原尾 美智子

Various surgical energy devices are used for axillary lymph-node dissection. However, those that reduce seroma during axillary lymph-node dissection are unknown. We aimed to determine the best surgical energy device for reducing seroma by performing a network meta-analysis to synthesize the current evidence on the effectiveness of surgical energy devices for axillary node dissection for breast cancer patients. We searched MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, and World Health Organization International Clinical Trials Platform Search Portal. Two reviewers independently selected randomized controlled trials (RCTs) comparing electrosurgical bipolar vessel sealing (EBVS), ultrasonic coagulation shears (UCS), and conventional techniques for axillary node dissection. Primary outcomes were seroma, drained fluid volume (mL), and drainage duration (days). We analyzed random-effects and Bayesian network meta-analyses. We evaluated the confidence of each outcome using the CINeMA tool. We registered with PROSPERO (CRD42022335434). We included 34 RCTs with 2916 participants. Compared to the conventional techniques, UCS likely reduces seroma (risk ratio [RR], 0.61; 95% credible interval [CrI], 0.49-0.73), the drained fluid volume (mean difference [MD], - 313 mL; 95% CrI - 496 to - 130), and drainage duration (MD - 1.79 days; 95% CrI - 2.91 to - 0.66). EBVS might have little effect on seroma, the drained fluid volume, and drainage duration compared to conventional techniques. UCS likely reduce seroma (RR 0.44; 95% CrI 0.28-0.69) compared to EBVS. Confidence levels were low to moderate. In conclusion, UCS are likely the best surgical energy device for seroma reduction during axillary node dissection for breast cancer patients.

BACKGROUND: In nipple reconstruction, the width, length, and thickness of modified star flaps are concerns for long-term reconstructed nipple projection. However, the flap's projection has not been analyzed, based on its thickness. The aim of the present study was to investigate how flap thickness in a modified star flap influences the resulting reconstructed nipple and achieves an appropriate flap width in design. METHODS: Sixty-three patients who underwent nipple reconstruction using a modified star flap following implant-based breast reconstruction between August 2014 and July 2016 were included in this case-controlled study. The length of laterally diverging flaps was 1.5 times their width. The thickness of each flap was measured using ultrasonography, and the average thickness was defined as the flap thickness. We investigated the correlation between the resulting reconstructed nipple and flap thickness, and the difference of the change in the reconstructed nipple projection after using a thin or thick flap. RESULTS: The average flap thickness was 3.8 ± 1.7 (range 2.5-6.0) mm. There was a significant, linear correlation between the flap thickness and resulting reconstructed nipple projection (β = 0.853, p < 0.01). Furthermore, the difference between the thin and thick flaps in the resulting reconstructed nipple projection was significant (p < 0.01). CONCLUSION: Measuring the flap thickness preoperatively may allow surgeons to achieve an appropriate flap width; otherwise, alternative methods for higher projection might be used. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Primary peritoneal carcinoma is usually advanced at diagnosis and curability is low unless the patient has a small tumor burden. Peritoneal carcinoma can occur in association with hereditary breast and ovarian cancer syndrome, which is thought to account for 5-6% of all breast cancer. Mutations of two breast cancer susceptibility genes, BRCA1 and BRCA2, are responsible for hereditary breast and ovarian cancer. Women with BRCA1/2 mutations often undergo risk-reducing salpingo-oophorectomy (RRSO) to prevent both ovarian and breast cancer. However, peritoneal carcinoma has been reported to develop after RRSO in patients with BRCA1/2 mutations. We experienced a patient with peritoneal carcinoma and inguinal lymph node metastasis after surgical resection of breast cancer and subsequent RRSO. This report describes the first case of peritoneal carcinoma arising after RRSO in a Japanese patient with BRCA1 mutation, including a review of the literature on peritoneal carcinoma associated with BRCA1/2 mutation.

BACKGROUND: In breast reconstruction using a tissue expander (TE), sufficient coverage of the TE with the pectoralis major (PM) muscle, particularly with a musculofascial flap, is highly important for avoiding postoperative complications. In patients in whom the PM is thin, intraoperative trauma often occurs, leading to troublesome repair. The present study aimed to investigate the usefulness of preoperative measurement of PM thickness in planning of breast reconstruction using a TE. METHODS: In this case-control study, we identified 68 patients (70 breasts) with mammary carcinoma treated with simple mastectomy and TE insertion from April 2014 to December 2016. We measured average PM thickness at two specific points, sternocostal PM distance on the long axis and sternocostal PM area preoperatively using magnetic resonance imaging. Then, we analyzed the difference in PM thickness among individuals and its relationship to intraoperative trauma to the PM or surgical difficulty creating a muscular pocket (delicate PM). RESULTS: Average PM thickness was significantly larger in younger patients (p = 0.046) and those with larger breasts (p < 0.01). In addition, average PM thickness on the affected side was significantly smaller in patients with delicate PM (12 breasts) (p < 0.01). PM thickness had a significant influence on delicate or firm PM (odds ratio 27.40; 95% confidence interval 2.01-372.00; p = 0.013). CONCLUSION: These findings demonstrate the usefulness of preoperative measurement of PM thickness in planning of breast reconstruction using a TE. Dissection should be performed more carefully in patients with average PM thickness less than 2.9 mm.

Implant-based breast reconstruction can be performed using a choice of various types of breast implants. However, cases where the breast shapes are unsuitable for implant-based reconstruction method are occasionally encountered. We present two patients with wide trunks who underwent breast reconstruction using an unusual configuration that involved a latissimus dorsi myocutaneous flap combined with two paranemic implants.

Adjuvant chemotherapy and anti-estrogenic therapy can result in decreased volume of the contralateral breast, following mastectomy for the treatment of breast cancer. However, no data on the effect of adjuvant therapy on contralateral breast volume have previously been reported. We aimed to evaluate the extent to which adjuvant therapy and differences in breast density contribute to decreased breast volume. We conducted a prospective cohort study, selecting 40 nonconsecutive patients who underwent immediate breast reconstruction with mastectomy and expander insertion followed by expander replacement. We measured the contralateral breast volume before each procedure. The extent of the change was analyzed with respect to adjuvant therapy and breast density measured by preoperative mammography. The greatest decrease in breast volume was 135.1 cm3. The decrease in breast volume was significantly larger in the adjuvant therapy (+) group, particularly in patients with high breast density, than in the adjuvant therapy (-) group. Significant differences between the chemotherapy (+), tamoxifen (+) group and the chemotherapy (-), tamoxifen (+) group were not found. Breast density scores had a range of 2.0-3.3 (mean: 2.8). In breast reconstruction, particularly when performed in one stage, preoperative mammography findings are valuable to plastic surgeons, and possible decreases in the contralateral breast volume due to adjuvant therapy, particularly in patients with high breast density, should be considered carefully.

Objective: In breast reconstruction, decision of projection of silicone breast implant in tissue expander replacement is difficult because of the need to consider several parameters that cannot be expressed in accurate numerical form. The present study aimed at a quantitative analysis based on decreased projection of the reconstructed side compared with silicone breast implant projection and to develop a new method for simple and practical decision of silicone breast implant projection. Methods: Thirty-five patients who had mammary carcinoma and were treated with simple mastectomy, tissue expander insertion, and replacement with anatomical silicone breast implant from April 2013 to March 2016 were retrospectively identified. We recorded the projection of used silicone breast implant (Pi). The projections of reconstructed breast 6 months after silicone breast implant insertion (Pr) and that of the unaffected breast during silicone breast implant selection (Pu) were measured. The difference between Pi and Pr was defined as the revised numerical value (Rev). We investigated whether Rev significantly differed according to age, body mass index, or Pu and analyzed correlations between Rev and age, Pu, and body mass index. Results: Mean Rev in all patients was 1.2 ± 0.3 cm. Rev was significantly higher in patients with higher body mass index than in those with lower body mass index (P < .01) and in patients with higher Pu than in those with lower Pu (P < .01). Significant positive correlations of Rev with body mass index and Pu were found (β = .63, P < .01 and β = .67, P < .01, respectively). Conclusions: Rev was a simple, practical, and cost-effective concept. We believe that it is a useful indicator for deciding silicone breast implant projection.

Objective: It is generally difficult to achieve symmetry in implant-only breast reconstruction with ptosis, and it remains unclear what quantitative criterion may be applied in cases of breast ptosis regarding the application of this modality. Our study aimed to suggest a criterion for obtaining good aesthetic outcomes and a symmetrical inframammary fold that is well-fitting for the brassiere in implant-only breast reconstruction after simple mastectomy. Methods: We classified into 3 groups 50 consecutive patients who underwent implant-only breast reconstruction that created an inframammary fold using a modified internal method after simple mastectomy. The classification was based on the rostrocaudal distance along the chest wall between the lowest point of the breast the and the inframammary fold on the contralateral side (Dc, in millimeters). Thereafter, we compared this distance on the reconstructed side (Dr, in millimeters), Dc-Dr, and projection of the implant (Pi, in centimeters) between the groups and investigated the correlation between Dr and lower (Pi < 5.0 cm) and higher Pi (Pi ≥ 5.0 cm). Results: Dr was similar to Dc in groups 1 and 2 (0 ≤ Dc < 10 mm, 40/50 [80%]); however, Dr was significantly lesser than Dc in group 3 (Dc ≥ 10 mm, 10/50 [20%]). In addition, we found significant positive correlations between Dr and lower Pi and between Dr and higher Pi. Conclusions: A Dc below 10 mm may be a good indication for implant-only breast reconstruction. Furthermore, the modality may be applied where Dc is 7 mm or less in cases with lower Pi and where Dc is 13 mm or less in cases with higher Pi.

Liposarcomas are soft tissue sarcomas of adipocyte origin. We describe a case of a dedifferentiated retroperitoneal liposarcoma with an unusual presentation on recurrence as a large, multicystic tumour. The patient was a 72-year-old woman who had undergone multiple treatments including two prior resections. For her most recent locoregional disease recurrence, the patient was offered surgical debulking for symptom palliation. At this operation, performed after two cycles of chemotherapy, the tumour cyst fluid was analysed and found to have a predominance of immune cells with no identifiable malignant cells. This case and the results of our tumour cyst fluid analysis raise several interesting considerations for the management of this unique situation in a rare disease.

Adult T-cell leukemia-lymphoma (ATL) is an aggressive peripheral T-cell neoplasm that develops after long-term infection with the human T-cell leukemia virus-1 (HTLV-1). HTLV-1-specific cytotoxic T lymphocytes (CTLs) play an important role in suppressing proliferation of HTLV-1-infected or transformed T-cells in vitro. Efficient induction of antigen-specific CTLs is important for immunologic suppression of oncogenesis, but has evaded strategies utilizing poorly immunogenic free synthetic peptides. In the present study, we examined the efficient induction of HTLV-1-specific CD8+ T-cell response by an HTLV-1/hepatitis B virus core (HBc) chimeric particle incorporating the HLA-A*0201-restricted HTLV-1 Tax-epitope. The immunization of HLA-A*0201-transgenic mice with the chimeric particle induced antigen-specific gamma-interferon reaction, whereas immunization with epitope peptide only induced no reaction as assessed by enzyme-linked immunospot assay. Immunization with the chimeric particle also induced HTLV-1-specific CD8+ T-cells in spleen and inguinal lymph nodes. Furthermore, upon exposure of dendritic cells from HLA-A*0201-transgenic mice to the chimeric particle, the expression of CD86, HLA-A02, TLR4 and MHC class II was increased. Additionally, our results show that HTLV-1-specific CD8+ T-cells can be induced by peptide with HTLV-1/HBc particle from ATL patient, but not by peptide only and these HTLV-1-specific CD8+ T-cells were able to lyse cells presenting the peptide. These results suggest that HTLV-1/HBc chimeric particle is capable of inducing strong cellular immune responses without adjuvants via effective maturation of dendritic cells and is potentially useful as an effective carrier for therapeutic vaccines in tumors, or in infectious diseases by substituting the epitope peptide.

OBJECTIVE: We recently developed a real-time virtual sonography (RVS) system that enables simultaneous display of both sonography and magnetic resonance imaging (MRI) cutaway images of the same site in real time. The aim of this study was to evaluate the role of RVS in the management of enhancing lesions visualized with MRI. METHODS: Between June 2006 and April 2007, 65 patients underwent MRI for staging of known breast cancer at our hospital. All patients were examined using mammography, sonography, MRI and RVS before surgical resection. Results were correlated with histopathologic findings. MRI was obtained on a 1.5 T imager, with the patient in the supine position using a flexible body surface coil. Detection rate was determined for index tumors and incidental enhancing lesions (IELs), with or without RVS. RESULTS: Overall sensitivity for detecting index tumors was 85% (55/65) for mammography, 91% (59/65) for sonography, 97% (63/65) for MRI and 98% (64/65) for RVS. Notably, in one instance in which the cancer was not seen on MRI, RVS detected it with the supplementation of sonography. IELs were found in 26% (17/65) of the patients. Of 23 IELs that were detected by MRI, 30% (7/23) of IELs could be identified on repeated sonography alone, but 83% (19/23) of them were identified using the RVS system (P = 0.001). The RVS system was able to correctly project enhanced MRI information onto a body surface, as we checked sonography form images. CONCLUSIONS: Our results suggest that the RVS system can identify enhancing breast lesions with excellent accuracy.

BACKGROUND AND AIM: Partial splenic embolization (PSE) is often performed to improve thrombocytopenia in liver cirrhotic patients. The aim of this study was to evaluate the efficacy and safety of PSE in combination with trans-catheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). PATIENTS AND METHODS: From January 2004 to December 2007, 8 HCC patients associated with hypersplenism caused by cirrhosis were synchronously treated with TACE and PSE. Fifteen patients with TACE alone at the same period were enrolled as a control. Follow-up examinations included a calculation of peripheral blood cells (leukocytes and platelets), liver damage, duration until recovery, and treatment-associated complications. RESULTS: Initially, there were no significant differences in sex, age, Child-Pugh grade and peripheral blood cell counts between two groups. After treatment, leukocyte and platelet counts were significantly higher in PSE combined with TACE group during the follow-up period than TACE group (p<0.01). Severe complications never occurred in both groups. CONCLUSION: PSE combined with TACE is more effective than TACE alone for patients with HCC associated with hypersplenism caused by cirrhosis.

OBJECTIVE: We have measured the concentration of immunoreactive neutrophil elastase (ir-NE) in the tumor extracts of 313 primary human breast cancers. Sufficient time has elapsed, and we are now ready to analyze its prognostic value in human breast cancer. METHODS: ir-NE concentration in tumor extracts was determined with an enzyme-linked immunosorbent assay that enables a rapid measurement of both free-form ir-NE and the A1-protease inhibitor-complexed form of ir-NE. We analyzed the prognostic value of this enzyme in human breast cancer in univariate and multivariate analyses. RESULTS: Patients with breast cancer tissue containing a high concentration of ir-NE had poor survival compared to those with a low concentration of ir-NE at the cutoff point of 9.0 microg/100 mg protein (P = .0012), which had been previously determined in another group of 49 patients. Multivariate stepwise analysis selected lymph node status (P = .0004; relative risk = 1.46) and ir-NE concentration (P = .0013; relative risk = 1.43) as independent prognostic factors for recurrence. CONCLUSIONS: Tumor ir-NE concentration is an independent prognostic factor in patients with breast cancer who undergo curative surgery. This enzyme may play an active role in tumor progression that leads to metastasis in human breast cancer.

This mini-review summarizes our recent experimental and clinical studies on neutrophil elastase (NE) and cancer based on our original view point. Neoplasms metastasize as a result of a complex series of events. This process requires various degradative enzymes including proteases. NE has broad substrate specificity under physiological conditions, and excessive NE results in digestion of not only elastin, but also other extracellular matrix proteins. Several cell lines from human breast cancer and human lung cancer produce immunoreactive NE. The amount of immunoreactive NE in tumor tissue is an independent prognostic indicator of patients with breast cancer and lung cancer. Furthermore, a specific NE inhibitor completely suppressed growth of cancer cells transplanted into severe combined immunodeficiency mice. The use of NE inhibitor would seem to be a promising way to prevent the invasion and metastasis of cancer.

BACKGROUND: We prospectively tested whether circulating tumor cells could be detected in peripheral blood of patients with thyroid tumors by a reverse transcription-polymerase chain reaction (RT-PCR) to detect carcinoembryonic antigen (CEA) messenger RNA (mRNA). METHODS: We assayed for CEA mRNA by RT-PCR in peripheral blood sampled before and 2 to 3 weeks after curative surgery for thyroid tumors in 121 patients. Blood samples from 7 patients with chronic thyroiditis and 7 healthy subjects served as controls. RESULTS: No control samples were positive for CEA mRNA by RT-PCR. Of 121 preoperative samples from patients with thyroid tumor, 6 were positive (5.0%). Preoperative frequencies of CEA mRNA positivity in benign tumor, papillary carcinoma, follicular variant papillary carcinoma, minimally invasive follicular carcinoma, and widely invasive follicular carcinoma were 0%, 0%, 0%, 44.4% (4/9), and 50.0% (2/4), respectively. Among positive patients only one, who had widely invasive follicular carcinoma, remained positive after surgery. CONCLUSIONS: RT-PCR detection of tumor cells in preoperative blood often can distinguish malignant from benign follicular thyroid tumors.