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Summary Carcinoma with apocrine differentiation is an androgen receptor (AR)-positive subset of triple-negative breast carcinomas. In addition to carcinoma with apocrine differentiation, other AR-positive triple-negative breast carcinomas occur, albeit less frequently. We found that α-methylacyl-CoA racemase (AMACR), also known as P504S, is overexpressed in carcinoma with apocrine differentiation and non-neoplastic apocrine metaplasia. We aimed to evaluate AMACR as a possible marker of carcinoma with apocrine differentiation. We immunohistochemically examined the expression of AMACR in carcinoma with apocrine differentiation and nonapocrine carcinomas and compared it with that of gross cystic disease fluid protein-15 (GCDFP-15). In total, 212 breast carcinomas were evaluated: 39 carcinomas with apocrine differentiation, 28 ductal carcinomas in situ with apocrine morphology (ADCIS), and 145 nonapocrine breast carcinomas. AMACR was expressed in 38 of 39 (97.4%) carcinomas with apocrine differentiation and in 27 of 28 (96.4%) ADCIS, consistent with the expression of GCDFP-15. However, in nonapocrine carcinomas, AMACR expression was observed in 32 of 145 (22.0%) lesions, whereas GCDFP-15 expression was observed in 91 of 145 (62.7%) lesions. For carcinoma with apocrine differentiation, AMACR was as sensitive as GCDFP-15 (both 97.1%) but more specific (77.9% versus 37.2%). In selected cases, AMACR messenger RNA (mRNA) levels were quantitatively determined relative to that of TATA-binding protein mRNA, and they comprised 5.23, 1.33, and 0.60 for carcinomas with apocrine differentiation, nonapocrine carcinomas, and normal breast tissue, respectively. Conclusion Our findings demonstrate that AMACR expression may be used for differentiating carcinoma with apocrine differentiation from nonapocrine carcinomas and indicate that AMACR is a more sensitive carcinoma with apocrine differentiation marker than GCDFP-15.

Aim This multicenter, observational study aimed to investigate the survival benefit of eribulin as well as that of taxane-based regimens in Japanese patients with metastatic breast cancer (MBC) in a real-world setting. Methods This study enrolled women with MBC who received eribulin or taxane-based regimens with or without bevacizumab in routine clinical practice from July 2011 to March 2014. Patients were followed until September 2015. The primary endpoint was overall survival (OS). Secondary endpoints included progression-free survival (PFS), post-progression survival (PPS) and adverse events. Efficacy findings were adjusted according to demographics. Results In total, 216 patients receiving eribulin monotherapy (n = 101), taxane monotherapy (n = 73) or taxane plus bevacizumab (n = 42) were followed for a median time of 15.4 months. Median OS, PFS and PPS were 22.3, 8.1 and 14 months in the eribulin monotherapy group; 13.2, 3.6 and 7.6 months in the taxane monotherapy group; and 12.9, 5.7 and 6.3 months, in the taxane plus bevacizumab group, respectively. The incidence of neutropenia was 67.3, 41.1 and 16.7%, and the incidence of grade 4 neutropenia was 1.0, 8.2 and 7.1% in the eribulin monotherapy, taxane monotherapy and taxane plus bevacizumab groups, respectively. One patient (1.0%) discontinued eribulin and 18 patients (15.7%) discontinued taxane-based regimens because of adverse events. Conclusion In Japanese MBC patients in a real-world setting, eribulin showed a survival benefit and tolerability similar to that in previous reports.

The Japan Association of Breast and Thyroid Sonology (JABTS) proposed, in 2003, a conceptual classification system for non-mass abnormalities to be applied in addition to the conventional concept of masses, to facilitate detecting ductal carcinoma in situ (DCIS) lesions. The aim of this study was to confirm the utility of this system and to clarify the distribution of these findings in DCIS lesions. Data on 705 surgically treated DCIS lesions from 16 institutions in Japan were retrospectively reviewed. All 705 DCIS lesions could be classified according to the JABTS classification system. The most frequent findings were hypo-echoic areas in the mammary gland (48.6%), followed by solid masses (28.0%) and duct abnormalities (10.2%) or mixed masses (8.1%). Distortion (1.3%), clustered microcysts (1.4%) and echogenic foci without a hypo-echoic area (2.5%) were uncommon. These results suggest that the concept of non-mass abnormalities is useful in detecting DCIS lesions.

The use of color Doppler ultrasound (CD) for distinguishing between benign and malignant breast lesions remains controversial. This study (JABTS BC-04 study) was aimed at confirming the usefulness of our CD diagnostic criteria. We evaluated ultrasound images of 1408 solid breast masses from 16 institutions in Japan (malignant: 839, benign: 569). Multivariate analysis indicated that vascularity (amount of blood flow), vascular flow pattern ("surrounding marginal flow" or "penetrating flow") and the incident angle of penetrating flow were significant findings for distinguishing between benign and malignant lesions. However, the sensitivity and specificity of B-mode alone did not improve significantly with CD addition (97.6% → 97.9%, 38.3% → 41.5%, respectively). We explored the causes of these negative results and found that age should have been considered when evaluating vascularity. Simulation experiments suggested that specificity is significantly improved when age is taken into consideration (38.3% → 46.0%, p0.001) and we thereby improved our diagnostic criteria.

The Japan Association of Breast and Thyroid Sonology (JABTS) proposed, in 2003, a conceptual classification system for non-mass abnormalities to be applied in addition to the conventional concept of masses, to facilitate detecting ductal carcinoma in situ (DCIS) lesions. The aim of this study was to confirm the utility of this system and to clarify the distribution of these findings in DCIS lesions. Data on 705 surgically treated DCIS lesions from 16 institutions in Japan were retrospectively reviewed. All 705 DCIS lesions could be classified according to the JABTS classification system. The most frequent findings were hypo-echoic areas in the mammary gland (48.6%), followed by solid masses (28.0%) and duct abnormalities (10.2%) or mixed masses (8.1%). Distortion (1.3%), clustered microcysts (1.4%) and echogenic foci without a hypo-echoic area (2.5%) were uncommon. These results suggest that the concept of non-mass abnormalities is useful in detecting DCIS lesions.

Radial scarは線維性結合組織からなる中心部分を機軸として乳管が放射状に配列し,その上皮に過形成変化を伴う病変である.癌との鑑別がしばしば困難で,異型過形成を伴う場合は乳癌発生のリスクとなる.その報告例は未だ少ない.今回われわれはradial scarの1例を経験したので報告する.症例は41歳,女性.左乳房痛を認め,当科を受診.左乳房C領域,疼痛部位よりやや内側に硬結を触知した.エコーにて同部位に境界不明瞭な後方エコーの減衰を伴う低エコー領域を認めた.マンモグラフィーではdistortionが認められた.穿刺吸引細胞診を施行したところ二相性の増殖性変化のみられる上皮が採取されClass IIIaであった.針生検では二相性の保たれた乳管上皮の乳頭状増殖が認められ,乳管内乳頭腫が疑われた.悪性の可能性を考慮し,確定診断のため左乳腺腫瘤切除術を施行した.病理組織診断はradial scarであった.

A recent trend for less invasive surgery has increased consideration for a minimized scope of lymphadenectomy for submucosal cancer; however, feasibility criteria have not been precisely established.Patterns and sites of nodal involvement were retrospectively investigated in 294 patients with solitary submucosal gastric cancer in association with other clinicopathologic characteristics, including pre- and intraoperative evaluations of cancer depth (cT) and nodal involvement (cN).Among the early (cT1) and node-negative (cN0) cancer, intestinal (or =1.5 cm) and diffuse types (or =1.0 cm) of submucosal cancer showed low incidences of nodal involvement (3%) confined to the first tier. When the cancer exceeded these cutoff diameters, positive nodes of the second tier were confined to three priority stations (left gastric, common hepatic, and celiac arteries) at an incidence of 2.3%. Perigastric and preferential dissection of these three node stations (modified D2 dissection) showed survival benefits identical to those of a conventional D2 dissection.When submucosal cancer is evaluated as cT1cN0, a virtually sufficient minimized scope of lymphadenectomy is a D1 dissection for that within the cutoff diameter and a modified D2 dissection for that exceeding the cutoff diameter. These two types of dissection can even cover the infrequently observed node-positive stations and can realize no residual disease at surgery.

症例は66歳の男性で腹部腫瘤を主訴に当科入院した. 24年前の胃切除術の既往があった. CT上腫瘤は低濃度で不均一に造影された. MRIではT2像にて内部不均一な低信号を示し, Gd T1像で辺縁とT2像上の高信号部分に造影効果を認めた. 腹腔内異物肉芽腫の診断で腫瘤を摘出した. 腫瘤割面にガーゼと肉芽組織を認め, 組織学的には繊維成分を含む肉芽組織が異物巨細胞・泡沫細胞を伴って認められた. 腹腔内異物肉芽腫の画像所見として特異的なものは少ないが, MRIではT2像で低信号と高信号を呈するものに大別され, おのおの増殖性変化と浸出性変化を反映する. この両変化の割合により多彩な画像所見を呈する. 本症例のCT・MRI上の画像所見は, 組織学的所見を如実に描出していた. 腹腔内異物肉芽腫は画像診断により術前診断のみならず, 組織学的所見の推測まで可能と考えられた.

BACKGROUND AND OBJECTIVES A variety of minimal invasive treatment strategies for early gastric cancer without reducing the curability have been introduced, however, the indications for the local resection of early gastric cancer have not been precisely established. METHODS Two approaches are adopted in this study to elucidate indications for local resection. One is a retrospective review of surgically resected, postoperatively histologically proven early gastric cancers between 1976 and 1996 (611 patients), and the other is the patient selection from those who underwent modified D(1) lymphadenectomy in a prospective manner between 1987 and 1996, based on the preoperative and intraoperative diagnoses of mucosal, node negative, nonpalpable gastric cancer (125 patients). In these approaches, patterns of nodal involvement in association with clinicopathological characteristics of gastric cancer were investigated. RESULTS The depressed with ulceration type and histologically high grade type were predominant characteristics of mucosal, node positive gastric cancer patients. Of these patients, after the exclusion of those who were diagnosed to have submucosal or advanced cancer preoperatively or who had palpable cancer intraoperatively, the gastric cancer < or =4 cm in maximum diameter had positive nodes confined to only one station adjacent to the cancer without simultaneous nodal involvement in the other stations. CONCLUSIONS Local resection can be performed for gastric cancers < or = 4 cm in maximum diameter that meet our criteria for modified D(1) lymphadenectomy, in association with the frozen section confirmation of cancer negative in the simultaneously dissected lymph nodes in the stations adjacent to the cancer. The adjacent lymphadenectomy and frozen section examination make the application of local resection possible for a wider segment of patients.

A case of unusually hypermobile floating gallbladder in a 79-year-old woman with histologically distinct double cancers of the gallbladder is described. The patient presented with an abdominal cystic mass, which was palpable with easy mobility from the right lower quadrant practically to the left upper quadrant. Exploratory laparotomy was performed and the cystic mass was found to be a floating gallbladder. The cystic duct was elongated and obstructed, and had a long mesentery. After the operation, latent double cancers of the gallbladder were discovered on histopathological examination. The obstruction of the cystic duct was due to chronic inflammation and had resulted in hydrops of the gallbladder. This was suspected to have played an important role in the carcinogenesis. We believe that this is the first report of a floating gallbladder associated with double gallbladder cancers.

A 74-year-old woman with impaired glucose tolerance exhibited virilization. An examination of various hormone levels showed normal pituitary hormone and adrenal hormone levels. However, the patient's blood testosterone level was remarkably high and was suspected of having caused the virilization. An abdominal computed tomography revealed a multilocular cystoma in the left ovary with the features of a mature cystic teratoma. In addition, a chest computed tomography revealed the presence of a mass in the left breast that was subsequently diagnosed as breast cancer based on the results of a biopsy. After the simultaneous surgical resection of the ovarian and breast tumors, her blood testosterone level decreased. The mature cystic teratoma containing a Brenner tumor was considered to be responsible for the high testosterone level because of the presence of androgenic enzymes. This case is extremely rare, but the case was accurately diagnosed through a comprehensive analysis.

To improve the quality of breast cancer screening by ultrasonography, both effective training and evaluation of the performance of the examiners of breast ultrasound are essential. The Educational Committee of the Japan Association of Breast and Thyroid Sonology, an NPO, has established 2-day training programs on breast ultrasonography with tests at the end of the programs. The tests are performed using images to evaluate the ability of observers to detect and evaluate lesions on ultrasound. Ability to detect lesions was examined by using videos, and ability to evaluate lesions was examined by using still images. The results of tests taken by 422 physicians and 415 technologists were analyzed. In a comparison between physicians and technologists, the video specificity, the still image sensitivity, and the percentage of category agreement did not show any significant differences. The video sensitivity, the still image specificity, and the percentage of disease name agreement were significantly higher in technologists. Observers who had experienced

We have reported the Diagnostic Guidelines for Non-Mass Image-Forming Lesions. These have been discussed in the subcommittee of the Japan Association of Breast and Thyroid Sonology (JABTS) and the Japan Society of Ultrasonics in Medicine.

To make a standard diagnosis, it is important to have a standard lexicon. Although many kinds of expression are possible for the same feature of a breast tumor, a technical term must be a word that is seldom confused with another different concept. Especially, a halo or boundary high echo must be a word that is used to express a malignant sign.

Many aspects of internal echoes of mass image-forming breast lesions have been discussed. These points, as well as other themes, should be documented or corrected through further investigation in wide clinical practice.

76 Diagnostic Criteria for Breast Lesions has been widely used since its release in 1988 by the Japan Society of Ultrasonics in Medicine (JSUM). However, improved diagnostic procedures and new data led to a growing desire for revisions to this publication. Prompted by that growing demand, in 2000 the JSUM set up a Subcommittee on Diagnostic Criteria for Breast Diseases (SCDCBD-JSUM; chairman, Ei Ueno), thus launching a study of new diagnostic guidelines for these diseases. The subcommittee classified breast diseases into two categories, mass imageforming and non-mass image-forming lesions as shown on ultrasonograms, and won approval of its classification for mass image-forming lesions as part of the revision process. These revisions were published in the Journal of Medical Ultrasonics and JSUM members have been invited to comment. The Japan Association of Breast and Thyroid Sonology’s Committee on Diagnostic Criteria for Breast Diseases (CDCBDJABTS; chairman, Tokiko Endo) also engaged in a study of the terminology that provides the basis for these classifications. Details of these studies are elaborated here.

In conclusion, endoscopic ultrasonography yielded valuable information on the deeper mucosal layers and blood flow in gastric cancer and wall. Endoscopic ultrasonography also allowed puncture under ultrasonic guidance. This technique may thus become indispensable for the diagnosis and treatment of gastric cancer.

Background The feasibility of a less invasive operation for early stage cancer of the gastric cardia with a low frequency of lymph node involvement has been previously demonstrated by us. Precise discrimination among mucosal, submucosal, and advanced cancers, as well as accurate evaluation of the proximal tumor margin are prerequisites for such stage-specific treatment. EUS is considered the most reliable staging modality. However, there is no EUS study specifically of cardia cancer. Methods Forty-five patients with gastric cardia cancer who underwent gastrectomy with at least first-tier lymphadenectomy were retrospectively analyzed. The results of preoperative linear-array echoendoscopy (7.5 MHz) with respect to cancer depth, lymph node involvement, and esophageal invasion were compared with postoperative histopathologic findings. Results Overall diagnostic accuracy for depth of invasion was 71%. Sensitivity for T1, T2, and T3 lesions was 100%, 31% and 75%, respectively. Overstaging of T2 cancers was the main diagnostic error. Mucosal (pT1-m) and submucosal (pT1-sm) cancers were correctly discriminated in 81% of patients. Diagnostic accuracy for lymph node involvement was 80%. EUS had positive and negative predictive values of 90% and 80%, respectively, for esophageal invasion. Conclusions For gastric cardia cancer, the linear-array echoendoscope yielded satisfactory results with respect to depth of invasion, lymph node involvement, and esophageal invasion evaluation. The information obtained is useful to the performance of stage-specific treatment.

Diabetic mastopathy is an unusual stromal fibrotic lesion, but typically occurs in long-standing insulin dependent and younger diabetic patients. We report a case of diabetic mastopathy in an older diabetic patient. The patient was a 76-year-old woman with a history of type 2 diabetes mellitus for 13 years and 3 years of insulin treatment. She developed a 3 cm, hard, mobile nodule in the left breast. Mammography revealed a dense mass. Ultrasonography showed an irregular-shaped hypoechoic lesion with an unclear boundary and acoustic shadowing. Since fine needle aspiration biopsy delivered insufficient material and core needle biopsy did not yield any specific findings for diagnosis, clinically diabetic mastopathy was the prime suspect but breast cancer could be completely ruled out. Surgical excision was thus performed and diabetic mastopathy was confirmed pathologically. We report on this rare case of diabetic mastopathy in a 76 year-old type 2 diabetic patient.

The unusual occurrence of an "inside-out" appendix reported here is a case of complete intussusception of the appendix of a 45-year-old woman with Peutz-Jeghers syndrome in whom the diagnosis of intussusception was made preoperatively. At laparotomy, the lead point of intussusceptum was revealed to be a Peutz-Jeghers syndrome polyp of the appendix. There was also a cystic lesion in the pancreas, and subsequent distal pancreatectomy revealed a cystadenocarcinoma of the pancreas. Two jejunal Peutz-Jeghers syndrome polyps and two duodenal Peutz-Jeghers syndrome polyps were found via intraoperative endoscopies. The duodenal polyps were endoscopically removed, whereas a jejunal wedge resection was performed for the adjoining jejunal polyps. One of the two duodenal polyps possessed an adenocarcinoma focus. To our knowledge, this is the first report of complete intussusception of the appendix caused by a Peutz-Jeghers syndrome polyp.