The involvement of axillary reverse mapping nodes in patients with clinically node-negative breast cancer.

BACKGROUND: Axillary reverse mapping (ARM) was developed to preserve the lymphatic drainage from the upper arm during sentinel lymph-node (SLN) biopsy or axillary lymph-node dissection (ALND). However, the oncological safety of ARM has been controversial because of not infrequent involvement of ARM nodes. METHODS: Patients with clinically negative nodes (cN0) underwent SLN biopsy and ARM. SLNs were identified using blue dye and radioisotope, and ARM nodes were traced using the fluorescent method. Patients with positive SLN underwent the standard ALND. After surgery, they were followed up for more than 3 years. RESULTS: A total of 507 patients with cN0 breast cancer were enrolled between May 2009 and November 2017. SLNs were identified in 499 (98%) of 507 patients, and ARM nodes were identified in 159 (31%) patients in the SLN field. The crossover rate of SLN-ARM nodes was 28%. Among 95 patients with positive SLNs, 70 patients underwent conventional ALND. ARM nodes were identified in 65 (93%) of those patients in the ALND field. The mean number of removed ARM nodes was 7.2 (range 0-25) in patients who underwent the standard ALND. Although ARM nodes were involved in 18 of 65 patients, the involved ARM nodes were the same SLNs identified in 14 (78%) patients. Since SLN-ARM nodes should be removed, ARM nodes were involved only in 4 (5.7%) patients after SLN biopsy. CONCLUSIONS: Except for positive SLN-ARM nodes, the involvement of ARM nodes is infrequent in patients with positive SLN.

Feasibility study of axillary reverse mapping for patients with clinically node-negative breast cancer.

BACKGROUND: The axillary reverse mapping (ARM) procedure was developed to identify and preserve arm lymphatic drainage during axillary lymph node dissection (ALND), thereby theoretically reducing the incidence of arm lymphedema. However, the oncological safety of this procedure has not yet been determined. METHODS: Two hundred ninety-two patients with clinically negative nodes (cN0) underwent both sentinel lymph node (SLN) biopsy and ARM. SLN was identified by dye and gamma probe methods, and ARM nodes were identified using a fluorescence imaging system. If SLN was histologically positive, ALND was performed with removal of ARM nodes. Otherwise, identified ARM nodes were preserved unless they coincided with SLN. Postoperatively, SLN as well as ARM nodes were histologically examined with H&E staining. RESULTS: SLN was identified in 286 of 292 patients, and ARM nodes were identified in 90 patients. In 54 patients with positive SLN, SLN was the same as the ARM node in 19 patients (the concordance type), whereas it was not an ARM node in the remaining 35 patients (the separate type). Non-SLN and ARM node was not involved in 51 of 54 patients with positive SLN, while it was involved in 3 patients of the concordance type. CONCLUSIONS: When ARM nodes were involved in patients with cN0, these were most often the SLN-ARM nodes. Therefore, it may be concluded that ARM nodes that do not coincide with SLNs might be preserved during ALND in SLN-positive patients.

Oncoplastic breast conserving surgery: Volume replacement vs. volume displacement.

Oncoplastic breast conserving surgery (BCS) has emerged as a third option between conventional BCS and mastectomy. Oncoplastic BCS includes two fundamentally different approaches: volume replacement and volume displacement. The former involves partial mastectomy and immediate reconstruction of the breast with the transposition of autologous tissue from elsewhere, while the latter involves partial mastectomy and using the remaining breast tissue to fill the defect resulting from extirpation of the tumor. There are several benefits associated with oncoplastic BCS. First, it allows partial mastectomy without cosmetic penalties, and can achieve better cosmetic outcomes than total mastectomy with immediate breast reconstruction. Second, it avoids the need for total mastectomy in an increasing number of patients without compromising local control. Third, partial breast reconstruction is less extensive and has fewer complications than conventional procedures. Partial mastectomy and partial breast reconstruction can be carried out either simultaneously as a one-stage procedure, or using a two-stage approach. Although patients prefer a one-stage procedure, it requires intraoperative confirmation of complete tumor excision using frozen-section analysis. Moreover, oncoplastic BCS requires combined skills, knowledge, and understanding of both oncological and plastic surgeries, which may be optimally achieved by an oncoplastic surgeon.

Is axillary reverse mapping feasible in breast cancer patients?

In the surgical treatment of breast cancer, axillary lymph node dissection (ALND) can be avoided not only in sentinel lymph node (SLN)-negative patients but also in SLN-positive patients who undergo breast-conserving surgery with whole-breast irradiation and systemic therapy. However, it should be performed not only in clinically node-positive patients but also in other SLN-positive patients who do not meet the Z-0011 criteria. The axillary reverse mapping (ARM) technique has been developing for identifying and preserving lymphatic drainage from the arm during ALND, thereby expected to minimize arm lymphedema. Nevertheless, ARM nodes could be involved not only in clinically node-positive patients but also in clinically node-negative patients. Previously, it was considered that preservation of the ARM lymphatics or lymph nodes is not oncologically safe in patients with axillary lymph node metastases. However, recent studies have demonstrated that the ARM procedure is oncologically feasible in clinically node-negative, SLN-positive patients when ARM nodes do not coincide with SLNs. When ARM nodes do not coincide with SLNs, they are not involved even in SLN-positive patients. On the other hand, ARM lymphatics/nodes within the boundaries of a standard ALND should be resected in SLN-positive patients, when ARM nodes are SLN-ARM nodes. Therefore, surgical treatment of the axilla can be individualized on the basis of the axillary nodal status.

Risk of developing ovarian cancer among women with ovarian endometrioma: a cohort study in Shizuoka, Japan.

Although some studies have indicated that endometriosis may increase the risk of developing ovarian cancer, there are no data from epidemiologic studies in Japan. We prospectively analyzed all cases of ovarian endometrioma enrolled in the prefecture-wide Shizuoka Cohort Study on Endometriosis and Ovarian Cancer Programme, which was initiated in 1985. To evaluate the risk of ovarian cancer by time periods subsequent to ovarian endometrioma diagnosis, a cohort of 6,398 women with a clinically documented ovarian endometrioma in Shizuoka between 1985 and 1995 was identified from the Shizuoka Cancer Registry (SCR), with follow-up through 2002. Ovarian cancer incidence among cohort members was ascertained by linkage to the SCR using a unique person-identification number. Standardized incidence ratios (SIR) and their 95% confidence intervals (CI) were computed by a use of prefecture-wide rates of ovarian cancer, adjusted for age and calendar year. During follow-up of up to 17 years of the ovarian endometrioma cohort, 46 incident ovarian cancers were identified, yielding that the ovarian cancer risk was elevated significantly among patients with ovarian endometrioma (SIR = 8.95, 95% CI = 4.12-15.3). The SIR did not increase with increasing follow-up duration. The risk increased with increasing age at ovarian endometrioma diagnosis, with a SIR equal to 13.2 (95% CI = 6.90-20.9) in women above 50 years of age. Our findings for the first time support the hypothesis that ovarian endometrioma increases the subsequent risk of developing ovarian cancer in Shizuoka, Japan.

Telling the diagnosis to cancer patients in Japan: attitude and perception of patients, physicians and nurses.

The aim of this study was to clarify patients', physicians', and nurses' perceptions with regard to the communication of diagnosis to cancer patients in Japan. Sixty-three cancer patients, 35 physicians and 21 nurses were enrolled for this study: 54 of the patients wished to be informed of the diagnosis, of whom 34 had actually been told that they had cancer. Physicians did not tell the truth to the remaining 20 patients, of whom seven were not told the diagnosis because family members objected. Twenty-one of the 35 physicians thought that telling the true diagnosis had a positive effect and 27 thought that disclosure of the diagnosis to cancer patients should be promoted. Sixteen of the 21 nurses did not experience any difficulties with patient care after the diagnosis was disclosed. The present study suggests that medical staff and family members should respect the patient's standpoint because patients have the right to know about their own condition. Physicians should first provide the details of the disease to their patients. Thereafter, family members should be informed, but only with the patient's consent.

Jumping translocation of homogeneously staining region and tetraploidy with double minutes in acute myelomonocytic leukemia.

We report a 71-year-old patient with acute myelomonocytic leukemia (AMMoL) who had complicated chromosomal abnormalities showing diploidy with a jumping translocation of a homogeneously staining region (hsr) and tetraploidy with double minutes (dmin). The analysis of gene amplification showed that hsr and dmin were the results of C-ETS 1 gene amplification. After induction chemotherapy, tetraploidy with dmin completely disappeared, while diploidy with hsr and del(11)(q23) remained until the patient died. It is speculated that hsr is more stable than dmin during chemotherapy and that the presence of tetraploidy is not necessarily a factor of poor response to chemotherapy for acute leukemia.

Elimination of adult T cell leukemia cells by ultrasound in the presence of porfimer sodium.

Sonodynamic effects using porfimer sodium (Photofrin; Pf) on leukemic and normal cells were evaluated. The purpose of this experiment was to compare cell survival among MT-2 cells, normal peripheral mononuclear cells (PMNCs) and adult T cell leukemia (ATL) patients' PMNCs after sonodynamic treatment. Cells were exposed to 450 kHz ultrasound at an intensity of 500 mW/cm2. The survival rate of MT-2 cells exposed to ultrasound alone for 80 s was 20.1 +/- 4.8%, whereas survival rates exposed to ultrasound in combination with 25, 50 and 100 microg/ml of Pf resulted in 11.5 +/- 2.9, 3.2 +/- 1.6 and 1.6 +/- 1.4%, respectively. There was a significant difference of cell survival between the group exposed to ultrasound alone and the Pf-combined groups (n = 6, p < 0.05). On the other hand, in the normal human PMNCs, no significant differences of cell survival rates were found between ultrasound-treated groups with and without Pf. We similarly examined the survival rate of PMNCs in the peripheral blood of five acute-type ATL patients (n = 5) after ultrasound (60 s, 300 mW/cm2) exposure with or without 100 microg/ml of Pf. Comparison of cell survival rate between ultrasound alone and ultrasound plus Pf showed significant differences (69.4 +/- 22.5 and 30.0 +/- 23.0%, respectively). There were no significant cytotoxicities in all Pf alone treated groups of the MT-2 cells, the normal PMNCs and the ATL patients' PMNCs (p < 0.05). It was suggested from this study that there was a specific selectivity of sonodynamic effects to MT-2 cell lines and ATL patients' PMNCs. It is anticipated that this new method of treatment, i.e. sonodynamic therapy, could be used for extracorporeal blood treatment of acute-type ATL patients.

[Comparison between monotherapy with imipenem/cilastatin sodium (IPM/CS) and combinations of IPM/CS and other drugs for treating bacterial infections in patients with hematopoietic disorders].

One hundred and nine patients with infections concurrent with hematopoietic disorders were treated with imipenem/cilastatin sodium (IPM/CS) either alone (IPM/CS monotherapy) or in combination with other antimicrobial drugs (IPM/CS combination therapy). The following results were obtained. 1. One hundred and nine patients were allocated at random to two groups: 53 patients to IPM/CS monotherapy and 56 patients to IPM/CS combination therapy. Fourteen patients (6 and 8 in the 2 groups, respectively) were excluded from the clinical evaluation. There were not significant differences between the two groups with respect to the background. 2. The efficacy rates of the 2 treatments against bacterial infections were as follows: in the IPM/CS monotherapy group, 62.5% in 8 patients with sepsis, 75.0% in 23 patients with fever of undetermined origin (FUO), 50.0% in 10 patients with pneumonia, and 68.3% in the 47 patients, and in the IPM/CS combination group, 85.7% in 7 patients with sepsis, 63.6% in 24 patients with FUO, 50.5% in 8 patients with pneumonia, and 67.4% in the 48 patients. The differences between the two groups were not significant. 3. Among the drugs used in combination with IPM/CS, antibiotics other than penicillins, cephalosporins, and aminoglycosides were used in 12 patients and a high efficacy rate of 91.7% was obtained. 4. Bacteriologically, 19 and 17 strains were isolated from the IPM/CS monotherapy and combination therapy groups respectively, and the eradication rates were 100% and 88.9% respectively. 5. Side effects were noted in 2 patients in the IPM/CS monotherapy group and 7 in the combination therapy group, but all of these resolved after discontinuation or completion of the treatment. The efficacies against severe bacterial infections in the presence of hematopoietic disorders were not different between IPM/CS alone and IPM/CS in combination with other antibiotics. Adverse reactions were uncommon with the monotherapy.

Hemorrhage from abdominal non-Hodgkin's lymphoma treated successfully by emergency transcatheter arterial embolization.

A 49-year-old Japanese woman with follicular lymphoma who presented with severe abdominal and back pain is reported. She was known to have malignant lymphoma and had been previously treated with combination chemotherapy. An abdominal tumor occurring at the root of the mesentery and involving the superior mesenteric artery (SMA) had been diagnosed by computed tomography (CT), magnetic resonance imaging, and abdominal angiography. Emergent ultrasonography and CT findings showed intraperitoneal bleeding from the abdominal tumor. Selective SMA angiography revealed extravasation from a small branch originating from the dorsal pancreatic artery, which was embolized through a catheter by using platinum coils. It should be noted that a large tumor of malignant lymphoma, involving large vessels, may bleed, and in such a case selective transcatheter arterial embolization may be one of the effective modalities for hemostasis.

[Clinical efficacy of fluconazole against fungal infections in hematological diseases].

Clinical efficacy of fluconazole was evaluated against fungal infections complicated with hematological diseases. Fluconazole 200 approximately 400 mg was administered intravenously to 20 suspected fungal infections occurring in patients with hematological diseases (acute leukemia 6, malignant lymphoma 11, adult T cell leukemia 2, chronic myelogenous leukemia blastic crisis 1). These mycoses included 8 cases of suspected pulmonary fungal infection, 10 cases suspected fungemia, and two cases of suspected hepatic fungal abscess. The clinical response rate was 60.0%. Side effects were observed in two cases, one with transient liver function test abnormality and the other with nausea. Fluconazole is considered to be a potent, safe antifungal agent for the treatment of suspected fungal infections associated with hematological diseases.

The successful application of jejunal interposition for severe dumping syndrome: report of a case.

We report herein the case of a 76-year-old man with intractable dumping syndrome which had manifested itself 3 years after he underwent a gastric resection and Billroth I reconstruction for a gastric ulcer. Despite aggressive medical therapy by the time of admission, he had suffered from disabling dumping symptoms for 9 years. In an attempt to relieve these symptoms, a 15-cm segment of the jejunum was placed isoperistaltically between the lesser curvature of the remnant stomach and the duodenum, and a selective vagotomy was performed. The dumping symptoms that he had experienced preoperatively completely disappeared after the revisory surgery. Postoperatively, an upper gastrointestinal series demonstrated a larger gastric pouch and slower gastric passage into the small intestine than what was seen preoperatively, while gastric emptying studies using the acetaminophen method also showed normal patterns in both the early and late postoperative phases. Thus, we consider that this surgical procedure is a simple and effective way to inhibit rapid gastric emptying and to slow intestinal transit in the treatment of dumping syndrome.

Sinonasal malignant lymphoma of natural killer cell phenotype associated with diffuse pancreatic involvement.

We report a case of sinonasal lymphoma with a natural killer (NK) phenotype. This 40-year-old man was admitted to our hospital because of left nasal obstruction. Physical examination and computed tomography of the skull revealed a tumor in the left nasal cavity and maxillary sinus. Histopathological examination revealed a diffuse proliferation of pleomorphic lymphoid cells. Imprint cytology showed that tumor cells contained some azurophilic granules, and expressed CD2, CD8, CD16, CD56 and HLA-DR antigens with little expression of other lymphoid or myeloid markers. Southern blot analysis revealed germline configuration for immunoglobulin heavy chain and T-cell receptor genes. These findings indicated that these cells were in fact NK cells. The patient's enlarged pancreas was also involved by lymphoma and the pattern of involvement simulated that seen in primary pancreatic lymphoma. Ulcerative colitis (UC) was also present, a rare finding in this disorder.

[A case report of an acute promyelocytic leukemia patient showing remarkable thrombopoiesis prior to granulopoiesis by hM-CSF treatment after chemotherapy].

We report a case of an acute promyelocytic leukemia patient who showed remarkable thrombopoiesis prior to granulopoiesis by human macrophage colony-stimulating factor (hM-CSF) treatment after chemotherapy. A 50 year-old man was diagnosed as acute promyelocytic leukemia (FAB classification: M3) with t(15;17). He received two courses of induction therapy with daunorubicin and cytarabine followed by consolidation therapy with cytarabine and mitoxantrone. After each course of chemotherapy. hM-CSF (8 x 10(6) units, daily) was given for 14 days. After each treatment with hM-CSF, the increase in number of platelets preceded increase of granulocytes and reticulocytes. When serum levels of granulocyte-macrophage-colony stimulating factor (GM-CSF), granulocyte-colony simulating factor (G-CSF), interleukins-3 (IL-3) and -6 (IL-6) were measured, only that of G-CSF was increased after hM-CSF treatment.

[Clinical evaluation of bone marrow fibrosis in non-Hodgkin's lymphomas].

A study was performed in 62 patients with non-Hodgkin's lymphoma (ATL included) who were hospitalized between 1985 and 1991 and who underwent bone marrow aspiration and biopsy before or after treatment or at the time of recurrence. The relationships between the extent of bone marrow fibrosis and other prognostic factors as well as the effects of chemotherapy and bone marrow fibrositic prognosis were examined. The results were as follows: 1) The periods of survival in patients with high degree of fibrosis in bone marrow were significantly shortened. 2) The extent of bone marrow fibrosis significantly correlated with the presence or general symptoms, bone marrow invasion, and blood levels of LDH and Ca on blood biochemical examinations. 3) Effective therapy reduced collagen fibers as well as reticulin fibers in bone marrow. 4) Sixty-four percent of relapsing cases showed increase of bone marrow fibrosis. These results suggest that understanding the state of bone marrow fibrosis over the clinical course may give a good guide of indication the prognosis of malignant lymphoma.