[Decision-Making Regarding Adjuvant Therapy for Hormone Receptor-Positive, HER2-Negative Early Breast Cancer].

In December 2021, abemaciclib was approved as an adjuvant treatment for hormone receptor-positive, HER2-negative, high-risk early breast cancer in Japan. The Oncotype DX Breast Cancer Recurrence Score program(Oncotype DX)is a test that can be used to limit overtreatment in hormone receptor-positive, HER2-negative, low-risk early breast cancer. Although the target groups of both these are different and usually without many overlapping indications, we encountered a case in which this therapy and test were used in a short time period. Our experience suggests that even if the result of Oncotype DX indicates that hormone therapy alone is sufficient, it does not imply that abemaciclib is unnecessary, although this has not been directly studied in the monarchE trial. While a wider choice of treatment options is desirable for patients, more clinical data and trials are needed to further validate the utility of abemaciclib without chemotherapy.

[Survey of spike-specific immunoglobulin G antibodies at approximately 3 months and 9 months after vaccination against coronavirus disease 2019 (severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) in health care workers].

OBJECTIVE: We investigated the antibody titer of spike-specific immunoglobulin G (IgG) antibodies after receiving coronavirus repair uridine ribonucleic acid (RNA) vaccine (BNT162b2, Pfizer) in health care workers. METHODS: At one hospital, health care workers received the vaccination between February and May 2021. A survey using questionnaires and spike-specific IgG antibody tests (Abbott) was conducted in 293 participants who had been vaccinated at least once and consented to this study at the time of medical checkups between April and May 2021. We calculated the antibody titer in each age group and days post-vaccination. We examined whether antibody titers of 4,000 AU/mL or higher (probability of high titer: approximately 95%, Abbott) were associated with adverse reactions after vaccination. In addition (1), the antibody titers at approximately 100 days after the second vaccination in 11 participants were remeasured. Furthermore (2), the antibody titers at approximately 260 days after the second vaccination in 13 participants were remeasured and compared with the initial measurements. RESULTS: Of the participants, 276 were post-2 doses (A), 14 were post-1 dose (B), and 3 discontinued the second vaccination (C) at the time of health checkup. The median antibody titer was 11,045.8 AU/mL (50.7-40,000) in group A, 122.7 AU/mL (2.6-1,127.0) in group B, 27,099.3 AU/mL in one of group C who had recovered from coronavirus disease 2019 (COVID-19), and 574.2 AU/mL (283.3 and 865.1) in the other two of group C. The median antibody titer was the highest in those in their 20s, and there was a significant difference between those under and above 40 years of age. The median titer was the highest in 2 weeks to 1 month after the second vaccination. After the second dose, fatigue (≥ moderate) was associated with antibody titers of 4,000 AU/mL or higher. The antibody titers of 11 and 13 participants at approximately 100 and 260 days after the second vaccination were significantly lower than those at the first measurement, with median values of 2,838.0 AU/mL (832.9-5,698.6) and 512.0 AU/mL (154.0-1,220.0), respectively. CONCLUSIONS: Antibody titers were higher in participants under 40 years of age than those 40 years or older. In addition, the percentage of high antibody titer (≧ 4,000 AU/mL) was higher in those who had severe fatigue after the second vaccination. The peak of antibody titer after the second dose was approximately 1 month, and the titer may decline gradually.

[A Case Report of Triple Negative Breast Cancer Diagnosed as Granulomatous Mastitis].

Granulomatous mastitis is a chronic inflammatory disease of unknown causes that forms a breast mass and may be difficult to distinguish from breast cancer on imaging studies. The patient was a woman in her 50's. Needle biopsy was performed for a mass in the upper outer quadrant of the right breast and revealed granulomatous mastitis. Breast magnetic resonance imaging showed that the tumor was malignant. Taking into account that there is a difference between histologic findings and imaging findings and that surgery after steroid therapy for granulomatous mastitis is more likely to cause complications, we decided to perform lumpectomy. The definitive pathological diagnosis was a triple negative, pT1cN0cM0 medullary carcinoma. Postoperative adjuvant chemotherapy was performed. The absence of axillary lymph-node metastasis was confirmed by right axillary sentinel lymph-node biopsy. Radiotherapy was performed on the preserved breast region. Even if granulomatous mastitis is diagnosed, biopsy should be repeated while paying attention to biopsy methods if there is a difference between pathological findings and image findings.

[A Case Report of Breast Cancer Followed Up as Intraductal Papilloma].

The patient was a 50-year-old woman. She had been diagnosed with bilateral breast tumors at another hospital 5 years previously and was followed up every 2 months. Ultrasonography showed hypoechoic masses in her breasts. The largest tumor in the right breast was 15mm in diameter and located in region A, while that in the left breast was 8mm in diameter and located in region B. Magnetic resonance imaging(MRI)showed multiple bilateral breast tumors. The largest tumor was 12mm in diameter and was suggestive of breast cancer. Core needle biopsies(CNB)of the largest tumors in both breasts were performed. Intraductal papilloma(IDP)and low-grade intraductal papillary carcinoma were diagnosed in the right and left breasts, respectively, on immunohistochemical staining. We performed left nipple-sparing mastectomy with sentinel lymph node biopsy and right tumor excision for diagnoses of carcinoma of the left breast(cTisN0M0)and IDP of the right breast. The histopathological diagnosis of the left breast tumor was pT1aN0M0, triple negative breast cancer with extensive intraductal components, and that of the right breast tumor was IDP with atypical ductal hyperplasia. Chemotherapy was administered postoperatively. Several studies have reported that peripheral IDP often coexists with or follows the development of carcinoma. Therefore, we should also closely follow-upthe patient's right breast.

[A Case Report of Ipsilateral Nipple Skin Recurrence].

We report our experience with a patient with breast cancer who showed recurrence in the nipple skin 5 years and 10 months after a breast-preserving surgery. The patient was a woman, and was 65-years old at the time of initial surgery. Breast-preserving surgery and axillary lymph-node dissection were performed for left breast cancer. Invasive ductal carcinoma of the breast(pT3N0M0)was triple-negative, and the patient postoperatively received adjuvant chemotherapy. Left breast pain developed 5 years and 6 months after surgery. Computed tomography showed no evidence of recurrence, and the symptoms resolved after treatment with non-steroidal anti-inflammatory drugs(NSAIDs). After 3 months, however, the left nipple had enlarged to about 1.5 cm, and the surrounding skin was red and painful. Treatment with NSAIDs was thus resumed. After 1 week, redness of the nipple skin and pain were improved. However, the nipple had enlarged to twice its normal size. Nipple skin biopsy was subsequently performed, and revealed adenocarcinoma invading the skin. Left axillary lymph-node metastasis was suspected, but there was no evidence of metastasis to other sites or recurrence. Conservative total mastectomy with axillary lymph-node dissection was thus performed. The histopathological diagnosis was the recurrence of invasive ductal carcinoma, arising mainly in the reticular layer of the dermis. Chemotherapy was administered postoperatively. There has been no evidence of recurrence as of 1 year after surgery.

[A case of spindle cell carcinoma of the breast].

The patient was a 53-year-old woman in whom ultrasonography of the breast revealed a lobular mass, 14 mm in diameter, in the right AB region. Spindle cells were obtained on fine-needle aspiration biopsy, but it was not possible to diagnose whether the tumor was benign or malignant. Contrast-enhanced magnetic resonance imaging showed a mass with a cystic component that was darkly stained in the early phase. Needle biopsy showed a dense proliferation of atypical spindle cells with no distinct epithelial-like arrangement. The differential diagnosis included mesenchymal malignant tumors such as fibrosarcoma, some phyllodes tumors, and epithelial tumors with sarcomatoid differentiation. Immunostaining revealed that the tumor was cytokeratin (AE1/AE3)-negative, partially CAM 5.2-positive, p63-positive, S100-negative, SMA-positive, partially vimentin-positive, with a Ki-67 index of 80% and negativity for ER, PgR, and HER2. Spindle-cell carcinoma was thus diagnosed. A partial right mastectomy with sentinel lymph-node biopsy was performed. Immunostaining of the resected specimen confirmed spindle cell carcinoma. The General Rules for Clinical and Pathological Recording of Breast Cancer classify spindle cell carcinoma as a special type of invasive cancer with a sarcomatoid structure, consisting of spindle-shaped cancer cells. This type of carcinoma is extremely rare, accounting for less than 1% of all breast cancers.

[Determination of treatment strategies for a 43-year-old single woman with Stage IV breast cancer].

The patient was a 43-year-old single woman. Her family history included schizophrenia in her mother and manic-depression in her father. Remicade® (infliximab) had been administered for 3 years to treat rheumatoid arthritis. The patient initially presented to our hospital with dyspnea. Computed tomography revealed left-sided breast cancer associated with multiple bone tumors and multiple pulmonary nodules. A poorly mobile mass with an ulcer was found in left breast. Core-needle biopsy and fluorescent in situ hybridization (FISH)revealed an invasive ductal carcinoma that was positive for estrogen and progesterone receptors and human epidermal growth factor receptor 2 (HER2, 2 +). The clinical diagnosis was Stage IV T4bN3M1 cancer (metastases to the lungs, liver, and bone). Because of the presence of bone metastasis, the patient was admitted and she received complete bed rest as supportive therapy. However, the patient decided to receive treatment on an outpatient basis after carefully discussing the following points: 1) treatment of pulmonary metastasis with dyspnea should receive priority; 2) anticancer agents not causing nausea were required; 3) the risk of bone fractures as a complication (spinal cord injury); 4) how she wanted to spend the limited time available with her family; and 5) how the patient wanted to.

[A case of acute appendicitis which occurred during chemotherapy for breast cancer].

The patient was a 66-year-old woman with left breast cancer who underwent left segmental mastectomy with sentinel lymph node biopsy. The histopathological diagnosis was estrogen receptor-positive (ER+), progesterone receptor-positive( PgR+), human epidermal growth factor receptor-2-equivocal( HER2()2+)( with no HER2 gene amplification by fluorescence in-situ hybridization analysis) invasive ductal carcinoma (scirrhous carcinoma) with Ki-67 expression of less than 10% (pathological T1c, N0, M0, stage I). The patient requested chemotherapy, and 4 cycles of docetaxel plus cyclophosphamide (TC) were scheduled. Fever and epigastric pain developed on day 13 of cycle 2. On day 22, the patient was examined before the third cycle of TC, and right lower abdominal pain was reported. Computed tomography revealed appendicitis and an intraperitoneal abscess. She was admitted to the hospital and underwent partial ileocecal resection. The patient was discharged on the 12th postoperative day with no further complications. Acute abdomen during chemotherapy for malignant tumors has been reported sporadically in patients with leukemia. A diagnosis of acute abdomen in patients undergoing cancer treatment requires careful assessment of gastrointestinal symptoms such as nausea and vomiting during chemotherapy, fever associated with granulocytopenia, and findings indicative of local inflammation. The patient in this case recovered uneventfully because imaging studies and surgery were performed promptly after presentation.

[A patient with thyroid cancer evaluated according to Response Evaluation Criteria in Solid Tumors during treatment for breast cancer recurrence in hepatic and cervical lymph nodes].

We describe a case of a 69-year-old woman who underwent left breast-preserving surgery and axillary dissection for left-sided breast cancer at 60 years of age. The histopathological diagnosis was papillotubular carcinoma, luminal A (pathological T1N0M0).In the eighth year after surgery, computed tomography (CT) revealed recurrence in the liver and cervical lymph node metastasis. The patient did not respond to 3 months of treatment with letrozole (progressive disease [PD]). Six courses of chemotherapy with epirubicin and cyclophosphamide (EC) were administered. Subsequently, the attending physician was replaced while the patient was receiving paclitaxel( PTX).After 4 courses of treatment with PTX, the liver metastasis disappeared (complete response [CR]).However, the cervical lymph nodes did not shrink (PD).The cytological diagnosis was papillary thyroid cancer with associated cervical lymph node metastasis. Total thyroidectomy and D3b cervical lymph node dissection were performed. The pathological diagnosis was pEx0T1bN1Mx, pStage IVA disease. Replacement of the attending physician is a critical turning point for patients. During chemotherapy or hormone therapy for breast cancer, each organ should be evaluated according to Response Evaluation Criteria in Solid Tumors (RECIST).In the case of our patient, thyroid cancer was diagnosed according to RECIST. Cancer specialists should bear in mind that the treatment policy may change dramatically depending on the results of RECIST assessment.

[A case of diabetic mastopathy which was difficult to diagnose].

The patient was a 73-year-old woman with diabetes mellitus who was receiving insulin therapy. A poorly demarcated mass of 2 cm in diameter was palpated in the C region of the left breast. Mammography showed a dense locally asymmetric shadow. Ultrasonography revealed an irregular, poorly demarcated, hypoechoic mass measuring 14×21×10 mm accompanied by an attenuated posterior echo. Needle biopsy showed no evidence of malignancy, and the patient was kept under observation. An ultrasonographic examination performed 6 months later showed no change, but the possibility of cancer could not be ruled out on contrast-enhanced computed tomography and magnetic resonance imaging. Tumor resection at the patient's request was therefore performed. Histopathological examination of the breast revealed interstitial fibrosis with superimposed ground-glass opacities and lymphocyte infiltration around the ducts, leading to a diagnosis of diabetic mastopathy. Diabetic mastopathy occurs primarily in patients with a prolonged history of diabetes mellitus. It is difficult to distinguish diabetic mastopathy from breast cancer by palpation and imaging studies. Most cases are conclusively diagnosed by needle biopsy. Clinicians should be aware of diabetic mastopathy to avoid overdiagnosis and overtreatment. In our patient, diabetic mastopathy could be diagnosed on the basis of clinical characteristics and needle biopsy.