[A Case of Completion Gastrectomy for Metachronous Gastric Cancer in the Remnant Stomach after Successful Treatment with ESD].

A 73-year-old man underwent distal gastrectomy, D2 lymphadenectomy, and Billroth Ⅰ reconstruction for Type 3 advanced cancer in the lower corpus lesser curvature in 20XX. After postoperative adjuvant chemotherapy, he self-detected a mass in the left breast. It was diagnosed as breast cancer. He underwent mastectomy and axillary lymphadenectomy 16 months after gastric cancer surgery. After postoperative adjuvant chemotherapy, gastric or breast cancer did not recur. However, periodic upper gastrointestinal endoscopy revealed an 8-mm 0-Ⅱa lesion in the anterior wall of the remnant middle stomach(Group 5)80 months after gastric cancer surgery. Endoscopic submucosal dissection(ESD)was performed, and radical resection was achieved. Periodic upper gastrointestinal endoscopy was performed thereafter; an ectopic 0-Ⅱa lesion was detected in the greater curvature of the remnant middle stomach(Group 5)21 months after ESD. Since this lesion suggested massive submucosal invasion, total resection of the remnant stomach and Roux-en-Y reconstruction were performed. The postoperative course has been favorable, and the patient has been alive without recurrence for 6 months postoperatively. A long period passes before intestinal juice reflux induces progression of a chronic inflammatory gastric mucosal lesion to cancer in the remnant stomach. Thus, long-term endoscopic follow-up may be necessary.

[A case of advanced gastric cancer exhibiting pathological complete response after neoadjuvant chemotherapy].

A 77-year-old woman diagnosed as having advanced gastric cancer with para-aortic lymph node metastasis received neoadjuvant chemotherapy with docetaxel, cisplatin, and S-1. After 2 courses of chemotherapy, distal gastrectomy with D2 lymphadenectomy was performed. There were no viable cancer cells in the primary lesion and lymph nodes. Currently, the patient is visiting our hospital for treatment with S-1 as adjuvant chemotherapy, and shows no signs of recurrence.

[The efficacy of early diagnosis of brain metastasis and systemic treatment after radiotherapy in patients with metastatic breast cancer].

We treated 9 patients diagnosed with brain metastasis from breast cancer. Although 1 patient was initially diagnosed as having Stage IV disease, 5 had Stage I/II early breast cancer. All patients had defined brain metastasis after chemotherapy. Brain metastasis was symptomatic in 7 patients, 4 of whom had brain edema, and asymptomatic in 2 patients. The median survival time from breast cancer metastasis was 23 days for patients who did not receive radiotherapy and 19.6 months for those who received radiotherapy. Among the patients treated with radiotherapy, the median survival time was 4.3 months for patients who did not receive further treatment and 19.7 months for those who received chemotherapy or chemotherapy with trastuzumab. One patient with a solitary brain metastasis underwent stereotactic radiosurgery, and treatment is being continued for 1 of the 2 patients who received systemic therapy after whole-brain radiotherapy and additional stereotactic radiosurgery at recurrence to control brain disease. Systemic treatment after radiotherapy is important for brain metastasis from breast cancer, and early diagnosis of brain metastasis facilitates the use of various available treatments.

[A case of coexisting borderline phyllodes tumor and non-invasive ductal carcinoma].

A 36-year-old woman with benign phyllodes tumor of the left breast had undergone lumpectomy 1 year ago and was admitted to our hospital because of a left breast mass on the operation scar. Ultrasonography showed a 35 mm low-echoic, elliptical mass with a high depth to width( D/W) ratio in the C area and a 10 mm low-echoic, polygonal mass with a high D/W ratio in the E area. Histological examination of an ultrasonography-guided vacuum-assisted biopsy specimen indicated recurrent phyllodes tumor. Since both tumors were assumed to be recurrent phyllodes tumors, quadrantectomy was performed. Finally, the mass in the C area was diagnosed as a recurrent phyllodes tumor and the mass in the E area was diagnosed as a fibroadenoma. A non-invasive ductal carcinoma was incidentally detected between the 2 tumors, and the surgical margin was negative. Radiotherapy was performed on the remnant breast tissue.

[A clinical case of recurrent small intestinal cancer successfully treated with FOLFOX6].

A 73-year-old man was referred to our hospital because of ileus. Enteroscopy revealed severe stenosis in the jejunum. He was diagnosed with small intestinal cancer. Partial resection of the jejunum, partial resection of the transverse colon, and lymphadenectomy were performed. A postoperative pathological examination showed skip metastasis in the jejunum (TNM: Stage IV). Six months later, lung and liver metastases were evident from computed tomography( CT). Nine courses of FOLFOX6 administered once every 2 weeks achieved a partial response. When 9 courses of chemotherapy had been completed, CT showed progressive disease. Subsequently, he has been administered with FOLFIRI in our outpatient clinic.

[A case of liposarcoma of the abdominal wall complicated by thrombocytpenia as a paraneoplastic syndrome].

A 59-year-old woman was admitted to our hospital because of right chest pain. CT scan showed a mass on the right abdominal wall and bilateral pleural effusion. The histological diagnosis following core needle biopsy was undifferentiated sarcoma. The right pleural effusion gradually increased despite negative cytology. Although we planned chemotherapy for the clinically diagnosed pleural invasion, thrombocytopenia as a paraneoplastic syndrome appeared. The minimum thrombocyte count was 4,000/mm3. While transfusion was not effective, per os dexamethasone at 2.0 mg/day kept the thrombocyte count at around 6×10 4/mm3. Anti-thrombocyte antibody was negative. Tumor resection surgery with partial diaphragm resection and 11th and 12th rib resection, and abdominal wall plasty with mesh was performed. The final histological diagnosis was dedifferentiated liposarcoma. The thrombocyte count returned to the normal range just after the operation. However, she died of pleural dissemination, peritoneal dissemination, and local recurrence 69 days after the operation.

[Two cases of stromal sarcoma, so-called malignant fibrous histiocytoma of breast treated with reduction surgery].

CASE 1: A 64-year-old woman with right breast cancer had a partial mastectomy and radiotherapy four years ago was admitted to our hospital because of right breast mass. The vacuum associated biopsy of tumor resulted in breast sarcoma, thus a nipple-spearing mastectomy was performed. The final histological diagnosis was stromal sarcoma, and was identical to histological findings of malignant fibrous histiocytoma. Three months after the operation, a chest wall recurrence appeared. Although tumor resection with latissimus dorsi flap was performed, there were pleural dissemination and malignant pleural effusion. She died six months after the first surgery. CASE 2: A 60-year-old woman was admitted to our hospital because of left breast mass, but she refused a further clinical examination. She readmitted fourteen months later due to a huge sized left breast mass with necrosis and smelling discharge. CT scan showed a huge tumor of left breast and multiple lung metastases. Biopsy of the tumor resulted in breast sarcoma. Total mastectomy with split thickness skin grafting was performed. The final histological diagnosis was identical to the first case. A local recurrence appeared thirty days after the operation, and she died fifty-one days after the operation.

[Postoperative axillary-lymph-node recurrence in breast cancer patients].

We investigated 13 cases of axillary-lymph-node recurrence, who received an operation for an early stage breast cancer. They are the first recurrence of only regional without metastatic disease; the 4 patients, who had sentinel-lymph-node by biopsy at first operation, received an axillary lymph adenectomy, and 5 patients received re-lymph-adectomy after axillary lymph node dissection. The other 4 patients received only systemic therapy. Receptor conversion between primary and lymph-node recurrent site was identified for ER in 2 patients; one showed a lower expression of ER and the other showed for HER2. These led to a change in the subsequent treatment plan; 6 patients had systemic chemotherapy after recurrence, 1 patient had endocrine, 2 patients had trastuzumab and 4 patients continued the same treatment prior to surgery. Ten out of 13 patients were alive without recurrence, and 3 patients were with distant metastasis. However, one of the 3 patients who had a distant metastasis died due to brain and lung metastasis. Axillary node recurrence should be treated with axillary dissection, if possible, and receptor measurement in primary and recurrent site is useful for subsequent treatment.

[A clinical case of the esophagogastric malignancy palliated with covered metallic stent with anti-reflux mechanism].

Esohophageal stents are often used in treating malignant stricture. But, when stents are placed across the esophagogastric junction, they may lead to esophagogastric reflux. We report a case of successfully treated esophagogastric strictures using the new stent with anti-reflux mechanism (long cover type Niti-S™ esophageal stent). A 78-year-old man presenting with severe strictures from the lower esophagus to cardiac part of stomach was histopathologically diagnosed as adenocarcinoma. CT scan images showed multiple liver metastatic tumors. However, he refused chemotherapy. Palliation using long cover type Niti-S™ esophageal stent was performed. No adverse effect was occurred. He started solid meals on the 7th postoperative day. He was thereafter able to ingest solid meals without the symptom of esophgogastric reflux and stenosis until he died of the primary disease two month later.

[Multicenter phase II study of pre-administered uracil/tegafur (UFT) plus gemcitabine for unresectable/recurrent pancreatic cancer].

Our objective was to evaluate the efficacy and toxicity of the pre-administration of UFT (uracil/tegafur: prodrug of 5-FU) and GEM combination therapy for unresectable/recurrent pancreatic cancer in the outpatient setting. UFT (250mg/m(2)/day) was orally administered from day 1 through day 6 and from day 8 through 13, and GEM (800mg/m(2), div/30 min) was administered on day 7 and 14, with a one-week rest every 3 weeks based on results of the previous phase I study. Thirty-six pts (24 male, 12 female) were enrolled (median age, 63.8 yrs). There were 8 partial responses (25%). Eighteen pts (56%) had stable disease, and 6 pts (19%) had a progression. The median survival time was 7. 0 months( range 1.5 -66). Grade 3 toxicities were leucopenia (17%), thrombocytopenia (3%), nausea (3%), and liver dysfunctions(3%). There were no Grade 4 toxicities. Pre-administered UFT plus GM is a promising treatment for unresectable/recurrent pancreatic cancer in the outpatient setting.

[A clinical case of lymph node recurrence after resection of gastric cancer successfully treated by combination chemotherapy with irinotecan and cisplatin].

A 60-year-old female who was diagnosed as gastric cancer underwent distal gastrectomy and received adjuvant chemotherapy (S-1 therapy). After 6 months, the tumor marker (CEA) was elevated. CT revealed para-aortic lymph nodes enlargement. Lymph node metastasis was confirmed. The patient was administered combination chemotherapy with irinotecan (CPT-11) and cisplatin (CDDP) Seven months later, CT revealed lymph node metastasis had disappeared. After judgment of complete response (CR), we continued the treatment for 22 months. The patient was followed without any recurrence in May 2010.

[Three cases of breast cancer with skin metastasis after mastectomy treated by radiotherapy].

We reported three cases of patient with triple negative skin metastasis after mastectomy of breast cancer. All three cases had received radiotherapy for skin metastasis. Radiation therapy was effective for recurrent sites, and could improve patient's QOL. After radiotherapy, 2 patients died due to a distant metastasis. Case 1 was resistant to chemotherapy. Case 2 was no indication of chemotherapy because of dementia metastases. Case 3 was the only one continued chemotherapy. It appears that a further consideration was needed for the timing of radiotherapy to be performed among the treatments of locoregional recurrence and distant metastasis of breast cancer.

[Two cases of bronchiolitis obliterans organizing pneumonia (BOOP) induced radiotherapy after surgery of breast cancer].

We report two cases of bronchiolitis obliterans organizing pneumonia (BOOP) induced radiotherapy after surgery of breast cancer. One of the patients was a 58-year-old woman. She underwent a conserving surgery for bilateral breast cancers, and received radiation therapy to the remaining part of bilateral breasts. Two months after the termination of irradiation, cough, fever and general fatigue developed. We clinically diagnosed this case as BOOP after radiation therapy. After initiation of oral steroid therapy, the clinical symptoms and radiographic findings disappeared. Another patient was a 57-year-old woman. She underwent radical mastectomy for right breast cancer. A month after the operation, she suffered from local recurrence, so radiation therapy to the thoracic wall was performed. After irradiation, resection of the thoracic wall lesion was performed because of malignancy from local skin biopsy specimen. Two months after the termination of irradiation, cough, dyspnea and fever developed. We clinically diagnosed this case as radiation-induced BOOP by BAL and TBLB findings. After an initiation of steroid therapy, the clinical symptoms and radiographic findings disappeared. It is important to be aware of BOOP as a complication in the patient who was given radiation after surgery of breast cancer.

[A case of surgical approach to the recurrence of the para-aortic lymph nodes after resection of rectal cancer].

A 63-year-old female diagnosed as rectal cancer underwent low anterior resection and received adjuvant chemotherapy (folinate/tegafur/uracil therapy). After 6 months, lymph node metastasis was confirmed by an elevation of the tumor marker (CEA) and a FDG-PET image. After administration of 37 courses of mFOLFOX6 therapy, surgical excision was performed to the lymph node recurrence, because it was difficult to continue mFOLFOX6 therapy with grade 3 neuropathy. After 8 months from the last operation, no lymph node metastasis was appeared in the para-aortic area.

[The efficacy of surgical resection and chemo-endocrine therapy for patients with local recurrence or axillary lymph node metastasis of breast cancer].

We evaluated a surgical resection and chemo-endocrine therapy and prognosis for patients with local recurrence or axillary lymph node metastasis of breast cancer. Twenty-one patients with local recurrence or axillary lymph node metastasis without a distant metastasis were enrolled in this study. Thirteen of the 21 patients underwent a surgical resection. Resection of recurrent lesion in residual breast after breast conserving therapy for six of the 13 patients, axillary lymph node dissection (ALND) for four, and resection of thoracic wall lesion for three were performed. Five of the patients who underwent resection of residual breast lesion, four of the patients who underwent ALND and two of the patients who underwent resection of thoracic wall lesion have survived. One of the patients who underwent resection of residual breast lesion and one of the patients who underwent resection of thoracic wall lesion were dead. In eight non-operable patients, five were dead and three have survived. Median recurrence free interval was 24 months in operable patients and 27 months in non-operable patients. Median survival time after recurrence was 29 months in operable patients and 12 months in non-operable patients. The surgical with chemo-endocrine therapy promises to control well to local recurrence or axillary lymph node metastasis for the patients we selected.

[Two patients having recurrent breast cancer with brain metastases well controlled with a gamma knife radio-surgery].

We report two patients having recurrent breast cancer with brain metastases that was controlled well with a gamma knife radio-surgery. The patient is a 50-year-old woman. She underwent radical mastectomy for right breast cancer in September 1993. She suffered from multiple liver metastases in June 2000, so CEF therapy contained hepatic arterial infusion chemotherapy, and extended right lobectomy of the liver were performed in December 2001. Afterward, pleurodesis was carried out to the carcinomatous pleurisy. Then she underwent simple total hysterectomy and bilateral oophorectomy for torsion of the metastatic ovarian tumor. MRI study revealed brain metastases with a diameter of 1 cm in her right midbrain in April 2005, so a gamma knife radio-surgery was performed. After the radio-surgery, a weekly paclitaxel therapy followed by peroral chemotherapy with capecitabine was started, and she took the regimen continuously. Another patient is a 56-year-old woman. She underwent skin sparing mastectomy with axillary lymph node dissection for right breast cancer in November 2002. Metastases to the base of her skull were found in October 2004, so a gamma knife radio-surgery was carried out. After the radio-surgery, a weekly paclitaxel therapy with anastrozole was started. In both of the two patients, the metastatic brain tumors have not shown growth so far and are under good control as of March 2006.

[Two patients of recurrent breast cancer with carcinomatous pleurisy well controlled pleural effusion].

We report two patients of recurrent breast cancer with carcinomatous pleurisy well controlled pleural effusion. One patient is a 49-year-old woman. She underwent radical mastectomy for right breast cancer in September 1993. She suffered from multiple liver metastases in June 2000, so CEF therapy contained hepatic arterial infusion chemotherapy and extended right lobectomy of the liver were performed in December 2001. Right pleural effusion was detected in December 2003, then, pleurodesis was carried out with OK-432 after thoracic drainage. After pleurodesis, a weekly paclitaxel therapy was started and she was taking the regimen continuously. Another patient is a 55-year-old woman. She underwent radical mastectomy for left breast cancer in September 1999. Local recurrent lesions on the left chest and left pleural effusion were found in May 2003. After thoracic drainage, infectious pleurisy was complicated, so the drainage tube was removed after the therapy for preventing infection. After pleurodesis, CE therapy followed by peroral chemo-endocrine therapy was performed. Both of the two patients are receiving outpatient treatment without recurrent pleural effusion as of July 2005.

[A case of advanced pancreatic cancer with multiple liver metastasis that improved remarkably with use of low-dose cisplatin and TS-1].

The prognosis and QOL of unresectable pancreatic cancer are very poor. A symptomless 60-year-old male was admitted for examination of a high serum CA19-9 level. Following ultrasound and abdominal CT, we diagnosed unresectable advanced pancreatic cancer with multiple liver metastasis. After we obtained his informed consent, we administered continuous infusion of 5-FU and low-dose cisplatin (CDDP) infusion (low-dose FP therapy) for 3 weeks. He then underwent combination chemotherapy with low-dose CDDP and TS-1 on an outpatient basis. During the chemotherapy, he did not experience any major adverse event and his QOL was relatively good. On follow-up CT 3 months later, the primary tumor in the pancreas was found to be stable. However, the size and number of liver tumors were remarkably reduced. The serum CA19-9 level had also remarkably decreased from 48,300 U/ml to 1,480 U/ml. In conclusion, the combination chemotherapy using low-dose CDDP and TS-1 can be effective in cases of unresectable pancreatic cancer with multiple liver metastasis.

[A case of multiple liver metastases from breast cancer in which we confirmed disappearance of cancer cells after hepatic resection following hepatic arterial infusion chemotherapy].

A 46-year-old woman underwent right mastectomy for stage IIA breast cancer in 1993. Six years and 8 months after this operation, she was diagnosed as having multiple liver metastasis form the breast cancer. An intra-arterial catheter was inserted percutaneously into the hepatic artery and she was given hepatic arterial infusion chemotherapy and general chemoendocrine therapy. The metastatic liver tumors were gradually reduced in size and tumor markers returned to the normal range. However, tumor size was unchanged after February 2001. After obtaining her informed consent from the patient, we performed hepatic resection in December 2001. Histopathologically, three scars were observed and no tumor cell was found. She has been free from recurrence to date. This case suggests that chemoendocrine therapy including hepatic arterial infusion chemotherapy is effective for breast cancer patients with liver metastasis.