[Six synchronous primary cancers - a case report]

A 60-year-old man presenting with dysphagia was referred to our hospital with a diagnosis of esophageal cancer and gastric cancer. Upper gastrointestinal endoscopy revealed type 2 tumors in the upper thoracic esophagus and in the lesser curvature of the angular incisure, and elevated lesions in the duodenum and in the transverse colon. Laryngoscopy revealed erosion of the right vocal cord. Computed tomography (CT) of the chest revealed a nodule in the middle lobe of the right lung. Laryngomicro surgery was performed for the right vocal cord erosion, and it was diagnosed as carcinoma in situ. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) were performed for the lesions in the duodenum and in the transverse colon, respectively; the lesions were diagnosed as adenocarcinoma in adenoma. After 2 courses of neoadjuvant chemotherapy with the 5-fluorouracil (5-FU), cisplatin, and Adriamycin (FAP) regimen, subtotal esophagectomy with reconstruction of the pedunculated jejunum through the antethoracic route, total gastrectomy, and resection were performed on the right middle lobe of lung. Pathological examination revealed esophageal cancer (fT4N0M0, fStageIII), gastric cancer (ypT3N0M0, pStageIIA), and primary pulmonary adenocarcinoma (pT1bN1M0, pStageIIA). After surgery, the patient was treated with chemoradiotherapy (60 Gy, with 2 courses of 5-FU plus cisplatin [FP]), and 6 months after the operation, he was in good health without recurrence.

[Efficacy of endoscopic gastroduodenal stenting for unresectable gastric cancer with gastric outlet obstruction]

METHODS

We performed endoscopic gastroduodenal stenting for gastric outlet obstruction (GOO) caused by unresectable gastric cancer in 15 patients. We compared the clinical outcomes of the stent placement procedure with those of a gastrojejunostomy performed in 32 patients.

RESULTS

Stent placement was performed safely without complications, and the median number of days until oral food intake could be resumed and the median number of days spent in the hospital was 2 and 15 days, respectively. The GOO score improved in 13 patients (87%); however, re-interventions were necessary for 7 patients due to stent obstruction caused by tumor growth. No differences between the stenting and gastrojejunostomy groups were found for the rate of improvement in GOO score, the duration until oral food intake could be resumed, or the overall survival rate. Patients in the stenting group had significantly fewer complications and shorter hospital stay. However, more re-interventions were required for patients of the stenting group compared to patients of the gastrojejunostomy group.

CONCLUSION

Endoscopic gastroduodenal stenting can be performed safely and is beneficial for the improvement of oral food intake.

[Evaluation of laparoscopic hepatectomy for hepatocellular carcinoma with cirrhosis]

Laparoscopic hepatectomy has been reported as a safe and effective approach for the treatment of hepatocellular carcinoma ( HCC). However, few studies have reported survival outcomes after laparoscopic hepatectomy in HCC patients with cirrhosis. In the present study, we evaluated the surgical outcomes and disease-free survival in these cases. Between June 2010 and March 2013, 35 HCC patients with cirrhosis underwent laparoscopic hepatectomy. Operative variables for laparoscopic vs open hepatectomy were as follows: operative times, 268.3 vs 183.3 minutes (p=0.0043); blood loss volume, 151.0 vs 1,106.1 g (p<.001); 1-year disease-free survival rate, 73.1 vs 71.6%; and 2-year disease-free survival rate, 39.9% vs 28.6% (p=0.568), respectively. Laparoscopic hepatectomy is feasible and safe in selected patients with liver cirrhosis, with similar outcomes in disease-free survival when compared with open hepatectomy.

[A case of appendiceal intussusception induced by appendiceal carcinoma]

A 26-year-old man was admitted to hospital because of lower quadrant pain. Colonoscopy showed a polypoid lesion (0- Ip: protruded, pedunculated)in the cecum. Endoscopic biopsy revealed a tubular adenoma with severe atypia. Laparoscopy- assisted ileocecal resection was performed, as the diameter of the tumor made colonoscopic treatment difficult. Appendiceal intussusceptions were found in the excised specimen. The tumor was mucosal in origin. The patient remained cancer-free after the surgery.

[A case of simultaneous laparoscopic resection of colorectal cancer and a synchronous liver metastasis]

A 39-year-old woman was referred to our hospital with a history of fecal occult blood.She was diagnosed with advanced sigmoid colon cancer.A colonoscopy indicated a stenosis, and an enhanced abdominal computed tomography (CT) scan revealed liver metastasis.The patient was operated on for a total of 337 minutes, and an estimated 35 mL of blood was lost. This is the shortest operating time and lowest amount of blood loss of which we are aware.Although an intra-abdominal abscess occurred, the patient recovered well and was discharged on postoperative day 25.Herein, we describe the case of a patient who underwent simultaneous laparoscopic resection of sigmoid colon cancer and a synchronous liver metastasis.We also review the efficacy of simultaneous laparoscopic resection of colorectal cancer and synchronous liver metastasis in this report.

[A case of gastric outlet obstruction and rectal obstruction due to metastases from breast cancer treated by gastroduodenal and colon stenting]

Malignant bowel obstruction often causes oral intake difficulties and decreases quality of life. In Japan, gastroduodenal stenting for malignant gastric outlet obstruction has been covered by health insurance since 2010, while colon stenting has been covered since 2012. Both approaches are useful treatments for malignant bowel obstruction. Here we report the case of a woman with gastric outlet obstruction and rectal obstruction due to breast cancer metastases who was able to eat solid food after duodenal and colon stenting. When choosing whether to perform endoscopic stenting or surgical intervention such as gastrojejunostomy, ileostomy, and colostomy for treating malignant bowel obstruction, it is important to assess the patient's general condition and prognosis as well as the obstruction position.

[A case of colonoscopy release of intussusception due to sigmoid colon cancer]

A 53-year-old woman with recurrent abdominal pain was referred to our hospital. Based on the enhanced abdominal computed tomographic (CT) finding, she was diagnosed with intussusception of the sigmoid colon. Colonoscopy was performed to release the intussusception, and a lead point lesion was detected. An advanced cancer was found in the rectum, which could be pushed back into the sigmoid colon easily using pressurized air. A more-advanced colon cancer was also detected on the oral side of the lesion. The patient was diagnosed with double cancer of the sigmoid colon and was treated with laparoscopic sigmoidectomy with lymph node resection (D3). Preliminary reduction by colonoscopy prior to surgery is an effective option in cases of adult intussusception. Colonoscopy can be used to perform definitive and qualitative diagnoses.

[A case of hyoid bone metastasis from breast cancer]

A 69-year-old woman had undergone breast conserving surgery and axillary lymph node dissection for left breast cancer 10 years previously. The tumor was positive for estrogen receptor (ER) and progesterone receptor (PgR), and negative for human epidermal growth factor receptor-2 (HER2). Adjuvant tamoxifen and radiation therapy were administered to the conserved breast for 5 years. The patient detected a painless neck mass 1 year previously. Computed tomography (CT) revealed a hyoid bone mass, and fine needle aspiration cytology indicated a diagnosis of adenocarcinoma. Positron emission tomography combined with CT (PET-CT) revealed masses in the pelvis, spine, hyoid bone, and cervical lymph node. For definitive diagnosis, excisional biopsy of the hyoid bone was performed. Immunohistostaining revealed that the cells were CK7 (+), CK20(-), mammaglobin (+), GCDFP-15 (+), ER (+), PgR (+), and HER2 (-). The final diagnosis was multiple bone metastasis(hyoid, pelvis, spine)as well as cervical lymph node metastasis from breast cancer. After diagnosis, the patient was treated with anastrozole and denosumab, and she achieved a partial response. She has experienced progression free survival for 12 months. Metastasis to the hyoid bone is uncommon for breast cancer. We report a case in which hormone therapy was effective after it was selected based on the results of excisional biopsy.

[A case of malignant phyllodes tumor after surgery for breast cancer]

A 63-year-old woman underwent breast-conserving resection and axillary lymph node dissection for bilateral breast cancer in December 2008. Histopathological diagnosis for the right breast cancer was t=1.3 cm, n=1/29, estrogen receptor (ER) (+), progesterone receptor (PgR) (+), human epidermal growth factor receptor 2(HER2) (-), and that for the left breast cancer was t=1.8 cm, n=9/28, ER (+), PgR (+), and HER2 (-). She was administered adjuvant chemotherapy (4 courses of fluorouracil, epirubicin, and cyclophosphamide [FEC 100] and 4 courses of docetaxel[DTX], 75 mg/m²), letrozole, and bilateral radiation therapy for the remaining breast tissue. She noticed a mass in the left breast in December 2013. Fine-needle aspiration cytology and core-needle biopsy indicated a malignant phyllodes tumor or stromal sarcoma. Positron emission tomography-computed tomography (PET-CT) revealed the accumulation of fluorodeoxyglucose (FDG) only in the mass. The tumor enlarged rapidly to more than 5 cm during the pre-operative period. In January 2014, the patient underwent left mastectomy. The histopathological diagnosis was malignant phyllodes tumor in the left breast, with a tumor diameter of 7 cm, and negative margins. Presently, 6 months after the operation, the patient is alive without recurrence.

[A case of recurrent duodenal gastrointestinal stromal tumor resistant to imatinib and sunitinib, successfully treated with regorafenib]

Regorafenib is a novel, orally administered multi-kinase inhibitor that has recently been approved for the treatment of recurrent gastrointestinal stromal tumor (GIST). We report a case of successful treatment of recurrent duodenal GIST, which was found to be resistant to imatinib and sunitinib, with regorafenib. A 62-year-old woman underwent a pancreatoduodenectomy for duodenal GIST; after 2 years, a computed tomography (CT) scan detected liver metastases. The patient received imatinib for 6 years, and underwent 2 hepatectomies. Subsequently, she received sunitinib for 10 months; however, CT scans revealed the presence of multiple vertebral metastases. She underwent a laminectomy for the palliative treatment of the vertebral metastases. Upon immunohistochemical examination, the recurrent tumor stained positive for c-kit, confirming the diagnosis for GIST. Consequently, the patient received regorafenib; although the treatment controlled the liver metastases, the vertebral metastases were found to have progressed. She survived for 9 years and 5 months after the initial surgical resection. Regorafenib might be beneficial in the treatment of recurrent GISTs that prove to be resistant to imatinib and sunitinib.

[Analysis of axillary recurrence after breast reconstruction]

In recent years, breast reconstruction is being increasingly performed. Axillary resection is the standard treatment for axillary recurrence after a negative sentinel node (SN) biopsy. Appropriate treatment in the event of a negative SN artifact poses a problem. Case 1: A3 9-year-old woman with right breast cancer underwent Bt+SN (negative)+TE, IMP. Approximately 8 years postoperatively, axillary lymph node recurrence was diagnosed. Axillary resection was performed, and the reconstructed breast was preserved. Case 2: A4 0-year-old woman with right breast cancer underwent Bt+SN (negative)+TE, IMP. Approximately 8 years postoperatively, axillary lymph node recurrence was diagnosed. Axillary resection was performed, and the reconstructed breast was preserved. Case 3: A5 7-year-old woman with right breast cancer underwent Bt+SN (negative)+ TE, IMP. Because the metastatic lymph node was near the reconstructed breast, axillary resection and removal of the reconstructed breast was performed. It is expected that the incidence of axillary lymph node recurrence after breast reconstruction will increase in the future. For axillary lymph node recurrence, surgical resection needs to be performed to achieve a complete recovery. Therefore, it may be necessary to perform surgery without preserving the reconstructed breast.

[Cetuximab improved the poor performance status of a colorectal cancer patient]

A 60-year-old man with unresectable colon cancer required treatment for hydronephrosis, acute cholecystitis, and obstructive jaundice before chemotherapy. His performance status (PS) gradually deteriorated to PS 4. Cetuximab monotherapy was initiated instead of intensive chemotherapy. His general condition improved and mFOLFOX7 therapy was then continued in addition to cetuximab. A computed tomography (CT) scan after 6 months of chemotherapy revealed a partial response (PR). Cetuximab monotherapy may contribute to the treatment of patients with a poor PS.

[A case report of a splenic abscess due to colon cancer in splenic flexure infiltrating into spleen]

An 80-year-old man was admitted to our hospital with fever and dizziness. He was diagnosed with splenic abscess and invasion of descending colon cancer by enhanced abdominal computed tomography. A type 2 colon cancer was also observed in the descending colon by colonoscopy. There was no distant metastasis. Therefore, he underwent left hemicolectomy with splenectomy. A histological diagnosis of mucinous adenocarcinoma was made. The pathological findings were pT4b, pN1, cM0, fStage IIIa. The patient was discharged on the ninth post-operative day without any complications. We herein report a rare case of splenic abscess due to invasion of colon cancer and review 8 previous case reports. An en block resection including lymph node resection is recommended in such cases for curative resection.

[Mesenteric recurrence of leiomyosarcoma of the kidney seven years after the first operation - a case report]

A 60-year-old woman presented to our hospital with a pelvic tumor detected by using computed tomography at the Department of Urology of another hospital. Her medical history indicated that she had undergone left nephrectomy and left hemicolectomy for a tumor of the left kidney 7 years previously. Leiomyosarcoma of the left kidney was diagnosed on the basis of the histopathological examination at the previous hospital. Recurrence of leiomyosarcoma was suspected, and a second operation was performed. A mesenteric tumor was detected. Leiomyosarcoma recurrence was diagnosed on the basis of another histopathological examination. The patient remains free of disease and recurrence 3 years after the second operation. Primary leiomyosarcoma of the kidney is a rare disease, even among renal tumors. The prognosis of leiomyosarcoma of the kidney is poor because of frequent metastasis and recurrence. Radical resection is the preferred first choice for treatment, but recurrence still occurs frequently. In our case, the mesenteric recurrence was detected 7 years after the first operation. There have been no previous reports of mesenteric recurrence of leiomyosarcoma of the kidney. Although histopathological and immunohistochemical examinations indicated a poor prognosis, the patient is alive and there are no signs of recurrence 3 years after the second operation.

[A case report of matrix-producing carcinoma of the breast]

A 43 -year-old woman with a palpable mass in the right breast consulted a neighborhood doctor. She was diagnosed with right breast cancer after core needle biopsy, and she was referred to our hospital. Mammography revealed an indistinct mass with calcification in the lower outer quadrant of the right breast. Ultrasonography revealed a hypoechoic mass with a high echo spot. Magnetic resonance imaging (MRI) revealed a high intensity tumor with peripheral enhancement. The patient underwent mastectomy with sentinel lymph node(SN) biopsy and axillary lymph node dissection. Histologically, the tumor was composed of a solid-tubular carcinoma with a centrally located metaplastic cartilaginous element. There was an abrupt transition between these components, without intervening spindle cells or osteoclastic cells. Subtyping via immunohistochemical analysis for estrogen receptor (ER), progesterone receptor (PgR), and human epidermal growth factor receptor 2 (HER2) demonstrated that the tumor was triple negative (TN). The histological diagnosis was matrix-producing carcinoma (MPC). Adjuvant chemotherapy was administered, and she has been recurrence-free. MPC has unique features, such as emphasis of the peripheral zone of the tumor by using contrast enhanced-computed tomography (CT) and gadolinium-diethylene triamine pentaacetic acid (Gd-DTPA) MRI. Most cases of MPC that have been reported were TN. The 5 year survival rate for MPC is poorer than that for breast cancer. In Japan, 7 cases of MPC recurrence have been reported within 2.5 years, suggesting that careful follow-up is necessary for 2-3 years after surgery.

Nuclear accumulation of annexin A2 contributes to chromosomal instability by coilin-mediated centromere damage

Most human cancers show chromosomal instability (CIN), but the precise mechanisms remain uncertain. Annexin A2 is frequently overexpressed in human cancers, and its relationship to tumorigenesis is poorly understood. We found that annexin A2 is overexpressed in the nuclei of CIN cells compared with cells with microsatellite instability (MIN). Ectopic annexin A2 expression in MIN cells results in a high level of aneuploidy and induces lagging chromosomes; suppression of annexin A2 in CIN cells reduces such CIN signatures with apoptosis of highly aneuploid cells. Ectopic expression of annexin A2 in MIN cells reduces the expression of centromere proteins. Conversely, annexin A2-knockdown in CIN cells increases the expression of centromere proteins. Moreover, the endogenous expression levels of centromere proteins in CIN cells were greatly reduced compared with MIN cell lines. The reduced expression of centromere proteins likely occurred due to aberrant centromere localization of coilin, a major component of the Cajal bodies. These results suggest that nuclear accumulation of annexin A2 has a crucial role in CIN by disrupting centromere function.

Characterization of Membrane-bound Spermidine Dehydrogenase ofCitrobacter freundii

Spermidine dehydrogenase found in the membrane fraction of Citrobacter freundii IFO 12681 was solubilized with Triton X-100 and further purified to homogeneity. The properties of the membrane enzyme were almost identical to those obtained from the soluble fraction of the organism with respect to molecular and catalytic properties. Thus, binding properties of the enzyme to the bacterial membrane were checked. The ratio of enzyme activity found in the soluble fraction to the membrane fraction was dependent on salt concentration during cell disruption. A hydrophobic interaction was largely involved in anchoring the enzyme to the membrane fraction. Purified spermidine dehydrogenase from the soluble fraction was readily adsorbed into the membrane fraction in the presence of salt. Spermidine dehydrogenase appeared to be a membrane-bound enzyme localized in the cytoplasmic membranes in a manner that makes a partial release of the enzyme possible during mechanical cell disruption. When spermidine oxidation was done with the resting cells of C. freundii, a stoichiometric formation of two reaction products, 1,3-diaminopropane and gamma-aminobutyraldeyde, was observed without any lag time. These facts indicate that the enzyme is localized on the outer surface of the cytoplasmic membranes or in the periplasmic space of the organism.

Lamin B2 prevents chromosome instability by ensuring proper mitotic chromosome segregation

The majority of human cancer shows chromosomal instability (CIN). Although the precise mechanism remains largely uncertain, proper progression of mitosis is crucial. B-type lamins were suggested to be components of the spindle matrix of mitotic cells and to be involved in mitotic spindle assembly; thus, B-type lamins may contribute to the maintenance of chromosome integrity. Here, using a proteomic approach, we identified lamin B2 as a novel protein involved in CIN. Lamin B2 expression decreased in colorectal cancer cell lines exhibiting CIN, as compared with colorectal cancer cell lines exhibiting microsatellite instability (MIN), which is mutually exclusive to CIN. Importantly, lamin B2 knockdown in MIN-type colorectal cancer cells induced CIN phenotypes such as aneuploidy, chromosome mis-segregation and aberrant spindle assembly, whereas ectopic expression of lamin B2 in CIN-type colorectal cancer cells prevented their CIN phenotypes. Additionally, immunohistochemical analysis showed a lower expression of lamin B2 in cancer tissues extracted from patients with sporadic colorectal cancer (CIN-type) than that from patients with hereditary non-polyposis colorectal cancer (HNPCC; MIN type). Intriguingly, mitotic lamin B2 in MIN cancer cells was localized outside the spindle poles and mitotic lamin B2 localization was diminished in CIN cancer cells, suggesting an important role of lamin B2 in proper mitotic spindle formation. The obtained results suggest that lamin B2 maintains chromosome integrity by ensuring proper spindle assembly and that its downregulation causes CIN in colorectal cancer.

[Efficacy and safety of eribulin for metastatic breast cancer patients]

In the EMBRACE trial, eribulin was reported to significantly increase overall survival compared to treatment of the physician 's choice when given to patients with recurrent or metastatic breast cancer who had received prior treatment, including an anthracycline and a taxane. In April 2011, eribulin was approved in Japan for the treatment of inoperable or recurrent breast cancer. In this article, we report on the efficacy and safety of eribulin in cases we encountered. Twenty patients with advanced and recurrent breast cancer were administered eribulin in our hospital during the period from August 2011 to December 2012. The median age was 62 years(range, 42-76 years); 16 patients had the estrogen receptor(ER)(+)/human epidermal growth factor receptor 2(HER2)(-)subtype, whereas 4 patients had the triple-negative subtype. Following recurrence, the median number of chemotherapy regimens was 3(range, 0-5). Regarding the antitumor effects of eribulin, no cases showed complete response(CR), 5 cases showed partial response(PR), and 10 cases showed stable disease(SD); therefore, the response rate(CR+PR)was 25% and the clinical benefit rate(CR+PR+B6-month SD)was 35%. Median progression free survival was 146 days, and median overall survival was 482 days. In terms of adverse events(AEs), observed cases of hematotoxicity were of neutropenia(75%), leucopenia(75%), and anemia(80%). Cases of Grade 3 hematotoxicity or higher were of neutropenia(40%), leucopenia(20%), and febrile neutropenia(1 case, 5%). The observed non-hematotoxic AEs were peripheral neuropathy(30%)and general malaise(35%), although none were of Grade 3 or higher. The therapeutic efficacy of eribulin in the present study was relatively better than that in previous reports(EMBRACE trial, Japan Domestic 221 trial). The frequency of Grade 3 or higher AEs was low, and the drug was well tolerated. We believe that eribulin is a novel drug that provides therapeutic efficacy while maintaining quality of life(QOL).

[Analysis of elderly breast cancer patients aged 90 years and older]

In recent years, although the number of elderly patients with breast cancer is increasing, there are very few reports of breast cancer in elderly patients aged 90 years and older. In this study, we examined breast cancer patients who were 90 years of age or older. Patient background characteristics, clinicopathologic features, and treatment strategies were examined for 9 elderly breast cancer patients aged 90 or older who were treated at our department from January 2000 to December 2012. The median age of the patients was 91 (range, 90-99)years, and complications were reported in 7 patients (77.8%). The median tumor diameter was 4.3 (range, 1.4-6.0) cm, and T4 disease was observed in 6 patients (66.7%). Axillary lymph node status was negative in 6 patients (66.7%). Pathological diagnoses were invasive ductal carcinoma in 8 patients and ductal carcinoma in situ in 1 patient. Seven patients were hormone receptor positive and 1 patient was hormone receptor negative. Human epidermal growth factor receptor (HER)-2 status was negative in 8 patients. Surgery was performed safely in 5 patients and there were no signs of postoperative metastases. Four patients were treated with hormone therapy. The response rate( partial response[ PR] and complete response[ CR]) was 50%. Our findings suggest that when treating breast cancer patients aged 90 years or older, it would be necessary to offer medical treatment considering the possibility of comorbidities and the complications associated with medical treatment.

[A case of massive pancreatic neuroendocrine carcinoma successfully treated with surgical resection and postoperative everolimus administration]

A 55-year-old woman presented to our hospital with a chief complaint of abdominal pain. Computed tomography (CT) revealed a massive tumor originating from the tail of the pancreas, with liver and lymph node metastasis. Percutaneous biopsy was performed and yielded a diagnosis of pancreatic neuroendocrine carcinoma. The patient underwent distal pancreatectomy, lateral segmentectomy of the liver, para-aortic lymph node dissection, and cytoreductive surgery for treatment of peritoneal dissemination. Octreotide was administered on post-operative day (POD) 3. Treatment with everolimus (10 mg/day) was initiated on POD 32. Stable disease according to the Response Evaluation Criteria in Solid Tumors( RECIST) was observed for 4 months, and the patient survived for a total of 9 months after surgery. Everolimus was tolerated safely and was effective for the treatment of pancreatic neuroendocrine carcinoma.