Sarcoid-like reaction in a HER2-positive breast cancer patient: A case report.

INTRODUCTION AND IMPORTANCE: Sarcoid-like reaction is a systemic granulomatous reaction that may develop in the lymph nodes and organs of cancer patients. Distinguishing a sarcoid-like reaction from metastasis is difficult. Accurate diagnosis of this reaction is key to preventing overtreatment. CASE PRESENTATION: A 51-year-old woman presented with a lump in her left breast and swollen lymph nodes in her left axilla and infraclavicular fossa. A core biopsy was performed, leading to the diagnosis of grade 2 infiltrating ductal carcinoma, clinical stage T2N3M0 with estrogen and progesterone receptor negativity and human epidermal growth factor receptor-2 positivity. After neoadjuvant therapy, the tumor in her left breast reduced in size, but the lymph nodes remained swollen. Mastectomy and axillary lymph node dissections were performed. In the pathological findings, epithelioid cell granuloma was observed in the lymph nodes. Based on these findings, lymph node swelling was attributed to a sarcoid-like reaction. CLINICAL DISCUSSION: SLRs have been reported in 4-14% of cancer patients. Although there are various imaging modalities for detecting swollen lymph nodes, the differential diagnosis of cancer metastasis is often difficult. CONCLUSION: Histological evaluation of swollen lymph nodes is required to prevent overtreatment; especially in cases where the tumor size is reduced by chemotherapy, but the lymph nodes remain swollen.

How pregnancy and childbirth affect the working conditions and careers of women surgeons in Japan: findings of a nationwide survey conducted by the Japan Surgical Society.

PURPOSE: To identify the conflicts between a career as a surgeon and pregnancy and childbirth for women in Japan. METHODS: The Japan Surgical Society conducted a nationwide survey on pregnancy and childbirth among its members who are women. The questionnaire included items regarding demography, working styles, and pregnancy and childbirth, including adverse events and harassment. RESULTS: The response rate was 29.9% (1068 responses, median age, 37 years). Among the responders, 61% were married and 47% had children (average number of children, 1.7). Half of the respondents reported having experienced sexual harassment and 62% reported having received unwelcome comments about pregnancy. About 20% had undergone fertility treatment. In total, 51% had pregnancies, with miscarriages in 33% of these. The top answer for the best timing for pregnancy and childbirth was after becoming board-certified. Nearly one-third of first-time mothers experienced adverse events during pregnancy and delivery, and 28% quit or changed their job because of their pregnancy and the birth of their first child. CONCLUSIONS: Japanese women who choose a career as a surgeon face obstacles during pregnancy and childbirth. It is vital to share the findings of this study and understand the issues associated with pregnancy and childbirth regardless of gender. Interventions are essential to ensure that every pregnant surgeon has a safe working environment to allow unobstructed development of her career.

Sentinel lymph node biopsy of primary apocrine sweat gland carcinoma of the axilla: A case report and review of the literature.

INTRODUCTION: Primary apocrine sweat gland carcinoma (PASGC) is a rare subtype of sweat gland carcinoma, mostly occurring in the apocrine-dense regions such as the axilla, areola, and scalp. PRESENTATION OF CASE: An 83-year-old woman developed a red elevating mass on her left axilla, without palpable axillary lymph nodes. Excision biopsy revealed that the tumor was PASGC. Additional wide resection and sentinel lymph node biopsy (SLNB) were performed without any adjuvant therapy. One year after the surgical procedure, the patient did not show any evidence of recurrence and axillary surgical complications. DISCUSSION: As PASGC arising in the axilla can progress aggressively, differential diagnosis is essential. Previous reports have shown the usefulness of SLNB, but the axillary management for patients with clinically node negative PASGC has not been established because of its rarity. Especially in axillary cases, to identify the true sentinel lymph nodes is sometimes considered inaccurate because the lymphatic flow is complicated in the axilla. CONCLUSION: Although SLNB in sweat gland carcinoma has believed safety and been performed, this is the first axillary PASGC case that was performed SLNB. Careful follow-up is needed.

Current conditions and issues of physicians and working conditions at institutions accredited by the Japanese Breast Cancer Society.

BACKGROUND: In Japan, with the rapid increase of breast cancer patients, there has been increasing demand for breast cancer treatment. As the main workforce for breast cancer treatment, women physicians are thought to be in key positions, since the number of women physicians has recently been increasing. METHODS: To clarify the current statuses and issues of physicians and work conditions at the accredited breast cancer care facilities, a survey was conducted by the Japanese Breast Cancer Society (JBCS). RESULTS: The main workforces engaged in breast cancer care are surgeons, and the number of breast surgeons of all institutions in this survey was 1338 (full time 1124, part time 214). The percentages of women among surgeons, breast specialists accredited by the JBCS, and residents are 22%, 25%, and 38%, respectively. Among breast specialists, more women tended to work at university hospitals and cancer hospitals. Twenty-eight percent of women were married and among those, 76% had at least one child. Many hospitals allow short working hours or exemption from in-house call for women surgeons during pregnancy and child-rearing. In contrast, half of the facilities apply a "single doctor-in-charge system", where the patient's primary physician has to be on-call every day. Many institutions convene conferences for breast cancer treatment planning before or after the scheduled working hours. CONCLUSIONS: Current systems for treatment of breast cancer should be improved so that all surgeons specializing in the breast can develop their career while maintaining their personal life.

Analysis of gender-based differences among surgeons in Japan: results of a survey conducted by the Japan Surgical Society. Part. 2: personal life.

PURPOSE: To assess the true conditions and perceptions of the personal lives of men and women working as surgeons in Japan. METHODS: In 2014, all e-mail subscribed members of the Japan Surgical Society (JSS, n = 29,861) were invited to complete a web-based survey. The questions covered demographic information, work environment, and personal life (including marital status, childcare, and nursing care for adult family members). RESULTS: In total, 6211 surgeons (5586 men and 625 women) returned the questionnaires, representing a response rate of 20.8%. Based on the questionnaire responses, surgeons generally prioritize work and spend most of their time at work, although women with children prioritize their family over work; men spend significantly fewer hours on domestic work/childcare than do their female counterparts (men 0.76 h/day vs. women 2.93 h/day, p < 0.01); and both men and women surgeons, regardless of their age or whether they have children, place more importance on the role of women in the family. CONCLUSIONS: The personal lives of Japanese surgeons differed significantly according to gender and whether they have children. The conservative idea that women should bear primary responsibility for the family still pertains for both men and women working as surgeons in Japan.

Analysis of gender-based differences among surgeons in Japan: results of a survey conducted by the Japan Surgical Society. Part 1: Working style.

PURPOSE: To assess the working styles of men and women working as surgeons in Japan. METHODS: In July, 2014, the Japan Surgical Society invited all their members (n = 29,861), through an internet campaign, to participate in a nationwide survey of surgeons. The items investigated in this descriptive study included demographic information and working styles, based on a questionnaire. RESULTS: In total, 6211 surgeons participated (response rate 20.8%, 5586 men and 625 women). The largest age stratum was 40-49 years for men and 30-39 years for women. Overall, respondents identified their labor contract, including salary and work hours, as the highest priority for improvement. Women with children were more likely to be part-time employees, work fewer hours, and take fewer house calls/on-calls than their male counterparts. Moreover, women of all ages earned a lower annual income than men, irrespective of whether they had children. Perception scores for discrimination related to work and promotion were significantly higher among women than men (p < 0.01 and p = 0.011, respectively). CONCLUSIONS: A significant difference in working style was observed between men and women working as surgeons in Japan.

Mentorship as Experienced by Women Surgeons in Japan.

BACKGROUND: Women have accounted for over 30% of new medical students since 1995 in Japan. Establishing support systems for women surgeons to continue their work is a major issue in Japan. Mentorship can be one of the most effective means to help women surgeons to continue their work. The purpose of this study was to clarify the current status of mentorship among Japanese women surgeons and to discuss the role of mentors for women surgeons. METHODS: Invitation letters were sent to all female members of the Japan Association of Women Surgeons in April 2011. An 84-item questionnaire survey was sent to those who agreed to participate in this study via the internet. RESULTS: Fifty-five surgeons participated in this study, a response rate of 48.7%. Sixty-seven percent of respondents found it difficult to continue in their job; 85% thought mentorship was necessary for women surgeons to progress in their careers; and 84% reported that they already had a mentor. Respondents thought that a mentor helped them to advance their clinical career, to stay in their job, and to provide moral support. However, mentors appeared to be less useful in helping them to advance their research career, to network, to increase their status, and to achieve a work-life balance. CONCLUSIONS: This study revealed areas where mentors appeared to be less helpful to women surgeons. The survey gave an indication of how to help improve and develop the career and personal life of women surgeons in Japan.

Factors that Can Promote or Impede the Advancement of Women as Leaders in Surgery: Results from an International Survey.

BACKGROUND: Compared with male surgeons, women have less success advancing their careers and are underrepresented in leadership positions in surgery. The purpose of this study is to identify the qualifications necessary to become leaders in surgery and the career barriers faced by women surgeons in various cultural environments. METHODS: A survey was performed with women surgeons in Japan, USA, Finland, and Hong Kong, China, to assess various barriers faced by women surgeons in the respective countries. To develop appropriate survey tool, a preliminary questionnaire was distributed to leaders in surgery and also in various organizations worldwide. RESULTS: The response rate was 23 % with 225 of 964 survey returned. Japanese women surgeons identify lacked family support as impeding a successful surgical career. US women surgeons feel more latent gender discrimination. Finnish women surgeons are less likely to need to sacrifice work-life balance, when holding leadership positions. Women surgeons worldwide are highly motivated to develop their career and agree the percentage of women surgeons in leadership positions should be increased. CONCLUSIONS: Women surgeons in different countries perceive different challenges. We must develop strategies and should not hesitate to negotiate to overcome these issues to reach leadership positions in surgery. This may be accomplished through networking worldwide to improve current conditions and obstacles.

The attitude and perceptions of work-life balance: a comparison among women surgeons in Japan, USA, and Hong Kong China.

BACKGROUND: The objective of the present study was to explore how women surgeons manage their work-life balance in three environmental and cultural settings. METHOD: Members of the Japan Association of Women Surgeons (JAWS), the United States of America (US) based Association of Women Surgeons (AWS), and the Women's Chapter of the College of Surgeons of Hong Kong (WCHK) were surveyed. RESULTS: Among 822 women surgeons contacted, 252 responded (response rate 31.8 %; 55.5 % JAWS, 28.2 % AWS, and 25.3 % WCHK). Japanese women surgeons think that work is the number one priority, whereas US and Hong Kong China (HK) respondents think the number one priority is home life. Work satisfaction level was generally high among women surgeons in all countries; however, 19 % of US surgeons are somewhat dissatisfied with their work and 76.1 % think that men are treated more favorably than women at work. Whereas 51.6 % of Japanese women surgeons think that men are treated more favorably than women at home, at the same time they placed more importance on the role of women in the family. More than half of Japanese women surgeons are "uncertain" about their career path in the future, whereas 55.2/87.1 % of US/HK respondents are optimistic. All surgeons recommended expanding support for child rearing or nursing care during work hours, promoting a flexible work schedule and changing some of the older conventional ideas about gender role. CONCLUSIONS: It is essential to address women surgeons' concerns to enable them to have a clearer vision and a challenging career, and to be more certain about their personal and professional goals.

Possible clinical cure of metastatic breast cancer: lessons from our 30-year experience with oligometastatic breast cancer patients and literature review.

BACKGROUND: Metastatic breast cancer (MBC) is generally incurable. However, 10-20-year relapse-free survival of MBC is approximately 2%, implying that at least a small subset of MBC patients achieve prolonged survival. We therefore analyzed long-term outcome in a particular subset, i.e., oligometastatic breast cancer (OMBC). METHODS: Data of OMBC subjects (N = 75) treated in our institution from April 1980 to March 2010 were retrospectively analyzed. OMBC was identified as: one or 2 organs involved with metastatic lesions (excluding the primary lesion resectable by surgery), fewer than 5 lesions per metastasized organ, and lesion diameter less than 5 cm. Patients were generally treated with systemic chemotherapy first, and those who achieved complete response (CR) or partial response (PR) were further treated, if applicable, with local therapy (surgical or radiation therapy) to maintain CR or to induce no evidence of clinical disease (NED), with additional systemic therapy. RESULTS: Median follow-up duration was 103 (6-329) months. Single or 2 organs were involved in, respectively, 44 (59%) and 31 (41%) cases with metastatic lesions, 48% of which were visceral. In cases where effects of systemic therapy, possibly in combination with other treatments, were evaluated (N = 68), CR or PR was achieved in 33 (48.5%) or 32 (47.1%), respectively, with overall response rate (ORR: CR + PR) of 95.6% (N = 65). In cases receiving multidisciplinary treatment (N = 75), CR or NED (CR/NED), or PR was induced in 48 (64.0%) or 23 (30.7%) cases, respectively, with ORR (CR/NED + PR) of 94.7% (N = 71). CR rates (60.5%) with systemic therapy and CR/NED rates (79.5%) with multidisciplinary treatment were significantly better in subjects with a single involved organ than in those with two involved organs (P = 0.047 and 0.002, systemic only or multidisciplinary treatments, respectively). Medians estimated by Kaplan-Meier method were: overall survival (OS) of 185.0 months and relapse-free interval (RFI) of 48.0 months. Estimated outcomes were: OS rates (OSR) of 59.2% at 10 years and 34.1% at 20 years, and relapse-free rates (RFR) of 27.4% at 10 years and 20 years. No disease progression was observed after 101.0 months as RFR. Cases with single organ involvement (N = 44) showed significantly better outcomes (OSR of 73% at 10 years and 52% at 20 years, RFR of 42% at 10 years and 20 years). Those who received local therapies (N = 35) also showed better prognosis: OSR of 82% at 10 years and 53% at 20 years, RFR of 38% at 10 years and 20 years. Three cases (4%) survived for their lifetime without relapse after achieving CR or NED, our definition of clinical cure. Multivariate analysis revealed factors favoring better prognosis as: none for OS, and single organ involvement with metastasis, administration of local treatment, and shorter disease-free interval (DFI) (P = 0.030, 0.039, and 0.042, respectively) for RFR. Outcomes in OMBC in literature were OSR of 35-73% at 10 years and 26-52% at 20 years, and RFR of 27-42% at 10 years and 26-42% at 20 years. CONCLUSIONS: The present analyses clearly indicate that OMBC is a distinct subgroup with long-term prognosis superior to MBC, with reasonable provability for clinical cure. Further prospective studies to better characterize OMBC are warranted to improve prognosis in MBC.

Impact of CD44+CD24- cells on non-sentinel axillary lymph node metastases in sentinel node-positive breast cancer.

Although complete axillary lymph node dissection (ALND) is the standard for evaluating axillary status after the identification of a positive sentinel lymph node (SLN) in breast cancer; approximately 40-60% of SLN-positive patients have negative non-SLN. In this study, to explore putative breast cancer stem cells with CD44+CD24- in the SLN, we retrospectively analyzed the expression of CD44+CD24- on metastatic tumor cells within SLNs as a predictive factor for positive non-SLNs (NSLNs). We tested 271 patients for SLNs using serial sectioning with cytokeratin immunohistochemistry (IHC) and hematoxylin-eosin staining and identified 67 patients who had a positive SLN biopsy and complete ALND. CD44 and CD24 expression was detected using double-staining IHC. Twenty-eight (41.8%) out of 67 patients had positive NSLN metastases. Seven positive SLNs with micrometastases were not available for the evaluation of CD24 and CD44 expression. Out of the remaining 60 patients, 19 (31.7%), 44 (73.83%) and 37 (61.7%) patients had CD24+, CD44+ and CD44+CD24- metastatic tumor cells in SLNs, respectively. Positive NSLN metastasis was significantly associated with the primary tumor size (P=0.004), CD24- expression (P=0.04), CD44+ expression (P=0.01) and CD44+CD24- expression (P=0.02). This report provides the first evidence of the existence of a putative stem-like phenotype within the SLN, which is significantly associated with positive NSLN in early breast cancer patients.