Hiroto Ishiki

Dedifferentiated epithelial-myoepithelial carcinoma of the parotid gland: a rare case report of immunohistochemical analysis and review of the literature

Dedifferentiation of salivary gland neoplasms is a rare event, unlike bone and soft part sarcomas, which was first described by Stanley et al. in 1988. An additional case of dedifferentiated epithelial-myoepithelial carcinoma (EMC) is reported here. The patient was a 70-year-old Japanese man who requested examination of the rapid growth of a mass in the right parotid region, which he had first noticed 25 years previously. Clinical examination showed an ill-circumscribed, 6.8 x 4.7 x 7.0-cm lesion. Histologically, most parts of the lesion were high-grade carcinoma (HGC) with sheetlike and nestlike growth of markedly atypical cells and comedonecrosis, whereas the minor part consisted of typical EMC. The outer clear cells of EMC were positive for alpha-smooth muscle actin (ASMA), p63, cytokeratin (CK) 14, and vimentin, and the inner ductal cells of EMC were positive for CKs and epithelial membrane antigen. HGC was negative for ASMA, CK14, and vimentin, but diffusely positive for p53 protein and cyclin D1. The Ki-67 labeling index of EMC was 11.5%, whereas that of HGC was 67.1%. These findings and a review of literature indicate that HGC arose from preexisting EMC, and this phenomenon is the dedifferentiation of EMC. Dedifferentiated EMC is extremely rare.

Synovial sarcoma of the head and neck: Rare case of cervical metastasis

Synovial sarcoma is a rarely encountered soft tissue sarcoma. Surgery with a wide surgical margin is the treatment of choice. However, there is no consensus on the treatment of head and neck synovial sarcoma in patients with cervical metastasis.

Primary adenoid squamous cell carcinoma of the oral cavity

Adenoid squamous cell carcinoma (ASCC) is an uncommon but well‐recognized variant of squamous cell carcinoma that was first described by Lever in 1947. ASCC has been reported to originate in the sun‐exposed skin of the head and neck and in other sites. An additional case of ASCC is reported here. The patient was a 64‐year‐old Japanese woman who requested examination of a reddish lesion on the left floor of the mouth. The biopsy material was diagnosed as squamous cell carcinoma. Clinical examination showed a well‐circumscribed, 20 × 10 mm‐sized lesion, which was categorized as cT2cN0cm 0. Tumor resection was therefore performed. Histologically, most parts of the lesion were conventional squamous cell carcinoma in situ, but the invasive part consisted of ASCC with gland‐like or reticular appearance. The latter part was negative for mucin staining. Immunohistochemically, this lesion was positive for pancytokeratin, high‐molecular‐weight keratin, cytokeratin (CK) 7/8, CK19, E‐cadherin and p53, but negative for vimentin, CK20, and S‐100 protein. The Ki‐67 labeling index was 50.3% in the ASCC part and 34.5% in the carcinoma in situ part. These findings and a review of the literature indicate that a gland‐like feature of ASCC is associated with the loss of cell adhesion in the center of the cancer nests, and it can be confirmed simply by mucin staining to be neither an adenosquamous carcinoma nor ductal involvement of conventional squamous cell carcinoma.

Alveolar soft part sarcoma of the larynx: A case report of an unusual location with immunohistochemical and ultrastructural analyses

Alveolar soft part sarcoma (ASPS) is a rare mesenchymal neoplasm of uncertain origin. In this article, we report a case of ASPS occurring in the larynx, an extremely rare location for this rather unusual tumor.

Assessment of Cancer-Related Fatigue, Pain, and Quality of Life in Cancer Patients at Palliative Care Team Referral: A Multicenter Observational Study (JORTC PAL-09)

Introduction Cancer-related fatigue greatly influences quality of life in cancer patients; however, no specific treatments have been established for cancer-related fatigue, and at present, no medication has been approved in Japan. Systematic research using patient-reported outcome to examine symptoms, particularly fatigue, has not been conducted in palliative care settings in Japan. The objective was to evaluate fatigue, pain, and quality of life in cancer patients at the point of intervention by palliative care teams. Materials and Methods Patients who were referred to palliative care teams at three institutions and met the inclusion criteria were invited to complete the Brief Fatigue Inventory, Brief Pain Inventory, and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 15-Palliative. Results Of 183 patients recruited, the majority (85.8%) were diagnosed with recurrence or metastasis. The largest group (42.6%) comprised lung cancer patients, of whom 67.2% had an Eastern Cooperative Oncology Group Performance Status of 0–1. The mean value for global health status/quality of life was 41.4, and the highest mean European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 15-Palliative symptom item score was for pain (51.0). The mean global fatigue score was 4.1, and 9.8%, 30.6%, 38.7%, and 20.8% of patients’ fatigue severity was classified as none (score 0), mild (1–3), moderate (4–6), and severe (7–10), respectively. Discussion Cancer-related fatigue, considered to occur more frequently in cancer patients, was successfully assessed using patient-reported outcomes with the Brief Fatigue Inventory for the first time in Japan. Results suggested that fatigue is potentially as problematic as pain, which is the main reason for palliative care.

Oral nutritional support can shorten the duration of parenteral hydration in end-of-life cancer patients: a randomized controlled trial.

Tube feeding or hydration is often considered for end-of-life cancer patients despite the negative effects on quality of life. The efficacy of oral nutritional support in this setting is unknown. We conducted a randomized trial to compare the efficacies of an amino acid jelly, Inner Power® (IP), and a liquid enteral product, Ensure Liquid® (EL), in terminally ill cancer patients. We randomly assigned patients to 3 arms: EL, IP, and EL+IP. The primary endpoint was drip infusion in vein (DIV)-free survival, which was defined as the duration from nutritional support initiation to administration of parenteral hydration. Twenty-seven patients were enrolled in the study, of whom 21 were included in the intention-to-treat analysis. The median age of the subjects was 69 yr. There were significant differences between the arms with regard to the median DIV-free survival (0.5, 6.0, and 4.5 days in the EL, IP, and EL + IP arms, respectively; P = 0.05). The median overall survival was 7, 9, and 8 days in the EL, IP, and EL + IP arms, respectively. IP may shorten the duration of parenteral hydration in terminally ill cancer patients and does not affect their survival.

Cancer Transitional Care for Terminally Ill Cancer Patients Can Reduce the Number of Emergency Admissions and Emergency Department Visits

Background: Emergency admissions and emergency department visits (EAs/EDVs) have been used as quality indicators of home care in terminally ill cancer patients. We established a cancer transitional care (CTC) program to monitor and manage terminally ill cancer patients receiving care at home. The purpose of this study was to evaluate the effectiveness of CTC by the frequency of EAs/EDVs. Methods: In a retrospective chart review, we identified 133 patients with cancer admitted to our department, of whom 56 met study eligibility criteria. The CTC consisted of at least 1 or more following components: (1) a 24-hour hotline for general physicians or home care nurses to reach hospital-based physicians, (2) periodic phone calls from an expert hospital-based oncology nurse to home care medical staff, and (3) reports sent to our department from home care medical staff. The primary outcome variable was the frequency of EAs/EDVs. Results: There were 32 EAs/EDVs and 69 planned admissions during the observation period. In the last 30 days of life, 16 patients (28.6%) had 1 EA/EDV and none had multiple EAs/EDVs. Compared with previous studies, our study found a similar or lower frequency of EAs/EDVs. Conclusion: Our findings suggest that the implementation of CTC reduces the number of EAs/EDVs by replacing them with planned admissions. Further prospective studies to evaluate CTC are warranted.

Prevalence of myofascial pain syndrome in patients with incurable cancer

BACKGROUND Myofascial pain syndrome (MPS) is a condition that involves skeletal muscles. It is caused by overload or disuse of muscles and is characterized by extreme tenderness in the muscles with taut bands. Treatment for MPS is different from that for cancer-related pain. Cancer patients have many factors that cause restriction of body movement and posture. Although cancer patients appear to demonstrate risk factors for MPS, its prevalence has not been reported in patients with incurable cancer. This study was conducted to investigate the prevalence of MPS in patients with incurable cancer. METHODS A retrospective chart review. The data for patients with incurable cancer who received palliative care at our department between September 2015 and March 2016 were investigated. We examined the prevalence of MPS, which was diagnosed on the basis of the Rivers criteria (RC) and Simons criteria (SC). We also examined the following factors associated with MPS: performance status (PS), use of medical devices, and primary cancer sites. The primary outcome was the prevalence of MPS based on RC. Secondary outcomes included the prevalence of MPS based on SC and the relationship between MPS and either PS or medical devices. RESULTS Thirty-four patients with incurable cancer were identified. MPS based on RC or SC was detected in 10 (29%) and 20 (59%) patients, respectively. Twenty-two of 34 patients who complained of pain, 10 (45%) had MPS based on RC and 20 (90%) had MPS based on SC. Age and central venous port were risk factors for MPS by multivariate analysis. CONCLUSION A very high prevalence of MPS was detected in our study population. MPS should be considered when patients with incurable cancer complain of pain.

Mapisal Versus Urea Cream as Prophylaxis for Capecitabine-Associated Hand-Foot Syndrome.

of a randomized phase III trial of the AIO Quality of Life Working Group. This trial compared the effect of Mapisal (a new ointment; Medac, Hamburg, Germany) and urea cream on the primary end point of reduction of the incidence of hand-foot syndrome (HFS) within 6 weeks. Secondary end points were time to development of HFS of any grade and of HFS greater than grade 1 as well as quality of life analyses. A total of 152 patients were evaluable. Of these, 47 patients (30.9%) experienced HFS, with 39.5% in the Mapisal arm and 22.4% in the urea arm (stratified odds ratio, 2.37; P 5 .02). Time to any-grade HFS was significantly longer in the urea group than in the Mapisal-treated group (P 5 .03), and skin-related quality of life was significantly worse in the group treated with Mapisal. The trial by Hofheinz et al 1 showed the superiority of urea cream over Mapisal; however, there are a few controversial points regarding the interpretation of the results. We believe the following three points require clarification from the authors: First, regarding the rationale of the study, the authors concluded that this trial demonstrated, contrary to their hypothesis, that urea cream is superior to Mapisal in preventing HFS in patients with cancer who were treated with capecitabine. In addition, it was revealed that the new ointment was more likely to increase adverse events. Although this trial was conducted as a phase III study, a phase II study or an exploratory study does not seem to have been performed—a rationale for a phase III trial is absolutely required before conducting it. Furthermore, in calculating the sample size of their study, Hofheinz et al 1 did not describe how the incidence of HFS was estimated at 10% in the Mapisal group. Hence, the sample size of this trial was set without an appropriate rationale, and we doubt that this sample size has enough statistical power to prove their clinical hypothesis. The sample setting in this trial was based on only the data for the effectiveness of Mapisal for pegylated liposomal doxorubicin, and the evidence for capecitabine was not shown. Second, regarding the selection of patients in the control arm, to our knowledge, there is no evidence that uric acid–based creams offer effective prophylaxis for capecitabine-associated HFS. To review, uric acid–based creams were shown to be ineffective in the prevention of capecitabine-induced HFS. 2 A randomized phase II study demonstrated the effect of a urea-based cream on sorafenibassociated hand-foot skin reactions. 3 In the trial by Hofheinz et al, 1 urea cream treatment was selected as the treatment for the best supportive care control arm; however, best supportive care as a control arm in this trial was poorly defined. A study with a poorly defined control arm is in danger of either creating excessiveness in or of underestimating the comparator arms. 4 Third, we believe that the results of this trial would have no impact on clinical practice even if Mapisal were found to be significantly more effective than urea, because urea cream is not recognized as the standard treatment. Because a phase III trial requires many resources and considerable effort, including that by the patients, it should be conducted after careful planning, and any harm caused to patients by the experimental treatment should, of course, be avoided. We insist that a phase III trial without established evidence of safety, tolerability, and efficacy should not be performed. We doubt that any arguments of ethical adequacy were offered during the approval process of this trial.

Quality of life and functional status of terminally ill head and neck cancer patients: a nation-wide, prospective observational study at tertiary cancer centers in Japan

Background Little is known about quality of life and functional status of patients with terminally ill head and neck cancers. Methods We conducted a multicenter, prospective, observational study to examine quality of life and functional status in terminally ill head and neck cancer patients. Results Of the 100 patients meeting inclusion criteria, 72 were observed until death. There was no significant difference in the quality of life score between baseline and Week 3. Forty patients (54.9%) could speak and 22 patients (30.5%) could have oral intake upon study entry. Fifty-three patients (74.6%) received enteral nutrition. Twenty-six patients (36.6%) required dressing changes for fungating tumors. The route of nutritional intake (nasogastric tube vs. percutaneous gastric tube) might be predictive for the duration of hospital stay (64 vs. 21 days, P = 0.0372). Conclusion There was no significant relationship between quality of life and functional status seen in this study. Feeding tube type could have the most impact on quality of life.