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Background We devised a breast-conserving surgery (BCS) utilizing a new image-processing and projection technique using a radiation treatment planning system (RTPS) and deformable image registration (DIR) for patients with breast cancer after neoadjuvant chemotherapy (NAC). RTPSs and DIR are commonly used in planning radiation treatment. The purpose of this pilot study was to evaluate the feasibility of our procedure. Patients and methods Twenty-six patients diagnosed with breast cancer underwent NAC and BCS between November 2014 and May 2020. Multidetector-row computed tomography was performed in the same position used for surgery before and after NAC. In the DIR, CT before NAC was fused to CT after NAC. The RTPS simulated the design of tumor excision, and excision area was projected onto the breast skin utilizing an irradiation device. Results In 26 patients with breast cancer after NAC, BCS was performed using the processing and projection technique of the RTPS with DIR. Only 1 of 26 patients showed carcinoma present in the surgical margins, and subsequently developed ipsilateral breast tumor recurrence. Mean excised volume was 33.5 cm3 (range, 12.8–62.8 cm3), and percent breast volume excised was 6.8% (range, 2.5–15.7%). Conclusions This pilot study confirmed the simplicity and utility of our procedure for minimally invasive BCS in patients with breast cancer after NAC. We will keep evaluating the safety and efficacy of our procedure in more patients.

A 70s woman with pancreatic metastases of HER2-negative breast cancer was being treated with bevacizumab plus paclitaxel. Tumor markers decreased after treatment initiation. After 8 months of treatment, the patient developed abdominal pain and distention, along with loss of appetite. Contrast-enhanced abdominal CT scan images showed the presence of a large 25 cm pseudopancreatic cyst and disappearance of the pancreatic metastatic lesions. Endoscopic ultrasound-guided cystogastrostomy was performed and an AXIOS stent was placed in the lower part of the gastric body. Subsequently, the cyst disappeared and her abdominal symptoms improved. The patient was able to resume treatment with other drugs and did not experience any recurrence of pancreatitis. Four months later, the AXIOS stent was removed. Bevacizumab plus paclitaxel is reportedly effective against HER2-negative metastatic breast cancer. Bevacizumab is a molecular targeted therapy against vascular endothelial growth factor, and the mechanism of its antitumor effect and complications are different from those of conventional drugs. Paclitaxel has also been reported to cause pancreatitis in rare cases. In this case, the mechanism of response to bevacizumab plus paclitaxel for metastatic pancreatic lesions or the development of drug-induced pancreatitis was considered to be the cause of pseudopancreatic cyst formation.

A 53-year-old woman, who had been operated with Bt plus Ax plus Ic for right breast cancer 2 years before, revealed an isolated hepatic metastasis at the S4 edge on follow-up computed tomography. The surgical approach is not recommended for distant metastases from breast cancer because of the lack of survival benefits according to the breast cancer guidelines. Nevertheless, the operation could be performed safely and easily for this patient owing to the location and size of the tumor. In addition, the case was a good indication for laparoscopic hepatectomy. We could perform the operation safely with a laparoscope, and the patient was discharged from the hospital on postoperative day 6. Hepatectomy is controversial for metastases from breast cancer. However, in select cases, hepatectomy with a laparoscope can be the therapeutic option as it can improve the survival of patients with hepatic metastases from breast cancer.

The patient was a 72-year-old man. A gastrointestinal endoscopy was performed because of his anemia and revealed semicircular type 3 tumor in the lower body of the stomach. Biopsy was performed to diagnose adenocarcinoma. Computed tomography(CT)showed no distant metastasis, and the operation was performed 3 weeks after first visit. During operation multiple liver metastasis were recognized, and we performed distal gastrectomy and partial liver resection. The final diagnosis was neuroendocrine carcinoma(NEC). EOB-MRI after surgery revealed multiple liver metastases of 10-20 mm in size, similar to the intraoperative findings, and chemotherapy with cisplatin(CDDP)plus S-1 was started. A significant reduction was recognized after 3 courses of chemotherapy. Gastric NEC has a high proliferative capacity, and distant metastasis may become apparent in a short period of time. Although there is no clear guideline for chemotherapy, CDDP plus S-1 could be 1 treatment option.

Phyllodes tumor is a rare interstitial and epithelial mixed tumor which constitutes 0.3-0.9% of all breast tumors. It is classified into benign, borderline malignant, and malignant. Differentiating this from fibroadenoma is difficult, however, when diagnosed, complete surgical resection is recommended. Patients and results: Forty-four patients who underwent surgery between April 2009 and April 2020 and were diagnosed with phyllodes tumors and the median observation period was 44 months. The average tumor diameter was 39.2 mm, and the surgical procedures performed were mastectomy in 3 cases, partial resection in 26 cases, and extirpation in 15 cases. The surgical margin was positive in 6 cases. Intra-breast recurrence occurred in 4 cases, of which the initial surgery in 3 cases was extirpation. The pathological diagnosis was malignant in 4 cases, malignant in 15 cases, and benign in 25 cases. Conclusion: In this study, intra-breast recurrence occurred in many cases treated by extirpation, and it was considered that the surgical technique for complete resection such as partial resection should be selected.

Case 1: A 77-year-old woman presented with redness and swelling with a peau d'orange appearance in the whole left breast. She was diagnosed with inflammatory breast cancer(T4dN1M0, stage ⅢB of the basal-like subtype). Four courses of FEC followed by 4 courses of docetaxel as the primary systemic therapy were effective. She underwent mastectomy and axillary dissection, and pathological examination revealed a partial response. She received radiation therapy after surgery. At present, 5 years after surgery, the patient is alive without recurrence. Case 2: A 46-year-old woman presented with redness and swelling with a peau d'orange appearance in the whole left breast and edema of the left arm. She was diagnosed with inflammatory breast cancer(T4dN3M1, stage Ⅳ of the HER2 subtype)with bone metastasis and cancerous pleurisy. After 4 courses of FEC as the primary systemic therapy, the breast tumor disappeared, but pleural effusion persisted. Subsequent chemotherapy with pertuzumab, trastuzumab, and docetaxel was effective, as computed tomography showed no lesions. She underwent mastectomy and axillary dissection, and pathological examination revealed a complete response. She received radiation therapy after surgery. At present, 2 years after surgery, the patient is alive without recurrence.

A 21-year-old woman was admitted for preshock due to severe anemia. A 5 cm gastrointestinal stromal tumor(GIST)at the jejunal flexure of her duodenum was diagnosed by enhanced CT examination. We performed a total laparoscopic pancreas- preserving duodenal sleeve resection with a 2 cm margin from the tumor. Functional end-to-end anastomosis was done with the patient lying in a right half lateral decubitus position in order to shift the weight of the tumor and duodenal mesentery to the right to prevent surgical capsule damage. We experienced one case(5.5%)of peritoneal(recurrent)GIST after laparoscopic gastrectomy. However, this is generally a safe and useful procedure for laparoscopic duodenal sleeve resection of duodenal GIST at a distal portion from the papilla Vater, when performed by a skilled team.

Intraductal papillary mucinous neoplasm(IPMN)of the pancreas often presents with multifocal lesions. Complete resection without residual skip lesions is essential for complete eradication of the disease. We experienced a case of IPMC in which intraoperative pancreatoscopy was used to determine the surgical margin. Intraoperative pancreatoscopy is a useful and easy method to evaluate the remnant duct and exclude residual tumor. A cystic lesion was incidentally detected in the pancreatic head of a 78-year-old man. Ultrasonography, abdominal computed tomography, magnetic resonance imaging, and endoscopic ultrasound revealed enhancing mural nodules in the pancreatic head and dilation of the entire main pancreatic duct. We performed pancreaticoduodenectomy for mixed IPMN. Intraoperative pancreatoscopy, which was performed to rule out skip lesions, showed no mucosal abnormalities in the remnant duct. The pathological diagnosis was non-invasive intraductal papillary-mucinous carcinoma(IPMC). No signs of recurrence were seen for 6 postoperative months.

In this study, a breast-conserving surgery(BCS)was performed involving the new image projection technique, using a radiation treatment planning system(RTPS)and a multi-leaf collimator(MLC), for patients with ductal carcinoma in situ (DCIS)and invasive ductal carcinoma(IDC)with ductal components. This study aimed to evaluate the feasibility of this procedure as a pilot study. From June 2014 to May 2017, 27 patients diagnosed with DCIS and IDC with ductal components underwent BCS. In the RTPS, the design of tumor resection was simulated, and the extent of resection was projected to the breast surface using the MLC. BCS was performed using this skin marking. Among 27 patients, 4(14.8%)had carcinoma in the surgical margins. As a pilot study, the simplicity and usefulness of this procedure was confirmed in BCS for patients with DCIS and IDC with ductal components. Further evaluation of its safety and efficacy will be conducted in more patients.

The patient was a 75-year-old man who was diagnosed as having jejunal gastrointestinal stromal tumor(GIST)and underwent partial resection of the small intestine including the tumor 12 years ago. Two years after the first resection, recurrence was detected, and a second resection was performed. Ten years after the second resection following recurrence, he took imatinib, and computed tomography(CT)revealed abdominal and liver tumors. We was diagnosed as having GIST recurrence, and a third resection, which included an abdominal tumor resection and partial hepatectomy, was performed. The pathological findings were metastatic abdominal GIST and angiomyolipoma of the liver. The Japanese Clinical Practice Guidelines for GIST suggest a surgical indication only for local recurrence of GIST and resectable liver metastases. Recurrent GIST cannot be completely cured with antineoplastic drugs alone. Multidisciplinary treatment is necessary for long-term survival of patients with recurrent GIST.

The patient was a 70-year-old man. He was diagnosed with advanced transverse colon cancer. A computed tomography (CT)revealed liver metastasis and tumor thrombosis of portal vein. We started combination chemotherapy with capecita- bine/oxaliplatin(CapeOX). Perforation of the tumor was observed 5 days after CapeOX therapy was started. Treatment with abscess drainage and ileostmy, infection was controlled and general condition was improved. After 9 courses of CapeOX, we changed chemotherapy regimen to irinotecan/tegafur-gimeracil-oteracilpotassium (IRIS)due to strong side effects. In CT and FDG-PET examination after 8 courses of IRIS, the tumor of transverse colon, liver metastasis, and the tumor thrombosis of portalvein became unclear. A year and 6 months have passed since chemotherapy was started, recurrence was not observed. For the patients with unresectable colorectal cancer, it is necessary to consider multidisciplinary treatments including chemotherapy while considering the general condition of them.

A 77-year-old men with abdominal pain suffered from gall bladder hemorrhage and liver abcess was admitted for intensive care of severe acute cholangitis. He had hemobilia which was treated by the endoscopic retrograde bile duct drainage. After 2 months treatment with rest for purulent myelitis, he had neoplastic change of liver abcess diagnosed as intrahepatic bile duct cancer by percutaneous core needle biopsy. He underwent surgery as central bisegmentectomy and left the hospital at home 3 months later after rehabilitation for surgical site infection. He noticed growing mass on right chest 6 months later after hepatectomy and was diagnosed as needle tract implantation in chest wall by CT examination. Pathological exam revealed cholangiocarcinoma by radical excision. He have disease free for 5 years after second operation. Although percutaneous biopsy for hepatic tumor increases risks of needle tract implantation and dissemination, there is an advantage of radical resection for tract implantaion.

We report 4 patients with occult breast cancer(OBC)who underwent breast conserving therapy(BCT)after neoadjuvant chemotherapy(NAC). All patients complained of axillary tumor and were diagnosed by core needle biopsy. Pathological examination of the axillary lymph nodes proved that 3 cases were adenocarcinomas and 1 case was squamous cell carcinoma, but imaging studies could not depict any primary lesions in the breast and other organs. Since distant metastasis was not observed, BCT with axillary lymph node dissection(ALND)was performed after NAC. All patients were undergoing whole breast irradiation. There were no residual cancer cells in the axillary lymph nodes in case 1 due to the treatment effect of NAC, but lymph node metastasis remained in other 3 cases. In the second case, she followed a rapid outcome, and pulmonary metastasis appeared in 7 months after surgery and died in 10 months. In the other 3 cases, there has not been found local and distant recurrence. Although OBC requires appropriate systemic treatment, present observation indicated that ALND with breast irradiation after NAC could be a useful option.

BACKGROUND: Aldehyde dehydrogenase 1 (ALDH1)-positive cells exhibit stem-like or progenitor ability and have been considered a clinically important diagnostic and therapeutic target in patients with breast cancer. In this study, the authors evaluated responsiveness to chemotherapy of ALDH1-positive cells in primary and metastatic lesions and its relation to prognosis for patients with lymph node-positive breast cancer. METHODS: In total, 115 patients who had breast cancer with cytologically confirmed lymph node metastases and who underwent surgery after neoadjuvant chemotherapy (NAC) were evaluated. By using ALDH1 immunohistochemistry in core-needle biopsy specimens of the primary tumor, cytology samples of axillary lymph nodes before NAC, and pathologic samples of each after NAC, the clinical significance of ALDH1-positive cell status was evaluated in primary and metastatic lesions before and after NAC. RESULTS: The presence of ALDH1-positive cancer cells, but not ALDH1-negative cancer cells, in primary and metastatic lesions after NAC was associated with a worse prognosis. In multivariate analysis, only ALDH1-positive cells in metastatic lesions after NAC correlated with overall survival. The responsiveness of ALDH1-positive cells to chemotherapy differed between primary and metastatic lesions, and the findings indicated that ALDH1-positive cells in metastatic lesions after NAC may clinically precede those in the primary lesion. CONCLUSIONS: The responsiveness of ALDH1-positive cells to chemotherapy in primary and metastatic lesions and its prognostic significance were clarified in patients with breast cancer. The authors concluded that ALDH1-positive status may represent a surrogate marker as a new concept in patients with lymph node-positive breast cancer. Cancer 2012. © 2011 American Cancer Society.

Background The use of neoadjuvant chemotherapy for breast cancer is effective as postoperative adjuvant therapy, permits more lumpectomies, and can be used to study breast cancer biology. Although pathological response is the strongest prognostic factor, response rates vary according to various parameters, such as dissociation between breast and axillary node responses. Purpose To clarify the correlation of response rates between breast tumors and metastasized lymph nodes and to identify the clinical significance; response rates measured on imaging were evaluated among breast cancer patients with axillary lymph node involvement. Material and Methods Subjects consisted of 98 patients diagnosed with node-positive breast cancer who received chemotherapy before surgery. The response to the therapy was evaluated by changes in the largest dimensions of the breast mass and of regional lymph nodes measured on a multidetector row helical CT before and after chemotherapy. The percent reduction was calculated as a response rate. The correlation between response rate and patient outcome was analyzed retrospectively. Results Breast tumor response rates correlated statistically well with those of lymph nodes (p < 0.001). Disease-free cases had a greater tumor and/or nodal response rates than recurrence cases (p = 0.021, p < 0.001, respectively), regardless of tumor size, histological grade and HER2 amplification. Cancer-associated death was observed more frequently in cases with lower response rates compared to surviving cases (p = 0.007, p = 0.021, respectively). The prognostic difference was found most strongly in nodal response rates (p = 0.001). Conclusion The present series evaluated the therapeutic effect of NAC on breast tumors and metastasized lymph nodes, and a significant correlation with patient outcome was observed. Evaluating the response rate measured by imaging could be used as a surrogate marker for prognosis before assessment of the pathological response which is ordinarily obtained after surgery.