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A 51-year-old man visited to our hospital because of chest discomfort and hematemesis. He was diagnosed with Mallory-Weiss syndrome and followed in outpatient clinic. One week later, he visited our hospital again for fever and discomfort. Chest computed tomography (CT) showed a foreign body perforated in the mediastinum in the upper esophagus, and he was urgently hospitalized for surgical removal of esophageal foreign body. Before surgery he vomited the esophageal foreign body with a lot of blood. Hematemesis was stopped spontaneously and contrast-enhanced CT revealed a pseudoaneurysm in the distal aortic arch, so thoracic endovascular aortic repair (TEVAR) was performed to prevent rupture. Esophageal endoscopy found that the site of esophageal injury healed spontaneously, so the patient was followed conservatively with antibiotics. He was discharged on postoperative day 18 uneventfully. TEVAR was an effective treatment for aortic injury caused by esophageal foreign body in our case.

The patient, a 33-year-old female, presented to her local doctor with lower abdominal pain. She was referred to our hospital for a plain CT scan, which revealed signs of ileitis. Because acute appendicitis could not be ruled out, the patient was hospitalized. On the third day of hospitalization, she underwent laparoscopic appendicectomy for perforated appendicitis. However, the inflammatory response persisted despite continued antibacterial treatment; we diagnosed this to be due to the formation of a postoperative residual abscess. Since drainage of the abscess was deemed necessary, the patient underwent EUS-guided transrectal drainage on the 26th day of hospitalization. The patient had a favorable postoperative course and was discharged on the 31st day of hospitalization. Along with some literature review, this report details a case in which transrectal drainage under ultrasound endoscopy was effective in treating a pelvic abscess. We report a case of a pelvic abscess that was drained through the rectum under EUS guidance and an internal and external fistula tube was placed. The abscess resolved without complications.

Recurrent gastric cancer(GC)with splenic metastasis showed poor prognosis, and its treatment strategy remains unclear. Recently, studies identified the considerable prognostic effect of metastasectomy in GC following intensive chemotherapy. Here, we successfully treated a patient with Epstein-Barr virus-positive esophagogastric junctional cancer with splenic metastasis who underwent metastasectomy and obtained pathological complete response following immune checkpoint therapy and had long-term survival. We reviewed the literature to discuss the clinical significance of our treatment strategy.

A 58-year-old man with Marfan syndrome visited our clinic for a routine examination. He had undergone a modified Bentall procedure with Carrel patch technique for annuloaortic ectasia 15 years previously. Computed tomography revealed an aneurysm of 43×57 mm in diameter at the right coronary ostium. He underwent resection of the aneurysm and coronary reconstruction using Piehler technique. He was discharged on the 37th postoperative day when his renal function recovered. Although the modified Bentall procedure may improve the surgical outcome, long-term follow-up is important because of various postoperative anastomotic complications in patients with Marfan syndrome.

A 39-year-old man was admitted to our hospital with back pain and numbness of the left leg. Computed tomography (CT) showed a giant bulla and tumor in the right lung, mediastinal shift to the left side and lesions suggestive of metastatic sacral tumor. Three days later, the patient visited the emergency room with dyspnea and tachycardia. Chest CT showed the progression of mediastinal shift due to the rapid expansion of the giant bulla, and an emergency surgery was performed. After induction of anesthesia, sudden respiratory and circulatory failure occurred. Considering further expansion of the giant bulla by positive pressure ventilation, veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO) was applied. After establishing ECMO, the condition of the patient became stable and the giant bulla could be resected successfully.

A 69-year-old man with hypertension was referred for an abnormal shadow detected on chest computed tomography(CT) at a medical checkup. Enhanced CT showed a highly enhanced posterior mediastinal tumor of 34×27 mm. Magnetic resonance imaging (MRI) revealed a low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. Thus, a neurogenic tumor was suspected and the surgery was performed. The tumor was carefully dissected as it was hyper-vascular and hemorrhagic. Immediately after tumor resection, the patient's blood pressure rapidly decreased, and phenylephrine hydrochloride was needed to maintain the blood pressure. The pathological diagnosis was paraganglioma.

Median sternotomy is a basic procedure in the cardiovascular surgery. Minimally invasive surgery (MICS) develops and becomes able to accomplish various operation on the cardiovascular surgery, but it cannot carry out all maneuvers. Medline incision is inferior at beauty and infection control than MICS. But medianstenotomy is still used widely. It's provided good field of vision and the incision method that evade the complexity of the operation. It is vital to carry it out surely and carefully so that there are not later complications by mediansternotomy. It is necessary to be careful about the right ventricle injury the case of the redo-sternotomy.

Tumor-induced osteomalacia (TIO) is a rare paraneoplastic disease characterized by hypophosphatemia and skeletal undermineralization. Overproduction of fibroblast growth factor 23( FGF23) from the responsible tumor is reported to be a causative factor. Removing the tumor is the only effective treatment for TIO, but identifying the tumor is sometimes difficult. A 43-year-old man complained of heel pain 4 years earlier, and the pain gradually expanded to the whole body. As a blood test showed the elevation of the serum FGF23 level and hypophosphatemia, he was diagnosed with FGF23-related hypophosphatemia. Chest computed tomography (CT) showed a 10-mm nodule in the right chest wall. Venous sampling for FGF23 revealed considerable elevation of the FGF23 level in the right subclavian vein. Therefore, a chest wall tumor was suspected as the tumor responsible for TIO, and surgical resection was performed. After surgery, hypophosphatemia improved within several days, and the FGF23 level also normalized.

We report a case of pathologicallycomplete response in ruptured hepatocellular carcinoma(HCC)treated with transcatheter arterial embolization(TAE). A 56-year-old man presented to our hospital with a hepatic tumor. Enhanced computed tomography(CT)revealed a tumor 65mm in diameter at S7/8 of the liver and the presence of abdominal fluid collection around the tumor. We diagnosed rupture of HCC and selective TAE was subsequentlyperformed. After TAE, the elevated PIVKA- / Ⅱ tumor marker level(1,008mAU/mL)decreased to the normal level. Three weeks after TAE, we performed right hepatectomy. The resected specimen revealed that the tumor consisted of necrotic tissue. Viable tumor cells were absent in this tumor. The pathological diagnosis was therefore HCC in which complete response was obtained with TAE.

A 57-year-old female underwent abdominoperineal resection for rectal cancer. Although she received postoperative adjuvant chemotherapy, she had presacral recurrence with pain 26 months postoperatively. We provided palliative care in parallel with systemic chemotherapy, but she had difficulty controlling pain despite using high-dose opioids at 43 months after surgery. Multimodal therapy contributed to a reduction in opioid use for a brief time. Nevertheless, she required high-dose opioid therapy again at 50 months after the procedure. Since she used a rescue dose for relieving anticipatory anxiety for pain, we estimated that she developed chemical coping. After we tried analgesic adjuvant therapy and psychotherapy, her opioid use was reduced. For 10 months afterward, her disease worsened with time, but her pain was well-controlled. In cases where it is difficult to control pain, protection against exacerbation or opioid dose escalation should be considered. Furthermore, psychological contexts, including chemical coping, should also be considered. It may lead to the use of a proper dose of opioids and improve quality of life for patients.

Articular cartilage is exquisitely sensitive to their mechanical environment, and mechanical loading may be the most important external factor regulating cartilage metabolism. Mechanical loading regulates chondrocyte activity, and pathological excessive loading leads to abnormal mechanotransduction, which in turn induces cartilage degradation. Several studies report that moderate levels of exercise exerts beneficial effects, such as improvements in pain and physical function, and also mitigates joint destruction through the down-regulation of the expression of matrix proteases. Calcium signaling is an initial step in chondrocyte mechanotransduction that has been linked to many cellular processes, and recent studies found that calcium ion channels distinctively mechanically activated by physiological or pathological mechanical loading through transient receptor potential vanilloid 4(TRPV4)or Piezo ion channels. We review here the recent progress on mechanotransduction of chondocytes, highlighting the calcium ion channels.

Presently we, Keio Endocrine and Metabolite Survey (KEMS) study group conducted a questionnaire sur- vey with respect to panic values in the laboratories belonging to Keio University-associated hospitals. As to the initial setting, most of the laboratories answered to play a leading role in preparing the necessary matters to implementation of panic values and revise them corresponding to physician's request on each occasion. In almost all laboratories, they did not verify whether the notification procedure does work to exert appropriate clinical action. The numbers of critical values answered by the 18 laboratories distributed widely in the test items (8-39) and their critical limits (10-68). As to the critical limits, the lower limits of serum K and blood glucose converged among the laboratories, however, the limits of other test items diverged. The results of the present survey regarding to critical values, although being in small scale, may submit the im- portant issue to be solved in near future. [Short Communication].

We report the case of a 72-year-old man who had contracted acute paralytic poliomyelitis in his childhood. Thereafter, he had suffered from paresis involving the left lower limb, with no relapse or progression of the disease. He began noticing slowly progressive muscle weakness and atrophy in the upper and lower extremities in his 60s. At the age of 72, muscle weakness developed rapidly, and he demonstrated dyspnea on exertion and dysphagia. He died after about 14 years from the onset of muscle weakness symptoms. Autopsy findings demonstrated motoneuron loss and glial scars not only in the plaque-like lesions in the anterior horns, which were sequelae of old poliomyelitis, but also throughout the spine. No Bunina bodies, TDP-43, and ubiquitin inclusions were found. Post-polio syndrome is rarely fatal due to rapid progressive dyspnea and dysphagia. Thus, the pathological findings in the patient are considered to be related to the development of muscle weakness.

It is very important for advanced cancer patients who receive palliative care to select appropriate places to stay during the end-of-life period. We reviewed the cases of 147 patients who were referred to palliative care services from our hospital. Forty-four patients(30%)were referred to palliative care facilities, and 103 patients(70%)received palliative care in their homes. Fifty-two patients(47%)died at a palliative care facility, 41(37%)died at home, and 18(16%)died at our hospital. The proportion of patients who died at home was three times the number of people who wanted to die at home, according to a Japan National questionnaire. To increase cooperation between regional hospitals and home palliative care services, we attended meetings and conferences conducted by the Nishinomiya City Medical Association. As a result of these activities, we think that the number of patients who die at home has increased.

A 65-year-old woman underwent sigmoidectomy for colon cancer in January 2002. She had multiple liver metastases and received systemic chemotherapy (UFT-E plus CPT-11) for 6 months. She underwent partial hepatectomy of S7 and S3 and cholecystectomy in July 2003. After 4 years without recurrence, right adrenal and para-aortic lymph nodes metastases were detected and she underwent right adrenalectomy and para-aortic lymphadenectomy in July 2007. In July 2008, local recurrence (1 cm in size) was identified in the cavity of the right adrenal gland. She received chemotherapy (mFOLFOX6 plus bevacizumab) for 5 years. In May 2013, PET-CT showed abnormal accumulation of FDG in S7 of the liver (SUVmax 6.7). The enhanced EOB-MRI showed a mass lesion in S7 (3 cm in size) and 2 nodules (1 cm in size) in S3 and S4. We scheduled for liver surgery with reconstruction of the inferior vena cava (IVC) after systemic chemotherapy (FOLFIRI plus cetuximab). The patient underwent partial hepatectomy of the tumor in S7 combined with resection of the diaphragm and IVC. Reconstruction of the IVC was performed using a ringed Gore-Tex tube graft in February 2014. The patient is still alive without recurrence 18 months after surgery.

The patient was a 65-year-old man. In July 2014, he was diagnosed with rectal cancer in a different hospital and underwent high anterior resection(type 2, T3N0M0, StageⅡ [TMN classification, 7th edition]). During the operation, a small nodule was detected in segment 4 of the liver. Contrast-enhanced abdominal CT revealed a tumor measuring 5 cm in diameter located in segment 4/8 of the liver with a tumor thrombus in the main trunk of the portal vein. In August 2014, the patient was referred to our hospital for further examination and treatment. MR imaging showed a lobulated tumor located in segment 4/8 of the liver. Gadoxeticac id-enhanced hepatobiliary phase MR imaging showed that the tumor was less enhanced than was the adjacent liver parenchyma. 18F-FDG-PET/CT demonstrated abnormal accumulation of 18F-FDG in the main tumor(SUVmax=18.3). There was no obvious abnormal accumulation in the other organs. In September 2014, he underwent extended left hepatectomy and portal vein tumor thrombectomy. The resected specimen showed a well-differentiated adenocarcinoma. Immunohistochemical staining results were CK7/CK20 (-/+) and CDX2 (+), which suggested that the tumor was derived from the gastrointestinal tract rather than the liver. The pathological diagnosis was a liver metastasis from rectal cancer. In the 6 months after the operation, intrahepatic recurrence was detected, and the patient was treated with systemicchemotherapy.

Repeated pancreatectomy for metachronous pancreatic cancer has rarely been reported. We report 3 cases with metachronous pancreatic ductal carcinoma that developed after pancreatectomy for the first pancreatic cancer. They were successfully resected by removal of the remnant pancreas. In all 3 cases, the cancers in the remnant pancreas were treated with repeated pancreatectomy. The histological margin of the first pancreatic resection was cancer-free in all the cases. Furthermore, the second cancer tissue contained carcinoma lesions in situ adjacent to invasive ductal carcinoma. Based on these findings, the 3 patients were diagnosed with metachronous pancreatic cancers.

In decades, the signaling pathways that regulate chondrogenesis and the differentiation of chondrocytes have been identified. Molecular biological understanding of the commitment of mesenchymal cells to the chondrogenic lineage, which leads to endochondral bone formation, is necessary to understand pathophysiology of bone/cartilage metabolic diseases and cartilage degenerative diseases. In this review, we show how multiple growth factors and signaling molecules are integrated to activate a series of transcription factors in connection with morphological cell features, which regulates chondrogenesis and chondrocyte differentiation.

Background: We performed a multicenter study in order to clarify the present conditions of the childhood allergic rhinitis treatment in many departments of otorhinolaryngology and pediatrics/internal medicine in the Tohoku region, northern Japan., Methods: We performed a questionnaire survey about patient backgrounds, nasal symptoms, QOL disturbance, and treatment agents, for childhood allergic rhinitis patients under age 12., Results: The total number of cases was 814, the mean age of the patients seen in pediatrics/internal medicine departments was significantly lower than that in otorhinolaryngology. The merger rate of bronchial asthma of the patients seen in pediatrics/internal medicine was significantly higher, and nasal symptoms and QOL disturbance of the patients seen in otorhinolaryngology were significantly more severe. For therapeutic agents, antihistamines were most prescribed, and the combination of LT receptor antagonist and intranasal steroids was used for the cases in which nasal symptoms were severe. The nasal symptoms in the combination group were significantly improved compared with the antihistamine monotherapy group., Conclusion: It was indicated that the combination therapy was useful in the severe cases of childhood allergic rhinitis.

The mediastinal mature teratoma is uncommon in adult and sometimes ruptures. We present a case of perforation of mediastinal mature teratoma. A 22-year-old man, who had been scheduled for surgery to resect anterior mediastinal teratoma, was referred to our hospital due to sudden chest pain. The enhanced computed tomography findings suggested a perforation of the teratoma and the emergency surgery was performed. Extirpation of the tumor with partial resection of right upper lung, pericardium, and superior vena cava was performed. The histological diagnosis was mature teratoma and the defect of the mediastinal pleura was found to be the site of perforation. The patient was well and discharged from the hospital without complications.

Anti-human T-lymphocyte immunoglobulin, rabbit (ATG, Zetbulin(®) intravenous infusion liquid), is an immunosuppressive agent that is indicated for aplastic anemia in Japan. The "prevention of graft-versus-host disease (GVHD) for allogeneic hematopoietic stem cell transplantation in adults" indication has been added to ATG in 32 countries worldwide, but has not yet been approved for GVHD prevention in Japan. The pharmacokinetics of ATG in Japanese people has not yet been assessed. In this study, to assess ATG pharmacokinetics, ATG (2 mg/kg/day from day-4 to day-1) as a pretransplant treatment was administered to six patients who had received transplantation of HLA-haploidentical stem cells. The ATG concentration was measured using an ELISA kit for rabbit IgG. The serum ATG concentration increased with administration for 4 consecutive days, peaking at a concentration of 66.0 μg/ml (±8.8 SD). Subsequently, it gradually decreased with an elimination half-life of 21.9 days (±20.4 SD) but was still detectable in serum even a few weeks after allogeneic hematopoietic stem cell transplantation. We found the pharmacokinetics of ATG in this study to be comparable to those described in previous reports from Europe.

Stem cell transplantation from HLA-haploidentical related donors (haploSCT) has been highlighted as an alternative donor source. The regimen consisting of post-transplant cyclophosphamide (PTCY) has been highly prevalent in the US, Europe, and Japan. Considering the status overseas and the current status in Japan, we aim to show our efforts in haploSCT. We initially established the "haplo-full (original)" regimen, which was found to be excessively toxic for general use. Thus, we added ATG to diminish the GVH reaction (haplo-full with ATG). Unfortunately, "haplo-mini (original)" was found to be relatively weak against refractory diseases. Thus, we intensified the preconditioning regimen, which has enabled us to deal with refractory and post-transplant relapse (FAMC-T). One of the characteristics in haploSCT in Hyogo is the use of steroids from the beginning of SCT. The aim of this strategy is to diminish the inflammation affecting GVHD-target organs, and to suppress chemokine release. Since chemokines produced by the preconditioning regimen are well known to induce GVHD, chemokine suppression should effectively suppress GVHD development. The dependency of the GVL effect on chemokines is unclear, possibly serving as a therapeutic window to separate GVHD from the GVL effect.

A 62-year-old woman visited a nearby hospital with chief complaints of diarrhea and weight loss.A computed tomography (CT)scan showed a hypovascular tumor approximately 2 cm in diameter in the pancreatic uncus, and the patient was referred to our department for thorough examination and treatment.The patient was diagnosed with cT4 (A) N0M0, cStage IV a cancer of the pancreatic uncus.The treatment consisted of 3 weeks of gemcitabine and 1 week of drug withdrawal; after completion of 4 courses, concomitant administration of S-1 (ie GS therapy) was initiated.The tumor gradually shrank, and it was not observed on a CT scan 1 year and 8 months later.Although no obvious distant metastasis was observed, a low density area around the superior mesenteric artery still remained.Possibility of viable tumor could not be completely ruled out; therefore, a pancreaticoduodenectomy was scheduled.However, because sclerosis around the superior mesenteric artery was quite severe, bled easily, and was difficult to separate, we decided that excision was impossible and resumed the GS therapy. The primary lung cancer that developed subsequently was resected, and the GS therapy was continued.The tumor in the pancreatic uncus was resected after growth was observed 3 years and 9 months after the initiation of chemotherapy.The patient is currently receiving chemotherapy as an outpatient.

The patient was a 40-year-old woman.She began experiencing abdominal pain and constipation in July 2005.S he underwent endoscopy in August, which revealed rectal cancer.She was referred to our hospital for surgery and underwent anterior resection with lymph node dissection in September. The pathological diagnosis was tub2, SS, N2, ly1, v1, stage III b. After discharge, she began oral chemotherapy. However, in April 2006, computed tomography (CT) revealed recurrence in the Douglas pouch. She began FOLFOX4 treatment in May.On follow-up CT performed in July, the recurrent sites were limited to 2 nodules and were deemed resectable. The patient underwent peritoneal dissemination resection, and the pathological diagnosis was metastatic tumor.She subsequently received 11 postoperative FOLFOX4 courses. The chemotherapy regimen was changed to the de Gramont regimen because of peripheral neuropathy. After 56 courses of the de Gramont regimen, the chemotherapy regimen was further changed to UFT/UZEL. The patient received 28 additional courses but experienced hair loss and requested treatment cessation. To date, she remains alive without recurrence.

A 70-year-old man presenting with melena was referred to our clinic. A clinical examination revealed a bulky tumor in the lower rectum. After ileostomy, 4 courses of capecitabine plus oxaliplatin (XELOX) therapy were administered as neoadjuvant chemotherapy. Computed tomography (CT) revealed significant reduction of the tumor. Laparoscopic super-low anterior resection with lateral lymph node dissection was performed. The pathological examination revealed no residual cancer cells, and a diagnosis of pathological complete response was made. The patient has been disease-free for 1 year after the operation. Neoadjuvant chemotherapy with XELOX might be promising for patients with locally advanced rectal cancer.

In recent years, there has been significant progress in systemic chemotherapy for metastatic or recurrent colorectal cancer. We investigated the clinical efficacy and feasibility of the bevacizumab and capecitabine /oxaliplatin(CapeOX)combination for untreated colorectal cancer. From October 2009 to June 2012, 38 patients were included, 18 receiving CapeOX alone and 20 receiving CapeOX plus bevacizumab. The response rate and disease-control rate were 16% and 5 0%, respectively, in the CapeOX arm, and 5 5% and 8 5%, respectively, in the CapeOX plus bevacizumab arm. Median progression-free survival was 8.0 months in the CapeOX arm and 1 2.8 months in CapeOX plus bevacizumab arm. The median overall survival was 21.6 months in the CapeOX arm and 3 4.0 months in CapeOX plus bevacizumab arm. Our results suggest that CapeOX treatment can be useful in the outpatient setting and more effective when combined with bevacizumab. Except in cases of bevacizumab intolerance, addition of bevacizumab to CapeOX treatment is considered useful as first-line therapy for metastatic or recur- rent colorectal cancer.

Given the vast amount of visual information in visual scenes, the capacity of our brain to processes such scenes is severely limited. The core mechanism of selection is referred to as visual attention, and it has been the topic of intense investigation for over 25 years in experimental psychology and cognitive neuroscience. Visual attention is not a single, unitary mechanism, but consists of multiple subcomponents. Attention can be directed to various aspects of visual information, such as spatial location, features, or objects. Additionally, attention is guided by external factors such as the salience of stimuli, or whether we are able to move our attention volitionally. The purpose of this article is to review the status of these components of attentional guidance and how they interact with each other, with an emphasis on psychophysical studies.

A 38-year-old man was admitted to our hospital with neck pain, dysesthesia of both hands, and weakness of the left upper limb. He had been diagnosed with a chronic active Epstein-Barr virus infection (CAEBV) at the age of 34 and had undergone umbilical cord blood transplantation at the age of 37. MRI of the spinal cord revealed an intramedullary hyperintense lesion on T₂-weighted images with gadolinium enhancement. Because his laboratory tests revealed proliferation of CD19(+) lymphocytes in the peripheral blood, and EBV DNA was detected in both peripheral blood and CSF, he was diagnosed as having post-transplant EBV associated lymphoproliferative disease. However, chemotherapy did not alleviate his symptoms. At a later time, quantitative chimerism analysis of his CSF showed a higher proportion of lymphocytes that had originated from the recipient. Finally, he was diagnosed as having a recurrence of CAEBV in the central nervous system, and his symptoms were restored by intrathecal chemotherapy (methotrexate, cytosine arabinoside, and prednisolone). Quantitative chimerism analysis of CSF was useful for diagnosing the recurrence of CAEBV in the central nervous system.

A 64-year-old woman presented to our hospital with subcutaneous tumors in the right thoracic region. After undergoing a thorough medical evaluation, she was diagnosed with multiple skin metastases arising from cancer of the descending colon. Surgical resection of the primary lesion was performed and FOLFIRI (5-fluorouracil, levofolinate calcium, irinotecan) and cetuximab chemotherapy for the metastases was initiated. The patient subsequently entered remission and did not experience any major side effects. This case report details an effective therapy for colon cancer with multiple skin metastases and presents a discussion of the expression profiles of epidermal growth factor receptor in both the primary and metastatic lesions.

Purpose: We have reported, in a randomized, controlled study, that tegafur-uracil(UFT)and protein-bound polysaccharide K(PSK)combination therapy significantly improves the 5-year disease-free survival rate and reduces the risk of recurrence compared to UFT alone for Stage II or III colorectal cancer. In this study, we examined the efficacy of PSK by stratifying patients according to the preoperative lymphocyte ratio(Lym)., Methods: In a randomized, controlled study, 205 patients were eligible(137 in the UFT/PSK group and 68 in the UFT group). Of these, 193 patients with available preoperative Lym data were analysed(131 in the UFT/PSK group and 62 in the UFT group)., Results: Among patients with a preoperative Lym of <35%, the relapse-free survival(RFS)rate was 76.5% in the UFT/PSK group and 55.8% in the UFT group(p=0.008). However, in patients with a preoperative Lym of ≥35%, the RFS rate did not differ between the 2 groups. Similarly, overall survival was significantly higher in the UFT/PSK group than in the UFT group in patients with a preoperative Lym of <35%, whereas no intergroup difference was found among patients with a preoperative Lym of ≥35%., Conclusion: This study suggests that a low preoperative Lym is a good predictor for response to PSK in patients with Stage II or III colorectal cancer.

Malignant gastric outlet obstruction( GOO) compromises the ability to eat and drink. Surgical gastrojejunostomy has long been the standard palliative procedure for patients with GOO. However, it might not be applicable for patients with a poor general condition. In Japan, duodenal stenting for malignant GOO has been covered by health insurance since April 2010. In our hospital, 5 patients with malignant GOO underwent duodenal stenting using a WallFlexTM stent( Boston Scientific Corporation). Subsequently, we evaluated the safety and efficacy of duodenal stenting for malignant GOO. Most of the patients in this study were elderly, had systemic inflammation, and were malnourished. We achieved 100% technical and clinical success rates. Four patients were discharged from the hospital. No major complications such as perforation were noted. The median survival time after stenting was 86 days. In conclusion, endoscopic duodenal stenting for malignant GOO is safe and effective, and it could be an option for palliative therapy.

It is considered that cancer stem cells have the same characteristics as normal stem cells, such as drug-resistance, self-renewal, differentiation, and tissue-formation. Normal stem cells depend on their surroundings, a niche. Cancer stem cells may also depend on their own niche. Because cancer stem cells are resistant to present remedies, it is important to find a remedy targeting cancer stem cells. The remedy must not only target cancer stem cells themselves but also target the niche surrounding the cancer stem cells.

A 70-year-old female presented with epigastralgia. Gastrointestinal endoscopic examination showed advanced gastric cancer type 2. Computed tomography(CT)showed a liver tumor of 37mm in segment 6. She was treated with oral S-1, 80 mg/body for 14 days, followed by a 7-day rest, and CDDP 20mg/m2(day 1 and 8). After ten courses of treatment, CT showed reduction of the primary cancer, the liver tumor, and the affected lymph nodes. Then, distal gastrectomy, lymph node dissection, and partial liver resection were performed. The histological diagnosis was no viable cancer cells found in stomach, liver or lymph nodes. One year and 1 month postoperatively, the patient is alive without recurrence.

Pectus excavatum is generally an isolated abnormality of the chest wall. However, some patients have a concomitant pectus deformity and cardiac & aortic disease. Decisions must be made regarding the operative approach and whether the pectus excavatum should be corrected during the same session. We report 2 patients with acute Stanford type A aortic dissection and pectus excavatum who underwent emergency operation. In case 1, median sternotomy is an unsuitable approach for open heart surgery, since the heart and great vessels are displace into the left hemithorax. But combined sternotomy and left anterior thoracotomy provided excellent surgical exposure. In case 2, we proceeded with a leftsided costotomy of four ribs and place a normal chest retractor providing as excellent exposure as combined sternotomy and left anterior thoracotomy. A left-sided costotomy of four ribs can be performed safely, eliminating the risks of median sternotomy in acute stanford type A aortic dissection with pectus excavatum.

A 50-year-old woman was diagnosed with ascending colon cancer with bilateral ovarian metastases, carcinomatous peritonitis, and carcinomatous pleurisy. Nine courses of mFOLFOX6 treatment resulted in the disappearance of her ascites and pleural effusion and a marked decrease in her serum CEA and CA19-9 levels. Additionally, the primary tumor and ovarian metastases became smaller. Therefore, a right hemicolectomy with D3 lymph node dissection, total hysterectomy, and bilateral salpingo-oophorectomy were performed. Postoperatively, we changed the chemotherapy from mFOLFOX6 to bevacizumab+FOLFIRI because the patient had an allergic reaction to oxaliplatin, and we suspected lung metastasis. Because the lung metastasis grew after ten courses of bevacizumab+FOLFIRI, we changed to cetuximab+FOLFIRI. Unfortunately, 28 months after her diagnosis, the patient died of carcinomatous pleurisy.

We present a case of a 59-year-old female who was admitted to our hospital for upper abdominal pain. She was diagnosed with pancreatic body carcinoma by computed tomography and magnetic resonance imaging. We started gemcitabine+S-1 chemotherapy because the tumor had invaded the celiac trunk, common hepatic artery, superior mesenteric vein, and splenic vein. We reduced the S-1 to 100mg/body after the third course of gemcitabine(1, 000mg/m2 on days 1 and 8, every 21 days)+S-1(120mg/body on days 1-14, every 21 days)because of side effects. The tumor became smaller, and the celiac trunk and common hepatic artery were released. Thus, we conducted a distal pancreatectomy with a D2 lymph node dissection.

Combination therapy with angiotensin II receptor blocker (ARB) and calcium channel antagonist is recommended as one of the effective therapies for hypertension. The sub-analysis of Heart Institute of Japan Candesartan Randomized Trial for Evaluation in Coronary Artery Disease (HIJ-CREATE) study showed that combination therapy of candesartan and amlodipine reduced the risk of major adverse cardiovascular event (MACE) by 39% (p = 0.015), as compared to that using amlodipine with non-ARB in hypertensive patients with coronary artery disease. Among the individual events in MACE, the incidence of unstable angina pectoris requiring hospitalization was significantly lower by 52% (p = 0.007). These results suggest that the combination of ARB/Ca antagonist may have an advantage not only for blood pressure lowering but also in preventing cardiovascular event in high-risk hypertensive patients.