[The case of a long-surviving patient with breast cancer and brain metastases treated using multidisciplinary therapy]

We present the case of a 55-year-old-woman who was diagnosed with left breast cancer, and underwent a left mastectomy and left axillary lymph node resection. The histopathological examination indicated scirrhous carcinoma and lesser papillotubular carcinoma[estrogen receptor-negative (ER-), progesterone receptor-negative(PgR-), and human epidermal growth factor receptor 2-positive, grade 3 (HER2, 3+)] with lymph node metastases. Adjuvant chemotherapy consisting of epirubicin and cyclophosphamide (EC) followed by paclitaxel was administered. During the therapy, the patient noticed a mass on her left chest wall. It was diagnosed as a locally recurrent tumor. A computed tomography (CT) scan indicated supraclavicular lymph node metastasis. The patient underwent radiotherapy and was administered chemotherapy with TS-1 and trastuzumab. Brain metastases were found 24 months postoperatively, and the patient underwent surgery and wholebrain radiotherapy. After these, systemic capecitabine and trastuzumab chemotherapy was administered. The therapy was subsequently changed to capecitabine and lapatinib. There have been no subsequent metastatic tumors, and good control has been achieved for a long time after the detection of brain metastases.

A patient with scirrhous stomach cancer treated with combination of hyperthermotherapy and 5-aminolevulinic acid (ALA)

A 35-year-old female with scirrhous stomach cancer (stage IV) was treated with a combination of 5-aminolevulinic acid (ALA), sodium dichloroacetate (DCA), hyperthermotherapy, and immunotherapy as terminal care. The patient survived for one year and seven months, during which her quality of life was markedly improved and she returned to work. The patient was diagnosed with poorly-differentiated adenocarcinoma and progressive signet-ring cell carcinoma, accompanied by left ovarian metastasis, peritoneal dissemination, and right hydronephrosis stage IV, and treated with combination chemotherapy with tegafur-gimeracil-oteracil potassium (TS-1) and docetaxel. Oral ALA and DCA were concomitantly administered at 50 mg each three times a day (150 mg/day, respectively). In addition, hyperthermotherapy using thermotron was concomitantly performed at 2- to 3-week intervals. Cellular immunotherapy with αβ T- and immature dendritic cells was also performed. The disease did not progress for 11 months, her quality of life was markedly improved, and she was able to return to work. However, the signs of enlargement of the ovarian metastatic lesion were noted later, for which chemotherapy with four cycles of second-line paclitaxel and a half dose of irinotecan and cisplatin as third-line treatment were performed. Combination of ALA/DCA, hyperthermotherapy, and cellular immunotherapy may be a low-invasive palliative therapy superior in maintaining quality of life of tumor-bearing terminally ill individuals.

Usefulness of multidisciplinary therapy combining neoadjuvant chemotherapy with S-1 plus cisplatin and postoperative sequential chemotherapy in patients with scirrhous gastric cancer

BACKGROUND/AIMS

The outcomes of patients with scirrhous gastric cancer (SGC) remain poor. We retrospectively compared outcomes according to historically different treatments for SGC and studied the therapeutic usefulness of NAC with S-1 plus cisplatin followed by postoperative sequential chemotherapy.

METHODOLOGY

We studied 93 patients with SGC. Between 1995 and 2000, 29 patients did not receive NAC and were instead given conventional anti-cancer drugs. Between 2000 and 2003, 20 patients received 4 weeks of NAC with low-dose cisplatin plus 5-fluorouracil (5-FU) followed by postoperative sequential treatment with new anticancer agents (neoadjuvant low-dose FP group). Between 2003 and 2006, 44 patients received 2 courses of NAC with S-1+cisplatin followed by postoperative sequential administration of new anticancer agents (neoadjuvant S-1+cisplatin group). Response rates and overall survival were compared among the treatment groups.

RESULTS

The rates of response to NAC were 15% in the neoadjuvant low-dose FP group and 36% in the neoadjuvant S-1+cisplatin group. Overall survival was significantly longer in the neoadjuvant S-1+cisplatin group than the other groups.

CONCLUSIONS

Our results suggest that multidisciplinary therapy combining NAC with S-1+cisplatin and postoperative sequential administration of new anticancer drugs is therapeutically useful in patients with SGC.

[A case of type 4 gastric cancer with positive peritoneal lavage cytology, which relapsed at the peritoneum at the time of seven years and eight months after resection]

A 55-year-old woman was admitted to our hospital with a complaint of appetite loss and body weight loss. Upper digestive endoscopy showed a giant fold at the greater curvature stomach and diffused edematous gastric mucosa. Abdominal contrast CT demonstrated a significant thickening of the gastric wall and a large number of lymph node swelling. A clinical finding was Stage IIIB (T3N2M0) Type 4 gastric cancer of poorly differentiated adenocarcinoma. Total gastrectomy, splenectomy and D2 lymph node dissection were performed. Although there was no peritoneal dissemination, peritoneal lavage cytology was positive. After the operation, S-1 alone chemotherapy was administered for four years. No recurrence had occurred for about seven years and eight months after resection. However, the patient was pointed out the signs of recurrence (ascites and induration) by CT. Now, S-1 alone chemotherapy was performed again, and the patient has been in good health.

[Three scirrhous gastric cancer cases with CY negativity in second-look staging laparoscopy after chemotherapy to whom curative surgery was carried out]

Case 1: A 77-year-old female with scirrhous gastric cancer was diagnosed as c4T3N1H0M0P0CY1/stage IV, and S-1/docetaxel combined therapy was carried out. The wall thickness of stomach improved after 11 courses. Case 2: A 48-year-old female with scirrhous gastric cancer was diagnosed as c4T3N1H0M0P0CY1/stage IV, and S-1/CDDP/paclitaxel combined therapy was carried out. The wall thickness of stomach improved after 5 courses. Case 3: A 37-year-old man with scirrhous gastric cancer was diagnosed as c4T3N0H0M0P1CY1/stage IV, and S-1/CDDP/paclitaxel combined therapy was carried out. The wall thickness of stomach improved after 5 courses. In all cases, CY and P negativity was confirmed in second-look staging laparoscopy and curative surgery was carried out.

Retrospective analysis of prognosis for scirrhous-type gastric cancer: one institution's experience

BACKGROUND

Scirrhous gastric cancer is biologically aggressive, and the prognosis is poor even with curative surgery. We compared outcomes with different therapies in order to identify prognostic factors.

METHODS

Records for 83 patients, who were treated between 1991 and 2004, were evaluated for survival and stage, treatment, and clinicopathological factors.

RESULTS

Cumulative 5-year overall survival was 10.2% for all 83 patients, including 27 (32.5%) patients with stage II/III disease and 56 (67.4%) with stage IV disease. The 5-year overall survival rate and median survival time for patients with stage II/III disease after curative surgery were 24.3% and 1150 days. For patients with stage IV disease, 2-year and 5-year survival rates after initial surgery were 13.7% and 0% and median survival was 250 days. In contrast, preoperative chemotherapy for advanced, unresectable disease produced 2-year and 3-year overall survival rates of 53.6% and 26.8% and medican survival was 910 days.

CONCLUSION

Aggressive surgery alone does not seem to improve outcome, but preoperative chemotherapy might be beneficial and should be investigated further.

Preclinical study of a "tailor-made" combination of NK4-expressing gene therapy and gefitinib (ZD1839, Iressa) for disseminated peritoneal scirrhous gastric cancer

We evaluated the effect of a "tailor-made" chemo-gene therapy in scirrhous gastric cancer (SGC)-bearing nude mice. For this tailor-made approach, we first selected gefitinib (epidermal growth factor receptor-tyrosine kinase inhibitor)-sensitive SGC cell lines, and 5/8 cell lines demonstrated various degrees of gefitinib-sensitivity. In the highly gefitinib-sensitive NUGC-4, the biological response to NK4 (HGF antagonist/angiogenesis inhibitor) was examined. Subsequently, the composition of an NK4-expressing ternary complex (cationic lipid/nucleic acid/HMG-1, 2 protein) was optimized for maximum transfection activity in NUGC-4. Finally, mice were peritoneally coinoculated with NUGC-4 and scirrhous-associated gastric fibroblasts, NF22, on day 0. Animal models were orally administrated gefitinib (50 mg/kg/day, on days 7-28), and peritoneally NK4-expressing ternary complex (on days 14, 21 and 28). NK4-expression suppressed the gefitinib-resistance induced by the interaction between fibroblasts and SGC, and eventually, this tailor-made combination synergistically decelerated the disease progression by inhibiting proliferative, angiogenic and antiapoptotic effects in tumor tissues. On day 28, both the hemoglobin concentration (g/dl) (control (n = 8), 11.9; treated (n = 8), 17.3; p = 0.0014) and the numbers of mice in good condition (control, 2; treated, 8; p = 0.0012) were significantly greater, and the abdominal girth (mm) (control, 81.1; treated, 70.3; p = 0.0036) was significantly reduced. The median points of bloody ascite-free survival time (days) (control, 22; treated, 44; p < 0.0001) and time to euthanasia (days) (control, 36.5; treated, 56; p < 0.0001) were also significantly prolonged. This combination is a potentially useful approach to the treatment of peritoneal gefitinib-sensitive SGC dissemination.

Flare-up of Dermatomyositis Along with Recurrence of Breast Cancer

Dermatomyositis is an idiopathic inflammatory myopathy with characteristic cutaneous manifestations. The association between dermatomyositis and malignancy is becoming more clearly delineated. A sort of dermatomyositis is thought to be paraneoplastic syndrome and dermatomyositis may follow clinical course of malignancy. We report a 68-year-old woman with dermatomyositis, whose clinical onset of dermatomyositis was apparently concomitant with breast cancer. Dermatomyositis had settled down and oral steroid could be tapered after the resection of breast cancer. Creatine kinase value was elevated before the detection of the first and second recurrence and in the terminal state. At the second recurrence, skin lesions and creatine kinase value had flared up and immediate metastatic check-up revealed the recurrence. Our case shows dermatomyositis, which was thought to be paraneoplastic syndrome, that followed clinical course of malignancy and suggests immediate check-up is needed for early detection of recurrence when dermatomyositis flares up after the resection of the malignancy.

Therapeutic strategy for scirrhous type gastric cancer

BACKGROUND/AIMS

As no appropriate therapeutic strategy has yet been established in scirrhous type gastric cancer, we retrospectively analyzed the therapeutic outcomes in patients with this type of cancer.

METHODOLOGY

A total of 183 patients with scirrhous type gastric cancer were enrolled in the study. 127 of them underwent resection; 61 potentially curative gastrectomy; 66 palliative resection; and 56 had no surgery.

RESULTS

Univariate analysis revealed that the number of metastatic lymph nodes and the depth of invasion influenced prognosis in curatively resected cases, whereas no factor did so after palliative resection. Multivariate analysis showed that prognosis was affected independently by peritoneal metastasis and non-regional lymph node metastasis in all resected cases, but by the number of metastatic lymph nodes in curatively resected cases. There was no significant difference in survival between patients undergoing and those not undergoing palliative gastrectomy. Prophylactic (6) and therapeutic CHPP (12) had no efficacy on peritoneal metastasis. Furthermore, left upper abdominal evisceration (LUAE) (9) did not improve long-term results in curatively resected cases.

CONCLUSIONS

In scirrhous type gastric cancer, gastrectomy including extended lymph node dissection is justified only in patients with limited lymph node metastasis, and palliative gastrectomy should be not performed because it has no efficacy on survival.

Management protocol for scirrhous gastric cancer

BACKGROUND

The prognosis for patients with scirrhous gastric cancer (SGC) is extremely poor. However, the management protocol for this type of cancer has not been well discussed. In this study, we retrospectively evaluated the management of SGC and we introduced a new treatment protocol for SGC.

PATIENTS AND METHODS

Between 1991 and 2001, 58 patients with SGC were treated. Thirty-nine, who underwent gastrectomy, were divided into 3 sub-groups according to peritoneal metastasis (P) and peritoneal washing cytology (CY) status [P(-)/CY(-), P(-)/CY(+), and P(+)/CY(+)]. The survival rates of these 3 sub-groups were compared with patients who did not have a gastrectomy (n=19), retrospectively. From 2002, we started a new treatment protocol for SGC. Laparoscopic diagnosis of P or CY and intraperitoneal chemotherapy (IPC) were performed before performing laparotomy on 10 patients with SGC.

RESULTS

The 5-year survival rate of the 19 patients in P(-)/CY(-) was 11.6%. The survival rates of patients with P(-)/CY(+) or patients with P(+)/CY(+) were no different from patients who did not have gastrectomy (pleural effusion or ascites negative). In 10 patients who were treated with the new protocol, 7 with P(-)/CY(-) underwent gastrectomy after IPC and 3 with P(+)/CY(+) underwent repeated IPC.

CONCLUSION

Gastrectomy may not have prognostic benefit for patients with SGC with CY(+). Thus, we recommend laparoscopic diagnosis of peritoneal metastasis or peritoneal cytology before performing laparotomy on these patients.

Poorly differentiated carcinomas of the thyroid with trabecular, insular, and solid patterns: a clinicopathologic study of 183 patients

BACKGROUND

The term poorly differentiated (PD) carcinoma was proposed 20 years ago to define aggressive, follicular-derived thyroid carcinomas with behavior intermediate between follicular/papillary and anaplastic carcinomas. Among the variable histologic patterns recognized in such tumors, trabecular-insular-solid (TIS) areas usually are predominant. Conversely, some authors pointed out that PD carcinomas are characterized by unequivocal, high-grade histology with atypias, high mitotic counts, and necrosis rather than by a specific growth pattern.

METHODS

The clinicopathologic features of a series of 183 thyroid carcinomas with predominant (n = 165 tumors) or focal (n = 18 tumors) TIS growth patterns were studied by univariate and multivariate overall survival analyses and were compared with clinical outcomes. Subgroups included tumors with predominant oxyphilic features (n = 66 tumors) and (residual) papillary carcinoma features (n = 24 tumors). Control groups of papillary (n = 68 tumors), follicular (n = 71 tumors), and anaplastic (n = 35 tumors) carcinomas also were included for overall survival analysis.

RESULTS

TIS carcinomas had an intermediate behavior between papillary/follicular and anaplastic carcinomas (P < 0.0001). Univariate and multivariate statistical analyses demonstrated that age > 45 years (P = 0.007), the presence of necrosis (P < 0.0001), and a mitotic count > 3 per 10 high-power fields (P = 0.01) were associated with poor outcome. A simplified scoring system based on statistically significant parameters allowed the identification of three prognostic subgroups (P < 0.0001).

CONCLUSIONS

PD TIS carcinomas overall followed a more aggressive course compared with differentiated thyroid carcinomas, irrespective of the extent of the TIS component. However, a numeric scoring system applied to specific clinicopathologic parameters further may identify three prognostic categories of patients who have significantly different survival rates at 5 years and 10 years.

Neoadjuvant chemotherapy with S-1 for scirrhous gastric cancer: a pilot study

We conducted a pilot study using S-1 (TS-1), a novel oral derivative of 5-fluorouracil, as neoadjuvant chemotherapy for potentially resectable scirrhous gastric cancer. The neoadjuvant chemotherapy consisted of two courses (each, 4-week administration and 2-week withdrawal) of S-1 at 100-120 mg/body per day. Five patients were enrolled in this pilot study and underwent resection. The response rate for the neoadjuvant chemotherapy was 60% (three partial response [PR]; two stable disease [SD]). Three of the five patients received curative resection; the other two patients received noncurative resection because of localized peritoneal dissemination and positive results on cytological examination of the abdominal washing. No toxicity of grade 3 or more was exhibited during the two courses of chemotherapy. Pathological examination of the resected specimens revealed a marked reduction in the distribution of viable cancer cells in the stomach in the three patients with PR. In one of these patients, pathological findings suggestive of the possibility of disappearance of the cancer cells in the perigastric and paraaortic lymph nodes were noted. Because of the unexpectedly high response to S-1, we consider that the efficacy of S-1 as neoadjuvant chemotherapy for scirrhous gastric cancer should be verified by phase II and III trials.

Predictive value of estrogen receptor status as assessed by ligand-binding assay in patients with early-stage breast cancer treated with breast conserving surgery and radiation therapy

It is important to determine which factors are predictive for the prognosis of patients treated with breast conserving surgery (BCS) and radiation therapy (RT) in order to make a decision as to the adjuvant treatment. Although estrogen receptor (ER) is known to be a predictive marker for antiestrogens in breast cancer, the prognostic effect of hormone receptors has not been fully analyzed in Japanese breast cancer patients treated with BCS and RT. A total of 153 breast cancer patients having up to three positive nodes in the axilla as identified histologically and treated with both BCS and RT with or without systemic therapy were enrolled in this study. All tumors were measured for ER and progesterone receptor (PR) using ligand-binding assay (LBA). ER was inversely related to patients' age, however, PR was not related to any clinical features. When ER was classified into negative, weakly positive and strongly positive categories, with cut-off levels of zero and 50 fmol/mg protein, the relapse-free survival (RFS) was significantly better in patients with tumors having strongly positive ER than in patients with tumors having negative ER. Multivariate analysis revealed that ER as well as nodal status, was an independent predictive factor for RFS, however, PR was not. As a result, we believe that ER measured by LBA is valuable for predicting prognosis of early-stage breast cancer patients treated with BCS and RT.

A case report of immunotherapy on a patient with advanced gastric cancer by adoptive transfer of OK-432-reactive HLA-matched allogeneic lymphocytes

Adoptive immunotherapy (AIT) for non-hematological malignancies, using HLA-matched donor lymphocytes, has been rarely reported. For a 35-year-old male patient with peritoneal disseminated advanced gastric cancer, we performed AIT using lymphocytes from his HLA-matched 37-year-old brother and a streptococcal preparation, OK-432, as an antigen. After the donor had been immunized by intradermal administration of OK-432, OK-432-reactive lymphocytes were induced in vitro and transferred to the patient intravenously with OK-432. Low-dose systemic immunochemotherapy, using interleukin-2, 5-fluorouracil and cyclophosphamide, was concurrently administered with AIT. As a result, the Schnitzler metastasis in the patient reduced in size without any significant graft-versus-host-related complications. One of the effector mechanisms of therapeutic benefit was suggested to be cytokine release from the transferred OK-432-reactive lymphocytes. Our findings suggest the safety and efficacy of AIT using lymphocytes from an HLA-matched sibling and OK-432 as an antigen. Further studies to investigate the use of tumor-associated antigen and an HLA-matched sibling's lymphocytes for AIT of advanced cancer are warranted.

[Osteogenesis imperfecta and breast carcinoma. A case study of radiobiological interest]

PURPOSE

Osteogenesis imperfecta (OI) is an inherited disorder of connective tissue with abnormal quality and/or quantity of type 1 collagen. The frequency of the association of OI and breast cancer as well as the frequency of radiation induced side-effects in patients with OI are not known. Certain diseases with widespread collagen alterations such as systemic lupus erythematodes or dermatomyositis--although not exactly comparable to congenital OI--carry a high risk for radiation injuries in case of irradiation with normal doses. The report of a patient with osteogenesis imperfecta type I and postmastectomy irradiation might therefore be of some radiobiological interest.

METHODS

Report of a 46-year-old women with OI type I and breast cancer with a 14-year follow-up time after mastectomy and external beam irradiation.

RESULTS

During all the follow-up time there was no radiation injury in this patient with OI type I and breast cancer.

CONCLUSION

Mostly it is not possible to draw a valid conclusion from a case report, but with this experience the combination of OI type I and radiotherapy seems not to cause unusual radiation injury. Contrary to OI of type II and III, in the majority of the cases of OI type I there is a normal quality, but diminished quantity of collagen type I. This could be one of the possible reasons for the absence of adverse radiation effects. Finally, it might be of interest, that the gene-locus of the two alpha-1(I)-chains of collagen type I is situated at chromosome 17q21-22, where also the location of the "breast-cancer gene" is supposed to be. A genetic examination was, unfortunately, refused by the patient.

[Chemotherapy of scirrhous gastric cancer]

Cancer chemotherapy plays a central role in the treatment of recurrent or unresectable scirrhous gastric cancers classified mainly as Borrmann type 4. Though we have no specifically effective drugs for scirrhous gastric cancer, 5-FU and its derivative, MMC, anthracyclines, CDDP, CQ and ACNU are known to be relatively effective single agents against this tumor. In an attempt to enhance the effect of single agents, several combined chemotherapy regimens have been devised and tested. These regimens included 5-FU + MMC, UFT + MMC, UFT + CDDP, MTX.5-FU, FAM, FAP, EAP and ELF regimen. At present, combined therapies using 5-FU and MTX or CDDP may be the most attractive of these combined regimens.

Clinical aspects of ovarian tumors of low malignant potential

A review of 21 cases of ovarian tumors of low-malignant potential diagnosed in our department over a period of 13 years was undertaken. Ninety percent of the patients presented with stage I disease. The average age at diagnosis (45 years) was younger than commonly found in patients with invasive epithelial cancer. Three patients received postoperative chemotherapy, and all of those were evaluated by second-look laparotomy. One of our patients with stage Ic serous tumor recurred with lung metastases. In two other patients with mucinous tumors, mucocele of the appendix was found. The five year survival in this series was 100%. Our study emphasizes the need for a prospective study to evaluate the value of adjuvant therapy in the various stages of these ovarian neoplasms.

Metastatic breast carcinoma of the orbit

Two Caucasian females in whom an orbital mass was the first sign of metastasis from a breast carcinoma are described. Each subject had undergone a radical mastectomy to treat a primary breast carcinoma, one six years and the other eight years previously. Each presented with ipsilateral proptosis, and restricted upper eyelid action; one had altered ocular motility. In each subject an open biopsy of the orbital mass via an eyelid crease incision revealed metastatic scirrhous adenocarcinoma of the breast. The clinical features, investigations, and treatment of orbital metastases from breast carcinoma are discussed.

[Local immunotherapy of breast cancer: a case of advanced breast cancer improved by combined local injection therapy with OK-432 and rIL-2]

An effective immunotherapy for breast cancer has yet to be established. We have recently experienced an inoperable case of advanced breast cancer due to mental disorder. Combined local injection therapy with OK-432 and rIL-2 was performed in addition to non-surgical multi-disciplinary treatment, with obvious therapeutic effects. The case is a 67-year-old female, who had a 5.0 x 4.7 cm tumor in the area A of the left mammary gland. Aspiration cytologic examination revealed class V breast cancer. Besides systemic chemotherapy, local injection therapy with OK-432 2.0 KE on day 1 and rIL-2 500 U on day 3 was performed. Upon starting local injection therapy, a rapid reduction was noted in the tumor diameter (reduction rate, 75.5%). Tumor makers of CEA, CA 15-3 also showed obvious diminution. Although the dose and interval of administration remain to be further examined, the combined local injection therapy with OK-432 and rIL-2 was suggested to be an effective local immunotherapy for breast cancer.

[Two cases of advanced breast cancer with distant metastasis showing long-term survival with multidisciplinary treatment including intra-arterial infusion chemotherapy]

Two cases of advanced breast cancer are reported that have had no recurrence for more than five years after multidisciplinary treatment including intra-arterial infusion chemotherapy. The first case is a 62-year-old housewife who had brain metastases. The primary lesion and distant metastases were completely responsive to irradiation combined with chemoendocrine therapy. The other one is a 38-year-old housewife with ovarian metastasis that was revealed after oophorectomy. In this case chemoendocrine therapy was added without irradiation after intra-arterial infusion chemotherapy. These cases indicate that intra-arterial infusion chemotherapy can be recommended as a component of multidisciplinary treatment even in advanced breast cancer with distant metastasis.

[Basic and clinical study of adoptive immunotherapy using cytotoxic T lymphocyte (CTL) against cancers]

Cytotoxic T cells (CTL) have been known to be one of the effector cells responsible for regression of tumors. In tumor-bearing hosts, CTL insufficiently attack the tumor because the suppressor cells inhibit the induction and activation of CTL. In our in vitro study, CTL were induced from peripheral blood lymphocytes (PBL) of cancer patients. These CTL showed the specific cytotoxic activity against autologous tumor in one case and broad specificity against tumors in other cases. A patient with breast cancer was treated with adoptive immunotherapy of CTL because she had severe side effect from antineoplastics . Her breast cancer was histologically scirrhous type adenocarcinoma which was resistant to antineoplastics. Patient's PBL were cocultured with mitomycin C treated-autologous tumor, and they were proliferated with interleukin 2 or T-cell growth factor (TCGF). Then, these CTL were injected to this patient intravenously at the interval of one or two weeks. Before serial injection of CTL, antineoplastics was prescribed in order to inhibit the function of suppressor cells and cancer cells. The sizes of tumors were gradually reduced, suggesting clinical regression. We suggest that combined treatment of adoptive immunotherapy using CTL and antineoplastics (CTL therapy) is very useful in the treatment of cancer patients.

[Breast cancer associated with pregnancy]

Two cases of breast cancer associated with pregnancy were reported and the immunological assessment was performed in the second case. Case 1: A 36 year-old woman in the first trimester of pregnancy and having a large axillary mass and breast lump was admitted. She was diagnosed as having Stage IIIb breast cancer. After interruption of pregnancy, she received an extended radical mastectomy and radiotherapy. However, she died nine months after surgery for brain and liver metastases. Case 2: A 30 year-old woman in her second trimester of pregnancy was admitted for a large breast mass. She was diagnosed as having Stage IIIa breast cancer. Interruption of pregnancy was again necessary to perform surgery followed by chemotherapy. After an extended radical mastectomy she was placed on a combination chemotherapy regimen with cyclophosphamide, adriamycin and 5-FU. In both cases tumors began to develop rapidly at pregnancy. Immunological studies in Case 2 showed a depression of T-lymphocyte function and NK cell activity. Our study suggests that the depression of cell-mediated immunity during pregnancy may promote tumor growth.

[Hyperthermia adjunct to surgery in the treatment of scirrhous carcinoma of the stomach]

In approximately 80% of patients with scirrhous carcinoma of the stomach, recurrence of cancers occurs even after potentially curative resection, and recurrence most frequently occurs in the form of peritoneal metastasis. Such recurrence may be attributable to possible intraperitoneal dissemination of malignant cells already present at the time of surgery. We performed intraoperative peritoneal cytology on patients with scirrhous carcinoma of the stomach. Free cancer cells were demonstrated in the Douglas cavity in 16 of 32 (50%) patients who underwent potentially curative gastrectomy. The postoperative 5-year survival rate was 23% in patients without detectable free cancer cells in the peritoneal cavity, compared with only 9% in patients with microscopic evidence of intraperitoneal free cancer cells. Therefore, we have applied hyperthermic continuous peritoneal perfusion (CHPP) on patients with scirrhous carcinoma of the stomach in order to develop a surgical adjuvant therapy effective for the prevention of recurrence of peritoneal involvement. The results obtained so far from our study have shown an increased 3-year survival rate of patients undergoing potentially curative gastrectomy, but no improvement of therapeutic outcome in terms of postoperative 5-year survival.

Breast cancer: presentation and prognosis in the community hospital

A retrospective analysis of all breast cancer primarily treated at this institution during the ten-year period from 1967 to 1977 revealed 336 cases; in 308 of these cases, complete follow-up of five or more years was available. Clinical staging using the TNM system (tumor, node, metastasis) showed stage I disease in 60 patients, stage II in 94, stage III in 105, and stage IV in 49. Pathologic classification of these 308 cases showed a high incidence of infiltrating ductal carcinoma (88%). Early in the study operative treatment consisted of radical mastectomy, with modified radical mastectomy being more common in the later years. Simple mastectomy was occasionally done palliatively. Adjuvant treatment using cyclophosphamide (Cytoxan), methotrexate, 5-fluorouracil, radiation, and/or hormonal manipulation was then given according to a set protocol. In general, five- and ten-year survival improved with this combined treatment. The mortality among patients with stage I infiltrating ductal carcinoma not given adjuvant therapy suggests the need for proper selection of patients in this group who should receive adjuvant chemotherapy because they are at increased risk.

[Proliferation of scirrhous type of gastric carcinoma and its treatment]

An attempt was made to clarify the clinical prognosis of scirrhous type of gastric carcinoma and to improve its treatment. The cases of gastric carcinoma operated and histologically well analyzed from 1969 to 1973 was 178, and scirrhous type was included in 52%. Advanced carcinoma (more than ss alpha) was 80% in scirrhous type and 40% in non-scirrhous type. Five year survival rate in scirrhous type was 45% and 59% in non-scirrhous type. (P divided by 0.09). In pm carcinoma, however, the 5 year survival rate of scirrhous type was higher than that of non-scirrhous type (P divided by 0.06). Between the primary lesions and lymphatic metastasis, histologic type was not the same in 70%. The survival rate of scirrhous type in lymphatic metastasis was again higher than that of the non-scirrhous type. Mitotic index was 18.6 +/- 8.6 in scirrhous type, 52.8 +/- 13.5 in medullary type, 54.1 +/- 16.5 in intermediate type and 53.3 +/- 11.5 in non-cancerous gastric epithelium. For the scirrhous type with a large amount of highly degenerated interstitial and poor blood vessel supplying, many doses of chemotherapeutic agents may be necessary, and, especially, cytostatic agents should be administered for long periods.

Changing patterns of breast cancer

Changes in treatment of breast cancer are high-lighted as follows: 1) Outpatient breast biopsy offers advantages in planning treatment and also saves money, 2) Mammograms are increasing the numbers of breast tumors found early, 3) For many reasons modified mastectomy is finding increasing use, 4) Breast cancer appears to be multifocal at least one-half of the time. Multifocal breast cancer is more aggressive, 5) Bilateral breast cancer appears to have a very favorable prognosis, especially when non-simultaneous.

Detection of the estrogen receptor and response to endocrine therapy in male breast cancer patients

The estrogen receptor was measured in breast cancer of two male patients. Both patients had a positive receptor content in their tumors. The dissociation constant and number of binding sites were both very similar to those in the female counterpart. In one of the patients, the number of binding sites in the metastatic lesions of the liver was similar to that in the primary site. The patient responded well to the endocrine ablation therapy with a remission period of 8 months. The estrogen receptor was found to be positive in 12 out of 14 cases of male breast cancer reported previously including the present 2 patients. Three out of 4 cases with positive receptor contnet, including the present case, responded to orchiectomy.

The uptake and metabolism of (4-14C)testosterone in human breast cancer growth in organ culture

The uptake and metabolism of [4-14C]testosterone was studied in 10 tissue samples of human female breast grown in organ culture. Four samples were from carcinomas, 4 were non-cancerous tissue from the uninvolved part of the cancer bearing breast, and two were from fibroadenomas. In all cases testosterone was metabolized to androstenedione, androsterone, dihydrotestosterone, androstanedione and androstanediol. The non-cancerous tissues showed greater retention, uptake and conversion of testosterone into metabolites than the cancerous tissues. The retention of testosterone in the fibroadenomas samples was lower than that in samples of either cancerous or non-cancerous tissue. The uptake and conversion of testosterone into metabolites in one case of fibroadenoma was similar to that seen in cancerous tissue samples but in the other case it was considerably higher.