Rare recurrence pattern after complete response to chemotherapy in a patient with rectal cancer: a case report.

BACKGROUND: Colorectal cancer (CRC) often metastasizes to the liver, lungs, lymph nodes, and peritoneum but rarely to the bladder, small intestine, and skin. We here report the rare metastasis of anal cancer in the left bladder wall, followed by metastases to the small intestine and skin, after abdominoperineal resection and left lateral lymph node dissection with chemotherapy in a patient with clinician Stage IVa disease. CASE PRESENTATION: A 66-year-old man presented with 1-month history of bloody stool and anal pain and diagnosed with clinical Stage IVa anal cancer with lymph node and liver metastases (cT3, N3 [#263L], M1a [H1]). Systemic chemotherapy led to clinical complete response (CR) for the liver metastasis and clinical near-CR for the primary tumor. Robot-assisted laparoscopic perineal rectal resection and left-sided lymph node dissection were performed. Computed tomography during 18-month postoperative follow-up identified a mass in the left bladder wall, which was biopsied with transurethral resection, was confirmed as recurrent anal cancer by histopathologic evaluation. After two cycles of systemic chemotherapy, partial resection of the small intestine was performed due to bowel obstruction not responding to conservative therapy. The histopathologic evaluation revealed lymphogenous invasion of the muscularis mucosa and subserosa of all sections. Ten months after the first surgery for bowel obstruction and two months before another surgery for obstruction of the small intestine, skin nodules extending from the lower abdomen to the thighs were observed. The histopathologic evaluation of the skin biopsy specimen collected at the time of surgery for small bowel obstructions led to the diagnosis of skin metastasis of anal cancer. Although panitumumab was administered after surgery, the patient died seven months after the diagnosis of skin metastasis. CONCLUSIONS: This case illustrates the rare presentation of clinical Stage IVa anal cancer metastasizing to the bladder wall, small intestine, and skin several years after CR to chemotherapy.

Significance of in vitro photodynamic cytodiagnosis with 5-aminolevulinic acid in biliary brush cytology for malignant biliary stricture.

BACKGROUND: For the early diagnosis of malignant biliary stricture due to biliary-pancreatic carcinoma, conventional biliary brush cytology with endoscopic retrograde cholangiopancreatography (ERCP; the conventional method) is not sensitive enough. METHODS: Two hundred nine patients with biliary stricture who were admitted between September 2015 and June 2020 were enrolled in this study. Biliary brush cytology was performed on all patients. Samples were diagnosed independently by an expert pathologist and medical doctor with conventional cytology and photodynamic diagnosis (PDD) with 5-aminolevulinic acid. RESULTS: The definitive diagnoses were 49 benign and 160 malignant diseases. The conventional method had a sensitivity of 77.5% (124/160) and specificity of 100% (49/49). The PDD method had a sensitivity of 77.5% (124/160) and specificity of 67.3% (33/49). The conventional method identified 36 malignant diseases as false negatives, while the PDD method enabled successful diagnoses of malignant diseases in 19 of these 36 patients. When PDD was combined with the conventional method, the sensitivity significantly increased to 89.4% (143/160, P = 0.006), and for biliary tract diseases only, the sensitivity increased to 95.6% (88/92, P = 0.001). CONCLUSIONS: Malignant biliary stricture can be diagnosed effectively and safely with the in vitro PDD method. The sensitivity could be further increased by combining PDD with the conventional method.

[A Case of Resection of Sigmoid Colon Metastasis from Pancreatic Cancer].

A 73-year-old man underwent distal pancreatectomy for invasive pancreatic ductal carcinoma in 2018. He showed stenosis of sigmoid colon due to recurrence of pancreatic cancer and received transverse colostomy in 2020. One year after initiation of gemcitabine monotherapy, he complained of abdominal pain. CT images and colonoscopy revealed accumulation of mucus in sigmoid colon due to stenotic lesions. Because conservative treatment using antibiotics was not effective, we performed sigmoidectomy. Histological examination revealed that tubular adenocarcinoma located mainly in the muscularis propria invaded into the colonic mucosa. Immunohistochemical analysis showed positive staining for CK7, and negative for CK20. We diagnosed sigmoid colon metastases of pancreatic cancer.

Brain metastasis from gallbladder neuroendocrine carcinoma.

A 52-year-old woman was diagnosed with unresectable gallbladder neuroendocrine carcinoma (GB-NEC) exhibiting lymph node and peritoneal metastases, and received eight courses of chemotherapy with irinotecan plus cisplatin. Radiological examinations revealed significant regression of the GB tumour and disappearance of metastatic lesions, so the patient underwent laparoscopic cholecystectomy. However, the patient presented with multiple haemorrhagic brain metastases (BMs) and died 13 months after the initial diagnosis despite neurosurgical interventions. Pathological examination of the resected gallbladder demonstrated an extensive fibrous scar along with tubular adenocarcinoma components, which may indicate that the chemotherapy eliminated a pre-existing neuroendocrine carcinoma (NEC) component. Furthermore, pathological analysis confirmed that the BMs comprised NEC. In patients with advanced GB-NEC, conversion surgery may be a reasonable option if a first-line chemotherapy leads to downstaging of the tumour. Second-line drug therapy and systemic screening might also be considered in cases with BMs.

Cerebral arterial air emboli after stent insertion in esophageal cancer complicated with esophago-left atrial fistula: An autopsy case and review of the literature.

Cerebral arterial air embolism is a rare and unexpected complication of advanced esophageal cancer. The entry of air to systemic circulation is an esophago-left atrial or pulmonary vein fistula formation. Herein, we report an autopsy case of a 64-year-old man. He was diagnosed esophageal cancer 2 years ago and underwent chemotherapy and concurrent chemoradiotherapy but the disease progressed, unfortunately. Then two metal stents were inserted into the middle thoracic esophagus as a palliation of dysphagia. After initiation of oral intake, he developed deterioration of consciousness. The cranial computed tomography showed cerebral arterial air emboli with multiple low-density areas. He failed to gain consciousness again and died one and half days later. In a literature survey, this autopsy case is the first presentation that confirmed histologically the close association between stent placement and formation of esophago-left atrial fistula. Due to the fatality of cerebral arterial air embolism, clinicians should keep in mind the possibility of this catastrophic complication after multimodality treatment of esophageal cancer.

[A Middle-Term Survival Case of Pancreas Tail Cancer with Colonic Obstruction].

A 63-year-old man had abdominal pain and sequential constipation and diarrhea. He complained of abdominal pain and vomiting, and was admitted to the hospital with a diagnosis of ileus. CT demonstrated a colonic obstruction at the splenic flexure, which was suspected to be colon cancer. Ileostomy was performed in March 2015, and he underwent radical resection in May 2015. Cancer of the pancreas tail had invaded the spleen, colon, stomach, and left renal capsule. Distal pancreatectomy was performed, along with extended right hemicolectomy, left nephrectomy, partial gastrectomy, and stoma closure. He received adjuvant chemotherapy for 6 months after the operation. He is alive without recurrence of pancreatic cancer for over 3 years.

[A Case of Stage IV Metaplastic Breast Cancer in Which Primary Tumor Was Removed after Treatment with Anti-HER2 Systemic Therapy].

The patient was a 58-year-oldpostmenopausal woman. Vacuum assistedbiopsy of the left breast tumor revealedinvasive ductal carcinoma. Immunohistochemical examination was negative for estrogen receptor(ER), negative for progesterone receptor(PgR), andshowedan HER2 score of 3+. FDG-PET/CT revealedmultiple metastases to the left supracravicular and axillary lymph nodes and lungs. She was diagnosed with HER2-positive T3N3M1, Stage IV breast cancer. A 2-year regimen of chemotherapy with trastuzumab andvinorelbine achieveda complete response with regardto the metastatic sites; however, the size of the primary tumor increasedd espite the chemotherapy, andsurgical resection of the left breast with axillary lymph node dissection was performed for local control. Pathological examination of the surgical specimen revealed metaplastic carcinoma with sarcoma component surrounded by non-invasive ductal carcinoma. No component of invasive ductal carcinoma was found. Immunohistochemically, metaplastic carcinoma was negative for ER, negative for PgR, andrevealedan HER2 score of 0. There was discordance of HER2 status between pre- andpost -chemotherapy. The patient receivedno further chemotherapy following surgery andhas been without disease progression for 6 years. We suggest there is heterogeneity, that is, the metastatic sites andthe partial primary tumor were HER2-positive invasive ductal carcinoma and the remainder of the primary tumor was triple negative metaplastic carcinoma. As a result, the patient was able to discontinue chemotherapy with higher quality of life.

An unusual case of Epstein-Barr virus-positive large B-cell lymphoma lacking various B-cell markers.

BACKGROUD: Epstein-Barr virus (EBV) is associated with B-cell lymphoma in various conditions, such as immunodeficiency and chronic inflammation. We report an unusual case of EBV-positive diffuse large B-cell lymphoma (DLBCL) lacking the expression of many B-cell markers. CASE PRESENTATION: An 83-year-old man presented with a submandibular tumor. Histology of a lymph node biopsy specimen revealed diffuse proliferation of centroblast- or immunoblast-like lymphoid cells with plasmacytic differentiation. Scattered Hodgkin/Reed-Sternberg-like cells were also visible. A routine immunohistochemistry antibody panel revealed that the tumor cells were negative for B-cell and T-cell markers (i.e., CD3, CD19, CD20, CD38, CD45RO, CD79a, CD138, and Pax-5), but were positive for CD30 and MUM-1, not defining the lineage of tumor cells. The final diagnosis of EBV-positive DLBCL was confirmed based on the expression of B-cell-specific transcription factors (Oct-2 and BOB.1), PCR-based identification of monoclonal rearrangement of the immunoglobulin genes, and the presence of EBV-encoded small RNAs in the tumor cells (identified using in situ hybridization). CONCLUSION: The downregulation of broad band of B-cell markers in the present case with EBV-positive DLBCL posed a diagnostic dilemma, as the possible diagnoses included differentiation from anaplastic large cell lymphoma and CD20-negative B-cell lymphomas. Results of immunohistochemical panel including B-cell-specific transcription factors and gene rearrangement analyses critically support the correct diagnosis.

Classical type and blastoid variant mantle cell lymphoma in the same lymph node: Histology and cytological findings from a touch imprint specimen.

Blastoid variant (BV) is one of the aggressive variants of mantle cell lymphoma (MCL). BV-MCL is defined by its blastic cytomorphology. Previous studies using sequential biopsies in cases with MCL have demonstrated that classical type MCL (C-MCL) often transforms or relapses as an aggressive variant, but a histopathological transition from C-MCL to an aggressive MCL variant in the same pathological specimen has been shown in only a limited number of the cases. We present a case of MCL in which a histological transition between C-MCL and BV-MCL was observed in the same lymph node. A 53-year-old man presented with a submandibular tumor. Touch imprint cytology revealed a monotonous proliferation of large blastic lymphoid cells. Histology revealed a transition between a large lymphoid cell component and small foci of small- to medium-sized cell component within the tumor. Both components were CD5(+), CD10(-), CD20(+), cyclin D1(+), and SOX11(+) on immunohistochemistry. Fluorescent in situ hybridization revealed the translocation of IgH/BCL1 locus. These findings led to a final diagnosis of BV-MCL with coexistent C-MCL. The present case suggests the existence of a pathogenetic pathway of MCL from C-MCL to BV-MCL. Because it is important to accurately identify BV-MCL for prognostication, appropriate ancillary diagnostic tools should be used in suspected cases. Diagn. Cytopathol. 2017;45:364-370. © 2016 Wiley Periodicals, Inc.

[A Case of Pure Squamous Cell Carcinoma of the Breast in an Elderly Woman Diagnosed by Cytology].

A n 85-year-old woman presented with a mass in the left breast. A3 7mm lobulated mass including enhancement of a cyst of 37mm was detected by sonography. An axillary lymph node had increased to 16 mm. Atypical cells dyed by light green and orange G were identified by fine needle aspiration and cytology. She was diagnosed with left breast cancer(cT2N1M0, Stage II B), histologically suspected to be squamous cell carcinoma. She underwent a left-breast-conserving surgery and axillary lymph node dissection. On pathology, a cyst of 34×30mm was noted. The tumor grew from inside the cyst to the surround- ing tissue and it had a trend for keratinocytes. Lymph node metastases affected 1/11. By immunostaining, the tumor was found to be ER(+), PgR(-), HER2(-), CK5/6(+), p40(+), mammaglobin(-), and GCDFP15(-). There was no component of ductal carcinoma. She received radiotherapy to the left breast and tamoxifen as an adjuvant therapy. Squamous cell carcinoma of the breast is rare. We encountered a case of pure squamous cell carcinoma of the breast in an elderly woman. We report this case with a discussion of the relevant literature.

[A Case of Peritoneal Metastasis of Breast Cancer Diagnosed by Laparoscopic-Assisted Right Hemicolectomy].

The patient was an 86-year-old woman. She underwent right breast-conserving surgery and sentinel lymph node biopsy for breast cancer in August 2006. The pathological diagnosis was invasive ductal carcinoma, T1N0M0, Stage Ⅰ, ER (+), PgR (-), HER2 (-). She was treated with tamoxifen for 5 years as adjuvant therapy and showed no signs of recurrence. In November 2014, CA15-3 was elevated and an accumulation of FDG in the right paracolic sulcus was observed on PET-CT. Peritoneal metastasis of breast cancer was suspected, and an operation was performed for a definitive diagnosis. During the operation, the tumor was seen on the paracolic sulcus, and laparoscopic-assisted right hemicolectomy was performed. A poorly differentiated adenocarcinoma was diagnosed by pathological examination, and immunostaining results were as follows: CK7(+), CK20(-), mammaglobin (-), GCDFP-15 (-), ER (-), PgR (-), and HER2 (-). Because there was no original lesion other than the breast cancer, the tumor was diagnosed as a metastasis of breast cancer. The frequency of peritoneal metastasis of breast cancer is low. In this case, pathological diagnosis was necessary for a definitive diagnosis. A change of subtype was also confirmed, and the treatment strategy was decided appropriately. Surgical resection should be considered for peritoneal metastasis of breast cancer when the operation can be performed safely.

[A case of recurrent duodenal gastrointestinal stromal tumor resistant to imatinib and sunitinib, successfully treated with regorafenib].

Regorafenib is a novel, orally administered multi-kinase inhibitor that has recently been approved for the treatment of recurrent gastrointestinal stromal tumor (GIST). We report a case of successful treatment of recurrent duodenal GIST, which was found to be resistant to imatinib and sunitinib, with regorafenib. A 62-year-old woman underwent a pancreatoduodenectomy for duodenal GIST; after 2 years, a computed tomography (CT) scan detected liver metastases. The patient received imatinib for 6 years, and underwent 2 hepatectomies. Subsequently, she received sunitinib for 10 months; however, CT scans revealed the presence of multiple vertebral metastases. She underwent a laminectomy for the palliative treatment of the vertebral metastases. Upon immunohistochemical examination, the recurrent tumor stained positive for c-kit, confirming the diagnosis for GIST. Consequently, the patient received regorafenib; although the treatment controlled the liver metastases, the vertebral metastases were found to have progressed. She survived for 9 years and 5 months after the initial surgical resection. Regorafenib might be beneficial in the treatment of recurrent GISTs that prove to be resistant to imatinib and sunitinib.

[A case of hyoid bone metastasis from breast cancer].

A 69-year-old woman had undergone breast conserving surgery and axillary lymph node dissection for left breast cancer 10 years previously. The tumor was positive for estrogen receptor (ER) and progesterone receptor (PgR), and negative for human epidermal growth factor receptor-2 (HER2). Adjuvant tamoxifen and radiation therapy were administered to the conserved breast for 5 years. The patient detected a painless neck mass 1 year previously. Computed tomography (CT) revealed a hyoid bone mass, and fine needle aspiration cytology indicated a diagnosis of adenocarcinoma. Positron emission tomography combined with CT (PET-CT) revealed masses in the pelvis, spine, hyoid bone, and cervical lymph node. For definitive diagnosis, excisional biopsy of the hyoid bone was performed. Immunohistostaining revealed that the cells were CK7 (+), CK20(-), mammaglobin (+), GCDFP-15 (+), ER (+), PgR (+), and HER2 (-). The final diagnosis was multiple bone metastasis(hyoid, pelvis, spine)as well as cervical lymph node metastasis from breast cancer. After diagnosis, the patient was treated with anastrozole and denosumab, and she achieved a partial response. She has experienced progression free survival for 12 months. Metastasis to the hyoid bone is uncommon for breast cancer. We report a case in which hormone therapy was effective after it was selected based on the results of excisional biopsy.

[A case of malignant phyllodes tumor after surgery for breast cancer].

A 63-year-old woman underwent breast-conserving resection and axillary lymph node dissection for bilateral breast cancer in December 2008. Histopathological diagnosis for the right breast cancer was t=1.3 cm, n=1/29, estrogen receptor (ER) (+), progesterone receptor (PgR) (+), human epidermal growth factor receptor 2(HER2) (-), and that for the left breast cancer was t=1.8 cm, n=9/28, ER (+), PgR (+), and HER2 (-). She was administered adjuvant chemotherapy (4 courses of fluorouracil, epirubicin, and cyclophosphamide [FEC 100] and 4 courses of docetaxel[DTX], 75 mg/m²), letrozole, and bilateral radiation therapy for the remaining breast tissue. She noticed a mass in the left breast in December 2013. Fine-needle aspiration cytology and core-needle biopsy indicated a malignant phyllodes tumor or stromal sarcoma. Positron emission tomography-computed tomography (PET-CT) revealed the accumulation of fluorodeoxyglucose (FDG) only in the mass. The tumor enlarged rapidly to more than 5 cm during the pre-operative period. In January 2014, the patient underwent left mastectomy. The histopathological diagnosis was malignant phyllodes tumor in the left breast, with a tumor diameter of 7 cm, and negative margins. Presently, 6 months after the operation, the patient is alive without recurrence.

[A case report of matrix-producing carcinoma of the breast].

A 43 -year-old woman with a palpable mass in the right breast consulted a neighborhood doctor. She was diagnosed with right breast cancer after core needle biopsy, and she was referred to our hospital. Mammography revealed an indistinct mass with calcification in the lower outer quadrant of the right breast. Ultrasonography revealed a hypoechoic mass with a high echo spot. Magnetic resonance imaging (MRI) revealed a high intensity tumor with peripheral enhancement. The patient underwent mastectomy with sentinel lymph node(SN) biopsy and axillary lymph node dissection. Histologically, the tumor was composed of a solid-tubular carcinoma with a centrally located metaplastic cartilaginous element. There was an abrupt transition between these components, without intervening spindle cells or osteoclastic cells. Subtyping via immunohistochemical analysis for estrogen receptor (ER), progesterone receptor (PgR), and human epidermal growth factor receptor 2 (HER2) demonstrated that the tumor was triple negative (TN). The histological diagnosis was matrix-producing carcinoma (MPC). Adjuvant chemotherapy was administered, and she has been recurrence-free. MPC has unique features, such as emphasis of the peripheral zone of the tumor by using contrast enhanced-computed tomography (CT) and gadolinium-diethylene triamine pentaacetic acid (Gd-DTPA) MRI. Most cases of MPC that have been reported were TN. The 5 year survival rate for MPC is poorer than that for breast cancer. In Japan, 7 cases of MPC recurrence have been reported within 2.5 years, suggesting that careful follow-up is necessary for 2-3 years after surgery.

[Identification of the primary lesion in a patient with concomitant breast and kidney cancer following fracture of the femur].

A 61-year-old woman was diagnosed with breast cancer [T3N3cM0: Stage IIIC, estrogen receptor [ER] (+), progesterone receptor [PgR] (+), human epidermal growth factor receptor 2[HER2] (-)]at the time of initial presentation. Following diagnosis, combined modality therapy including hormone therapy and chemotherapy were initiated, but hemorrhage from the primary lesion and bone metastases were observed. Priority was given to treatment of the breast cancer, and chemotherapy was administered, after which, right mastectomy and axillary lymph node sampling were performed to assess local disease control. In addition, concurrent right kidney enucleation was performed for a renal lesion. The renal neoplasm was diagnosed as T1aN0M0, Stage I. After this intervention, treatment of the breast cancer was continued, but pain of the right femoral region developed, and bone metastasis was diagnosed on close inspection. The bone metastasis was considered to derive from the breast cancer. During hospitalization, the patient fell and broke her right femur. Open reduction and internal fixation was performed immediately, and bone metastasis of kidney cancer was diagnosed via perioperative cytodiagnosis. Pulmonary metastasis, local recurrence, and metastasis to the shoulder blade have been detected. The metastases are considered to derive from the breast cancer, for which treatment has been continued. In the case of concomitant cancers, biopsy for metastatic foci can be considered essential, whenever it can be performed safely.

[Is standard radical mastectomy still a treatment option for select patients with breast cancer ?].

BACKGROUND: Currently, minimal surgery is the treatment of choice for most breast cancer patients. However, some patients with locally advanced breast cancer( LABC) require standard radical mastectomy( SRM) before or after systemic therapy. PATIENTS AND METHODS: We reviewed the medical records of 7 patients with breast cancer who underwent SRM in our hospital between January 2007 and April 2013 and examined their clinicopathological features and prognostic outcomes. RESULTS: The average patient age was 68 years. SRM was performed because of muscle invasion( n=6), Rotter lymph node metastases( n=3), and level III lymph node metastases( n=3). After SRM, the wound was closed by skin grafting in 2 of the 7 patients. With regard to postoperative complications, 2 patients required rehabilitation for shoulder joint stiffness, whereas wound infection and arm edema were encountered in 1 and 2 patients, respectively. During the median follow-up time of 26 (range; 4-69) months, 3 patients experienced recurrence. The metastatic sites in the 3 patients were the supraclavicular lymph nodes, the chest wall, and the liver, respectively. CONCLUSIONS: Quality of life( QOL) following SRM was acceptable in the patients examined. SRM could be considered as a treatment option in select patients with LABC.