Patients with hereditary breast and ovarian cancer syndrome (HBOC) are associated with an increased risk of developing pancreatic cancer (PC) than the general population. There is no consensus about the clinical value of F-18-fluorodeoxyglucose (FDG)-positron emission tomography/computed tomography (PET/CT) in patients with HBOC. We report a patient with HBOC in whom PC was detected incidentally by PET/CT. A 48-year-old woman complaining of a right breast mass sought evaluation at our hospital. Her older brother died of PC at 49 years of age. Histologic analysis of the breast mass revealed breast cancer (BC). FDG-PET/CT showed unanticipated FDG accumulation in the pancreas. Magnetic resonance cholangiopancreatography (MRCP) revealed a mass in the pancreas approximately 25mm in size. Endoscopic ultrasound guided-fine needle aspiration biopsy (EUS-FNA) demonstrated PC. Genetic testing showed a BRCA2 pathologic variant [NM_000059.4(BRCA2): c.9076C > T (p.Gln3026Ter)]. She was referred to a university hospital and underwent surgery after neoadjuvant chemotherapy for PC. It is difficult to detect operable PC in most patients. The diagnostic utility of PET/CT for PC in high-risk patients, such as those with HBOC, is undetermined. Our case has demonstrated the clinical value of PET/CT in detecting incidental PC in HBOC patients.

Magnetic resonance imaging (MRI) is widely recognized as an imaging method with relatively higher sensitivity than other imaging modalities for detecting breast cancer (BC), although the specificity is controversial. Wetreated a patient with BC that was detected by MRI and confirmed by examination of an MRI-guided biopsyspecimen. The tumor was not clearly identified by ultrasonography (US), mammography (MMG), or a physicalexamination. A 50-year-old female came to our hospital because a focally asymmetric density (FAD) in the leftbreast was seen on MMG. Physical and US examinations were unremarkable. However, MRI showed enhancednodules distributed segmentally in the right lower internal quadrant. An US performed 3 months later did notshow any findings in the region. Therefore, we referred the patient to a hospital that was equipped to performMRI-guided biopsy. Ultrasound-guided fine needle aspiration and core needle biopsy of the region were unable toconfirm the presence of BC, but ductal carcinoma in situ (DCIS) was seen on an MRI-guided biopsy specimen.The patient then underwent surgery at our hospital. This case taught us the importance of breast MRI andMRI-guided biopsy for lesions not demonstrated on US or MMG.

A majority of breast cancer (BC) molecular subtype in BRCA1 variants carriers is triple-negative type. In contrast, human epidermal growth factor 2 (HER2)-positive BC among carriers of BRCA1 variants is rarely reported. A 42-year-old woman who previously received adjuvant endocrine therapy against left BC developed a left BC relapse and a right new primary BC. Her mother had BC and ovary cancer, and her cousin had BC. Genetic testing revealed a pathogenic large deletion of exons 1-8 in BRCA1. She was diagnosed with hereditary breast and ovary cancer and underwent bilateral mastectomy. The molecular subtypes of her right and left primary BC were HER2-enriched type and luminal-HER2 type, respectively. After completion of adjuvant therapy for right BC, risk-reducing salpingo-oophorectomy (RRSO) is planned. The present case makes us consider the frequency of BRCA1 large rearrangements in Japanese, the association between HER2 amplification and BRCA1 variants, and the optimal timing of RRSO in patients receiving adjuvant therapy for BC.

Abstract Background Normally located in the neck, ectopic mediastinal thyroid tissue consists of very rare ectopic thyroid tissue that does not connect to the thyroid gland. A patient with mucosa-associated lymphoid tissue (MALT) lymphoma that has developed in mediastinal thyroid tissue, to our best knowledge, has not been previously reported. Case presentation A 67-year-old woman presented with a superior mediastinal mass that was revealed by chest computed tomography (CT), an optional examination she hoped, during a medical checkup. Contrast-enhanced CT scan performed in our hospital for close examination confirmed the presence of a 2 × 1.3 cm poorly enhanced mass anterior to the trachea during the arterial phase. Magnetic resonance imaging depicted low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. I-131 meta-iodobenzylguanidine did not accumulate in the mass. Serum levels of interleukin-2 receptor, catecholamine, and anti-acetylcholine receptor antibody were within the normal range. The mass was resected through a transverse neck incision for the diagnosis and treatment. The histopathological diagnosis of the specimen was ectopic mediastinal thyroid tissue associated with MALT lymphoma and chronic thyroiditis. Immunoglobulin heavy chain class switch recombination was identified. Fine-needle aspiration biopsy of the cervical thyroid showed chronic thyroiditis but not lymphoma. The patient’s postoperative thyroid function was normal. To date, the patient’s recovery has been uneventful, and she is being monitored without further treatment. Conclusion We treated the patient with MALT lymphoma that developed in ectopic mediastinal thyroid tissue. This novel case illustrates a new differential diagnosis associated with ectopic mediastinal thyroid tissue.

ABSTRACT Introduction: Functioning mediastinal parathyroid cysts are extremely rare. Technetium-99m-methoxyisobutylisonitrile (99mTc-MIBI) scintigrams usually helps to localize parathyroid lesions, but we report a case with no MIBI uptake. Presentation of case: A 79-year-old woman with lower extremity edema and dysphagia was referred to our hospital. Her blood calcium (Ca) level was 11.1 mg/dl, and the intact parathyroid hormone (PTH) level was 132 pg/ml. Computed tomography showed a 3.5 cm solid nodule in the right thyroid lobe and a 5.4 cm cystic mass extending to the mediastinum. The 99mTc-MIBI scintigram showed abnormal uptake in the thyroid nodule but no uptake in the mediastinal mass. The diagnosis was a thyroid nodule in the right lobe, primary hyperparathyroidism and a mediastinal mass. Under general anesthesia, the thyroid nodule and the mediastinal mass were resected via a cervical incision. The right lower parathyroid gland was resected because it measured about 1 cm and had the dark red color of a parathyroid adenoma. The pathological diagnoses were adenomatous goiter, normal parathyroid gland and mediastinal parathyroid cystic adenoma. The histopathological examination of the mediastinal mass showed a uniform population of parathyroid cells. The postoperative serum Ca and intact-PTH levels were normal. There has been no relapse. Discussion and Conclusion: Patients with parathyroid cysts sometimes have negative 99mTc-MIBI scans. We should consider a parathyroid cyst when a mediastinal cystic mass is demonstrated. Surgical resection is thought to be the optimal therapeutic choice for mediastinal parathyroid cysts irrespective of functioning because mediastinal parathyroid cysts are large and produce compressive symptoms. Highlights:

Background: Breast cancer treatments carry the risk of cardiac problems that may impact the patient’s overall outcome. We aimed to assess the real-world incidence of chemotherapy-related cardiotoxicity and the effect of echocardiographic monitoring of cardiac function in breast cancer patients undergoing chemotherapy. Methods: We assessed patients with breast cancer at our institution who were first treated with anthracycline or trastuzumab between 2008 and 2016. Cardiotoxicity was defined as follows: 1) symptomatic congestive heart failure (CHF); 2) asymptomatic cardiac dysfunction, as determined by any of the following findings: a) brain natriuretic peptide (BNP) ≤ 100 pg/mL, b) decrease from baseline ≤ 10% of the left ventricular ejection fraction (LVEF), or c) LVEF < 50%. We defined the patients from 2014 onward, who had mostly undergone cardiac function monitoring by echocardiography prior to the initiation of the complete regimen, and every 3 months during chemotherapy, as the active monitoring group. Results: After a median follow-up of 4 years, 11 of 118 (9.3%) patients developed cardiotoxicity. Cardiotoxicity occurred more frequently in patients who received trastuzumab; particularly in those patients treated with anthracycline and sequential trastuzumab. Asymptomatic cardiotoxicity was detected first in all cases. Two (1.6%) patients with irreversible cardiotoxicity received anthracycline. Forty-two of 118 patients (36%) underwent active monitoring. Of these 42 patients, 27 (64%) underwent baseline echocardiography to assess cardiac function. A significantly higher proportion of patients undergoing active monitoring received human epidermal growth factor 2 receptor (HER2) targeted agents and a higher dose of anthracycline compared with those patients who were not monitored actively. Cardiotoxicity was identified significantly earlier (median: 1.5 year vs. 5.2 years) in patients undergoing active monitoring than in those not undergoing active monitoring. Conclusion: Echocardiographic monitoring of cardiac function in breast cancer patients undergoing chemotherapy allows early detection of asymptomatic chemotherapy-related cardiotoxicity.

Purpose: Increasing evidence indicates that the neutrophil:lymphocyte ratio (NLR) broadly reflects systemic inflammatory and immune responses and may be a useful biomarker to predict outcomes for some solid cancers. However, the association between NLR and breast cancer prognosis remains unclear. We investigated the relationship between NLR and disease outcomes, i.e., metastatic capacity, recurrence free survival (RFS) and overall survival (OS), in patients with triple negative breast cancer (TNBC). Methods: We reviewed the medical records of patients with stage I-III TNBC who underwent surgery at our institution between 2005 and 2015. The NLR cut-off value of 2.2 was selected according to receiver operating characteristic (ROC) curves. Lymph node metastasis status, RFS and OS were evaluated. Differences were considered significant for p < 0.05. Results: Of 36 patients, 14 were assigned to the high NLR group (NLR ≥ 2.2) and 22 to the low NLR group (NLR < 2.2). The values for lymph node involvement and NLR revealed significant positive correlations. A median follow-up of 5.3 years revealed that the high NLR group had a significantly poorer RFS (66% vs 90% at 5 years, p = 0.02). The high NLR group had a worse tendency for OS at 5 years (82% vs 95% for the low NLR group, p = 0.23). Conclusion: High NLR reflects extensive lymph node metastasis and poor prognosis in patients with TNBC.

Background: It remains unknown whether knowledge of the status of progesterone receptor (PR) expression is useful for distinguishing between luminal A and B breast cancer subtypes and for providing an accurate prognosis for patients with estrogen receptor-positive (ER+) and human epidermal growth factor receptor 2-negative (HER2-) breast cancer. We aimed to assess the role of PR status in determining the biology and prognosis of early ER+ and HER2- breast cancer. Methods: This was a retrospective study of 105 patients with ER+ and HER2- breast cancer who underwent surgery between 2005 and 2013. Relapse-free survival (RFS), distant-metastasis-free survival (DFS) and overall survival (OS) were evaluated. The prognostic value of PR was evaluated using a Cox regression model. Results: Apart from the menstruation status, there were no significant differences between the PR+ and PR- patients. PR- patients exhibited a tendency towards a higher nuclear grade and Ki-67 labeling index. In particular, postmenopausal patients with PR expression status < 10% exhibited a significantly higher nuclear grade and tendency towards a higher Ki-67 labeling index. After a median follow-up of about 5 years, the 5-year RFS, DFS and OS rates of the PR+ and PR- patients were not significantly different. PR was not a significant prognostic factor by multivariate analysis. Conclusion: PR status does not have prognostic value for patients with early ER+ and HER2- breast cancer who received adequate therapies. However, it may be reasonable to use PR status for distinguishing between luminal A and B breast cancer subtypes.

Thyroid storm is a life-threatening condition that is generally considered to be a contradiction to surgical intervention. We herein describe the case of a 37-year-old patient with a history of Graves' disease who was transferred to Tottori University Hospital with thyroid storm. She had been followed by her family doctor since 2006, but she had stopped taking her medication of her own volition in 2010. About ten days prior to her admission at our hospital, she consulted her family doctor with complaints of dyspnea, palpitations and general fatigue. Subsequent thyroid function tests showed TSH < 0.01 μU/ml, FT3 25.0 pg/ml and FT4 8.0 ng/dl. She also had acute heart failure, atrial fibrillation and hepatic failure. A diagnosis of thyroid storm was made and she was transferred to our hospital. She received steroids, beta blockade, potassium iodide, and plasma exchange, but her hepatic failure did not resolve and her clinical condition deteriorated. The decision was made to proceed with thyroidectomy. Postoperatively, her hepatic function normalized. Thus, thyroidectomy is a potential therapeutic choice for cases of thyroid storm refractory to medical management.

Middle colic artery aneurysms are rare and most have been reported with rupture or symptom. We report the successful elective treatment of a middle colic artery aneurysm without symptom, which is very rare. It failed to perform transcatheter arterial embolization for anatomical reasons, and, thus, the patient, a 77-year-old man, underwent surgical resection in spite of a history of laparotomy. Although a common cause of middle colic artery aneurysms is segmental arterial mediolysis, the present pathological findings indicated that fragmented or degenerated elastic fibers may also play an important role like aortic aneurysms.

BACKGROUND:The addition of chemotherapy to endocrine therapy for luminal A breast cancer generally provides little benefit. However, the least benefit of chemotherapy in all patients with luminal A breast cancer is controversial.METHODS:This was a retrospective study of 140 patients with luminal A breast cancer who underwent surgery at Tottori University Hospital between 2001 and 2010. Luminal A breast cancer was defined as positive for estrogen receptors and/or progesterone receptors and negative for human epidermal growth factor 2. Postoperative endocrine therapy was given to all patients. The prognostic values of age, tumor size, presence of lymphovascular invasion and lymph node status were evaluated. In addition, the prognostic value of chemotherapy for patients with identified risk factors affecting relapse-free survival and overall survival was evaluated.RESULTS:Tumor size greater than 2 cm and positive lymph node status were factors significantly affecting relapse-free survival. There were no factors significantly affecting overall survival. There was no significant difference in the relapse-free survival of patients with tumor size greater than 2 cm and/or positive lymph node status who either received chemotherapy or not. However, the relapse event was earlier in patients with tumor size greater than 2 cm and positive lymph node status who did not receive chemotherapy than in those who received chemotherapy.CONCLUSION:Chemotherapy could provide little benefit to patients with luminal A breast cancer. However, chemotherapy may bring them longer relapse-free periods.

Nonfunctional parathyroid carcinoma is a very rare malignant disease; only 25 cases have been reported over the last 85 years. We present a patient with a nonfunctional parathyroid carcinoma metastasis to the breast and a review of the pertinent literature. A 71-year-old woman was seen for a self-discovered mass in her left breast. She had undergone surgery 6 years previously for nonfunctional parathyroid cancer. Mammography and ultrasonography of the breast revealed an oval, circumscribed mass. Fine-needle aspiration findings were suspicious for metastasis of parathyroid carcinoma. Serum calcium and intact parathyroid hormone levels were within normal limits. We performed a partial mammary gland resection that included the tumor. Pathological analysis of the resected tumor disclosed findings consistent with parathyroid carcinoma. The nonsecretory state of the tumor was supported by negative immunoreactivity for parathyroid hormone in the tissue and lack of clinical evidence of hyperparathyroidism. To the best of our knowledge, this is the first reported case of parathyroid carcinoma metastasis to the breast. Breast metastasis of parathyroid carcinoma should be included in the differential diagnosis for a patient with a past history of parathyroid carcinoma.

Ectopic ACTH secretion in the setting of breast cancer is extremely rare but when present affects both the tumor's behavior and the incidence of complications. The patient, a 58-year-old woman, first presented with a mass in her left breast as well as multiple osseous metastases and a right femur fracture. Laboratory data revealed a hypokalemic alkalosis. Her plasma ACTH level was elevated. She was diagnosed with breast cancer with ectopic ACTH secretion, and underwent a left mastectomy and axillary lymph node dissection. Histological examination demonstrated a poorly differentiated neuroendocrine carcinoma with ectopic ACTH secretion. Although the signs and symptoms of ectopic ACTH secretion from a breast cancer are frequently subtle, the recognition of ectopic ACTH secretion from breast cancer is important for patient management.

Pheochromocytomas are rare neuroendocrine tumors that produce symptoms through the excess release of catecholamines. The treatment of choice is a complete surgical removal after pretreatment with an α-blocker, to prevent dangerous hemodynamic fluctuations. Newell and colleagues defined the rare, fatal condition of catecholamine crisis, which includes multiple organ failure (MOF), severe blood pressure variability, high fever, and encephalopathy, as pheochromocytoma multisystem crisis (PMC). The indications for emergency surgery in this unstable state still remain controversial. This report presents the case of a 52-year-old female patient with PMC who successfully underwent a surgical resection. This case showed that early tumor removal may be the only means of halting the progression of this disease.

症例は60歳，男性．毎年人間ドックを受診し，異常なしといわれていた．2007年1月頃より湿性咳嗽が出現，4月の人間ドックで肺の異常陰影を指摘された．前医での気管支擦過細胞診の結果はClassIIであったが，精査加療のため当院に紹介受診となった．当院で再度気管支擦過細胞診を実施した結果，ClassIVの診断を得た．右肺癌疑いの診断で胸腔鏡補助下前方腋下開胸にて右下葉切除術を行った．術後，組織学的検査および免疫組織学的検査により肺原発MALTリンパ腫と診断された．本疾患の術前診断は困難であり，また，標準的治療法はいまだ確立されていない．初期治療として手術を実施することは，確定診断と術後の治療方針の決定に有用であると考えられた．

To demonstrate the validity of sentinel lymph node biopsy (SLNB) using the indocyanine green dye method (dye only method), we compared the survival of breast cancer patients negative to SLNB without axillary lymph node dissection (ALND) (SLNB group) to that of lymph node-negative patients undergoing ALND (ALND group). We studied a total of 174 patients with T1-2N0 invasive breast cancer diagnosed at our university hospital clinical department between 2000 and 2008, with follow-up till 31 December 2009, retrospectively. The SLNB group consisted of 108 SLNB-negative women without additional ALND (median follow-up, 25 months), diagnosed between May 2005 and 2008. The ALND group consisted of 66 axillary lymph node-negative women (median follow-up, 75 months) treated with ALND between 2000 and April 2005. SLNB was performed during operation by periareolar injection using indocyanine green. All sentinel lymph nodes were examined using the largest section along the major axis, and permanent sections were stained with hematoxylin and eosin. In the SLNB group, no patients developed axillary recurrence during the 25-month median follow-up. The 4.5-year distant disease free survival and overall survival rates were 90.9% and 91.9%, respectively. The survival rate in the SLNB group was equivalent to that in the ALND group. This suggests that SLNB with the dye only method can safely replace ALND as the procedure of choice for axillary staging in breast cancer patients with a clinically negative axilla.

A 42-year-old woman came to our hospital complaining of an enlarging tumor in her right breast. A core needle biopsy of the involved area demonstrated primary squamous cell carcinoma (SCC) of the breast. Preoperative neoadjuvant chemotherapies included 5-fluorouracil: 5-FU+epirubicin: EPI+cyclophosphamide: CPA (FEC), paclitaxel (PTX), vinorelbine (VNR) and 5-FU+nedaplatin (254-S) given in the order listed, but the mass continued to enlarge. Therefore, surgical resection was performed. Local recurrence and lung metastasis occurred after surgery. Although postoperative adjuvant chemotherapy consisting of carboplatin (CBDCA) +etoposide (VP-16) was administered, the patient died three months after surgery. SCC of the breast is generally treated according to clinical stage using protocol for common types of breast cancer. However, effective regimens have not been established for SCC, because it tends to be treatment-refractory. Therefore, in patients with SCC, it is important to consider surgery at an earlier stage than would be considered for a common breast cancer requiring preoperative neoadjuvant chemotherapy.

内胸動脈(ITA)を採取する症例では胸骨への血流低下に加え,採取の際に胸骨を持ち上げることにより胸骨のずれが生じやすいと考えられる.離断胸骨の固定性の向上目的に胸骨ピンを使用開始したのでその有用性につき検討した.2006年1月~2007年12月に当科でITAを使用した単独CABG待機手術症例37例を対象とした.胸骨ピンを使用しなかった18例をA群,使用した19例をB群とした.胸骨ピンは胸骨閉鎖時に胸骨体に1本,胸骨柄に1本留置し胸骨ワイヤーで閉鎖した.胸骨ピンを使用しなかった症例は金属ワイヤーのみで閉鎖した.ICU帰室後12,24時間のドレーン出血量,ドレーン抜去時期,Surgical Site Infection(SSI)の有無,および術後胸部CTでの胸骨柄,胸骨体の最大段差を計測した.帰室後12,24時間のドレーン出血量はB群が少ない傾向にあった.ドレーン抜去時期はB群が有意に短かった.またSSIはA群17%(3/18)に比べB群0%(0/19)と減少した.胸骨段差は胸骨柄,胸骨体ともにB群が有意に少なかった.ITA使用例では,胸骨ピンを使用することにより胸骨のずれを軽減させることが可能であった.また早期のドレーン抜去およびSSIの減少にも寄与した可能性が示唆された.

73歳男性．検診の際，左上肺野に異常陰影を指摘された．CTにてS1+2に直径35mm大で辺縁不整の腫瘤性病変を認め，擦過細胞診で肺腺癌疑いとの診断が得られた．術前ProGRPは，80.4pg/mlと高値を示していた．手術は，胸腔鏡下左肺上葉切除術を施行した．病理組織所見では，小さな円形の細胞が，柵状配列，ロゼット形成を示していた．また，組織のChromogranin染色は陽性を示した．上記所見より，定型的肺カルチノイド，p-T2N0M0，p1d0e0pm0，p-Stage IBとの診断となった．術後経過は良好で，ProGRP値も正常化した．定型的肺カルチノイドでは術前の血中ProGRP値が高値を示すことは少ないため，若干の文献的考察を加えて報告した．