[A case of HER2-positive breast cancer for which preoperative chemotherapy with pertuzumab resulted in a pathological complete response].

A right breast tumor was identified during screening in a 56-year-old woman, and she was then diagnosed with Stage II B breast cancer (T2N1M0) of Luminal -HER2 type. She was treated with preoperative chemotherapy with pertuzumab, trastuzumab, and docetaxel followed by epirubicin, cyclophosphamide, and fluorouracil. She was judged to have achieved a clinical complete response after 4 courses of pertuzumab, trastuzumab, and docetaxel, and she then underwent partial resection of the right breast and sentinel lymph node dissection. Pathological examination revealed that a pathological complete response was achieved. Combination therapy with pertuzumab, trastuzumab, and docetaxel seems to be a useful preoperative chemotherapy regimen for HER2-positive breast cancer.

Umbilical metastasis derived from breast cancer: report of a case.

Umbilical metastases mainly arise from malignancies of the digestive and gynecological systems, but rarely from breast cancer. A 64-year-old woman with a history of breast cancer was referred to us for investigation of a painful lesion in the umbilicus. Immunohistochemical staining of a specimen obtained by biopsy from the nodule showed umbilical metastasis of breast cancer. After a work up, she was successfully treated with a combination of surgery and endocrine therapy. We report this case to reinforce that not all periumbilical tumoral deposits are consistent.

[Evaluation of breath alcohol concentration after the administration of alcohol-based docetaxel].

In the present study, we measured breath alcohol concentration(BAC)after the administration of alcohol-containing docetaxel(OTX)in breast cancer patients, and examined the safety of OTX outpatient administration. Twenty breast cancer patients who received OTX chemotherapy at our outpatient facility were included. The administered doses were 100mg/m2 in 5 cases, 75mg/m / 2 in 13 cases, and 60 mg/m2 in 2 cases. BAC was measured 3 times: immediately after infusion, 30 minutes after infusion, and 60 minutes after infusion. No symptoms of hot flash or drunkenness due to alcohol were observed. BAC was detected in 10 cases(50%)immediately after infusion, in 7 cases(35%)at 30 minutes after infusion, and in 1 case(5%) at 60 minutes after infusion. BAC was more than 0.15mg/L in only 1 case(5%)and reduced to less than 0.15mg/L in all cases after 30 minutes. Our results suggest that the effects of alcohol are alleviated 60 minutes after infusion and that patients receiving OTX could return home safely.

Safety assessment of intravenous administration of trastuzumab in 100ml saline for the treatment of HER2- positive breast cancer patients.

BACKGROUND: The infusion rate is considered to affect incidence and severity of infusion reactions (IRs) caused by protein formulations. Trastuzumab (TRS) is approved for 90-minute infusion as the initial dose followed by 30-minute infusion with 250 ml saline. In the study, we evaluated the safety of TRS intravenously administered over 30 minutes with 100 ml saline to reduce burden of patients, safety of infusion with 250 ml saline already being established. MATERIALS AND METHODS: Women with HER2 positive breast cancer, ≥18 years and ≥55% left ventricular ejection fraction (LVEF), were registered in the study. Patients received 8mg/kg of TRS 250 ml over 90 minutes followed by 6mg/kg of TRS 100ml over 30 minutes in a three-week cycle. RESULTS: A total of 31 patients were recruited, 24 for adjuvant therapy and seven with metastases. The median age was 59 years (range 39 to 82). The total number of TRS doses ranged from 5 to 17 with the median of 15. Mild IR occurred in two patients at the first dose. However, no IR was observed after reducing to 100 ml saline. No decrease of LVEF, increase of serum brain natriuretic peptide or any other adverse events were reported. CONCLUSIONS: Intravenous infusion of TRS with 100 ml saline over 30 minutes in breast cancer patients can be considered safe based on results from the study. It can be given on an outpatient basis as with the currently recommended dilution in 250 ml saline.

[Three-day-type transdermal fentanyl patch conversion by rapid titration method with short-acting oral oxycodone for cancer pain].

This study compared the efficacy and safety of a 3-day-type transdermal fentanyl patch conversion by the rapid titration method to short-acting oral oxycodone for cancer pain.We evaluated seven hospitalized cancer patients who had moderate to severe cancer pain.Pain intensity was rated using an 11-point(0-10)numerical rating scale(NRS).All 7 patients initially reported their pain intensity at rest as NRS≥4 during treatment by Non-Steroidal Anti-Inflammatory Drugs(NSAIDs).Short - acting oral oxycodone(OxiNorm®)5 mg was administered to all patients.One hour after short-acting oral oxycodone was administered, pain assessment was carried out using NRS by the author.Short -acting oral oxycodone was administered four times a day periodically, and as a rescue dose.If the total daily dose of short-acting oral oxycodone was stable for 2 days, we switched to the 3-day-type transdermal fentanyl patch.The optimal dosage of the 3-day-type transdermal fentanyl patch was determined by titration of short-acting oral oxycodone.All 7 patients reported mild levels(NRS≤2)of cancer pain for 2 days.No serious side effects were reported.The 3-day-type transdermal fentanyl patch conversion by the rapid titration method with short-acting oral oxycodone can be accomplished safely and effectively for patients with moderate cancer pain.

[A case of late recurrence of urothelial carcinoma in an ileal conduit after radical cystectomy and ileal conduit diversion for bladder cancer].

Recurrence of urothelial cancer in an ileal conduit after radical cystectomy is rare. A 79-year-old man suffered bladder cancer (UC cTisN0M0 G2＞3) and underwent total cystectomy with ileal conduit. He had recurrence of the right renal pelvis carcinoma 6 years after the total cystectomy, and was treated by right radical nephroureterectomy (pT3 G2＝3). The patient had another episode of recurrence in the ileal conduit 13 years after the initial operation. The entire ileal conduit (UC, G3, ew (-)) was resected and left cutaneous ureterostomy was performed. This case suggests that long-term follow-up is necessary after radical cystectomy and ileal conduit for urinary diversion.

[A case of Fournier's gangrene reconstructed using a rectus abdominis muscle flap].

We encountered a case of Fournier's gangrene complicated with vesicorectocutaneous fistula that was treated with a pedicled rectus abdominis muscle flap (pedicled RA m-c flap). A 75-year-old man was admitted with consciousness disorder and swelling of the scrotum. The patient had noticed swelling of the scrotum 4 days before admission, but he had ignored this condition. The scrotum and the penis appeared necrotic. On the basis of clinical and radiological findings, we diagnosed this condition as Fournier's gangrene. Surgical debridement was performed in conjunction with the use of broad-spectrum antibiotics. After the patient's general condition was improved, the broad defect in the perineal tissue was covered with a pedicled rectus abdominis muscle flap. The flap was successful. In Japan, this is the first case of Fournier's gangrene complicated with vesicorectocutaneous fistula that was treated with a pedicled RA m-c flap. In order to determine whether plastic surgery after debridement shortens the duration of hospitalization, we reviewed the cases of 120 patients with Fournier's gangrene in Japan. We conclude that plastic surgery after debridement does not shorten the duration of hospitalization, however, this procedures is very useful to deep and broad defects by Fournier's gangrene.

[A case of prednisolone therapy for radiation-induced hemorrhagic cystitis].

Hemorrhagic cystitis resulting from radiation to pelvic visceral malignant lesions often might be incurable and there have been no established definitive treatment. We experienced a case with severe radiation-induced hemorrhagic cystitis refractory to conventional therapy. The treatment with oral administration of prednisolone was performed and obtained a successful result. Gross hematuria disappeared in 2 weeks in this case. This experience suggested that oral administration of prednisolone could be considered the treatment for patients with radiation-induced hemorrhagic cystitis when usual treatments including transurethral electro-coagulation are unsuccessful.

[Clinical features of reversed halo sign in cryptogenic organizing pneumonia].

Reversed halo sign (RHS) is often seen in computed tomography (CT) scans of cryptogenic organizing pneumonia (COP). To investigate its clinical features, we retrospectively reviewed 30 cases of COP in 13 men and 17 women, whose age range 28 to 73, with a mean of 58.4 years. All diagnoses were made with transbronchial lung biopsy (TBLB), but it took an average of 24.8 days from the first visit until the diagnosis of COP. RHS was seen in 7 cases (23%) and multiple RHSs were seen in 3 cases. We treated 5 cases (71%) with steroids. Their CT images showed parenchymal abnormalities which started as nodular lesions, then enlarged, and then the central lesion changed into ground-glass opacities, until finally, RHS was formed. The presence of RHS does not necessarily indicate a marked difference in the clinical course of COP. In conclusion, in the present series RHS was a phase of the clinical course of COP, and was useful to diagnose COP.

[A case of extranodal NK/T-cell lymphoma, nasal type, with skin ulceration and multiple nodules in the lung].

We report a rare case of extranodal NK/T-cell lymphoma, nasal type, with skin ulceration and multiple nodules in the lung, and will compare this case with others in the literature. A 54-year-old man was troubled with flare and swelling of his right arm for one month. He was referred to our hospital because of subcutaneous nodules with ulceration on the right arm, fever, and general fatigue. Chest radiograph revealed multiple nodular shadows in both lungs. The patient was admitted for further evaluation. Chest computed tomography revealed multiple nodules in both lungs with ground-glass opacities around some of them. Some nodules seemed to be clustered in the right lower lobe. Biopsy specimens of subcutaneous nodules and transbronchial biopsy specimens of pulmonary tissue demonstrated only extensive necrosis. A VATS lung biopsy from the right S9 was then taken. Pathological and immunohistological findings suggested a diagnosis of extranodal NK/T-cell lymphoma, nasal type (WHO classification), stage IVB. The patient was transferred to the department of hematology in another hospital for systemic chemotherapy, but died 2 months later.

[A case of hypersensitivity pneumonitis resulting from inhalation of Aspergillus niger in a greenhouse worker who raised roses].

A 57-year-old woman was referred because of exertional dyspnea, fever, and cough in June 2006. She had been employed to culture roses in greenhouses since 1991 and had developed a cough during the summer from 2003. Chest CT scan revealed diffuse centrilobular micronodules. Transbronchial lung biopsy specimens demonstrated alveolitis with lymphocytes and non-necrotizing epithelioid cell granulomas. After admission, both the patient's symptoms and laboratory data improved without medication. However, upon her return to work in the greenhouse, cough and exertional dyspnea reappeared. Aspergillus niger was detected in the greenhouse. Her serum was assayed for precipitating antibodies against various antigens, and precipitating antibodies against Aspergillus fumigatus, Aspergillus flavus, Aspergillus glaucus, and Aspergillus niger were demonstrated. In a double immunodiffusion test, cross-reactivity between Aspergillus niger and other Aspergillus species was indicated. Consequently, she was diagnosed as having hypersensitivity pneumonitis resulting from the inhalation of Aspergillus niger.

[A case of sarcoidosis with pleural involvement but with no mediastinal or hilar lymph node enlargement].

A 66-year-old woman was referred to our hospital because of right chest pain on inspiration. Chest X-ray film revealed diffuse opacities, predominantly in the lower lung field, and right pleural thickening. Serum ACE and lysozyme levels were elevated. Chest CT revealed diffuse ground-glass opacity, centrilobular granular nodules, bronchovascular bundle irregular thickening and right pleural irregular thickening over the right inferior lobe, but bilateral hilar lymph node enlargement was not present. Bronchoalveolar lavage (BAL) fluid demonstrated increased numbers of total cells and CD4 T-helper lymphocytes. The transbronchial lung biopsy specimen revealed non-caseating epithelioid cell granulomas. From these findings, we established a diagnosis of type III sarcoidosis with pleural involvement. The patient has been observed without treatment, and 10 months later the lung involvement and pleural thickening have disappeared.

[An autopsy case of invasive thymoma extending to the right atrium with superior vena cava syndrome as the initial manifestation].

We report a case of invasive thymoma presenting with superior vena caval obstruction and intracardiac extension. A 74-year-old man was admitted in July 2002 with swelling of the face and right upper extremity. Computed tomography of the chest revealed a small anterior mediastinal mass, which infiltrated the lumen of the superior vena cava extending into the right atrium. Invasive thymoma was strongly suspected, but he refused any medical treatment. His health declined steadily, with repeated right-sided heart failure. He died due to cardiac tamponade 50 months after his first visit. On autopsy, the tumor was diagnosed as a thymoma classified as type B3 according to the WHO histological classification. Formation of a tumor thrombus in the superior vena cava and the right atrium is a rare mode of extension of thymoma. In this respect, our case may be valuable for improving the understanding of the natural course of invasive thymoma.

Multiple thoracoabdominal gunshot wounds with complicated trajectories.

A 41-year-old man was shot three times with a custom-made handgun. There were six small round wounds on the surface from two bullets that went into the body and one bullet found in a wall behind the victim at the scene. The gunshot wound in the left supraclavicular region bled massively. He was transferred to our hospital and soon fell into shock. A chest radiogram showed right hemothorax. Resuscitation and blood transfusion were started, and right thoracic drainage was immediately undertaken. The left subclavicular region was incised, and bleeding from the left subclavian vein stopped. Right thoracotomy was done, and bleeding from the lung was controlled. Laparotomy was needed to look for the missing trajectory. Speculation regarding trajectories of bullets in patients with multiple thoracoabdominal gunshot wounds is difficult, and an emergent operation is often needed to control bleeding or to evaluate possible organ injury.

Correlation between low platelet count and multicentricity of hepatocellular carcinoma in patients with chronic hepatitis C.

We investigated correlations between laboratory test results and multicentric development of hepatitis C virus (HCV)-related hepatocellular carcinoma (HCC) in 202 patients who underwent liver resection. Two types of HCC were considered to meet multicentricity criteria: in one, at least one tumor was well-differentiated, with at least one other being less differentiated; in the other, all tumors included well-differentiated HCC with or without less differentiated components. Forty-five patients had multicentric HCC. Platelet counts were lower in patients with multicentric HCC than in others. Serum concentrations of type IV collagen 7s domain and alpha-fetoprotein, histologic hepatitis activity score, and histologic hepatic fibrosis score were higher in patients with multicentric HCC. By multiple logistic regression analysis, low platelet count was an independent risk factor for multicentric HCC. The proportion of patients with multicentric HCC was significantly higher among patients with low platelet counts (below 10(5)/mm(3)) than in patients with a higher count. Thus, HCC patients with a platelet count below 10(5)/mm(3) may require particularly careful examination for multicentricity.

Bile leakage after living donor liver transplantation demonstrated with hepatobiliary scan using 9mTc-PMT.

Although it is recognized that hepatobiliary scan is of value in assessing postoperative complications of biliary surgery or cadaveric whole liver transplantation, there have been few reports regarding its usefulness following living donor liver transplantation. We performed living donor liver transplantation in a patient with biliary cirrhosis due to hepatolithiasis, using a right lobe graft from her sister. On the 15th postoperative day, bile discharge appeared from the operative wound. The leakage point could not be identified by computed tomography and cholangiography from the biliary drainage catheter. Hepatobiliary scan with Tc-99m Sn-N-pyridoxyl-5-methyltryptophan (99mTc-PMT) demonstrated biliary extravasation from the left side of the anastomosis of the hepatico-jejunostomy, indicating biliary leakage from the anastomosis. Conservative therapy was continued because the radioisotope flowed smoothly into the reconstructed jejunum and the biliary drainage catheter, and the leakage was stopped on the 63th postoperative day. Hepatobiliary scan is useful in determining the therapeutic plan as well as detection of bile leakage and identification of leakage points after living donor liver transplantation.