Background: Although breast-conserving therapy consisting of wide excision followed by radiation therapy has been established as a standard treatment for breast cancer, a number of patients are ineligible for this treatment option. We carry out skin-sparing mastectomy (SSM) with immediate breast reconstruction for such patients. This study assessed therapeutic outcomes with SSM in patients treated at our department.
Patients and Methods: Thirteen patients who underwent an SSM with immediate breast reconstruction between November 2000 and October 2002 were reviewed. Fourteen patients treated by a conventional non-skin-sparing mastectomy (NSSM) with immediate breast reconstruction during the same period served as controls.
Results: The SSM technique was used more often in patients with ductal carcinoma in situ (DCIS) or early-stage cancer including T1 (P = 0.0132). Minor flap necrosis was observed in 2 patients who underwent an SSM and in 1 who underwent an NSSM postoperatively. Two patients (14.3%) who underwent an NSSM presented with local recurrences and 3 (21.4%) with distant metastases. It is remarkable that no patients who underwent an SSM presented with local recurrence and 1 (7.7%) with distant metastasis.
Conclusion: SSM with immediate breast reconstruction is a preferable surgical option for patients ineligible for breastconserving therapy, especially those with wide-spreading DCIS.

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An esophageal duplication cyst is a cyst originating in the foregut. These cysts are relatively rare, accounting for only 0.9 to 2.5% of mediasternal tumors. A patient presented with a duplication cyst from the abdomen, which had perforated into the esophageal lumen with a consequent abscessation. This cyst was surgically resected. The patient was a 57-year-old man and he presented at a nearby hospital with epigastric pain in November 2006. An examination revealed a mass perforating into the esophageal lumen with a hemorrhage directly above the esophagogastric junction. Although conservative treatment was administered for 4 months, the mass was associated with abscessation and progressed into an intractable condition. Therefore, the patient was referred for surgical treatment. An examination revealed a nearly semicircular submucosal tumor situated just superior to the esophagogastric junction and persistent draining was also noted from its central recess. Abdominal computed tomography, magnetic resonance imaging scans and echography demonstrated a cystic lesion, 50 mm in diameter, containing fluid, walled with a thick septum having an irregular luminal surface and abutting on the wall of the abdominal esophagus. A surgical resection was indicated for this condition because the possibility of malignancy could not be ruled out based on the diagnostic imaging results. A laparotomy with a lower esophagectomy and fundusectomy were performed in combination with reconstruction by jejunal interposition. After the operation the patient's condition was favorable and he is now being followed on an outpatient basis. The histopathological diagnosis of the present case was a duplication cyst associated with the microscopic features of inflammation.

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Smart Care ^® (SC) is an automated weaning system which has been newly installed in the Evita XL Ventilator made by Dräger Medical (Lubeck, Germany). This study was performed to investigate the application of SC to postoperative respiratory management in patients with esophageal cancer, for the purpose of more objectively assessing postoperative weaning from the ventilator, which has largely been performed based on the individual physician's experience. This study included 8 patients with cancer of the thoracic esophagus who were weaned postoperatively from the ventilator using SC. The weaning was performed by adjusting the ventilator automatically using SC to decrease the preset pressure support (PS) level to 7 cmH₂O, using spontaneous respiratory rate (F spont), expiratory tidal volume (Vte) and end-tidal carbon dioxide pressure (etCO₂) as the assessment factors under the conditions of continuous positive airway pressure (CPAP) mode and a positive end expiratory pressure (PEEP) of 5 cm or less. In all 8 patients, weaning was accomplished with the display of the message "Consider Separation", in accordance with which the endotracheal tube was removed. The mean duration of intubation was 32 ± 4.0 hours, and that of SC use was 104.4 ± 42.8 minutes. SC proved remarkably useful in that all the patients had an uneventful course after the removal of the endotracheal tube and none required reintubation. It is expected in the future that the use of SC will enable the establishment of a uniform weaning protocol after esophageal cancer surgery, and this may contribute to the standardization and higher efficiency of postoperative respiratory management.

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  We reported a case which developed obstructive cholangitis of the accessory bile duct 30 years after undergoing a cholecystectomy. A 78-year-old male patient was admitted to the emergency department, presenting with a fever of 40 degrees Celsius with chills and abdominal pain. The patient's past medical history included a cholecystectomy performed approximately 30 years ago.
  Contrast-enhanced computed tomography (CT) and magnetic resonance cholangio-pancreatography (MRCP) findings led to a diagnosis of obstructive cholangitis associated with jaundice due to the obstruction of the accessory bile duct. This was possibly attributable to a ligation of the accessory bile duct which was injured during cholecystectomy. The intraoperative findings showed confluence of the dilated intrahepatic bile duct and the common bile duct in the vicinity of the cystic duct which was already resected. The accessory bile duct was ligated and resected at the confluence followed by right hepatic lobectomy. A histopathological examination of the resected specimen showed the cord-like, occluded area of the stenosed accessory bile duct with no neoplastic lesions. It should be noted that inflammation may occur in the accessory bile duct associated with difficult differentiation if cholecystitis develops concurrently due to gallstone incarceration in the neck of the gallbladder. Therefore, drip infusion cholangiography-CT and MRCP are required preoperatively for the sufficient visualization of direction of the bile ducts, and endoscopic retrograde cholangiography should also be performed if no satisfactory results are obtained from these imaging tests. It is important to ensure that the direction of the bile ducts in the individual segments is always confirmed before performing a cholecystectomy.

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We reported the first case of spontaneous rupture of the intrahepatic bile duct due to carcinoma of the ampulla of Vater. The patient was a 67-year-old male and he visited the hospital in a pre-shock state. He was diagnosed as panperitonitis and an emergency operation was performed on that day. A laparotomy revealed ascetic fluid containing bile to be retained in the abdominal cavity. Intraoperative cholangiography showed a complete obstruction of the lower common bile duct and the rupture of the intrahepatic (S3) bile duct. A lateral segmentectomy of the liver was performed, followed by T-tube biliary drainage. A two-stage checkup/operation was planned for treatment of the obstruction of the common bile duct. Endoscopic retrograde cholangiography (ERC) performed postoperatively revealed a mass in the ampulla of Vater causing a marked stricture of the common bile duct in that region. A pylorus-preserving pancreaticoduodenectomy including a regional lymphadenectomy was performed about 5 months after the initial operation. There has been no other reports documenting a two-stage operation for the resection of a malignant tumor after treatment with bile peritonitis . The avoidance of sepsis and multiple organ failure via surgical treatment directed against bile peritonitis at the appropriate time is considered optimal strategy to save the life of a patient with this condition.

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Cellular schwannoma is rare neoplasma and often situates in deep structures, so that its diagnosis is quite difficult. We herein report a case of a cellular schwannoma variant arisen in an intrapelvic space. A 62 year-old female had a magnetic resource imaging (MRI) examination of the lumber, which indicated a mass in the intrapelvic space behind the rectum. In T1-weighted image, the mass was slight low in intensity with cystic lesions being low. In T2-weighted image, the majority of the mass was low in intensity, whereas diffuse cystic lesions within it high. In computed tomography (CT), the tumor was well-demarcated round mass with heterogeneous low and intermediate attenuation area and punctual calcification. Because the mass was highly suspected as a pelvic mesenchymal neoplasm such as gastrointestinal stromal tumor or sarcoma, operation was performed. At laparotomy, the tumor had a thin capsule without invasion to the rectum or the mesorectum, and was arisen from the left hypogastric nerve. We cut off the left hypogastric nerve to extirpate the tumor. Macroscopically, it was a solid tumor and the color of the cutting surface was yellow-white with cysts. Pathologically, the tumor consisted of compact spindle cells arranged in short bundles or interlacing fascicles with high density. Nuclear palisading and Verocay body formation that is seen in the typical schwannomas were not spotted. Hyalinization, hemorrhage, xanthic change and lipofuscin precipitation were detected. Mitosis and necrosis were not present. Immunohistochemically, S-100β and glial fibrillary acidic protein (GFAP) was positive in tumor cells. Smooth muscle actin (SMA), CD34, CD117 and neurofilament were negative. MIB-1 index was less than 5%. Final diagnosis was obtained as a cellular schwannoma variant.

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We herein report a case of curative resection, after a response to chemotherapy with mFOLFOX6, for sigmoid colon cancer which had been unresectable due to an invasion of the primary lesion into the aorta. A 58-year-old male patient visited the department of internal medicine of our hospital with chief complaints of lower abdominal pain and a lower abdominal mass. Computed tomography suggested colorectal cancer, and the patient was referred to our department. A diagnosis of sigmoid colon cancer was made, and a laparotomy was performed. However, the cancer was unresectable due to its invasion into the aorta, which led to the implementation of sigmoid-rectal anastomosis. Thereafter, chemotherapy with mFOLFOX6 was initiated, and the tumor shrunk markedly after seven courses of the treatment. The clinical response was rated as partial response. Radical resection of the tumor was considered possible, and another laparotomy was performed. The tumor had shrunk markedly, and a separation of the tumor from the aorta was possible. Therefore, sigmoid colectomy was conducted followed by a D3 lymph node dissection. The overall findings were type 5, pSS, ly0, v0, pN0 (0/26), sH0, sP0, cM0, fStage II, PM0, DM0, RM0, and CurA. In the present study, mFOLFOX6 as neoadjuvant chemotherapy for colon cancer was found to be effective.

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We report a case of prostate cancer that was discovered by lymph node metastasis to along the common hepatic arterial nodes. The patient was a 72-year-old man who had undergone esophagectomy as surgical treatment of esophageal cancer. The obtained specimen of along the common hepatic arterial lymph node showed adenocarcinoma, which was positive for prostate-specific antigen (PSA). The histological findings of the esophageal lesion demonstrated squamous cell carcinoma. Serum PSA was 350 ng/ml and prostate needle biopsy revealed adenocarcinoma. The patient commenced on total androgen blockade consisting of LH-RH analogue and bicalutamide (anti-androgen). However, the patient died due to recurrence of esophageal carcinoma.

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Purpose: The purpose of this study was to investigate the efficacy and toxicity of primary endocrine therapy in postmenopausal elderly patients with endocrine-responsive breast cancer.
Patients and Methods: The study included 11 postmenopausal patients with breast cancer aged 70 years and over who started primary endocrine therapy between April 2004 and November 2007. Treatment consisted of 1 mg/day anastrozole or 25 mg/day exemestane and was continued until progressive disease was noted. In patients who had progressive disease, another aromatase inhibitor or tamoxifen was administered.
Results: The drugs used as primary therapy were anastrozole and exemestane in 7 and 4 patients, respectively. Seven patients had a performance status of 0 to 1 and 4 had 3 to 4. The best clinical response was a complete remission in 2 patients, in addition to partial remission in 4, stable disease in 4 (including 2 patients with long-term stabilization), and disease progression in 1, with a response rate of 55% and a clinical benefit rate of 73%. The average duration of primary treatment was 15.5 months, and 2 patients died during the study (one from cerebral hemorrhage and the other from breast cancer). With regard to safety, a fracture of the right fourth finger was observed in 1 patient.
Conclusion: Primary endocrine therapy with aromatase inhibitors resulted in a high response rate and a long-term clinical benefit, along with a superior tolerability. Therefore, this therapy can be effective in extremely elderly patients with endocrine-responsive breast cancer.

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A 65-year-old male patient presented with epigastralgia. At 57 years of age, the patient was diagnosed as cancer of the right breast (T1cN0M0) and underwent a mastectomy and axillary dissection. ER and PgR were positive, and HER2 was 2+. At six years after surgery, multiple metastatic lung tumors were found to have developed, and the patient underwent a partial resection of the left lung. Supraclavicular and mediastinal lymph nodes and pleural metastasis also developed postoperatively and were treated with chemotherapy. The patient developed epigastralgia at 30 months after the lung surgery, and underwent upper gastrointestinal endoscopy. An elevated lesion with a bridging fold was detected in the middle body of the stomach, and the results of a biopsy showed adenocarcinoma. The immunohistochemical staining results were positive for cytokeratin (CK) 7 and negative for CK20, and the patient was diagnosed as breast cancer metastasis to the stomach. Although breast cancer metastasis to the stomach has been detected in a small percentage of cases based on autopsy findings, it is extremely rare that a diagnosis of this disease is made in the clinical setting. A case of breast cancer metastasis to the stomach in a male patient is even rarer. A search of the Japan Centra Revuo Medicina database revealed only one such case among previous reports in Japan. In conclusion, it is necessary to address the possibility of breast cancer metastasis to the stomach when searching for a gastric tumor in a patient with a past history of breast cancer.

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