[Treatment Result of Neoadjuvant Endocrine Therapy in Postmenopausal Patients with Hormone Receptor-Positive Breast Cancer in Our Hospital].

To date, neoadjuvant endocrine therapy has shown the same rate of clinical objective response and breast-conserving surgery as neoadjuvant chemotherapy in postmenopausal patients with hormone receptor-positive breast cancer. Moreover, neoadjuvant endocrine therapy is recommended to the patients who are unable to tolerate side effects associated with chemotherapy or who are ineligible for immediate surgery because of their age and comorbidity. We discuss the result of neoadjuvant endocrine therapy in our hospital last 5 years. Nine patients underwent preoperative endocrine therapy between 2015 and 2019. Pathological examinations consisted 7 invasive ductal carcinomas and 2 mucinous carcinomas. The result of preoperative examinations was 7 partial response(PR), 1 complete response(CR), and 1 progress disease(PD). 3 months after initiation, all patients were examined by palpation and US. 6 months after initiation, all patients showed a partial response. These results suggest that neoadjuvant endocrine therapy allows downstaging of tumors and more minimally invasive surgery.

[A Case of Drug-Induced Interstitial Lung Disease Associated with Epirubicin and Cyclophosphamide Therapy before Operation].

We report the case of a 60-year-old woman with right breast cancer. Approximately 18 years had passed since the treatment for left breast cancer without recurrence. She became aware of the right breast tumor with mild pain 5 months before she came to the hospital. The diagnosis was right-sided breast cancer, cT2N0M0, StageⅡA, ER(-), PgR(-), HER2(-). Neoadjuvant chemotherapy was chosen, and then combined treatment with epirubicin(EPI)and cyclophosphamide(CPA) was started. The breast tumor had become smaller, but she complained of shortness of breath during the third course of chemotherapy. On the basis of her history of cancer onset, chest CT findings, and increase in serum SP-D levels, the combined therapy with EPI and CPA was suspected as the cause of the drug-induced interstitial lung disease(DILD). For this reason, the therapy was discontinued. After her recovery from this state, the operation(partial mastectomy and sentinel lymph node biopsy)was performed. S-1 was used as postoperative adjuvant therapy, and the respiratory symptoms did not recur or worsen. On the basis of the disease course, we made a diagnosis of DILD with EPI and CPA. Many anticancer drugs may cause DILD. In case of a suspicion of DILD onset, a prompt diagnosis and an appropriate treatment are important.

[A Case of Perforative Peritonitis Due to Intestinal Metastasis from Lung Cancer].

We here describe a case of an acute peritonitis due to perforation of a small intestine tumor metastasized from a lung cancer. A 66-year-old man who had undergone a bladder cancer procedure 2 years ago and was hospitalized for the second operation, complained sudden abdominal pain. An enhanced abdominal CTrevealed a small amount of free gas and ascites in the abdominal cavity. On the same day, emergency exploratory surgery was performed with the diagnosis of perforative peritonitis. A laparotomy revealed a jejunal tumor with perforation 40 cm distal from the Treitz ligament. After surgery, the patient confessed that he had got a notice of the recurrence of lung cancer which had been treated 9 years ago. The pathological result indicated the lesion was metastasis from lung cancer. Although small intestinal metastatic tumor from lung cancer is rare, it should be considered when acute abdomen is observed.

[A Case of Liver Failure Induced by Toremifene in a Patient with Metastatic Breast Cancer].

A 67-year-old woman underwent total mastectomy, postoperative radiation therapy, and adjuvant hormonal therapy more than 9 years 4 months previously. There were no symptoms of recurrence for 3.5 years after completing adjuvant hormonal therapy. A hard mass appeared on the front chest wall and was diagnosed as recurrence of breast cancer histopathologically. A computed tomography (CT) scan revealed multiple metastases in the left side of the chest wall, in the left Level Ⅱ axillary lymph nodes, and in the left lung. The patient was prescribed high-dose tremifene (HD-TOR 120 mg/day). After less than 4 months, she presented with general fatigue and yellow skin, and was admitted with grade 4 hyperbilirubinemia and grade 3 hepatic dysfunction (AST and ALT). CT and magnetic resonance imaging (MRI) showed no abnormal findings in the liver or biliary tract. Drug-induced liver injury (DILI) caused by HD-TOR was suspected and this therapy was discontinued. The liver dysfunction showed a tendency to improve with conservative treatment and the patient was discharged on the 10th day of illness. She had almost recovered after 5.5 months. A liver biopsy, a drug-lymphocyte stimulation test, and other detailed examinations were not performed, but we judged this case to be one of liver failure caused by HD-TOR-induced DILI.

[Repeated Insertion of Self-Expandable Metallic Stents as a Palliative Therapy for Unresectable Colorectal Cancer].

A 62-year-old man was admitted to our hospital for malignant rectal stricture due to metastatic rectal cancer. He underwent placement of a self-expandable metallic stent (SEMS). After the administration of 5 courses of FOLFOX4 with bevacizumab, chemotherapy-induced tumor shrinkage led to migration of the SEMS, which was removed immediately without complication. After 10 courses of chemotherapy, he had to discontinue the treatment due to liver failure resulting from tumor progression. Another SEMS was successfully inserted for the progression of rectal stenosis. The patient's QOL was maintained to the end with the SEMS. This case suggests that although it is essential to pay attention to possible complications, SEMS insertion is a very useful procedure for palliative therapy.

[Conversion Therapy of Initially Unresectable Rectal Cancer with Perforation via FOLFOX4 Chemotherapy].

We describe a case of perforated rectal cancer that became curatively resectable after FOLFOX4 chemotherapy. An 81- year-old woman was transferred to our hospital with a diagnosis of bowel perforation. She underwent emergency transverse colostomy, peritoneal lavage, and the insertion of indwelling drainage tubes, because the perforated rectal cancer was considered unresectable. After recuperation, she received chemotherapy consisting of FOLFOX4 and bevacizumab. Owing to a good response to the treatment after 4 months, rectal resection was achieved curatively. Wound dehiscence occurred as a postoperative complication. The patient chose not to receive adjuvant chemotherapy. Currently, she has been alive for more than 1 year 3 months after resection without recurrence.

[Long-term control of stage IV breast and gastric cancer with combination therapy of S-1 and paclitaxel].

We here describe a case of Stage IV breast and gastric cancer in which S-1/paclitaxel therapy was effective in maintaining the patient's QOL. A 50-year-old woman visited our hospital with complaints of her right breast tumor and right brachialgia. She was diagnosed with breast cancer with multiple bone metastases including cervical vertebrae. Accordingly, local radiation therapy and tamoxifen(TAM)administration was started immediately. Gastrointestinal endoscopy revealed gastric cancer, but laparotomy disclosed the gastric cancer was unresectable. At that time, the complaints of pain, nausea, and fatigue had increased and S-1/paclitaxel therapy was started immediately. The treatment reduced the size of the lesions in the breast and stomach and improved the QOL without serious adverse events. We have been maintaining partial response(PR)in this patient for 28 months.

[Three cases of endoscopic gastroduodenal stenting for gastric outlet obstruction caused by unresectable gastric cancer].

Gastroduodenal stenting for gastric outlet obstruction (GOO) caused by malignant disease has been covered by health insurance in Japan since April 2010. We have inserted WallFlex™ duodenal stents (WDS) in 3 patients with GOO caused by unresectable advanced gastric cancer. WDS placement was successful with no complications in all cases. Mean treatment time was 44.7 (35-50) minutes, and mean survival time after WDS placement was 34.7 (19-51) days. Oral food intake was improved in all patients but 1. Enteroparalysis due to peritoneal metastasis supposedly voided WDS placement in 1 patient. WDS placement for GOO caused by advanced gastric cancer is expected to be a safe and effective palliative treatment but sometimes yields no benefit in the patient with peritoneal metastasis.

[Four cases of operations for malignant disease in elderly patients].

The management of elderly patients with malignant disease is determined by their condition, complications, and living environment. Sometimes it is difficult to judge surgical indications for elderly patients. We report 4 cases of patients, 80 years or older, who underwent an operation for malignancy. In the first case we performed a bile duct excision for bile duct cancer, and in the second case we performed distal pancreatectomy for pancreatic cancer. Both operations were non-curative, and the patients were alive and maintained quality of life for 12 months after the operation. In the third non-curative operation, we performed total gastrectomy for remnant gastric cancer. The patient died of cancer 4 months after the surgery. In the fourth case we performed pancreaticoduodenectomy for bile duct cancer; it was a curative operation. The patient was in very good condition 4 months post-operation, but died suddenly due to acute myocardial infarction. In operations treating malignancy in elderly patients, it is important for the patients and their families to fully understand the significance of the operations.