Mucinous Carcinoma of the Breast: Clinicopathological Features and Long-term Prognosis in Comparison with Invasive Ductal Cancer; A Single Hospital's 30+-Year Experience.

Mucinous carcinoma (MC) of the breast is a rare and special type of malignancy, with a substantial amount of extracellular mucin. We compared the clinicopathological features and the long-term survival of MC patients with those of invasive ductal carcinoma-no special type (IDC-NST) patients, and we examined prognostic factors of MC. A total of 116 patients with mucinous carcinoma and 3,258 patients with IDC-NST who underwent surgery at our hospital (1977-2008) were enrolled. The 10-year overall survival rate and breast cancer-specific survival rate (BSS) of the MC patients (88.3%, 93.7%) were both significantly higher than those of IDC-NST patients (81.6%, 85.0%) (p=0.015, p=0.005, respectively). A Cox regression analysis demonstrated that MC tended to be an independent prognostic factor (hazard ratio 0.44, p=0.098). The BSS of the MC patients with positive lymph node (LN) metastasis was significantly poorer than that of the patients without it, by univariate analysis (p=0.002). The tumor size in the MC patients with positive LN metastasis (mean 3.2 cm) was significantly larger than that in the patients without it (mean 1.9 cm) (p=0.0004). Although a Cox regression analysis revealed no independent factor, MC patients with positive LN metastasis should be treated for advanced invasive ductal breast cancer.

Diminished Gastric Resection Preserves Better Quality of Life in Patients with Early Gastric Cancer.

Using the Postgastrectomy Syndrome Assessment Scale (PGSAS)-45, we compared the surgical outcomes and the quality of life (QOL) between patients undergoing limited gastrectomies and those undergoing conventional gastrectomies. In Oomoto Hospital between January 2004 and December 2013, a total of 124 patients who met the eligibility criteria were enrolled. Using the main outcome measures of PGSAS-45, we compared 4 types of limited gastrectomy procedures (1/2 distal gastrectomy [1/2DG] in 21 patients; pylorus-preserving gastrectomy [PPG] in 15 patients; segmental gastrectomy [SG] in 26 patients; and local resection [LR] in 13 patients) with conventional gastrectomy (total gastrectomy [TG] in 24 patients and 2/3 or more distal gastrectomy [WDG] in 25 patients). The TG group showed the worst QOL in almost all items of the main outcome measures. The 1/2DG, PPG, and SG groups showed better QOL than the WDG group in many of the main outcome measures, including the body weight ratio, total symptom score, ingested amount of food per meal, and the dissatisfaction for daily life subscale. The LR group showed a better intake of food than the 1/2DG, PPG, and SG groups. The body weight ratio of the LR group was better than that of the SG group. Diminished gastric resection preserved better QOL in patients with early gastric cancer.

Retrospective investigation of the clinical effects of tazobactam/piperacillin and sulbactam/ampicillin on aspiration pneumonia caused by Klebsiella pneumoniae.

Klebsiella pneumoniae is an important causative bacterium of aspiration pneumonia in many elderly patients. We retrospectively investigated the clinical effects of the early treatment of aspiration pneumonia and background factors in 24 patients from whom Klebsiella pneumoniae was isolated. Sulbactam/ampicillin (SBT/ABPC) was selected for early treatment in 12 of the 24 patients diagnosed with aspiration pneumonia, and tazobactam/piperacillin (TAZ/PIPC) was selected for the other patients. The effective rates and success rates of early treatment were significantly higher in the TAZ/PIPC group than in the SBT/ABPC group (p = 0.003 and 0.027, respectively). Although no significant difference was noted because of the limited number of cases, the survival rates after 30 days were 91.7 and 58.3 % in the TAZ/PIPC and SBT/ABPC groups, respectively. Several bacteria isolated with Klebsiella pneumoniae were resistant bacteria, such as methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa, and no anaerobe or extended-spectrum ß-lactamase-producing Klebsiella pneumoniae was isolated. Thirteen and 11 of the 24 cases were classified as healthcare-associated pneumonia (HCAP) and hospital-acquired pneumonia (HAP), respectively, with no case classified as community-acquired pneumonia (CAP). As population aging progresses, the frequency of aspiration pneumonia classified as HCAP will increase. To cover anaerobes, it is necessary to select antibacterial drugs, such as TAZ/PIPC, for early treatment in consideration of resistant gram-negative bacteria to improve the outcome, and not drugs with weak activity against these bacteria.

Primary osteosarcoma of the breast.

Presented herein is a case of primary pure osteosarcoma of the breast. A 59-year-old woman noticed a left breast tumor. Mammography showed a cluster of crushed stone-like calcifications, which gave the tumor a raw cotton-like appearance. Malignancy was suspected on fine-needle aspiration cytology of the tumor. An excisional biopsy was performed. The tumor was 2.0 x 2.4 cm in size. Histopathologically the tumor was composed of diffuse atypical cells with mitosis and a lot of bone. Atypical cells were thought to be neoplastic osteoblasts. Multinucleated osteoclastic cells were interspersed with osteoblasts. Spindle cells were found at the verge of the tumor. A few entrapped tubular structures were seen. Immunohistochemistry indicated that neoplastic osteoblastic cells of the tumor were stained positively for vimentin, but negatively for epithelial markers; which suggested that the tumor cell elements originated from epithelial cells. This tumor was diagnosed as primary extraskeletal osteosarcoma. Partial resection was additionally performed around the excisional biopsy without dissection of the axillary lymph nodes. Bone radionuclide scan after operation showed no abnormal uptake. At 5 years after surgery no recurrence was seen.

Foregut duplication cyst of the stomach with pseudostratified columnar ciliated epithelium.

Duplication cyst of the stomach with pseudostratified columnar ciliated epithelium is extremely rare. A 72-year-old Japanese woman visited Oomoto Hospital for examination of the stomach. Gastroendoscopy indicated a slightly depressed gastric cancer in the anterior wall of the middle third of the stomach. Adenocarcinoma was confirmed on endoscopic biopsy. Preoperative CT indicated a subserosal cystic lesion 2 cm in diameter on the lesser curvature of the stomach. The cystic lesion was resected through distal gastrectomy and systematic lymph node dissection. Histopathology showed that the cyst did not communicate with the gastric lumen, had pseudostratified columnar ciliated epithelium with circular muscle layers, and did not have gastric epithelium or cartilaginous tissue. The gastric cancer consisted of moderately differentiated adenocarcinoma with submucosal invasion and lymph node metastasis. Consequently, the present patient was diagnosed as having foregut duplication cyst of the stomach.

Increased preoperative serum C-reactive protein level predicts a poor prognosis in patients with localized renal cell carcinoma.

OBJECTIVE: To evaluate the value of the preoperative serum C-reactive protein (CRP) level in the prognosis of patients with localized renal cell carcinoma (RCC). PATIENTS AND METHODS: The study comprised 101 patients who had a radical nephrectomy for localized RCC (pT1-3N0M0). An elevated CRP was defined as >0.5 mg/dL before surgery. Survival rates for each variant were calculated using the Kaplan-Meier method, with the difference between survival curves evaluated using the log-rank test. Multivariate analysis was by Cox proportional hazard model; for all analyses the difference was considered significant when P < 0.05. RESULTS: The median (range) follow-up was 55 (2-187) months; 26 patients (26%) had high CRP levels, and 12 (46%) of these and three (4.0%) of the remaining 75 died from disease. The 5- and 10-year disease-specific survival rates (75% and 30%, respectively) in patients with high CRP levels were significantly worse than those in patients with normal CRP levels (both 93%, P < 0.001). In other variants, preoperative haemoglobin concentration, pathological stage, grade, histological type and microvascular tumour invasion were also related to disease-specific survival. By the Cox proportional hazards model, pathological stage and an elevated CRP were the most important prognostic factors for disease-specific survival in patients with localized RCC (P = 0.008 and 0.012, respectively). CONCLUSION: The preoperative CRP level was associated with poor survival in patients with localized RCC.

Possible involvement of bone morphogenetic protein 2 in heterotopic ossification in metastatic lesion from urothelial carcinoma of bladder.

Heterotopic bone formation caused by urothelial carcinoma is rare. The precise mechanism of heterotopic ossification is still unknown. We report a case of urothelial carcinoma with heterotopic bone formation in a metastatic site and investigate the expression of bone morphogenetic protein 2 (BMP-2) and the BMP receptor (BMPR)-Ib using immunohistochemistry. Positive staining of BMP-2 was observed in the cytoplasm of tumor cells in both bladder and psoas lesions. In addition, positive staining of BMPR-Ib was seen in osteoblast-like cells adjacent to bone formation in the psoas metastasis. The heterotopic ossification may result from the metaplasia of pluripotent stem cells into osteoblast cells induced by BMP-2 in a paracrine fashion.

Serotonin-2A and 2C receptor gene polymorphisms in Japanese patients with obstructive sleep apnea.

OBJECTIVE: The serotonin (5-HT) 2A and 2C receptor subtype plays an important role in the maintenance of upper airway stability and normal breathing in obesity. Polymorphisms in the 5-HT 2A receptor gene (HTR2A) and 5-HT 2C receptor gene (HTR2C) are associated with various diseases. The aim of this study was to investigate whether or not the HTR2A/C genotypes are associated with obstructive sleep apnea (OSA). METHODS: The PCR-restriction fragment length polymorphism method was used to determine genotypes of the HTR2A/C gene. The genotype distributions and allele frequencies were statistically analyzed. SUBJECTS: We studied 177 consecutive male patients with excessive daytime somnolence and an apnea plus hypopnea number [apnea-hypopnea index (AHI)] of greater than five per hour of sleep established by full polysomnography. One hundred Japanese men in whom OSA was clinically excluded were randomly selected as a control group. RESULTS: Genotypes and allele frequencies of 102T/C polymorphism of the HTR2A and 796G/C polymorphism of the HTR2C did not differ between controls and patients with OSA. HTR2C polymorphism was considered inappropriate for association studies because of low frequency of the mutant allele. Multiple regression analysis showed that age and body mass index (BMI) were significantly associated with OSA, but HTR2A polymorphisms were not. HTR2A polymorphisms had no significant relationship with AHI or BMI, although further study with more samples will be needed for powerful statistical analyses. CONCLUSIONS: These results indicate that age and BMI, not these polymorphisms, are associated with OSA in this population.

[A case of sarcomatoid carcinoma in the region of the female urethra].

A 78-year-old woman was presented with bleeding in the region of the genitalia. The tumor arose from the urinary meatus and biopsy was performed. The pathological examination revealed sarcomatoid carcinoma which was composed of squamous cell carcinoma and spindle cell sarcoma. She underwent urethrectomy and suprapubic cystostomy. She is alive at 26-month follow-up, after local radiation therapy of 50 Gy to the recurrence sites.

Facial axis angle as a risk factor for obstructive sleep apnea.

OBJECTIVE: Many Japanese patients with obstructive sleep apnea (OSA) are less obese than Caucasian OSA patients despite their similar severity of OSA, suggesting that their etiology of OSA may differ. The purpose of this study was to identify bony factors associated with OSA in the Japanese population. METHODS: The clinical records of study subjects were retrospectively reviewed, and cephalometric measurements based on Sella-Nasion references and the Ricketts method were statistically compared. PATIENTS: Two hundred and six consecutive Japanese men complaining of habitual snoring and daytime sleepiness were enrolled in the study. All subsequently underwent an overnight polysomnographic examination. RESULTS: Multiple regression analysis showed that the body mass index (p<0.0001) and facial axis angle (p=0.007) were the dominant overall determinants for the apnea hypopnea index. The sella to nasion to subspinale angle (SNA) and sella to nasion to supramentale angle (SNB) were lower in the non-obese, severe group than for non-obese, mild and moderate patients with OSA (p=0.0047 and 0.0016, respectively). CONCLUSION: The risk factors for OSA in Japanese men may be obesity and the dolico facial pattern seen by the Ricketts method. In addition, a smaller SNA and SNB seem to be associated with the severity of OSA in non-obese patients.

Pathological approach to breast conserving therapy.

There is no uniformly accepted definition of a positive margin in breast conserving surgery. In 1999, the Japanese Breast Cancer Society created the Guidelines for Breast-Conserving Treatment (GBCT). At that time, we did a questionnaire survey about the definition of margin status. Although 57.1% of hospitals/institutes used the definition of cancer cells present at the surface, the GBCT adopted the definition of cancer cells present within 5 mm of the surface. Moreover, the GBCT required that the distance between the edge of the cancer cells and the surface be recorded in millimeters when cancer cells were present within 5 mm of the surface. The risk factors for local recurrence after breast-conserving treatment were studied. From 1986 to 1995, 391 patients were treated with breast-conserving surgery at Osaka Medical Center for Cancer and Cardiovascular Diseases. Of these, 35 patients developed local recurrence. Multivariate analysis showed that positive margin (p=0.0002), high degree of ductal proliferative change around the tumor (p=0.0035) and high histological grade (p=0.0041) were significant independent risk factors for local recurrence, while radiation therapy (p=0.0327) significantly reduced local recurrence. There was no significant difference in the risk of local recurrence between the two different definitions of positive margin (tumor present at the surface and tumor present within 5 mm from the surface). It is hoped that more hospitals/institutes will adopt the definition of margin positivity presented by the GBCT and that a practical definition of margin positivity will be established.

Short-term use of continuous positive airway pressure ameliorates glomerular hyperfiltration in patients with obstructive sleep apnoea syndrome.

Patients with OSAS (obstructive sleep apnoea syndrome) demonstrate renal signs such as proteinuria, glomerular hypertrophy and focal glomerular sclerosis. We performed a clinical study to investigate the glomerular function in OSAS patients and the short-term effect of CPAP (continuous positive airway pressure) on it. OSAS patients underwent a sodium thiosulphate and p-aminohippurate double clearance test, polysomnography and ambulatory blood pressure monitoring before and a week after the induction of CPAP. Twenty-seven consecutive patients (24 males) with moderate-to-severe OSAS admitted to our hospital for the induction of CPAP, and 32 healthy donors for renal transplantation as controls participated in the study. Before treatment, the glomerular filtration rate, estimated by the sodium thiosulphate clearance test, was within normal range, and the renal plasma flow was significantly lower than normal in the OSAS patients, thus the FF (filtration fraction) value was much higher than normal. FF before CPAP was not significantly correlated with age, body mass index or blood pressure; however, indices of increased hypoxaemia correlated with increased FF values. Polysomnographic variables after CPAP showed significant improvements in all patients, and only the nocturnal blood pressures were slightly lower than before CPAP. In 21 patients who underwent the clearance test after CPAP, FF significantly decreased from 0.26 +/- 0.04 to 0.23 +/- 0.03 (P < 0.001). OSAS patients were generally in a glomerular-hyperfiltrating condition that appeared to cause the renal findings associated with OSAS. CPAP might prevent nephropathy by ameliorating the glomerular hyperfiltration in OSAS patients.

[Bladder stone formation caused by a Stamey cuff as the nidus indwelt 16 years ago].

Although foreign bodies left in the body may remain asymptomatic for long periods, they may also cause various complications. We present a case of a Stamey cuff placed in the retroperitoneal space, which remained asymptomatic for 16 years in a 62-year-old woman. When a vesical calculi formed, it caused voiding pain in the lower abdomen. She underwent transurethral cystolitholapaxy. The nidus of the stone was a Stamey cuff used in the Stamey procedure performed 16 years before. Open cystotomy was needed to remove it. Convalescence was uneventful and she had no complaints on urination. The possibility of calculous formation should be raised when there are symptoms on urination in a female with a history of pelvic surgery.

[Male infertility in an adult with unilateral Leydig cell tumor of the undescended testis].

We report a case of Leydig cell tumor of the postpubertal cryptorchid testis with the chief complaint of male infertility. A 36-year-old man had consulted another clinic and his semen analysis revealed oligospermia. A solid mass was palpated in the right inguinal undescended testis. He was referred to our hospital for treatment of the testicular tumor. Right inguinal orchiectomy was performed and pathological diagnosis was Leydig cell tumor with no malignant findings. After the surgery improvement was seen in his semen analysis. There was no evidence of recurrence 9 months after surgery.

[Bladder cancer producing granulocyte colony-stimulating factor (G-CSF): a case report].

A case of bladder cancer producing granulocyte colony-stimulating factor (G-CSF) is reported. A 76-year-old male was admitted to our hospital with gross hematuria and leukocytosis. He was diagnosed with advanced bladder cancer. His white blood cell (WBC) count and serum granulocyte colony-stimulating factor (G-CSF) level were elevated (peak WBC 22,010/microliter, peak G-CSF 351 pg/ml), which immediately normalized after cystectomy. The histopathological diagnosis was transitional cell carcinoma, grade 3, pT4, pN1. Immunohistochemical examination was positive for G-CSF and G-CSF receptor. There has been no recurrence of cancer for more than 23 months since the operation without any additional therapy.