patients under the age of 69 years. Within the same clinical stage, serum Trp/Kyn levels of breast cancer patients over the age of 70 years were lower than in patients under the age of 69 years. These results suggest that the immunological profile of breast cancer patients over the age of 70 years may be immunosuppressive compared to breast cancer patients under the age of 69 years.

[Clinical Evaluation of Indoleamine 2, 3-Dioxygenase in the Serum of Patients with Locally Advanced Breast Cancer during Mohs Paste Treatment]

Locally advanced breast cancer lesions often compromise patients' quality of life(QOL). Mohs paste is a histopathological fixative with zinc chloride as the main ingredient. It is applied when performing chemosurgery for skin tumors. In recent years, this paste has reportedly been very effective for the control of various symptoms of skin metastases in inoperable advanced cancers, such as pungent odor and hemorrhage, in the field of palliative care. We evaluated the clinical significance of indoleamine 2, 3-dioxygenase(IDO)in the serum of patients with locally advanced breast cancer during Mohs paste treatment. IDO activity was measured by the tryptophan(Trp)/kynurenine(Kyn)ratio. Trp and Kyn levels were measured using high performance liquid chromatography(HPLC). We collected serum samples from 3 locally advanced breast cancer cases: once in the pre-treatment phase, 2 times in the post-treatment phase, and 5 times in the post-treatment phase. Then, we measured the Trp/Kyn ratio and CRP in these samples during Mohs paste treatment. There were no significant differences in serum Trp/ Kyn ratios between the phases, but serum CRP values decreased after Mohs paste treatment. These results suggest that Mohs paste treatment for locally advanced breast cancer lesions may be useful in enhancing patients' QOL without immunosuppression.

[Indoleamine 2,3-Dioxygenase Activity during Letrozol Therapy for an Elderly Breast Cancer Patient]

We evaluated the clinical significance of indoleamine 2,3-dioxygenase(IDO)during letrozol therapy for an elderly patient with locally advanced breast cancer. IDO activity was measured by the tryptophan(Trp)/kynurenine(Kyn)ratio. Trp and Kyn levels were measured using high performance liquid chromatography(HPLC). Serum Trp/Kyn levels of the patient before endocrine therapy were lower than those after endocrine therapy. IDO activity decreased after endocrine therapy and correlat- ed with the number of metastatic lymph node lesions during letrozol therapy. These results suggest that measuring the Trp/ Kyn ratio may be useful for evaluating immunological metastatic status during endocrine therapy in elderly patients with locally advanced breast cancer.

[Clinical Evaluation of Immunosuppressive Acidic Protein in the Serum of Patients with Inflammatory Breast Recurrence]

Inflammatory breast recurrence after breast conserving surgery often compromises patient quality of life(QOL)and is associated with a poor prognosis. For this type of recurrence, the immunological situation of the patient is uncertain. We evaluated the clinical significance of immunosuppressive acidic protein(IAP)in the serum of patients with inflammatory breast recurrence during treatment. We collected serum from 3 patients at three different time points: the pre-treatment phase, recurrence phase, and the post-treatment phase. IAP was then measured from these multiple serum samples. There was a significant difference between serum IAP values in the pre-treatment and recurrence phases. The recurrence phase had a mean IAP value that was higher than the pre-treatment phase. The IAP values were indicative of the disease condition. These results suggest that serum IAP is a useful quantification of the immunological condition of patients with inflammatory breast recurrence.

Long-term survival following hepatectomy, radiation, and chemotherapy for recurrent pancreatic carcinoma: a case report

BACKGROUND

Recurrent pancreatic carcinoma (PC) is generally well known to have a poor prognosis. Cases in which multidisciplinary treatments have been remarkably effective are rare.

CASE PRESENTATION

Herein, we reported a case of long-term survival following a combination of hepatectomy for a liver metastasis and radiation and chemotherapy for abdominal lymph node metastases after a curative pancreaticoduodenectomy for PC. A 51-year-old Japanese man underwent a pancreaticoduodenectomy following a PC diagnosis in December 2011. After the surgery, the patient received 16 cycles of gemcitabine (GEM) adjuvant chemotherapy. Abdominal computed tomography (CT) after therapy with GEM (17 months after surgery) revealed a 1-cm nodule in the liver, for which the patient underwent partial hepatectomy in May 2013. Approximately 1 month after the hepatectomy, the patient underwent adjuvant chemotherapy using tegafur/gimeracil/oteracil (S-1) for 12 months. Approximately 1 year after the second surgery, an abdominal CT scan detected the abdominal lymph node metastases, for which the patient underwent radiation therapy. After the radiation therapy, combination therapy with 5-fluorouracil(5-FU)/leucovorin plus oxaliplatin or irinotecan was started in September 2014; 59 cycles of this chemotherapy have been administered up to the time of this report. At 67 months after the pancreaticoduodenectomy and 50 months after the hepatectomy, the patient has remained healthy with no relapse or recurrent lesions.

CONCLUSION

We have managed a long-term survivor who underwent hepatectomy for liver metastasis and radiation therapy and chemotherapy for abdominal lymph node metastases after curative pancreaticoduodenectomy for PC.

[Breast Cancer with Microinvasion and Lymph Node Metastasis Diagnosed by Microdochectomy - Report of a Case]

We report a case of breast cancer with microinvasion and lymph node metastasis. The patient was a 72-year-old woman who had spontaneous nipple discharge from her left breast. There was no detectable lesion on mammographyor duct endoscopy. Ultrasonography showed a low echoic lesion, 23×15mm in diameter, in the CD area of her left breast. Contrastenhanced MRI showed a high intensityarea, 25mm in diameter, in her left breast, so microdochectomywas performed. The histopathological diagnosis was invasive ductal carcinoma(invasion of 2mm)and the surgical margin was positive. Therefore, she underwent breast conserving surgeryplus axillaryly mph node dissection. The pathological diagnosis from the resected surgical specimen was invasive ductal carcinoma with micro lymph node metastasis, positive for ER and PgR and negative for HER2/neu protein expression. The Ki-67 labeling index was 10% and the surgical margins were negative. She was treated with radiation and endocrine therapy as adjuvant therapy. One year and 6 months after surgery, she was well without metastasis.

[A Case of Squamous Cell Carcinoma of the Right Breast]

Squamous cell carcinoma(SCC)of the breast is rare and its clinicopathological features have not been fully elucidated. We report a patient with SCC of the right breast who underwent surgical resection. A 51-year-old woman was admitted to our hospital because of a right breast tumor. A round tumor with an irregular surface measuring about 3.0×2.5 cm was palpable in the ACarea of the right breast. No abnormal data were observed on laboratory examination, including tumor markers such as carcinoembryonic antigen(CEA), cancer antigen 15-3(CA15-3), breast cancer antigen 225(BCA225), and SCC antigen. Mammography showed a mass with spiculation measuring 2.7×1.7 cm. Ultrasonography also demonstrated a hypoechoic solid tumor with an irregular surface, measuring 2.6×1.6 cm. The pathological diagnosis of a needle biopsy specimen was a mixed type of SCC. We performed a typical right mastectomy with axillary and supraclavicular lymph node dissection. The tumor size was 2.8×1.8 cm. SCC was histologically diagnosed. There was partial invasion to other tissues. The dissected lymph nodes were not involved by carcinoma. Hormone receptors(estrogen and progesterone)and HER2 results were negative. The pathological Stage was II A(T2, N0, M0). The patient refused chemotherapy. However, her condition remains satisfactory without recurrence 2 years after surgery.

[Difficult Decision about a Surgical Margin for a Non-Invasive Apocrine Carcinoma in the Breast - Report of a Case]

We report a case of non-invasive apocrine carcinoma. In this case, we could not identifythe surgical margin. The patient was 39-year-old woman. Micro calcifications were discovered on her right breast during breast cancer screening. Stereotactic vacuum assisted core needle biopsywas performed and the pathological diagnosis was sclerosing adenosis. A low echoic lesion, 26mm in diameter, was discovered in the CDE area of her left breast byultrasonography . A contrast enhanced MRI showed a high intensityarea, 26mm in diameter, on her left breast. Ultrasonographyguided vacuum assisted core needle biopsywas conducted on the low echoic area. The pathological diagnosis was non-invasive ductal carcinoma. We checked her whole bodyand found no metastatic lesion. She underwent breast conserving surgeryplus sentinel lymph node biopsy. We had great difficultyin classifying the surgical margin. The pathological diagnosis from the resected surgical specimen was non-invasive apocrine carcinoma, negative for ER and PgR, and positive for HER2/neu protein expression. The Ki-67 labeling index was 20%, the surgical margins were negative, and the clinical Stage was 0(Tis, N0, M0). She was administered radiation therapy and endocrine therapy as adjuvant therapy. Two years and 6 months after surgery, she is well without metastasis.

[CR of All Target Lesions in a Patient with Metastatic Esophageal Cancer and Generalized Weakness Treated with Systemic Chemotherapy after Nutritional Support]

We report here a case of CR of all target lesions in a patient with esophageal cancer with multiple metastases treated with systemic chemotherapy after nutritionalsupport. A 75-year-old man was referred to our hospital with a diagnosis of multiple- metastatic esophagealcancer in June 2014. He showed generalized weakness with poor dietary intake, and he was initially admitted for nutritional support by parenteral nutrition. Biopsy specimens revealed mixed squamous- and adenocarcinoma: MtLtUtAeG, 13 cm, type 2, cT3, IM1-St, cN3, cM1(liver, lungs, and stomach), cStage IV b esophagealcarcinoma. We had initiated 5-FU/CDDP/docetaxel(DCF)chemotherapy in July 2014. The target lesions exhibited PR after 2 courses of chemotherapy, and the primary esophageal lesion was markedly reduced, but was still present. The patient's renalfunction deteriorated after 8 courses of DCF, and the chemotherapy protocolwas changed to single-agent docetaxelonce every 3 weeks. The patient underwent 20 courses of the chemotherapy, and over a period of approximately 1 year from March 2015, CR of all target lesions was noted, with IR/SD of the primary tumor. The patient has survived and remained in good condition for 23 months following the initial diagnosis.

[Usefulness of Transnasal Decompression Tubes in Patients with Right-Sided Obstructive Colorectal Cancer]

PURPOSE

We performed this retrospective study to evaluate the usefulness of a transnasal decompression tube(long ileus tube)as a bridge to surgery in patients with right-sided obstructive colorectal cancer.

PATIENTS AND METHODS

There were 8 patients(5 men and 3 women, aged 64 to 85 years with a mean age of 75.9 years)who had undergone transnasal decom- pression in the last 10 years.

RESULT

1) The success rate of intubation was 100%(8/8). 2) Primary cancer location: Ascend- ing colon cancers were 37.5%(3/8)and right-sided transverse colon cancers 62.5%(5/8). 3) Decompression periods were from 1 to 43 days, with a mean period of 12.8 days. 4) Stage: Stage II was found at 12.5%(1/8), Stage II , III a, III b and IV were found at 25.0%(2/8), respectively. Advance Stages( III a, III b, and IV )were 75.0%(6/8). 5) Pathology: Well differentiated tubular adenocarcinoma(tub1)was at 37.5%(3/8)and moderately differentiated tubular adenocarcinoma (tub2)at 62.5%(5/8). 6) Operative procedures: Radical operation was performed in 6 cases except for 2 cases with stage IV disease. 7) Complications: Early complication were found in 37.5% of the cases(3/8). Wound infection was found in 12.5%(1/8), wound infection with rupture in 12.5%(1/8), and adhesive ileus in 12.5%(1/8). 8) Outcomes: The 5-year survival was 37.5%(3/8).

CONCLUSION

Transnasal tube decompression for right-sided malignant colorectal obstruction is useful for avoiding an emergency operation, and a single-stage operation can be performed in patients excluding Stage IV disease.

[Two Cases Pancreatic Carcinoma Detected Incidentally during Treatment of Acute Abdomen from Other Causes]

We report 2 cases of pancreatic cancer discovered incidentally in the wake of acute abdomen from other causes. Case 1 is a 67-year-old man who was referred to our hospital in October 2010 for the treatment of an incarcerated right inguinal hernia. The hernia was manually reduced, and mesh plug hernioplasty was scheduled for the next day. A 2.9 cm diameter tumor was detected in the tail of the pancreas on plain CT at the first visit and confirmed on enhanced CT soon after the hernia repair. A follow-up abdominal CT scan approximately 1 month later showed modest enlargement of the tumor to 3.5 cm diameter. The patient underwent distal pancreatectomy with lymph node dissection in December 2010. The histopathological diagnosis was tubular adenocarcinoma(tub1>tub2). Comprehensive findings were pT2, pN0, cM0, fStage II . He was treated with adjuvant chemotherapy consisting of gemcitabine 1,000mg/m2 for 6 months after surgery, and at 5 years and 7 months after surgery, he was alive and recurrence-free. Case 2 is a 74-year-old man who presented to our hospital with lower abdominal pain and diarrhea in early January 2016. Colonoscopy and barium enema revealed severe stenosis of the rectum(Rs). Rectal biopsy confirmed adenocarcinoma of the rectum. In addition, an enhanced CT scan showed irregular dilatation of the pancreatic duct in the pancreatic tail. The patient underwent low anterior resection and distal pancreatectomy, which was performed following an intraoperative pancreatic ultrasound examination that supported a diagnosis of pancreatic cancer. Pathological and comprehensive findings of rectal cancer were tubular adenocarcinoma(tub2)and pT3, pN0, cM0, fStage II , and those of the pancreatic cancer were tubular adenocarcinoma(tub2)and pT1, pN0, cM0, fStage I . The patient was discharged from the hospital 46 days after surgery. However, he died 18 days later due to sudden out-of-hospital cardiopulmonary arrest.

[Axillary Lymph Node Dissection and Chemotherapy were Useful for Occult Cancer - Report of a Case]

We report a case of occult cancer. In this case, axillaryly mph node dissection and chemotherapywere useful treatments. The patient was a 71-year-old woman who had left axillaryly mph node swelling. Mammographyshowed the swollen axillary lymph nodes, but there was no lesion in either breast. Ultrasonographyalso showed the swollen axillaryly mph nodes, but there was no malignant lesion in her breasts. CT showed swollen axillaryand mediastinal lymph nodes. We checked her entire body, but could not find a malignant lesion, so we diagnosed an occult cancer. She underwent axillary lymph node dissection. The pathological diagnosis from the resected surgical specimen was metastatic carcinoma, negative for ER and PgR, and negative for HER2/neu protein expression. She was given TC chemotherapyand her CEA value decreased. After 8 cycles of TC chemotherapy, she was well without metastasis.

[Indoleamine 2,3-Dioxygenase Activity during Fulvestrant Therapy for Multiple Metastatic Breast Cancer Patients]

We evaluated the clinical significance of indoleamine 2,3-dioxygenase(IDO)during fulvestrant therapyfor multiple metastatic breast cancer patients. IDO activitycan be measured using the tryptophan(Trp)/kynurenine(Kyn)ratio. Trp and Kyn were measured using high-performance liquid chromatography(HPLC). The serum Trp/Kyn level in patients with multiple metastatic breast cancer was lower than in patients without metastases. IDO activityincreased after breast cancer metastases developed. IDO activitywas correlated with the number of metastatic lesions during toremifene and fulvestrant therapy. These results suggested that measurement of the Trp/Kyn ratio is useful to evaluate immunological metastatic status during endocrine therapy.

[Clinical Evaluation of Immunosuppressive Acidic Protein in the Serum of Patients with Locally Advanced Breast Cancer during Mohs Paste Treatment]

Locallyadvanced breast cancer lesions often compromise the patient's qualityof life(QOL). Mohs paste is a histopathological fixative containing zinc chloride as the main ingredient. It has been applied to perform chemosurgeryon skin tumors. In recent years, this paste has reportedlybeen veryeffective for controlling various symptoms of skin metastases in inoperable advanced cancer, such as pungent odor and hemorrhage, in the field of palliative care. We evaluated the clinical significance of immunosuppressive acidic protein(IAP)and C-reactive protein(CRP)in the serum of patients with locallyadvanced breast cancer duringMohs paste treatment. The tryptophan(Trp)/kynurenine(Kyn)ratio measures IDO activity. Trp and Kyn were measured byhigh performance liquid chromatography(HPLC). We took serum samples from 3 locallyadvanced breast cancer cases, in the pre-treatment phase, 2 times after the treatment phase, and 5 times after the treatment phase. Then, we measured IAP and CRP in these samples during Mohs paste treatment. Serum IAP values did not differ significantlybetween each of the phases; however, serum CRP values were decreased byMohs paste treatment. These results suggested that Mohs paste treatment for locallyadvanced breast cancer lesions was useful for enhancing the patient QOL, without immunosuppression.