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Purpose: Root Cause Analysis (RCA) of reported incident reports can lead to measures to prevent the recurrence of accidents. The purpose of this study is to clarify the relationship between the occurrence of cases, causal factors, contributing factors, and the experience years of the reporters classified into three groups: less than 2 years, 3 to less than 5 years, and more than 5 years, for incident reports subject to RCA., Methods: From April 2018 to March 2023, a chi-square test was conducted between each item extracted from 239 cases subject to RCA and the experience years of the reporters, with a significance level of less than 5% considered significant., Results: Regarding the occurrence cases, radiological technologists with longer experience had more misidentified a patient and fewer errors in imaging conditions and range, while radiological technologists with 3 to less than 5 years of experience had more errors in imaging conditions (p<0.001). In terms of occurrence factors, radiological technologists with 3 to less than 5 years of experience had more cases of insufficient confirmation (p<0.05). For contributing factors, there was no significant difference between the experience year groups (p=0.19), with "Impatience" being the most common factor., Conclusion: This survey suggested that in incident reports of radiological technologists, "Impatience" is a contributing factor that can occur regardless of years of experience.

A 68-year-old male was referred to our hospital because plain computed tomography (CT) showed right hydronephrosis. Contrast-enhanced CT revealed a mass with an irregular margin and poor contrast effect in the lower pole of the right kidney, which invaded the perirenal fat tissues and the area around the inferior vena cava (IVC). Moreover, a thrombus extending from the right renal vein to the IVC was detected, some of which was suggestive of tumor components on contrast-enhanced magnetic resonance imaging (MRI). Biopsy of the renal pelvic mucosa revealed urothelial carcinoma, which was diagnosed as cT4N0M0 renal pelvic cancer. After five courses of neoadjuvant chemotherapy with gemcitabine plus carboplatin, the patient underwent right nephroureterectomy. To avoid tumor cell dissemination into the abdominal cavity, we removed the thrombus and a portion of the IVC were removed en bloc with the right kidney without opening the vein. On pathological diagnosis, the renal tumor was identified as high-grade urothelial carcinoma with sarcomatoid features and squamous differentiation. The tumor invaded the IVC wall through perirenal fat tissues and further developed into a mass in the lumen of the vein. Although the patient was treated with nivolumab as a postoperative adjuvant therapy, he developed liver metastases and local recurrence on the right psoas muscle 6 months after surgery and is currently receiving chemotherapy with enfortumab vedotin.

Migraine attacks, especially ones with aura, have symptoms similar to epileptic seizures, and the two may sometimes be difficult to differentiate clinically. However, the characteristic minute-by-minute symptom development and progress within 60 ‍min is useful for diagnosis. Although the details of its pathophysiology remain unsolved, cortical spreading depolarization (CSD) is one of the main pathogenetic factors. In epilepsy, clinical data have shown that ictal DC shifts could reflect impaired homeostasis of extracellular potassium by astrocyte dysfunction. Ictal DC shifts were found to be difficult to detect by scalp EEG, but can be clinically recorded from the seizure focus using wide-band EEG method. The similarity between DC shifts and CSD has been gaining attention from the neurophysiology point of view. The clinical implementation of infraslow activity/DC shifts analysis of scalp EEG is expected to elucidate further the pathophysiology of migraine, which may lie in the borderland of epilepsy.

A 33-year-old female was admitted to our department complaining of multifocal paresthesia and weakness of the upper and lower extremities that had developed over the previous three months. She had also been undergoing treatment for atopic dermatitis with dupilumab, an anti-interleukin 4/13 receptor antibody. A nerve conduction study revealed multifocal axonal sensorimotor neuropathy of bilateral limbs. On admission, a small erythema appeared on her right forearm, but it was atypical for vasculitic skin lesions due to its location and time course. Nonetheless, a biopsy revealed medium-sized vessel vasculitis. The patient was therefore diagnosed with vasculitic neuropathy caused by cutaneous arteritis. Methylprednisolone pulse therapy with prednisolone and azathioprine markedly improved her symptoms. A skin biopsy is useful when mononeuropathy multiplex is suspected, even if the skin findings are atypical for vasculitic rash.

Chimeric antigen receptor (CAR) T-cell therapy is an innovative treatment for B-cell malignancies and multiple myeloma. CAR T-cell therapy is now approved in Japan and has become one of the essential therapeutic options for chemotherapy-resistant disease. It has many unique features that distinguish it from conventional chemotherapies, including the limitations imposed by the production of CAR-T cells from autologous T cells, and the limited availability and mandatory waiting period for treatment. Importantly, each patient has only one opportunity to receive CAR T-cell therapy. To achieve the maximum therapeutic benefit from CAR T-cell therapy, it is necessary to understand all aspects of CAR T-cell therapy, including factors that influence its efficacy. The design of the entire treatment sequence, including before and after CAR T-cell therapy, is also important to optimize clinical outcomes. In addition, since this treatment is only available at a limited number of facilities, effective coordination between local hospitals and treatment centers is also important. This educational session will focus on the practical aspects of CAR T-cell therapy in adults and will provide indispensable knowledge for providing CAR T-cell therapy to patients with B-cell lymphoma and multiple myeloma.

Evidence-based medicine (EBM) is "decision-making for better patient care that integrates current evidence, and clinical expertise with patients' preferences, values and circumstances." It is important to distinguish research evidence from EBM, which is comprehensive decision-making that takes into account the diversity and individuality of clinical situations while respecting evidence as a general theory. Clinical practice guidelines are "a document that evaluates the total body of evidence through systematic review and presents recommendations that are considered optimal, taking into account the balance of benefits and harms, in order to support decision-making on important health-related issues by healthcare users and providers," and is useful in the practice of EBM. Shared decision making (SDM), which has been attracting attention in recent years, is "a process in which the patient and the health care provider, through dialogue, decide on a treatment plan that is acceptable to the patient, based on the patient's own preferences and values, research evidence, and clinical expertise" and must be understood in relation to the above definition of EBM and from the perspective of clinical ethics.

A 72-year-old woman with relapsed FLT3-ITD-positive acute myeloid leukemia was treated with gilteritinib and achieved complete remission with incomplete hematological recovery. However, two months later, she developed optic nerve infiltration and lost vision in her right eye while maintaining hematological remission on gilteritinib. Intrathecal injection of cytotoxic drugs reduced the number of blasts in the cerebrospinal fluid (CSF), but her vision did not recover. At the onset of optic nerve infiltration, at a dose of 80 mg/day gilteritinib, the plasma trough and CSF levels of gilteritinib were 151.9 ng/ml and 1.9 ng/ml, respectively, with a central nervous system (CNS) penetration rate of 1.3%. Hematologic progressive disease (PD) was detected after 40 days, and the patient died one month later. Target sequencing at the time of hematologic PD revealed the FLT3 F691L mutation, which is known to confer resistance to gilteritinib. In this patient, pharmacokinetic (low CNS penetration of gilteritinib) and pharmacodynamic (acquisition of a drug resistance mutation) mechanisms were thought to be responsible for the CNS relapse and hematologic PD, respectively. We believe this is a valuable case to report considering the scarcity of data on CNS penetration of FLT3 inhibitors and their effects on CNS disease in the literature.

During the past decade, many high-alert medications have been developed and used in clinical practice. Particularly, in the pharmacotherapy of high-alert medications with large individual differences, more attention is needed. To achieve appropriate and individualized pharmacotherapy, there are many issues to be addressed from a clinical pharmacology perspective, such as enhanced monitoring and prior risk identification. This paper is focusing on the therapeutic drug monitoring of molecularly targeted anticancer drugs, and the provision of real-world evidence based on the clinical implementation of pharmacogenetic testing.

Advances in understanding of the pathogenesis of B-cell lymphoma have led to development of various novel targeted therapies. Among them, CD19-targeted chimeric antigen receptor (CAR) T-cell therapies for relapsed and refractory B-cell lymphomas have shown remarkable efficacy in clinical trials, and three CAR T-cell products are now available in Japan. Real-world evidence (RWE) has shown that these products can provide comparable efficacy to clinical trials in clinical practice, where CAR T-cells were administered in patients with wider range of backgrounds. This finding will certainly broaden the role of CAR T-cell therapies in the treatment of B-cell lymphoma. However, since about half of the patients treated with CAR T-cell therapy progress thereafter, there is an urgent need for risk stratification and optimized management of refractory cases. Here, we review the results of clinical trials and RWE of CAR T-cell therapy in B-cell lymphoma.

T-lymphoblastic leukemia/lymphoma (T-ALL/LBL) has a poor prognosis. Nelarabine has recently shown relatively good results in patients with relapsed or refractory T-ALL/LBL, but requires careful monitoring for neurological complications. A 50-year-old man with early recurrence of T-LBL after allogenic peripheral blood stem cell transplantation received nelarabine monotherapy and achieved complete remission after 1 cycle. He then received umbilical cord blood transplantation, and experienced sustained disturbance of consciousness. He later died of multiple organ failure, and autopsy suggested that nelarabine-induced leukoencephalopathy had caused the disturbance of consciousness. This case suggests that physicians should carefully monitor patients for neurological complications and consider imaging follow-up and consultation with a neurologist.

The purpose of this study was to evaluate the effectiveness of a hands-on seminar using a Web conferencing system, based on the post-event questionnaires of the face-to-face and online seminars of the hands-on seminar. For participants to feel realistic training in the online seminars, four educational videos explaining the procedure of the practical skill were created. We compared results of questionnaires acquired from participants after the face-to-face and online seminars. The questions about expectation, comprehension, satisfaction level, and lecture time for the seminars were graded on a 5-point scale. The higher the scores, the higher the rating, except for lecture time. A score of 3 was appropriate for the lecture time, with a higher score indicating that the seminar felt longer and a lower score indicating that the seminar felt shorter. In the evaluation of classroom lectures, such as expectation, comprehension, and satisfaction level for the seminars, there were no significant differences between the face-to-face and online seminars, and both achieved high scores of 4 or more. There was a significant difference in the evaluation of lecture time for classroom lectures, with participants feeling that it was too short in the face-to-face but just right in the online. In all evaluations for hands-on training and discussion, there were no significant differences between the face-to-face and online seminars, and both achieved high scores of 4 or more and time was short. It was concluded that our proposed online seminar approach could achieve a high level of evaluation as face-to-face seminars.

Three-dimensional (3D) images, which are acquired by X-ray computed tomography (CT), are widely used in medical diagnosis and treatment. Recently, advances in image processing functions of 3D image analysis workstations have made it possible to confirm actual procedures, approach lesions from directions that are not visible during surgery, and observe important structures by moving images on the workstation. This is useful in providing a variety of information on the pathology in advance. However, depending on the manipulation of the creator, the 3D images provided can vary greatly in terms of the omission of blood vessels and tumors, the background color, the colors of organs, and the presentation including rotation directions and angles. In this study, we decided to create a manual for 3D image creation using our web hosting service to standardize the 3D images to be provided. In particular, dynamic content using the HyperText Markup Language (HTML) was created and posted to provide a useful support tool for 3D image creation. In addition, the data can be accessed via the Internet within the hospital, making them widely available in clinical and educational settings.

Purpose: This study aims to optimize the selection of the magnetic resonance imaging (MRI) scanners and metal artifact reduction magnetic resonance sequence (MARS) in patients with metallic implants by comparing the image quality of MARS at different static magnetic fields., Method: A titanium alloy hip prostheses stem was covered with the pork phantom. Nifedipine 10 mg was placed as a simulated lesion near the hip joint of the phantom. T 1 -weighted imaging (T 1 WI) and short tau inversion recovery (STIR) were acquired at both 1.5T and 3T. Several techniques of high-bandwidth (High BW), view angle tilting (VAT), and compressed sensing and slice encoding for metal artifacts correction (CS-SEMAC) were compared. Artifacts, sharpness, and visibility of lesions were evaluated visually by five radiological technologists using the normalized-rank approach., Result: CS-SEMAC reduced metal artifacts but showed bad sharpness. CS-SEMAC at 3T was the best visibility of lesions., Conclusion: If lesion visibility is a priority, CS-SEMAC with 3T is recommended as the first choice.

The standard treatment for advanced urothelial carcinoma includes platinum-based chemotherapy and programmed cell death protein 1 or programmed death ligand 1 inhibitors. However, urothelial carcinomas are often associated with both intrinsic and acquired resistance to these treatments. Paclitaxel, ifosfamide, and nedaplatin (TIN) chemotherapy has been proven to be effective as the second- or third-line treatment for platinum-resistant advanced urothelial cancer. Herein, we report two cases of patients with advanced bladder cancer resistant to platinum-based chemotherapy or pembrolizumab, who were treated with TIN chemotherapy. The first case was in a 66-year-old woman treated with gemcitabine and cisplatin (GC) chemotherapy followed by gemcitabine, paclitaxel, and cisplatin chemotherapy for multiple pulmonary metastases after radical cystectomy. Following reduction in pulmonary metastases after six courses of TIN treatment, metastasectomy and two courses of adjuvant TIN treatment were administered, with no recurrence for eight years. The other case was in a 70-year-old man treated with GC chemotherapy and pembrolizumab for invasive bladder cancer and multiple pulmonary metastases. We treated this patient with salvage pelvic exenteration. Pulmonary metastases significantly decreased after six courses of TIN chemotherapy. After a partial response for seven months; the patient died due to a novel cerebellar metastasis after six courses of TIN chemotherapy. Thus, we conclude that TIN chemotherapy can be considered as a third line treatment for advanced urothelial cancer resistant to platinum-based chemotherapy and pembrolizumab.

Chimeric antigen receptor T cell (CAR-T) therapy has strong efficacy as well as characteristic complications. Although overshadowed by the glaring clinical picture of cytokine releasing syndrome and immune effector cell-associated neurotoxicity syndrome, there are many other side effects that are important to manage. In this article, CAR-T-specific adverse events will be reviewed based on the actual clinical experience.

The use of human leukocyte antigen (HLA)-incompatible transplantations, in addition to cord blood transplantation, is rapidly increasing due to the development and refinement of graft-versus-host disease prophylactic treatment with post-transplant cyclophosphamide or anti-thymocyte globulin. However, caution must be observed in interpretating the significance of HLA incompatibility because each transplant source differs, which affect the association between HLA compatibility and transplant outcome. In addition, the loci that should be evaluated, the level of matching (antigen/allele), the direction of incompatibility (graft-versus-host or host-versus-graft), and the combination of incompatible HLA alleles must be understood. Notably, the significance of HLA incompatibility changes with the development and improvement of GVHD prophylactic treatment. Factors that should be prioritized in donor selection should be evaluated in the future. This article outlines the significance of HLA incompatibility in each transplant source.

Myoclonus is a sudden, shock-like involuntary movement in the extremities, face, or trunk without loss of awareness (LOA). However, if it becomes generalized and lasts more than 3 s, LOA occurs. Chorea is characterized by gross generalized movements without LOA. Ballism is a rapid, violent, and lateralized movement in the upper or lower extremities, usually in the proximal part of the body, such as throwing or flinging without LOA. These three abnormal movements commonly show hypermotor and hypotonic (or orthotonic) states. Although their underlying pathophysiology is varied, it is often attributed to hereditary diseases, and thus investigating the family history is important.

The frequency of the manufacturing failure of chimeric antigen receptor (CAR)-T cell therapy in clinical practice is unknown. To clarify the current state of how likely CAR-T cell production is to succeed or fail for B-cell acute lymphoblastic leukemia (B-ALL), we analyzed cases in which the production of tisagenlecleucel was performed for patients with B-ALL at 15 facilities in Japan from October 2019 to March 2022. Total 81 patients (47 males and 34 females) were analyzed. The median age at apheresis was 13 years (1-25) with a median number of prior treatments of 4 (1-9). The numbers of patients with histories of allogeneic transplantation, inotuzumab ozogamicin, or blinatumomab treatments were 51 (63.0%), 26 (32.1%), and 37 (45.7%), respectively. The median blast percentage and CD3 + cell counts in peripheral blood were 0% (0-91.5), and 611/µl (35-4,210) at apheresis, and the median number of CD3 + cells shipped was 2.2×10 9 (0.5-8.3). While cases with a history of heavy prior treatment before apheresis were included, no manufacturing failures were observed. Continuing to monitor the status of manufacturing failures is necessary as the number of B-ALL cases treated with CAR-T cell therapy increases.

Purpose: It has been reported that the placement of protective equipment in female pelvic radiography is predominantly inadequate compared with that of male. We analyzed the actual situation of ovarian shielding by protective devices using X-ray, CT, and MR images obtained in the past, and evaluated the effectiveness of gonadal protection in female hip radiography., Methods: The ovaries were contoured in MR images and the pelvic bone was extracted by CT images. The MR/CT fusion images were created using a 3D workstation. The amount of physiological fluctuation in the ovarian location was measured. The fusion images in the ray-summation display were manually superimposed with the X-ray image, and the percentage of ovaries that could be shielded by the protective device was classified into four categories: (a) complete protection, (b) partial protection, (c) failure of protection, and (d) image retaking., Results: The mean and maximum ovarian fluctuations were 1.1 cm and 3.9 cm in the superior and inferior directions, respectively, and 0.7 cm and 2.0 cm in the left and right directions, respectively. The percentage of ovaries shielded was 18.9% for complete protection, 58.5% for partial protection, 15.1% for inadequate protection, and 7.5% for image retaking., Conclusion: The effectiveness of gonadal protection is low because the protective device could not cover the entire ovary in about 80% of the female hip radiographs.

A 73-year-old woman was referred to our hospital for treatment of a 12 mm stone in the right ureteropelvic junction and pyonephrosis. A double-J ureteral stent was indwelled for right hydronephrosis and emphysematous pyelonephritis. After antibiotic treatment, flexible transurethral lithotripsy (f-TUL) was performed and all the stones were disintegrated and extracted without any complications. On the day after f-TUL, severe back pain occurred, and computed tomography revealed subcapsular hematoma and renal pseudoaneurysm. Angiography and selective embolization of the bleeding artery were performed to control the bleeding.

With the spread of cancer genomic medicine in Japan, the burden on expert panels is clearly increasing. Various factors, such as the conditions for calculation of reimbursement and the fact that the panels can only be conducted at core hospitals for cancer genomic medicine have contributed to this increase in the burden. This paper describes the challenges and future of expert panels in the implementation of cancer genomic medicine in Japan, based on the experience of our hospital.

Precise localization of the "epileptogenic zone(EZ)" is the goal of presurgical investigations in patients with drug-resistant focal epilepsy. Intracranial electroencephalography recordings are required when noninvasive evaluation results are not consistent. Although subdural grid electrodes(SDG)have been widely used in Japan, stereoelectroencephalography(SEEG)has been recently introduced. The principle of SEEG is based on anatomo-electro-clinical correlations to investigate surgical hypotheses that are primarily driven by the analysis of seizure semiology as well as other noninvasive investigations. The most important element of the SEEG methodology is to formulate preimplantation electrode trajectories considering the anatomo-electro-clinical correlations of epileptic seizures. If the preimplantation hypotheses are insufficient or incorrect, SEEG recordings will not identify the EZ. A detailed analysis of seizure semiology with respect to anatomo-electro-clinical correlates, particularly including various deep structures, such as the insular, operculum, and cingulate cortex, forms the basis of the implantation strategy for SEEG. The strategy of implantation is not to map the lobes/lobules but the epileptic networks, which usually involve multiple lobes, indicating that the theory of SEEG is completely different from that of SDG. Herein, we introduce the basics of SEEG, especially presurgical evaluations, with a representative case presentation.

The purpose of this study was to evaluate the effectiveness of metal artifact reduction (MAR) processing in cone beam computed tomography angiography using the relative artifact index (AI r ) and the difference due to tube voltage. A water phantom was imaged to obtain noise images. Next, a platinum alloy embolic coil was installed in the central part of the water phantom and the peripheral part, and then artifact images were acquired. The tube voltages were 70 kV and 109 kV, and four types of artifact images were acquired (with and without MAR). In all, 10 images in the z-direction from each image series were acquired (total: 40 images). The AI r value was calculated by setting a region of interest in the images, and multiple comparisons were made between the imaging conditions (significance level set at p<0.05). The AI r values were significantly lower by MAR, and MAR significantly reduced metal artifacts regardless of tube voltage (p<0.001). This study's results show that MAR with cone beam CT can reduce metal artifacts by more than 91%, and the effect is comparable regardless of tube voltage.

A 36-year-old man presented to our hospital with right scrotal swelling. A computed tomographic scan revealed a mass in the right scrotum, multiple masses in the lung and liver, and enlarged cervical, mediastinal, and retroperitoneal lymph nodes. After right high orchiectomy, he was diagnosed with nonseminomatous germ cell tumor (pT3N3M1b), with poor risk prediction according to the International Germ Cell Consensus classification. We started chemotherapy with bleomycin, etoposide, and cisplatin. Since serum alphafetoprotein (AFP) and human chorionic gonadotropin (HCG) levels did not decrease to normal levels, second-line chemotherapy with paclitaxel, ifosfamide, and cisplatin was administered. Six days after the start of treatment, the patient became unconscious, and his blood pressure decreased. Seven days later, blood tests revealed high uric acid levels, hyperphosphatemia, and increased creatinine. This was diagnosed as tumor lysis syndrome. Following diagnosis, continuous hemodiafiltration was started, and his condition gradually improved.

We retrospectively analyzed the effect of lymph node dissection (LND) in patients with renal cell carcinoma (RCC). Of 151 patients who underwent nephrectomy for RCC, 86 underwent LND. No distant metastasis (M0) was present in 71 patients, although distant metastasis (M1) was present in 15. Three (4.2%) and eight (53%) patients in the M0 and M1 groups, respectively, were clinical N-stage positive. Two (2.8%) and three (20%) patients in the M0 and M1 groups, respectively, were pathological N-stage positive. Both pathological N stage-positive patients in the M0 group were pathologically diagnosed with microphthalmia transcription family translocation RCC. The clinical and pathological positive node areas exhibited concordance in all three pathological N stage-positive patients in the M1 group. Chylous leakage occurred in 16 (19%) patients in the LND group (p＜0.05). Extended LND was a statistically significant risk factor for chylous leakage in the multivariate analysis. Only limited cases should undergo LND, owing to the low frequency of positive pathological lymph node metastasis, and high complication rate.

The Kyoto University has been promoting the"The 3rd Stage Cancer Professional Development Plan"in collaboration with Shiga University of Medical Science, Mie University, Osaka Medical and Pharmaceutical University, and Kyoto Pharmaceutical University. The theme of our plan is"Training of Cancer Professionals who will lead the way in advanced cancer treatment". As the distinctive educational programs, we have undertaken include: 1 )overseas training, 2 )a five-university collaborative short-term training program, 3 )a five-university collaborative medical forum, and 4 )an educational program of patient and public involvement. In the 3rd Stage of the program, 173 students have been accepted and 120 have obtained professional certifications as of the end of 2021. On the other hand, the 3rd Stage Cancer Professional Development Plan ended in FY2021, and it is difficult to continue the education of the students currently enrolled in the program. We sincerely hope that the sufficient budget will be allocated in FY2022 and beyond so that sustainable education can be implemented.

Magnetic resonance imaging (MRI) ultrasound fusion biopsy is becoming popular owing to the better detection rate of clinically significant prostate cancer (csPCa). We retrospectively evaluated the accuracy of MRI-targeted biopsy during the period of introduction at a single academic center by comparing findings of its specimen and whole-mount histopathology. Between June 2018 and January 2021, 106 transperineal MRI-ultrasound fusion biopsies using BioJet software were performed. Among the cases, 15 subsequently underwent robotic-assisted laparoscopic radical prostatectomy and were eligible for analysis. This study included all regions of interest (ROIs) with a Prostate Imaging Reporting and Data System v2 category of 3 or greater on pre-biopsy MRI．For each lesion, grade group of MRI-targeted biopsy specimens and prostatectomy specimens were compared. From a total of 25 ROIs identified among 15 males, csPCa was found in 21 (84%) of the concordant locations of prostatectomy specimens. However, MRI-targeted biopsy could diagnose csPCa in only 12 (48%) of them. In the csPCa undetected group, the ROI volume was significantly smaller (median volume 0.23 ml vs 0.40 ml, p＝0.03). We also found that in cases where PCa was not detected through MRI-targeted biopsy, the biopsy sample length was significantly shorter (median length 9 mm vs 17 mm, p＝0.01). Our data suggest that failure of detecting PCa in MRI-targeted biopsy could be due to technical errors at the introduction period of the technique. A sufficient sampling length of 10 mm or more is desirable, especially for small lesions.

Chimeric antigen receptor (CAR) T-cell therapy has become the standard of care for some B-cell malignancies due to its high antitumor efficacy. However, adverse events specific to CAR T-cell therapy, such as cytokine release syndrome (CRS), are frequently observed. Typical clinical manifestations of CRS include hyperthermia, hypotension, hypoxemia, and increased vascular permeability. Coagulopathy may also be observed along with to the typical symptoms of CRS. Previous studies, including ours, have revealed that the increase in interleukin-6 levels associated with CRS promotes production of plasminogen activator inhibitor-1 from the vascular endothelium, resulting in suppressed fibrinolysis and hypercoagulability and an exhaustible decrease in fibrinogen. Continuous monitoring of coagulation parameters is necessary during CAR T-cell therapy, and adequate provision of fresh-frozen plasma or cryoprecipitate is recommended if the patient is evaluated to be at high risk for severe CRS.

In Japan, 2 comprehensive genome profiling(CGP)tests for cancer was covered by national health insurance in June 2019, and cancer genome medicine was introduced at a total of 225 hospitals designated by the Ministry of Health, Labor and Welfare as"core center hospitals for cancer genome medicine(12 hospitals)"," core hospitals for cancer genome medicine (33 hospitals)", and"collaborative hospitals for cancer genome medicine(180 hospitals)". On the other hand, the interpretation of the results of the cancer CGP test must be discussed by an expert panel conducted at the core center hospitals for cancer genome medicine or the core hospitals for cancer genome medicine, and the results must be explained to patients in order to be covered by insurance. In other words, these hospitals are required to review not only their own cases but also those of collaborating hospitals. In addition, core center hospitals for cancer genome medicine are required to share information and develop human resources with core hospitals and collaborative hospitals for cancer genome medicine. We herein describes the system for providing cancer genome medicine in our hospital as a core center hospital for cancer genome medicine.

A man in his 60s was diagnosed with clear cell carcinoma of the right kidney with multiple lung metastases, tumor thrombus of the inferior vena cava (IVC), and invasion of the duodenum and pancreas. Ipilimumab plus nivolumab was administered as first-line therapy. After 3 treatment courses, computed tomography (CT) demonstrated a slight decrease in the size of the primary tumor and lung metastases. However, the patient became hemodynamically unstable due to persistent duodenal bleeding during treatment despite frequent blood transfusions. Axitinib was then initiated as second-line therapy. The duodenal bleeding ceased 10 days after starting axitinib and his anemia remissed. Subsequent CT showed further decrease in the size of the primary tumor and lung metastases. The patient underwent right nephrectomy after improvement of nutrition. IVC thrombectomy, and pancreaticoduodenectomy. The lung metastases disappeared on postoperative imaging and no additional treatment was provided. Twelve months after surgery, he was in good health and showed no signs of recurrence.

A 22-year-old woman was referred to our hospital for further examination of an incidentally discovered hypervascular pelvic tumor with a maximum diameter of 10 cm. Although Castleman disease was suspected based on the imaging findings and pathologic findings of the needle biopsy, a definitive diagnosis was not made. Preoperative transcatheter arterial embolization was performed to decrease intraoperative bleeding, and tumor resection was performed on the following day. As for posterior approach prior to anterior approach, the patient was placed in a prone position, and the dorsal aspect of tumor was approached through the dissection of gluteal muscles. Then, dilated branches of the internal iliac vein was found on the tumor capsule, which were safely ligated under direct vision with favorable visual field. Then, the patient was placed in a supine position, the tumor was completely resected by anterior approach without transfusion. Histopathological diagnosis was Castleman disease hyaline vascular type. The patient was discharged without complication and has been free from recurrence for 6 months after surgery.

Gender equality is one of the most important issues in the promotion of diversity. The participation status of female urologists in academic activities has not been clarified. In the present study, we analyzed a total of 10,288 articles published by 58,914 authors in Acta Urologica Japonica since the first issue in 1955 to the present. The author's gender was determined by an application program interface for gender estimation in combination with independent manual confirmation by two researchers. The increasing rate (⊿person/⊿year) of female authors was as low as 0.067 in 1955-79, but increased to 0.400 in 1980-2000 and 0.814 in 2001-20. Over the time periods, the annual total numbers of female authors (person/year) showed an increasing trend from 3.2 in 1955-79 to 16.3 in 1980-2000 and 26.0 in 2001-20. The numbers of female author individuals, the ratio of female authors to all authors and the ratio of publications by female first author to all publications also showed similar trends. These results suggest that gender equality is becoming more prevalent in the academic field of urology. The methods and data of this study are considered to be useful for the promotion of gender equality in the academic field of urology for the future.

A human leukocyte antigen (HLA)-matched related donor is considered as the first donor candidate in case of allogenic hematopoietic stem cell transplantation (allo-HSCT). Given the declining birthrate and aging population in Japan, the number of sibling donors is also decreasing. Hence, candidates other than HLA-matched siblings, named "alternative donors," have attracted increasing attention. Improved graft-versus-host disease (GvHD) prophylaxis with posttransplant cyclophosphamide or pretransplant antithymocyte globulin represented a major breakthrough in allo-HSCT with alternative donors by overcoming the barriers of HLA mismatch. In addition, there have been improved outcomes of unrelated cord blood transplantation, owing to better unit selection along with improved GvHD prophylaxis and supporting strategies. These changes have expanded the range of donor options and consequently, increased donor availability at the critical moment for allo-HSCT. The next challenge that warrants further investigation is the development of personalized strategies to select the best donor from the available multiple options according to the status of each patient.

To perform chimeric antigen receptor T (CAR-T) cell therapy in heavily pretreated patients with progressive disease and depleted lymphocytes, an optimized leukapheresis protocol must be established. To probe the effects of patient-related parameters on the collection efficiency of CD3 + cells, we retrospectively analyzed patients with relapsed/refractory diffuse large B-cell lymphoma who underwent leukapheresis for tisagenlecleucel at two centers. A total of 51 patients were analyzed, with a median age at apheresis of 59 years, and precollection hemoglobin levels, CD3 + cell counts, and platelet counts of 9.2 g/dl, 574/µl, and 15.8×10 4 /µl, respectively. A median of 3.0×10 9 (0.7-8.4) CD3 + cells were harvested with 8.7 (4.0-15.7) l apheresis volume. The collection efficiency 2 (CE2) for CD3 + cells was 61.0% (21.0-127.3). One-day apheresis was sufficient to obtain the designated cell numbers in all cases. Lower hemoglobin levels, higher CD3 + cell counts, and higher platelet counts before apheresis were significantly associated with lower CE2 for CD3 + cells. These results suggest a need to increase the apheresis volume in anemic, lymphocyte- or platelet-rich patients due to an expected low CE2. Erythrocyte transfusions before or during apheresis may be a reasonable option for patients with anemia.

In this study, we report a case of a 77-year-old woman who was presented with anemia in the winter of 2002. She was diagnosed with cold agglutinin disease (CAD) and treated with corticosteroids. Further, her hemoglobin levels were maintained between 7.0 g/dl and 8.0 g/dl. In May 2019, mature peripheral blood lymphocytes increased with exacerbation of hemolytic anemia. The lymphocytes were positive for CD19 and CD20, but negative for CD5, CD10, and CD23. Additionally, they were positive for cell surface IgM-κ. The B-cell neoplasm could not be further subclassified due to the lack of BCL2-IgH and BCL1-IgH rearrangement and morphology. The IgM-κ-type M-protein was found in serum, and the direct Coombs test was negative for IgG but positive for C3b/C3d. These findings suggested that small B-cell neoplasm-associated M-protein was involved in the development of CAD through complement activation. Based on the presence of TP53 deletion, the patient was treated with ibrutinib monotherapy. Although hemolysis rapidly improved with a dramatic decrease in lymphocytes, she died from a cerebral hemorrhage. It is assumed that ibrutinib improved CAD through suppression of small B-cell neoplasm-related M-protein. CAD can precede lymphoproliferative disorders; however, the risk of ibrutinib-associated hemorrhage should be noted.

In Japan, 14 opioids with a variety of dosage forms, such as oral preparation, injection, transdermal patch, transmucosal and suppository are clinically available as analgesics, and their use properly depends on the type and degree of pain and patient condition. Fundamentally, strong opioids are restricted to only treatment of cancer pain, while the indication of fentanyl transdermal patch and oxycodone tamper resistant tablet has been expanded for the treatment of non-cancer chronic pain. In US, the additional indication of opioids to chronic pain has led to prolongation and generalization of opioid use, which may contribute to "opioid crisis" in which opioid-related death strikingly increased due to opioid abuse and overdose-induced respiratory depression. Currently, opioid-related abuse and death have not been evident in Japan, while abuse of antitussive opioids (codeine and dihydrocodeine) are recently seen as a problem, which may suggest the sense of guilt to abuse legally-uncontrolled drugs (ex. weak opioids, antitussives or hypnotics) may be low in Japanese. In this review, I will summarize current status and issues in clinical use of opioid analgesics, and will talk about the necessity and expectation for development of novel analgesics without serious adverse reactions such as addiction and respiratory depression.

A woman in her 40s visited our hospital for further examination and treatment of a left renal tumor. Imaging studies showed that the patient had a large left renal tumor, 10.5 cm in diameter, which contained foci of necrosis. Open left radical nephrectomy was performed. In pathological examination, hematoxylin-eosin staining showed uniform small round cells with alveolar growth. Immunohistochemistry findings showed that CD99 and NKX2. 2 were positive, and synaptophysin was focally positive. Fluorescence in situ hybridization confirmed (11 ; 22) (q24 ; q12) chromosomal translocation which led to diagnosis of primary Ewing sarcoma of the kidney. Two months after the surgery, new tumors were found inside and outside of the left psoas muscles and in the left paracolic gutter. Six courses of chemotherapy were administered with VDC (vincristine/doxorubicin/cyclophosphamide) and IE (ifosfamide/etoposide). After completing the combined chemotherapy, the recurrent tumors disappeared completely on imaging. To prevent further recurrence, external radiation was administered to the left retroperitoneal region. About 16 months after the surgery, numerous new tumors appeared in the left retroperitoneal, left pleura, and erector spinae muscles. Chemotherapy was resumed following radiotherapy, and then trabectedin was administered. However, she eventually died of progressive disease at 26 months after the surgery.

From June 2019, 2 different comprehensive genomic profiling(CGP)test panels were covered by National Health Insurance System in Japan. However, the indication of CGP was solid cancer patients refractory to standard chemotherapy or those without standard of care, while other countries indicate CGP to chemotherapy naIve advanced cancer patients. To be covered by National Health Insurance System, certified core hospital for genomic medicine should hold expert panel with affiliated hospitals. We develop a unique system for expert panel collaborated with SYSMEX Corporation to streamline medical staffs' effort. To provide precision medicine to cancer patients, we have to maximize the merit of CGP and solve several issues.

Several biosimilars have appeared in cancer treatment. They should contribute to the reduction of medical cost. However, in Japan, a suspicion of medical staffs and patients to biosimilars and an obstruction of High-Cost Medical Expense Benefit to the burden reduction of patients suppress the use of biosimilars. Recently, several guidelines declare to promote the use of biosimilars. High-quality biosimilars are also going to be developed by next generation biotechnologies. The positive selection of biosimilars hopefully contribute to patients and national medical economy. In this review, we mention about the current subjects and future prospects of biosimilars.

The right renal artery has been considered to originate laterally from the anterior aspect of aorta. In some cases, it turns more ventrally than the aorta, which can lead to intraoperative right renal artery injury. For this reason, we evaluated how the right renal artery turns ventrally and analyzed the factors for ventral protrusion of the right renal artery. We examined contrast-enhanced computed tomography images of 195 individuals and measured their angles of the right renal artery and ventral protrusion from the aorta. Age and sex had no significant correlation with these variations. A weaknegative correlation was found between body mass index and these variations. Almost all the right renal artery originated from the ventral side of the aorta, and almost half the right renal artery arose ventrally more than the aorta. Careful attention should be paid to ventral protrusion of the right renal artery to prevent vascular injury during surgery using the anterior approach to the upper retroperitoneum.

Objectives　In Japan, the proportion of older people receiving end-of-life care in geriatric health services facilities (GHSF) is increasing. However, to our knowledge, there have been no previous studies investigating the relationship between the structure of GHSFs and the quality of end-of-life care evaluated by bereaved families.Methods　We secondarily analyzed data from the survey done by the Japan Association of Geriatric Health Services Facilities (JAGHSF) in January 2014. Study subjects were 3 recently bereaved family members who had experienced planned end-of-life care at different facilities of the JAGHSF.The dependent variable was the bereaved family members' satisfaction with end-of-life care, which was obtained based on the best answer out of a 5 point scale for the question "Didn't you regret your family member's death immediately after he/she died?" The independent variables included schemes of explanation of patients' conditions at GHSF, management, and education of facilities and staff by doctors. We conducted a univariate analysis, followed by a multivariable logistic regression analysis.Results　For the final analysis, we included 363 bereaved family members, of which 250 (68.9%) were satisfied with the end-of-life care. In a multivariable logistic regression analysis, family members' satisfaction was significantly associated with regular medical consultation by doctors for facility users (adjusted odds ratio 2.94, 95% CI 1.52-5.70), explanation about patients' conditions at the time of admission by facility staff other than doctors (2.07, 1.01-4.25), explanation about patients' conditions at the time of deterioration by facility staff other than doctors (3.12, 1.17-8.33), and stress management by doctors for facility staff (3.63, 1.84-7.16).Conclusions　Respect for the roles of the facility staff other than doctors, such as the participation of facility staff in explaining situations for facility users and family members and management of facility staff stress, may improve satisfaction with end-of-life care among bereaved family members. More attention is needed for these factors to improve the quality of end-of-life care in GHSFs.

Japan is currently one of the countries with a long life expectancy, in which a great number of older people need care for their daily living. Japan has become increasingly internationalized due to an increase in foreigners and international marriages. As the number of elderly foreigners and foreign-born Japanese increase, older adults who do not use Japanese as their first language will need more opportunities to receive care.　We examined characteristics such as country of origin, language spoken, lifestyle, living environment, and cultural background of elderly people who were either foreign permanent residents living in Japan or foreign-born Japanese (hereinafter referred to as elderly with an international background, in short, EIB) receiving care support. Ichushi-web, a medical literature database, was used [last search date: June 2, 2018]. These searches extracted 205 papers. After the first and second extraction procedures, only two papers matched this theme. These two reports were for Korean residents in Japan, so-called special permanent residents, and repatriates from China and their spouses, many of whom were aged 75 years old and above.　The number of permanent residents in Japan who speak a foreign language as their first language is increasing. Inhibition of communication between EIB and healthcare welfare service providers is expected to be an obstacle while accessing care support services. For this reason, we must provide them with information related to Japanese healthcare services. Medical interpretation efforts are scattered and the response to EIB in the event of disasters has been discussed. From the perspective of multicultural coexistence, it is necessary to provide long-term care insurance services and medical services to EIB. Such efforts may include development and sharing of tools and the placement of staff who can communicate with non-Japanese speakers. Staff must also understand various illness- and health awareness-related issues.　In the future, considering the increasing number of EIB who may require care services, we must consider cultural backgrounds and language diversification for EIB. These issues require clarification and development of acceptable solutions.