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Background Although a few cases of accessory breast cancer (ABC) have been reported, most were in the axillary region. We encountered an extremely rare case of ABC in the inframammary region (IMR). Case presentation The patient was a 68-year-old postmenopausal woman who had noticed a congenital accessory nipple in her left IMR with slight, occasional discharge 20 years ago. Recently, she noticed a mass under the accessory nipple and visited a nearby clinic; fine-needle aspiration cytology of the mass revealed that it was malignant. She presented to our department 2 weeks after she had noticed the mass. Physical and imaging examinations showed an irregular tumor mass 1.7 × 1.4 × 1.0 cm in size connected to the accessory nipple beneath the left normal breast. Neither distant metastasis nor lymph node swelling was observed. Ultrasound-guided core needle biopsy revealed the mass to be invasive ductal carcinoma. We diagnosed her tumor as ABC in the left IMR; cT1cN0M0: stage IA. Curative wide resection with sentinel node biopsy was performed. Intraoperative evaluation of the frozen section revealed a hot and green ipsilateral axillary lymph node that was free from carcinoma; therefore, nodal dissection was avoided. Histopathological examination including immunochemical staining revealed that the tumor was invasive ductal carcinoma arising from the accessory breast tissue, scirrhous type, 1.7 × 1.4 × 1.0 cm in size, with a solid intraductal component. There was no lymphovascular infiltration, and the surgical margin was 1.5 cm or more. The tumor was estrogen and progesterone receptor-positive, Her2/neu-negative, and had a Ki-67 labeling index of 20%. There was no involvement of the three hot and/or green nodes. The final classification was pT1cN0(sn)M0: stage IA. Letrozole 2.5 mg/day will be administered for 5 years as adjuvant hormonal therapy. Conclusions A cutaneous and/or subcutaneous lesion except for proper breast tissue on the milk line, or mammary ridge from axilla to groin may be an accessory breast tissue. Its serial abnormalities must be worried malignant potential to ductal carcinoma which needs some imaging and pathological examinations for definitive diagnosis and appropriate treatment according to the usual orthotopic breast cancer without delay.

Background The incidence of radiation-associated angiosarcoma (RAA) of the breast has been increasing, and its prognosis is reportedly poor. It is important to remove tumor tissues completely to prevent recurrence. Case presentation We report two cases of patients with RAA of the breast. Both patients had a nodule in their remaining breast a few years after undergoing breast-conserving surgery and radiation therapy for breast cancer. The nodules were diagnosed as angiosarcoma by skin biopsy and open biopsy, respectively. To determine the extent of lesion spread, mapping biopsy was performed before surgery. Both patients underwent mastectomy, extensive skin resection, and split skin grafting. Pathological findings showed that their tumors could be completely resected. After surgery, chemotherapy was performed. Conclusion In our cases, no local or distant recurrence has been detected in either patient for over 4 years. We identified the range of tumor invasion by preoperative mapping biopsy and completely resected all tumor tissue.

Apocrine papillary lesion (APL) is difficult to diagnose as benign or malignant. We experienced an APL remaining in the body for 22 years. We present a case of a 71-year-old woman who had undergone excisional biopsy 22 years previously at the first hospital that she visited. 1 year previously, she had undergone fine-needle aspiration cytology at a second hospital, and the lesion was diagnosed as potentially malignant. She underwent core-needle biopsy at a third hospital, but whether the lesion was benign or malignant could not be definitively diagnosed. We performed right mastectomy and sentinel lymph-node biopsy, because her tumor was suspected to be malignant based on imaging means, and malignancy could not be ruled out on either biopsy or cytology. The histopathological diagnosis was tiny foci of apocrine proliferative lesion with massive hemorrhagic necrosis and no tumor metastasis in two sentinel lymph nodes. Retrospectively, we compared all of the patient’s previous specimens with the present ones, and applied the recent pathological diagnostic criteria. Although the biopsy specimen excised 22 years ago suggested an encapsulated apocrine papillary carcinoma or a papilloma with apocrine ductal carcinoma in situ, neither infiltration nor metastasis has occurred. Furthermore, neither the pathological findings nor the clinical behavior has changed over time.

Therapeutic mammoplasty (TM) for breast cancer is a widely practiced oncoplastic technique. Intraductal spread towards the nipple or the location of the cancerous lesion on the central breast may become a contraindication for breast-conserving surgery. We herein report the results of TM in such cases. Six patients underwent TM that combined partial mastectomy with free nipple-areola (NA) grafting. The nipple was removed together with the cancerous lesions, and the areola was preserved for NA reconstruction. The tumors were located in the lower quadrant (n = 1), the central area (n = 1), the upper-outer area (n = 2), and the upper-inner area (n = 2). The types of mammoplasty that were performed included: amputation (n = 1), inverted T mammoplasty (n = 3), and L mammoplasty (n = 2). With the exception of one patient, all patients underwent inverted T mammoplasty on the contralateral breast in order to achieve symmetry. The total surgical and plastic periods ranged from 155 to 235 min (mean 207 min) and 100 to 150 min (mean 121 min), respectively. Oncological safety and excellent cosmetic results were achieved. TM combining partial mastectomy with NA grafting was successfully performed in patients with early-stage cancer in all quadrant areas.

To clarify the quality of life of patients who underwent esophagectomy for carcinoma by right thoracotomy, laparotomy and cervical anastomosis, 116 patients who were cancer free at the time of mailing a questionnaire were analyzed. A significant decrease in vital capacity for 3 years postoperatively, as well as in the percentage of ideal body weight, between 3 and 5 years were observed in 57 patients with three-field lymphadenectomy. Patients' quality of life undergoing three-field dissection was worse than those with less radical lymphadenectomy (59 cases) in terms of the performance status and difficulty in talking at 60 months or more postoperatively. Around 20% of all patients reported severe hoarseness due to permanent recurrent nerve paralysis, resulting in poor quantity of food intake at 24 months or less postoperatively and restricted daily activity and difficulty in talking at 60 months or more after the operation. When a patient suffers from vocal cord insufficiency caused by permanent paralysis of the recurrent nerve, early treatment before discharge from the hospital should be performed to improve the quality of life of such a patient.

The treatment of early breast cancer using breast-conserving therapy commonly ensures local control and acceptable cosmetic results. We herein report a useful technique, including the use of a thoracodorsal adipofascial cutaneous flap for reconstructing defects in the outer quadrant area after partial mastectomy, which achieved excellent results.We performed partial mastectomy followed by immediate volume replacement using a modified thoracodorsal adipofascial cutaneous flap with a crescent-shaped dermis in ten patients.The modified oncoplastic technique was performed without any complications in all patients. Sufficient blood flow to the cutaneous flap with the crescent-shaped dermis was visualized in two patients during the operation after the injection of indocyanine green. The oncological and cosmetic results were excellent to good in these patients.Oncoplastic surgery using a modified thoracodorsal adipofascial flap with a crescent-shaped dermis was successfully performed in patients with early cancer lesions in the outer quadrant, and the cosmetic results obtained were excellent.

Oncoplastic breast surgery (OBS), which combines the concepts of oncologic and plastic surgery, is becoming more common worldwide. We herein report the results of OBS in Japanese patients with Paget's disease. We performed OBS combining partial mastectomy with immediate breast reshaping using a keyhole-shaped skin glandular flap in two patients. In these two patients, who were diagnosed as having Paget's disease with a restricted intraductal component in the central area of their non-ptotic breast, we performed oncoplastic surgery combining partial mastectomy with immediate breast reshaping using a keyhole-shaped skin glandular flap. Neither of the two patients received contralateral surgery to produce symmetrical breasts. The observation period ranged from 6 to 12 months, and the bilateral breast volumes and inframammary lines were symmetric. OBS combining partial mastectomy with immediate breast reshaping using a keyhole-shaped skin glandular flap was successfully performed in two patients with Paget's disease.

Background: Oncoplastic surgery is becoming more common, however, only several reports have been published in Japan. We report the results of simple oncoplastic surgery for Japanese patients with early breast cancer in the upper quadrant area. Methods: In seven patients with a past history of breast-feeding and ptotic breasts, we performed oncoplastic surgery involving partial mastectomy and the resection of excess skin and parenchymal tissue. Results: None of the patients received a contralateral operation to produce symmetrical breasts. The width of the resected excess skin tissue ranged from 20 to 50 mm, with the mean width being 30 mm, and its length ranged from 50 to 90, with the mean length being 77 mm. The width of the resected gland tissue ranged from 40 to 65 mm, with the mean width being 53 mm, and its length ranged from 70 to 100 mm, with the mean length being 97 mm. The cosmetic results were excellent. Conclusions: Oncoplastic surgery using spindle shaped-resection was successfully performed in patients with upper quadrant lesions, and the cosmetic results were excellent.

We report a patient with breast cancer whose breast was immediately reconstructed using a local adipofascial flap and was then subsequently resected 3 years after the original surgical procedure due to local recurrence. In order to achieve local control of the solitary recurrent lesion, we resected the remnant breast, which gave us a useful opportunity to examine the previously implanted flap histologically. A 33-year-old Japanese female was diagnosed with T2N0M0 breast cancer in the outer area of her left breast and underwent partial mastectomy with immediate reconstruction using a local adipofascial flap. The breast lesion was considered to be invasive ductal carcinoma, scirrhous carcinoma, lymphatic invasion+, venous invasion-, estrogen receptor+, progesterone receptor+, and HER2/neu-. Involvement was noted in three of the twenty-five resected axillary lymph nodes. She received adjuvant hormone therapy, but developed a solitary local recurrence of the skin forty-five months after the initial procedure, for which she received total mastectomy, systemic chemotherapy, and hormone therapy. During the histological examination of the local adipofascial flap that had been implanted into the partial breast defect, normal fatty tissue and the implanted fascia were seen at the implantation site. This is a rare report in which a local flap that was implanted during oncoplastic breast surgery was histologically examined.

We have reported excellent results for immediate volume replacement using autologous tissues. In particular, volume replacement using a free dermal fat graft from the lower abdomen is thought to be appropriate for treating patients with breast cancer in the upper inner quadrant area. We have modified this technique and report the results of oncoplastic surgery in four Japanese patients with early breast cancer. Their breasts were non-ptotic, and each lesion was considered to be suitable for breast conservative surgery. Immediate volume replacement therapy using a free dermal fat graft from the lateral abdomen into the breast cavity was performed as breast-conserving surgery. The technique was easy to perform, and the cosmetic outcome was excellent.

Background Endoscopic thyroidectomy is a well-established surgical technique. We have been utilizing precordial video-assisted neck surgery (VANS) with a gasless anterior neck skin lifting method. Recently, natural orifice transluminal endoscopic surgery (NOTES) has generated excitement among surgeons as potentially scar-free surgery. We developed an innovative gasless transoral technique for endoscopic thyroidectomy that incorporated the concept of NOTES in a VANS-technique. Methods Incision was made at the vestibulum under the inferior lip. From the vestibulum to the anterior cervical region, a subplatysmal tunnel in front of the mandible was created and cervical skin was lifted by Kirschner wires and a mechanical retracting system. This method without CO2 insufflation created an effective working space and provided an excellent cranio-caudal view so that we could perform thyroidectomy and central node dissection safely. Results Beginning with our first clinical application of TOVANS in September 2009, we have performed eight such procedures. Three of the eight patients had papillary microcarcinoma and received central node dissection after thyroidectomy. All patients began oral intake 1 day after surgery. The sensory disorder around the chin persisted more than 6 months after surgery in all patients. Recurrent laryngeal nerve palsy revealed in one patient. Nobody had mental nerve palsy, and no infection developed with use of preventive antibacterial tablets for 3 days. Conclusions We developed a new method for gasless transoral endoscopic thyroidectomy with a premandible approach and anterior neck-skin lifting. TOVANS makes possible complete endoscopic radical lymphadenectomy for papillary thyroid cancer. We believe that this method is innovative and progressive and has not only a cosmetic advantage but also provides easy access to the central node compartment for dissection in endoscopic thyroid cancer surgery.

Purpose The efficacy of immediate breast reconstruction using a free dermal fat graft (FDFG) was evaluated clinically. Patients and methods A total of 22 breasts in 21 patients who underwent partial mastectomy for early breast cancer involving mainly the inner upper quadrant were enrolled in this study. The defect was reconstructed immediately by filling it with an autologous FDFG. At 6 months and 1, 2, 3, 4, and 5 years postoperatively, the width (horizontal length) and thickness (distance perpendicular to skin) of the FDFG on computed tomography (CT) scans were measured. Histologic samples from the implanted FDFG were collected by core needle biopsy (CNB). The correlations between clinical findings and volume of the FDFG on CT and the proportion of fatty tissue in the CNB were examined statistically. Cosmetic results were also evaluated. Results On CT, the mean width of the FDFG was 95%, 81%, 79%, 73%, 68%, and 47% and the mean thickness were 125%, 121%, 120%, 115%, 104%, and 103% at 6 months, and 1–5 years postoperatively, respectively. In the CNB samples, the mean fatty tissue distribution was 76%, 63%, and 54% at 1 year, 1–4 years, and >4 years postoperatively, respectively. The percent change in the width of the FDFG at 6 months after the operation displayed a significant negative correlation with the postmenopausal period and a significant positive correlation with the maximum surgical margin. On CT, thickness was negatively correlated with the size of the resected breast tissue, and thickness of the implanted FDFG. No clinicopathologic factors or technical factors were related to FDFG outcome and the proportion of fat tissue in the CNB sample, except for axillary dissection. Nineteen of 21 patients had good to excellent cosmesis. Conclusion FDFG implanted into breast defects after partial mastectomy undergo mild resorption and degeneration to fibrous tissue, but most patients have good to excellent cosmesis.

Background Recently, neoadjuvant chemoradiation therapy (CRT) has been introduced for treatment of esophageal squamous cell carcinoma (ESCC). This study was performed to investigate the usefulness of endoscopic ultrasonography (EUS) in comparison with EUS findings before and after CRT, and histologic findings. Methods There were 33 patients with potentially resectable ESCC who underwent neoadjuvant CRT. Preoperative EUS and histologic findings were compared. EUS criteria were established on the basis of low and high echoic regions. Resected specimens were examined by hematoxylin-eosin, azan, and cytokeratin immunohistochemical staining. Results Azan and cytokeratin staining clearly delineated fibrous changes and residual tumor. Low echoic regions corresponded to residual tumor and high echoic spots corresponded to fibrosis. All 12 patients classified as grade 1 on EUS diagnosis had histologic grade 1 tumors. Nineteen of 21 cases that presented with high echo were grade 2 or 3. The prognosis according to EUS diagnosis was similar to the histologic effect. Conclusions Preoperative EUS findings reflected the histologic effect after neoadjuvant CRT. EUS is a useful tool to assess the effect for CRT and to predict the prognosis in ESCC patients.

This report presents the results of oncoplastic surgery in three Japanese patients with breast cancer lesions involving the lower pole of the breast. Their breasts were ptotic, and their lesions were considered to be suitable for breast conservation surgery. There were treated with partial mastectomy resection using vertical-scar mammaplasty, with reduction surgery and recentralization of the nipple-areola complex. Two patients underwent a mirror-image biopsy on the contralateral breasts to determine the symmetry. The remaining patient had periareolar incision mastopexy without reduction added for the contralateral breast. A large surgical margin was used to remove excessive skin and parenchymal tissue. Ideal symmetry was achieved by performing reduction and/or mastopexy on the contralateral breast.

We report a case of early breast cancer, which was treated successfully by oncoplastic surgery. A 65-year-old Japanese woman was referred to us for investigation of a grouped calcification on mammography of her left breast, detected during mass screening for breast cancer. No mass lesion was palpated, but we suspected that the grouped calcification seen on the mammography was a malignant lesion in the lower area of the left breast. Ultrasonography and magnetic resonance imaging revealed ductal carcinoma in situ, restricted to the inner quadrant of the left breast. Achieving a good symmetrical outcome after partial mastectomy would have been made difficult by the degree of ptosis. Thus, we performed partial mastectomy followed by an amputation-type reduction operation with free nipple-areola complex grafting, which achieved good cosmetic and oncologic results.

症例は83歳，女性．2008年12月に左乳房腫瘤を自覚．近医での針生検で肉芽腫所見を認め，抗結核剤による治療目的で呼吸器内科へ紹介された．呼吸器内科医は，抗結核剤使用のために抗酸菌（結核菌）の同定が必要と判断し，喀痰，針生検組織，浸出液などについて種々の細菌学的検査を追加したが，いずれの検体からも陽性所見は得られず，腫瘤切除や組織生検を目的に当科へ紹介された．視触診で左乳房全体を占拠する6cm大の腫瘤が大胸筋や前鋸筋に固定して可動性不良．超音波検査で，不整形な低エコーの腫瘤が境界不明瞭に乳腺から大胸筋に広がっていた．結核性の場合での創傷治癒遅延を懸念し，切除やOpen Biopsyを避けて正常部分を介した針生検を行ったが，塗抹やPCRでも抗酸菌は証明されなかった．その過程で，喀痰の抗酸菌2カ月培養検査陽性との報告が届いた．INH/RFP/EBによる治療が開始され，9カ月後には腫瘤が著明に縮小し，可動性も良好となった．

BACKGROUND: The potential for reducing the need for second surgery for axillary lymph node dissection (ALND) has made the intraoperative evaluation of sentinel lymph nodes (SLNs) attractive. The goal of the current study was to evaluate the clinical application of the breast lymph node (BLN) assay, a real-time reverse transcriptase-polymerase chain reaction assay for SLN metastases, by comparing this test with routine pathologic examination. METHODS: A total of 117 patients with breast cancer underwent breast surgery with SLN biopsy. Each SLN was cut in half along the plane of the longest dimension. Half of each lymph node was examined by the 2 markers of the BLN assay, mammaglobin and cytokeratin 19, and the other half was examined by hematoxylin and eosin staining (H&E) and immunohistochemical staining (IHC) for pancytokeratins. RESULTS: A total of 204 SLNs were obtained from 117 patients. HE 40 SLNs from 32 patients were found to be positive for metastasis using the BLN assay. The assay results were correlated with the pathologic diagnoses by H&E and IHC staining (P

We report an unusual case of bilateral, synchronous breast cancer in a male patient who had a history of estrogen therapy for prostate cancer. A 64-year-old Japanese man was diagnosed with T1N0M0 prostate cancer and received a total prostatectomy. Twenty months after the resection, the patient developed multiple bone metastases, and received radiation therapy, systemic chemotherapy, and hormone therapy for 15 months. After completing this treatment, he was diagnosed with T1N0M0 primary breast cancer in his left breast and underwent a modified mastectomy. Five months after the mastectomy he received systemic chemotherapy followed by estrogen therapy because of the progression of prostate cancer. Three months after this treatment, he was diagnosed with T1N0M0 primary breast cancer in his right breast. To the best of our knowledge, this is a rare case of synchronous bilateral male breast cancer following hormone therapy for prostate cancer.

We report a case of bilateral breast cancer lesions treated successfully by partial oncoplastic surgery. A 46-year-old Japanese woman presented with a small mass in the right breast. Mammography showed neither a mass nor calcification in the right breast; however, an irregular-shaped mass lesion was shown in the left breast. Ultrasonography and fine-needle aspiration biopsy revealed ductal carcinoma in situ in the inner-upper quadrant of the right breast and invasive ductal carcinoma in the outer-upper quadrant of the left breast. We considered that it would be difficult to obtain a good symmetrical outcome after partial mastectomy for the bilateral breast lesions because of the asymmetrical location of each lesion and her ptotic breasts. Thus, we performed bilateral partial resection, followed by an inferior pedicle reduction mammaplasty-type operation, with and without axillary lymphadenectomy, and achieved good cosmetic and oncologic results.

Breast conservational therapy (BCT) has become a standard strategy for breast cancer, and ensures that local control with acceptable cosmetic results [Fisher B, Anderson S, Redmond CK, et al. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1995;333:1456-61] and immediate reconstruction after BCT has become increasingly popular even for early-stage breast cancer [Berrino P, Campora E, Santi P. Post-quadrantectomy breast deformities: classification and techniques of surgical correction. Plast Reconstr Surg 1987;79(4):567-72; Cooperman AM, Dinner M. The rhomboid flap and partial mastectomy. Surg Clin North Am 1978;58:869-73]. The breasts of Japanese women are sometimes too small to maintain symmetry, even after partial resection, and an insufficient resection margin may increase local recurrence if too much attention is paid to cosmesis. Use of an autologous free dermal fat graft (FDFG) for defect reconstruction has proven popular for some areas of the body [Lexer E. Free transplantation. Ann Surg 1914;60:166-94; Peer LA. The neglected free fat graft. Plast Reconstr Surg 1956;18:233-50]. Immediate reconstruction of the surgical defect was performed in seven Japanese women using autologous free dermal fat graft (FDFG) from the lower abdomen after breast-conserving surgeries for six malignant lesions and two benign masses located in the medial or central area of the breasts. The mean amount of resected tissue was 56.4 g (range, 28-108 g), while mean FDFG weight was 78.3g (range, 35-148 g). We obtained symmetry in the size of the whole breast, the position and level of the nipple, and shape. Autologous FDFG was useful for reconstruction, with a good cosmetic effect. This technique achieves better cosmetic results than the transposition of residual breast tissue, is more convenient than muscle flap grafting, and safer than implantation of foreign materials. This report documents our early experiences with seven patients who underwent BCT and immediate breast reconstruction using autologous FDFG.

We report a case of primary giant cell malignant fibrous histiocytoma (GCMFH) of the breast. A 56-year-old Japanese woman presented with a firm mass in the right breast. Mammography and ultrasonography revealed a well-circumscribed and lobulated mass in the upper outer quadrant of the right breast, indicative of a benign breast tumor or mucinous carcinoma. Magnetic resonance imaging revealed a restricted breast tumor without intraductal spread. Computed tomography and bone scintigraphy found no sites of distant metastases. Fine needle aspiration biopsy showed several clusters of atypical cells associated with numerous multinucleated giant cells. Breast-conserving surgery with axillary lymph nodes dissection was performed. Histological examination showed primary GCMFH of the breast. No metastases were identified in any of the 15 left axillary lymph nodes resected and surgical margins were free from tumor cells. The tumor was negative for both estrogen and progesterone receptor. Neither adjuvant chemoendocrine therapy nor postoperative radiotherapy was given, and the patient has remained disease free for 30 months postoperatively. To our knowledge, only 30 cases of primary MFH of the breast have been reported in the literature.

We report a case of metastatic breast tumor arising from a synovial sarcoma of the lower limb. A 27-year-old Japanese woman was diagnosed to have synovial sarcoma 14 months prior to finding a mass in her left breast. An excisional biopsy was performed and a metastatic synovial sarcoma to the breast was confirmed. Eight months after the resection of the breast lesion, the patient developed local recurrences in both her knee and breast. A tumor resection of the limb lesion and a simple mastectomy for the huge lesion, which was diagnosed to be a metastatic breast tumor without lymph node metastasis, were performed. After the operation, the patient received adjuvant systemic chemotherapy. To the best of our knowledge, this is only the second reported case of a solitary metastatic breast tumor arising from synovial sarcoma.

Sentinel lymph node biopsy is performed as a standard procedure in breast cancer surgery, and the development of quick and simple methods to detect metastatic lesions is in high demand. Here, we validated a new fluorescent method using γ-glutamyl hydroxymethyl rhodamine green to diagnose metastatic lymph nodes in breast cancer. One hundred and forty-nine lymph nodes from 38 breast cancer patients were evaluated in this study. Comparison of fluorescent and pathological images showed that this fluorescent method was successful for visualizing breast cancer cells in lymph nodes. This method had a sufficiently high sensitivity (97%), specificity (79%) and negative predictive value (99%) to render it useful for an intraoperative diagnosis of cancer. These preliminary findings suggest that this novel method is useful for distinguishing non-cancerous specimens from those in need of careful examination and could help save time and cost for surgeons and pathologists.

We report a rare case of sudden hemorrhage caused by breast cancer. A 70-year-old Japanese woman noted fresh bleeding from her left breast. On physical examination, continuous hemorrhage accompanied by an open cavity was observed in the left breast. Mammography and ultrasonography revealed a well-circumscribed mass, with solid and cystic components, that was highly suggestive of intracystic breast carcinoma with direct skin invasion. Computed tomography and bone scintigraphy showed no distant metastasis. Aspiration biopsy of the lesion showed several clusters of adenocarcinoma cells. Modified radical mastectomy was performed with a presumptive diagnosis of stage III B left breast cancer. Invasive ductal carcinoma without skin invasion was diagnosed histologically. To the best of our knowledge, only 6 other cases of sudden hemorrhage caused by breast cancer without skin invasion have been reported in Japan. We review the literature and discuss the clinical characteristics of this unusual phenomenon.

A 48-year-old Japanese woman underwent [F-18] fluorodeoxyglucose positron emission tomography (FDG-PET) as part of her medical examination. A small hot spot was detected in her right breast. Quadrantectomy with sentinel lymph node (SN) biopsy using an endoscope was performed, and ductal carcinoma in-situ of the breast was diagnosed. The tumor size was 0.9 cm in its greatest diameter, and there were no cancer cells detected in the SN on frozen hematoxylin-eosin staining and cytokeratin immunohistochemical staining. We reported this rare case of ductal carcinoma in-situ detected by FDG-PET as past of a medical checkup.

We report a case of a 49-year-old Japanese woman diagnosed with breast carcinoma with osseous and cartilaginous metaplasia with a poor outcome. Histological examination revealed invasive ductal carcinoma with undifferentiated sarcomatous components including chondrosarcomatous areas. Osseous metaplasia was also noted in a very limited area. Neither axillary lymph node metastases nor vessel invasion were observed. Immunohistochemical examination was negative for estrogen receptor, progesterone receptor and HER2 overexpression. Stage II A T2N0M0 carcinoma was diagnosed postoperatively. Five months after the operation, she developed lung metastases. Although she received systemic chemotherapy, the lesions increased in number and grew rapidly. She died of pulmonary distress 5 months after relapse.

症例は, 48歳,女性.左乳房の腫瘤を主訴に来院した.マンモグラフィ,乳房超音波検査,穿刺吸引細胞診にて乳癌と診断された.検血にて,白血球が18,200/μl, 腫瘍マーカーのCA15-3が64.5U/ml, 血清G-CSF値は67pg/mlと高値を示していた.乳癌の存在と,白血球の増加,血清G-CSF値の上昇,明らかな感染巣がないことより, G-CSF産生腫瘍を疑い手術を施行した.白血球数は第1病日より低下し1週間後には正常に復した.血清G-CSF値は,10pg/ml未満まで低下した.術後は良好に経過し8病日に退院した.手術を契機に白血球数および血清G-CSFが正常化し,また,腫瘍細胞がG-CSF免疫組織染色にて染色されたことより, G-CSF産生乳癌と診断した.

卵巣転移で発見された浸潤性小葉癌を経験したので報告する.症例は53歳の女性. 2005年1月,当院婦人科にて左卵巣腫瘍の診断で,子宮・両側卵巣・大網・虫垂切除術を受け,病理組織学的にこれら全ての臓器に転移性腺癌がみられた.原発巣検索目的で当科へ紹介され,視触診・マンモグラフィ・超音波で左乳房に2.0cm大の腫瘤を認めた. 2005年3月,腋窩リンパ節郭清を伴う乳房部分切除を行い,最終的な病理組織学的診断は多数のリンパ節転移と広範な腹膜播種を伴う浸潤性小葉癌(pT2N3M1: Stage IV)であった.転移性卵巣腫瘍が先行して発見された浸潤性小葉癌は極めて稀で,本邦2例目である.

Axillary leakage after axillary lymph node dissection (ALD) in breast cancer surgery is a frequent and troublesome complication. We conducted this study to establish an experimental model of axillary leakage after ALD; to evaluate axillary leakage in different nutritional states; and to examine the effects of dietary management on axillary leakage.Twenty-eight Wistar rats were divided into two groups according to whether they were fed a high-fat diet or a low-fat diet for 14 weeks before ALD. After ALD, a suction drain was placed in the axilla and continuous suction was started. Axillary leakage was monitored for 9 days, and the drainage fluid and serum were analyzed biochemically.The body weights of the two groups were not significantly different before or after ALD. The amount of cumulative drainage fluid was significantly higher on postoperative days 7 and 9 in the high-fat group. The serum phosphate lipid, total cholesterol, and free cholesterol levels, and the free cholesterol level in the drainage fluid were also significantly higher in the high-fat group.This model is useful for reproducing lymphatic leakage after ALD. Our findings also suggest that a low-fat diet may be advantageous for patients undergoing ALD as part of breast cancer surgery.

A great deal of clinical experience has firmly established the concept of the sentinel lymph node (SN) in breast cancer. SN biopsy allows treatment without axillary lymphadenectomy and has made it possible to perform a surgical intervention via just a small skin incision. In partial resection of the breast (quadrantectomy), we use a double retractor to form a workspace under the skin via a small axillary incision. Resection does not require a large incision even in cases in which the cancer lesion is located in the upper inner or lower inner quadrant of the breast, as the endoscope allows the surgeon to see the workspace formed by the double retractors.

乳房内側領域病変に対する乳房温存療法において,とくに乳房の小さい女性の場合,乳腺欠損部の補填が難しく,著しい術後変形をきたすことがある.内側領域の乳癌4症例に対し乳房温存術を行い,一期的に下腹部より採取した遊離真皮脂肪片による自家移植・補填を行い良好な結果を得た.術後経過観察中の理学所見(超音波検査, CT)より,移植片周囲に新生血管が増生していることが確認された.一般外科医にも習得可能な簡便な方法であり,乳房温存術後の整容性を保持するために有用な方法と思われる.

Prior to worldwide acceptance of the sentinel lymph node concept, internal mammary node dissection was regarded as unnecessary for diagnosis of breast cancer. More recently, the impact of internal mammary nodes dissection on the survival of breast cancer patients has come under scrutiny. We have encountered important breast cancer cases involving lymphatic streams that go from the tumor to both the internal mammary chain and axillary node basin simultaneously. Moreover, a lymphatic stream was found to go from the breast tumor to the internal mammary chain via intra-mammary gland lymph nodes. These cases indicate the dual importance of internal mammary sentinel node dissection as well as axillary sentinel node dissection.

Human leukocyte antigen (HLA)-F is one of the non-classical HLA class I molecules that protects the fetus in pregnancy. HLA-F expression was immunohistochemically examined and the association between clinical parameters and HLA-F expression was analyzed. Cancerous HLA-F and stromal HLA-F-positive infiltrating cells were detected in 91 (40.0%) and 186 (81.6%) cases, respectively. HLA-F positivity in cancer cells was significantly associated with tumor size (P

Background Axillary lymph node (ALN) status is an important prognostic factor for breast cancer. We retrospectively used contrast-enhanced computed tomography (CE-CT) to evaluate the presence of ALN, metastasis based on size, shape, and contrasting effects. Methods Of 131 consecutive patients who underwent CE-CT followed by surgery for breast cancer between 2005 and 2012 in our institution, 49 were histologically diagnosed with lymph node metastasis. Maximum Hounsfield units (HU) and mean HU were measured in non-contrasting CT (NC-CT) and CE-CT of ALNs. Results Of 12 examined measurements, we found significant differences between negative and metastatic ALNs in mean and maximum NC-CT HU, and mean and maximum CE-CT HU (P

To demonstrate the association of Epstein-Barr virus (EBV) with primary epithelial neoplasms in the south part of Kyushu, Japan, 761 carcinomas consisting of 75 lung, 61 breast, 107 esophagus, 102 colon, 58 pancreas, 45 thyroid, and 313 gastric cancers were examined by EBER-1 in situ hybridization. EBER-1 was detected in 23 cases (7.3%) out of 313 gastric carcinomas, while none of the other carcinomas was positive for EBER-1. Twenty-eight (9.4%) out of 313 gastric carcinomas were differentiated poorly to moderately carcinomas with prominent lymphoid cell infiltration, similar to so-called lymphoepithelioma-like carcinoma, and 19 cases (67.9%) were positive for EBER-1. Although two (2.6%) and 11(10.3%) out of 75 lung and 107 esophagus carcinomas were so-called lymphoepithelioma-like carcinomas, respectively, but EBER-1 was not detected in other epithelial neoplasms that originated from the lung, esophagus, breast, colon, pancreas, and thyroid in the south of Kyushu, Japan. As a result, EBV was associated with only some gastric carcinomas but not with other epithelial neoplasms originating from the lung, esophagus, breast, colon, pancreas, and thyroid in southern Japan.

Treatment of early breast cancer using breast conservative therapy (BCT) usually ensures local control and acceptable cosmetic results. To repair defects caused by partial mastectomy in the lower region of the breast, some reconstruction should be used. We developed a procedure involving the cranial based adipofascial (anterior rectus sheath) flap from immediately below the inframammary area for the reconstruction of defect due to partial mastectomy for patients with early breast cancer. In this procedure, a skin incision is made at the inframammary line, and the inframammary skin area is undermined. A tongue shaped flap composed of the subcutaneous fat and the anterior sheath of rectus abdominis muscle is pulled up and a C-shaped flap is rotated, gathered, and inserted to reconstruct the breast defect.

This study was designed to clarify the clinical and pathologic features of diffusely infiltrative squamous cell carcinoma of the esophagus. Diffusely infiltrative squamous cell carcinomas were classified grossly into two types, namely, scirrhous carcinoma and nonscirrhous carcinoma. There were seven patients with the former type and three with the latter type. Scirrhous-type carcinoma was associated with a prominently thickened esophageal wall with strictures, whereas nonscirrhous-type carcinoma demonstrated thickening of the esophageal wall without strictures. Microscopically, all patients had lymph node metastases and lymphatic invasion. Blood vessel invasion was found in seven patients and extranodal invasion was found in seven. The prognosis of patients with both types of carcinoma was extremely poor. Only two patients who underwent curative surgery as well as chemoradiotherapy survived for more than 1 year. Therefore, further morphological studies on the early stages of diffusely infiltrating esophageal carcinoma should be performed. New treatment strategies such as intensive preoperative chemoradiotherapy based on sensitivity tests in individual patients will be required for treating the advanced stages of this disease.

A clinicopathologic study was carried out on 30 patients with mucosal esophageal cancer (MEC). The depth of cancer invasion was subdivided histologically into three categories: m1 = carcinoma in situ (intraepithelial carcinoma) or carcinoma with questionable invasion beyond the basal membrane; m2 = cancer invasion confined to the lamina propria, and m3 = cancer reaching to or infiltrating into the muscularis mucosae. Lymph node metastases and lymphatic invasion were found only in the tumors reaching or infiltrating the muscularis mucosae (m3). The maximum histologic vertical extent of the tumors was more than 1 mm in 4 of 5 patients with lymph node metastasis or lymphatic invasion. None of the patients died of recurrent esophageal disease, and 3 of the 6 patients who had a second primary tumor died of this other malignancy. It is critical to distinguish between m1, m2 and m3 tumors to plan a treatment strategy, including an endoscopic mucosal resection.

We present three cases of esophageal leiomyoma (2 females and one male) treated by endoscopic lumpectomy, which were estimated arising from muscularis mucosae by ultrasonography (EUS). The location of these tumors were the upper thoracic esophagus in two cases and middle thoracic esophagus in one case. Endoscopically, all lesions were covered with normal epithelium with smooth surface. The tumors were visualized as a low echoic shadow continued from the second layer and the internal echo was homogenous by EUS. The tumors were diagnosed as esophageal leiomyoma arised from the muscularis mucosae. Two out of three tumors were easily resected with 2-channel endoscopy and the remaining tumor with over-tube. The resected esophagus showed a well demarcated nodular lesion composed of smooth muscles with interlacing-like pattern. Mitosis were rarely seen. Histologically, those three tumors were leiomyoma. Endoscopic lumpectomy is a very useful method for esophageal leiomyomas of intramural or intraluminal type which arise from the muscularis mucosae.

教室では, 原則として深達度m2までの早期食道癌は内視鏡的粘膜切除 (endoscopic mucosal resec tion, EMR) の対象としている. 1992年5月から96年8月までにEMRによって切除された30症例, 38病巣について, その適応の妥当性, 治療成績について検討した. その結果, 1) 内視鏡所見は28病集 (73.7%) が, 0-IIbまたは0-IIcであった. 2) 大きさは30病巣 (78.9%) が20mm以下であった. 3) 予測深達度と組織学的深達度の一致率はdysplasiaであった4例を除いて70.6% (24/34病巣) であった. 4) 合併症として, 動脈性出血が5例 (16.7%) に, 穿孔, 皮下気腫がそれぞれ1例 (3.3%) にみられた. 5) 再発が3例, 異時性食道癌が1例にみられ, いずれも再EMRを施行した. 6) 他病死1例, 深達度sm3で手術を施行した1例が癌死した. その他は最長4年5か月を含め, 全例生存中である. 深達度m2までの, 全周性でない癌はEMRの適応であり, その治療成績も満足できるものであった.

A 48-year-old Japanese woman was found to have local recurrence of breast cancer in the chest wall following neoadjuvant chemotherapy, total mastectomy with axillary lymphadenectomy, postoperative radiation therapy to the chest wall, and adjuvant systemic therapy using trastuzumab. As a third line of treatment after recurrence, bevacizumab with paclitaxel was initiated for several metastatic lesions on the skin of the chest wall, left internal costal lymph nodes, and right axillary lymph nodes. The wound on the chest wall continued to expand in diameter and depth after the third course of bevacizumab with paclitaxel until the rib was exposed. After stopping the bevacizumab, granulation tissue expanded and by 3 months, had covered the bottom of the ulcer. The patient died soon thereafter, despite systemic chemotherapy with eribulin; however, there was no further bleeding from the ulcer on the chest wall or the exposed ribs.

We report herein the case of a 65-year-old man with cirrhosis of the liver in whom a portal vein thrombus was found to be the cause of a marked elevation in serum alpha-fetoprotein (AFP). The patient presented with fever and abdominal pain, and a diagnostic work-up revealed a liver mass and an increased serum AFP concentration of 91,000 ng/ml. The mass gradually regressed, and the AFP concentration simultaneously decreased to 163 ng/ml. However, because hepatocellular carcinoma (HCC) could not be ruled out, a partial hepatectomy was performed. Histological examination of the resected specimen revealed a thrombus of the portal vein surrounded by the fibrosis associated with liver cirrhosis, but no neoplastic lesion was found. Thus, portal thrombus associated with liver cirrhosis might induce an extremely high level of AFP production.

胸部食道に対する頸部郭清の適応について, 鎖骨上と反回神経沿いリンパ節の術前超音波診断ならびに手術成績の面から検討した. 対象は1986年から93年にcl以上の切除を行った胸部食道癌136例 (3領域郭清105例, 2領域郭清31例) とした. 3領域郭清例において, 術前に鎖骨上リンパ節転移陰性とした84例中7例 (8.3%) に組織学的に転移が認められた. False negative 7例中5例は反回神経沿いに術前超音波診断および術中に転移を認めた. したがって, 術前超音波診断による鎖骨上リンパ節の転移の有無のみで頸部郭清を省略するのは危険であるが, 反回神経沿いリンパ節の術前・術中診断を加味すると97.6% (82/84例) の症例で頸部郭清の適応を術前診断にて判断可能であった. また術前に鎖骨上・反回神経沿いに転移陰性としたmp以上の症例における5生率は頸部郭清の有無に関係なく37%であった. 術前診断による鎖骨上または反回神経沿い転移陽性症例が頸部郭清の適応である.

Background. Lymph node metastases occur very frequently and extensively in patients with esophageal cancer. The aim of this pilot study was to try the targeting chemotherapy for lymph node metastases by use of bleomycin adsorbed on silica particles (BLM-SI). Methods. BLM-SI or bleomycin solution (BLM-SOL) was injected into the submucosa of the esophageal wall by means of endoscopy 3 days before operation in 16 patients with middle thoracic esophageal cancer. The distribution of bleomycin in the regional lymph nodes and surrounding connective tissues was studied. Results. When BLM-SI was administered, bleomycin activity was found in both the regional lymph nodes and connective tissues, not only in the mediastinal region but also in the cervical and abdominal region. Blemycin activity was significantly higher in all regions after BLM-SI administration than after BLM-SOL administration. Degenerative or necrotic changes were microscopically observed in 11 of 36 lymph nodes with metastatic foci. Bleomycin activity in the blood was significantly lower after BLM-SI was administered than after BLM-SOL. Serious systemic side effects except for fever were not observed in any patients. Conclusions. These results indicate that BLM-SI could be a useful treatment modality for targeting lymph node metastasis of esophageal cancer without serious side effects.

A series of 335 patients with squamous cell carcinoma of the thoracic esophagus undergoing resection and reconstruction via a right thoracotomy and laparotomy with cervical anastomosis between 1973 and 1990, were reviewed. Prior to 1982, the removal of lymph nodes was limited to the nodes in the mediastinum below the tracheal bifurcation and upper abdomen (142 patients). Nodal metastases were found in 89 of these patients at operation. The upper abdominal nodes were the most frequent sites of metastasis (47.2%). None of the 38 patients with positive nodes sampled from the neck and superior mediastinum survived for more than 45 months. In the 50 patients with recurrences, 30 were in the neck and/or superior mediastinum. During or after 1983, the superior mediastinal nodes, particularly the bilateral recurrent nerve nodal chains, were routinely removed (193 patients). Nodal metastasis was proven in 131 of the 193 patients, in whom 87 (45.1%) had metastasis in the neck and superior mediastinum. Eleven of these 87 patients survived for 45 months or more. In the 61 patients with recurrences, 20 were in the neck and/or superior mediastinum. These data suggest that recurrent nerve nodal chains should be removed to improve survival in patients with esophageal carcinoma.

食道表在癌71例の組織学的深達度について50μ ごとの亜連続切片を作製し再検討した. 深達度はep, mm1, mm2, mm3, sm1, sm2, sm3に細分類した. 粘膜癌で深達度が変更になった症例はepの6例中3例がmm1に, mm1の5例中1例がmm2へ, mm3の6例中1例がsm1となった. 粘膜下層癌では, sm2の18例中5例がsm3へ, sm3の14例中1例に固有筋層への浸潤を認めた.食道表在癌全体では71例中11例 (15.5%) に深達度の変更が認められた. これらの症例の肉眼型はepの症例ではO-IIb型が, mmではO-IIc型が, smでは隆起型であった. 切り出し時の隆起や陥凹部分のわずかなずれが深達度の誤差の要因と考えられた. いずれの症例でも再検した切片に新たなリンパ管侵襲や血管侵襲は発見されなかった. 今回の検討では治療上大きく問題となるほどの誤差は認められなかつた. 肉眼所見と組織学的深達度に差異がみられる症例に対しては深切りによる深達度の再検討が必要と考えられた.

胸部食道癌根治手術例で右開胸開腹, 頸部吻合, 胸骨後あるいは後縦隔経路再建の285例を対象とし, 再建術後の問題点と対策を検討した. 反回神経リンパ郭清を行わなかった1982以前の88例 (First Gr.) と, それ以降の197例 (Latter Gr.) の, 非再発死亡と再発例の生存率では, First Gr.で非再発死亡の生存率が再発例より有意に良好であった. しかし, Latter Gr.ではその有意差は消失し, 非再発死亡の66.7% (30/45例) は肺炎, 全身衰弱, 突然死であった. Latter Gr.の胸骨後再建80例と後縦隔再建117例では, 退院時の体重, 肺活量, 1秒量は後縦隔経路で有意にその落ち込みが少なく, 退院後3年の体重も良好に維持された. 術後3～5年経過例のアンケート結果でも後縦隔再建例で食物のつかえ感や誤飲, 腹痛, 息切れを訴える症例が少なかった. 消化器・呼吸器症状が少なく, 術後長期の栄養状態も良好な後縦隔経路は, 食道癌根治手術におけるfirst choiceの再建経路と考えられる.