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Our study aimed to investigate the effect of an anterior cruciate ligament injuries prevention program. Fifty-one female basketball players from high school participated in our study. Measurement was conducted before and after a 10-week prevention program. In alignment measurement, the distance between the hips, knees was measured during a drop-jump test, and the ratio of knee distance to hip distance (K/H ratio) was calculated. An isometric knee flexion test was also conducted by a hand-held dynamometer. After 10 weeks, this prevention program was continued for a further 12-month period. In the group of knee-in alignment, the K/H ratio was improved, and knee flexion muscular strength also improved. The incidence of ACL injuries was not significant, but non-contact ACL injuries decreased compared to the three years prior to conducting this prevention program. By conducting this prevention program, the possibility of decreasing non-contact ACL injuries and improvement of alignment is suggested. [ABSTRACT FROM AUTHOR]

The relation between high-sensitive C-reactive protein (CRP), a new coronary risk factor and exercise tolerance has not been elucidated. The aim of this study was to show the relation between the serum CRP concentration and peak oxygen uptake in 270 middle-aged and elderly subjects (67.4±6.6 years) with no cardiorespiratory diseases. Physical characteristics and blood chemistry indices were evaluated in the fasting state and peak oxygen uptake was estimated by a symptom-limited cardiopulmonary ergometer exercise test. Results: The mean serum CRP concentration was 0.637±0.715mg/L. The serum CRP concentration was significantly related to age (r=0.138, p=0.0238), body weight (r=0.183, p=0.0027), body mass index (r=0.345, p<0.0001), serum insulin concentration (r=0.187, p=0.0021), HOMA-R (r=0.171, p=0.0052), serum HDL-cholesterol concentration (r=-0.254, p<0.0001), serum LDL-cholesterol (r=0.138, p=0.0234), and peak oxygen uptake (r=-0.384, p=.0003). In stepwise multivariate analysis, only the peak oxygen uptake and BMI were significantly correlated with serum CRP concentration. In conclusion, these data suggest that exercise tolerance was independently associated with serum CRP concentration in middle-aged and elderly subjects. [ABSTRACT FROM AUTHOR]

It has been reported that a decreased systemic arterial compliance (SAC)increases with an increase in aerobic capacity through mild aerobic exercise training in middle-aged and elderly (under 70)people. This study investigated whether SAC might be increased with an increase in aerobic capacity during submaximal exercise through mild aerobic exercise training even in elderly people over 70. Seven elderly people (70∼78 years old)performed 12 weeks of aerobic exercise training (cycling at 80% ventilatory threshold for 30 minutes, 5 days/week). SAC and the oxygen uptake at the ventilatory threshold(V̇O2VT) were measured before and after the training. SAC and V̇O2VT increased in the majority of subjects(4/7 and 5/7)after the exercise training, although there were no statistically significant changes in the mean value of the indexes. Further study increasing the number of subjects is necessary to clarify whether SAC could be increased by mild aerobic exercise training even in elderly people over 70. [ABSTRACT FROM AUTHOR]

We previously demonstrated that the Modelflow method provides a reliable estimation of cardiac output during submaximal exercise in young people, but did not address this issue in elderly people. The present study tested the reliability of the Modelflow method for cardiac output estimation during submaximal exercise in elderly people. Four elderly subjects performed a multi-step stage cycle ergometer exercise at intensities corresponding to the 70, 90, 110 and 130% of their individual ventilatory threshold (VT), and their cardiac output was measured output using Modelflow and Doppler echocardiography methods simultaneously. The correlation coefficient in the overall data obtained by both methods was significant (r = 0.809. P < 0.0001), but the agreement between the two estimates was low not satisfactory (mean error: -1.5 ± 2.6 L · min-1; 95% confidence interval of the bias:-5.0 ∼ 1.9 L · min-1). However, at least below the VT level, the correlation coefficient was becoming higher (r = 0.889, P < 0.0001) and the agreement between the two estimates was much improved (mean error: -0.1 ± 1.2 L · min-1; 95% confidence interval of the bias: -2.6 ∼ 2.3 L · min-1). These results suggest that the Modelflow method provides reliable estimation of cardiac output in elderly people at intensities below the VT. [ABSTRACT FROM AUTHOR]

This study investigated the validity of the method, which uses a peripheral (finger) arterial pressure waveform recorded by rite volume clamp method (VC), for a noninvasive estimate of systemic arterial compliance (SAC) in young adults. The method was compared to a method using a carotid arterial blood pressure waveform recorded by applanation tonometry (AT), which was validated in the previous study. Continuous blood pressure waveforms were simultaneously recorded using VC and AT for 40 young adults at rest and for 22 young adults during light exercise (30 watt, 5 minutes). The finger arterial blood pressure waveform was transformed by the transfer function into the brachial arterial blond pressure waveform. Stable waveforms during the exercise were obtained in 100% of the subjects by VC, and in 86% by AT. Significant correlation between the ratios of the area tinder the waveform (total cardiac cycle to diastole) by VC and AT was observed at rest (r=0.76) and during exercise(r=0.83), and their agreements were acceptable. The finger arterial blood pressure waveform recorded using VC provides a valid and noninvasive estimate for SAC in young adults. [ABSTRACT FROM AUTHOR]

Cardiorespiratory fitness in elderly people may be affected by systemic arterial compliance, because an increase of arterial wall stiffness with aging may deteriorate circulatory function by an increase of left ventricular afterload. This study investigates the effects of systemic arterial compliance and cardiorespiratory fitness and the effects of exercise training on these indices in elderly people. In 32 elderly women, we studied cross-sectionally the relation between systemic arterial compliance and cardiorespiratory fitness in submaximal exercise(oxygen consumption at ventilatory threshold), and in 9 previously sedentary elderly healthy women, we studied longitudinally the effects of endurance training on these indices. There were significant positive correlations among systemic arterial compliance, oxygen consumption at ventilatory threshold, and the ratio of increase in oxygen consumption to increase in work rate. These indices significantly increased after the 12 weeks endurance training (80% of ventilatory threshold, 30 minutes/day, and 5 days/week). These results suggest that systemic arterial compliance may be a determinant of ventilatory threshold and endurance training can increase both arterial compliance and cardiorespiratory fitness in elderly people. [ABSTRACT FROM AUTHOR]

Carinoplasty can be divided into the one-stoma method, the montage method, the double-barrel method, and the Miyamoto method. The one-stoma method is usually performed with right upper sleeve lobectomy, and with an anastomosis of the intermediate trunk to a carina. On the other hand, in the montage method, the double-barrel method or the Miyamoto method, carina is completely resected and the trachea, left main bronchus and right bronchus are divided into three pieces. In the montage method, a side hole is created in the trachea, left main bronchus, or right bronchus, and an end-to-side anastomosis is added. In the double-barrel method, a crista is created by suturing the left and right bronchi with their medial walls side by side, and these two side-by-side bronchi are anastomosed to the trachea. The Miyamoto method was initially reported as a variant of the double-barrel method, but it is rather a variant of the montage method, characterized by the creation of a new lateral hole at the anastomosis line between the trachea and the left main bronchus.

Background: This study aimed to describe the surgical procedures involved in laparoscopic rectal resection in patients with obesity and report the short-term outcomes., Materials and Methods: A total of 194 consecutive patients who underwent laparoscopic rectal resection in our department from 2013 to 2018 were divided into non-obese(body mass index[BMI] <25 kg/m2; n=161)and obese groups(BMI≥25 kg/m2; n=33)and subsequently analyzed., Results: The operative time was significantly longer in the obese group(225 vs 266 min; p=0.003)than in the non-obese group. No conversions to laparotomy occurred in either group, and no discernible differences in blood loss(1 vs 5 mL; p=0.582), number of harvested lymph nodes(20 vs 17; p=0.356), and postoperative complication rates(9.3 vs 6.1%; p=0.547)were observed., Conclusion: Establishing an appropriate operative field, clarifying landmarks, and standardizing the procedure are important to assure safe laparoscopic rectal resection with adequate lymph node dissection in patients with obesity.

A 51-year-old woman presented to our hospital complaining of a lower abdominal mass and dysuria. She was diagnosed with advanced sigmoid colon cancer. The tumor was large, involving the bladder, and occupying the pelvic cavity. She received neoadjuvant chemotherapy with 4 courses of mFOLFOX6, in addition to panitumumab. The treatment resulted in a marked reduction of the tumor. A laparoscopic sigmoid colon resection, total cystectomy, neobladder reconstruction, complete uterine and bilateral adnexa resection and partial ileal resection were performed. The histopathological diagnosis was ypT4b(bladder), ypN0, ypStage Ⅱc, all with negative surgical margins. Adjuvant chemotherapy was not administered owing to the patient's refusal. She remained recurrence-free for 3 years of postoperative follow up.

A 47-year-old woman developed right femoral head necrosis during long-term steroid use for neuromyelitis optica spectrum disorder. She underwent a total hip arthroplasty because her right hip pain persisted after satralizumab treatment. There were no postoperative infections. Under oral administration of tacrolimus 3 mg, prednisolone 11 mg, and acetaminophen 2,275 mg, her postoperative body temperature was less than 38°C and normalized in about 2 days after the operation. No parameters indicating worsening of inflammation were observed in the blood test. In satralizumab-treated patients, infection cannot be ruled out even without inflammatory findings. In particular, if a slight fever of the 37°C-range or a mildly high white blood cell count persists, paying attention to signs of infection and actively investigating the presence or absence of infection using medical image diagnostic devices are necessary.

This article describes the perioperative complications, perioperative risk assessment, and perioperative management of patients with chronic obstructive pulmonary disease (COPD) and interstitial lung disease, especially idiopathic pulmonary fibrosis( IPF), which are the leading diseases in respiratory dysfunction. In COPD, testing for forced expiratory volume during the first second and pulmonary diffusing capacity is important and an algorithm for testing has been presented by the Japanese Association for Chest Surgery. Acute exacerbation of IPF is the leading cause of postoperative mortality in Japan, and risk factors are being analyzed. To reduce the occurrence of postoperative complications, it is important to carry out a risk assessment, select appropriate surgical strategy, and implement a well-planned perioperative management.

The subxiphoid approach in thymectomy provides better visibility around the left brachiocephalic vein than the lateral thoracic approach. Robot-assisted thoracoscopic surgery is easier to parform than video- assisted thoracoscopic surgery for surgery of the upper mediastinum, because the forceps can be moved with many joints. Robot-assisted thymectomy using the subxiphoid approach may be less traumatic and less invasive than median sternotomy. We must continue to devise surgical procedures to make oncologically curative surgery more minimally invasive.

We present a case of a 72-year-old man diagnosed with rectal cancer invading the urinary bladder/prostate. Preoperative chemoradiotherapy substantially reduced the tumor size. In collaboration with urologists, robot-assisted low anterior resection with total cystectomy was performed using the da Vinci Xi system. Depending on the surgical situation, the colorectal surgeon and urologist could smoothly and rapidly play the role of a console surgeon. Although the first robot-assisted multi-organ resection of our institution, the surgery was completed safely without any complications. Although the patient developed urinary tract infection postoperatively, he recovered and was discharged after postoperative 23 days. In conclusion, robot-assisted surgery would be useful in pelvic surgery involving multiple departments such as colorectal surgery, urology, and gynecology.

We report a hepatocellular carcinoma(HCC)case with lung metastasis that was successfully treated with transarterial chemoembolization(TACE)and percutaneous radiofrequency ablation(RFA). A man in his 60s took right robe liver resection for HCC after TACE for its rupture. Lung metastasis occurred at S1+2 and S6 in the left lung, and an adverse event interrupted standard molecular target therapies. Because extrahepatic metastasis had been seen only in these two locations for a long time, TACE was performed for both metastases. The feeders for both lesions were each intercostal artery, and controlling the drug inflow was necessary to avoid drug influx into the spinal cord branches when S6 metastasis was treated. The viable lesion remained in the S6 lesion, so RFA was added for both lung metastases. 100% tumor necrosis has been observed since the RFA.

A 68-year-old man was referred to our hospital because of back pain during swallowing. Upper gastrointestinal endoscopy revealed a lower esophageal type 3 tumor. The patient was diagnosed with esophageal squamous cell carcinoma by the biopsy specimen. CT scan showed thoracic lower esophagus wall thickening, left paracardiac lymph node swelling, and a low-density area in the liver. Therefore, the patient was diagnosed with Stage Ⅳb esophageal cancer. After introducing cisplatin plus 5-FU combination therapy, the liver metastasis disappeared. After 9 chemotherapy courses, the patient received radical chemoradiotherapy. After completing chemoradiotherapy, the patient was followed up without any treatment. After 3 years since the treatment initiation, the patient is surviving without any relapse.

Hemothorax is defined as blood accumulation in the pleural cavity with a hematocrit value of the effusion exceeding 50%. Symptoms and severity vary, ranging from asymptomatic to an imminent state of threatened cardiac arrest. This paper presents the etiology, initial work-up, and treatment of hemothorax, with an emphasis on massive hemothorax requiring an emergent thoracotomy for hemostasis. The etiology of hemothorax can be traumatic, iatrogenic, and non-traumatic/non-iatrogenic. Regardless of the etiology, the initial medical examination should be performed as in the initial trauma examination to evaluate the urgency, the amount of bleeding in the chest cavity, and the coexistence of pneumothorax. If massive hemothorax or tension pneumothorax is present, thoracic tube drainage should be started immediately. Contrast-enhanced computed tomography (CT) should be performed to identify the source of bleeding. Treatment includes fluid and blood transfusions to stabilize the circulation. Anticoagulants and antiplatelet agents should be neutralized, reduced, or withdrawn. Emergent thoracotomy for hemostasis is indicated for massive hemothorax with unstable circulation. Anterior-parasternal thoracotomy performed in the supine position has the advantage of rapid thoracotomy and good visualization. Endovascular therapy is effective when contrast-enhanced CT identifies the source of bleeding.

The number of lung transplantation performed in Japan is extremely low compared to other countries, whereas we have 10 facilities certified as cadaveric lung transplantation in Japan, meaning that there are low volume centers. By August 2021, we performed lung transplantation in 21 cases for 12 years, therefore, our facility should be considered as low volume center. Surgical outcomes at low volume centers are generally considered poor. However, the overall five-year survival rate of total cases was 84.8%, and that of cadaveric cases was 94.4% in our hospital. It was better than the average of about 73% of all facilities in Japan. These data suggested that the accreditation system in Japan is functioning well. On the other hand, there may be a disparity between facilities. At our facility, we are actively performing inverted lung transplantation so as not to lose the opportunity for transplantation, and we have performed it in three cases so far and have achieved good results.

Lenvatinib is reported to have a stronger angiogenesis-inhibiting effect in hepatocellular carcinoma(HCC)than sorafenib, but in many cases dose reduction and withdrawal are required due to the occurrence of adverse events. We report 12 cases of using lenvatinib for advanced HCC in our hospital together with a case of rapid re-growth due to withdrawal of lenvatinib. In 2 cases, metastases of HCC were controlled and radically resected. All patients required lenvatinib withdrawal due to Grade 3 adverse event, except for 2 cases that started with dose reduction. There were 3 cases in which drug withdrawal was required for 2 weeks or more, and in 2 of them, rapid re-growth of tumor was observed during the drug withdrawal and the treatment could not be continued. Although the use of lenvatinib may results in tumor shrinkage, suggesting that prolonged drug withdrawal may make disease management difficult. It is important to manage adverse events and minimize days of drug withdrawal by reducing the dose and systematically discontinuing the drug.

A 79-year-old man underwent a transrectal prostate needle biopsy with a prostate-specific antigen (PSA) level of 12.0 ng/ml. He was diagnosed with adenocarcinoma (Gleason score 4＋3, cT3aN0M0) and underwent radiation therapy. Eight months later, he was administered hormone therapy because of a rise in PSA level to 8.4 ng/ml. One year and 5 months later, he experienced back pain, and computed tomography revealed multiple lymphadenopathies and irregular prostate enlargement. The PSA level was 0.097 ng/ml. Re-biopsy of the prostate and biopsy of the lymph node were performed. Pathological examination revealed neuroendocrine differentiation of the prostate. The disease progressed rapidly, and the patient died 4 months after the biopsy. Neuroendocrine differentiation of prostate cancer is rare, and its development may not be consistent with PSA levels. Therefore, periodic imaging examinations should be conducted, even when PSA levels are low.

Here, we report a case of ascending colon cancer successfully treated with laparoscopic right hemicolectomy in a 74- year-old man with a medical history of hemophilia A. He was admitted to our hospital because of bloody stool and diagnosed with type 2 ascending colon cancer based on colonoscopy findings. Preoperatively, blood transfusion and administration of recombinant factor Ⅷ products were performed. Surgery involved laparoscopic right hemicolectomy plus group 3 lymph node dissection. No complications, such as bleeding, occurred during hospitalization. The patient was discharged on postoperative day 8. There have been a few reports of laparoscopic surgery for patients with hemophilia. However, this case suggests that it can be safely performed with planned factor Ⅷ supplementation in the perioperative period.

A 40-year-old man presented to the emergency department with periumbilical pain and fever. A computed tomographic scan confirmed multiple jejunal diverticulum with localized extraluminal air and panniculitis around it, and jejunal diverticulitis with localized perforation was suspected. His symptoms were mild, and extraluminal air was localized;therefore, he was advised bowel rest and administered only antibiotics. The patient's symptoms resolved without surgical treatment, and at the time of writing this report, there had been no recurrence. Small bowel diverticulitis is rare, and careful analysis of imaging studies is necessary for establishing a diagnosis. This was a rare case where small bowel diverticulitis was resolved without surgical treatment.

We reported a case of a 30s woman who underwent Hartmann's surgery for sigmoid cancer. Her pathological stage was Stage Ⅳ(pT4b, N1b, M1b[liver and lung]). Postoperatively, 10 courses of systemic chemotherapy with FOLFOX plus cetuximab( Cmab)or bevacizumab(Bmab)were administered. After the chemotherapy, partial liver dissection and radiofrequency ablation(RFA)for multiple liver metastasis were performed. After 2 years of systemic chemotherapy with FOLFIRI plus ramucirumab(RAM), no liver or lung metastasis was observed; however, left supraclavicular lymph node and para-aortic lymph node metastases existed and gradually increased. For the purpose of local control, the para-aortic lymph node metastasis was treated with cervical dissection and carbon ion radiotherapy. Therefore, carbon ion radiotherapy was a useful treatment for local control.

No large clinical trials have been conducted to prove the efficacy of peritoneal dissemination resection for colorectal cancer, and no evidence has shown the usefulness of resection for metachronous peritoneal dissemination. An elderly woman in her 70s underwent a laparoscopic transverse colectomy for transverse colon cancer in 2014, which was performed by another physician. The pathological diagnosis was tub2-por>muc, pT3, ly2, v0, pN2, and pStage Ⅲb. The patient was followed up with capecitabine plus oxaliplatin(CapeOX)therapy as an adjuvant chemotherapy for 6 months. Three years postoperatively, the CEA level increased to 10 ng/mL, and CT showed a nodular shadow in front of the left prerenal fascia. After the diagnosis of peritoneal dissemination recurrence and 8 courses of capecitabine plus bevacizumab therapy, other metastases were not observed. She was referred to our hospital for surgery and underwent laparoscopic peritoneal dissection at 3 years and 6 months after the first operation. Only one apparent disseminated recurrent lesion, which was resectable, was observed. However, at 4 years and 9 months after the initial operation, CT showed a recurrence of Douglas pouch peritoneal dissemination without any other obvious metastasis. Laparoscopic low anterior resection of the rectum and hysterectomy were performed. Here, we encountered a case that could be radically resected for peritoneal dissemination twice after the colon cancer surgery.

The apical invading lung cancer is the tumor infiltrating to the thoracic inlet, in other words, the 1st rib or the higher chest wall. Tumor arising in the posterior apex is invasive to the vertebral body, the sympathetic trunk, and the brachial plexus. Pancoast tumor is well known with typical triads, which is invasive to the sympathetic trunk and the brachial plexus in the posterior apex of the lung. Tumors originating in the anterior apex are called anterior apical tumors, and they often involve the subclavian vein and artery. Trimodality therapy is recommended to treat the apical invading lung cancer. Induction chemoradiotherapy followed by surgical resection lead to good local control and complete resection rate. Surgical approach should be selected based on the tumor location in the extreme apex. High posterolateral approach and hook approach are chosen for the tumor in the posterior apex. Anterior approaches developed by Masaoka, Dartevelle, Grunenwald, and Korst are suitable for the tumor in the anterior apex that are often invasive to the subclavian vessels. Surgical outcome depends on completeness of resection. Based on the preoperative evaluation of involved structures, appropriate surgical approach is important to achieve complete resection of the apical invading lung cancer.

The patient, a woman in her 70s, was diagnosed with occlusive ileus caused by sigmoid colon cancer.She underwent transanal stent placement to release the occlusion.Subsequent detailed testing revealed a 70×60mm mass on the dorsal side of the pancreas and PET-CT indicated an SUVmax 18.2 FDG uptake. EUS-FNA was performed twice.However, the mass was unable to be definitively diagnosed.The patient was then referred to our hospital.She underwent laparoscopic sigmoid colectomy and laparoscopic biopsy of the mass for sigmoid colon cancer.The patient progressed well postoperatively and was discharged home on postoperative day 9.The postoperative diagnosis was colon cancer(S, Type 2, 58×50 mm, tub2, pT4a [SE], pN1, Stage Ⅲa)and the biopsied mass was found to be a nodal marginal zone B-cell lymphoma according to histopathological testing.After undergoing chemotherapy at our hematology department, she has experienced no recurrence.

We report a case of recurrent pancreatic cancer in the remnant pancreas after pancreatoduodenectomy(PD)that was successfully treated by surgical resection. A woman in her 70s who was treated for multiple lung metastases of breast cancer was referred to our hospital because of obstructive jaundice. A low-density area in the pancreas head(19mm in diameter) and dilatation of the main pancreatic duct were observed on abdominal CT. She was diagnosed with pancreatic head cancer and underwent PD. Twenty months after PD, abdominal CT revealed a tumor in the pancreas tail, and she started receiving chemotherapy containing gemcitabine(GEM)for the diagnosis of recurrent pancreatic cancer in the remnant pancreas. Twelve months after the induction of chemotherapy, we performed surgical resection of the tumor(total pancreatectomy). The pathological diagnosis was moderately differentiated adenocarcinoma, which was similar to the primary lesion, and the tumor was confirmed as recurrence of pancreatic cancer. Although she died of multiple lung metastases of breast cancer 62 months after the total pancreatectomy, the recurrence of pancreatic cancer was not observed without adjuvant therapy during that time.

An 82-year-old man receiving oral administration of warfarin for atrial fibrillation underwent distal gastrectomy for advanced gastric cancer. The postoperative diagnosis was pT3(SS)N2M1H1P0CY0, pStage Ⅳ,(HER2, score 3+)gastric cancer. He received chemotherapy for the treatment of multiple liver metastases, following which, he developed lymph node metastases. Grade 3 anemia was observed at 46 months after initiation of chemotherapy when he was treated with third-line irinotecan plus cisplatin. Abdominal CT showed that CR for liver metastases and SD for lymph node metastases were maintained. Esophagogastroduodenoscopy and colonoscopy showed no intraluminal bleeding. As the anemia progressed, blood transfusion was required repeatedly instead of withdrawal of chemotherapy and replacement therapy of iron and vitamin B12. Double- balloon endoscopy revealed hemorrhagic tumor at duodenal stump. We diagnosed tumor bleeding from metastatic lymph node around pancreatic head invading to duodenum. Palliative radiotherapy(40 Gy/20 Fr)for hemostasis was performed. Finally, hemostasis and tumor shrinkage were achieved.

Here, we report a long-term survival case treated with docetaxel and S-1 combination therapy(DS therapy)for peritoneal dissemination of gastric cancer. A 58-year-old man was diagnosed with gastric cancer in 2006. Distal gastrectomy, D2 dissec- tion, and RY reconstruction were performed. The pathological diagnosis was gastric cancer, por2, pT3(SS), pN3a(8/27), pStage ⅢB. S -1 monotherapy was administered as an adjuvant chemotherapy for 1 year from 3 months after surgery. Five years after surgery, peritoneal dissemination and bladder recurrence caused rectal stenosis and hydronephrosis. We performed ileostomy and left nephrostomy. DS therapy was started 5 years and 2 months after the initial surgery. A complete clinical remission was observed 2 years and 10 months after starting DS therapy(23 courses). Multiple lymph node metastasis and bone metastasis were confirmed at 5 years and 5 months(57 courses). Even though irinotecan monotherapy was performed for five courses, the bone and lymph node metastasis increased at 5 years and 9 months after starting DS therapy, and the patient died at 69 years of age. DS therapy may be a useful option for peritoneal metastasis of gastric cancer.

We report a case of unresectable pancreas cancer. A 70-year-old woman presented with worsening diabetes and serum CA19-9 elevation. A tumor with portal vein and supra-mesenteric vein invasion was observed by computed tomography. She was diagnosed with unresectable pancreas head cancer that was locally advanced. Chemotherapy was administered with gemcitabine and nab-paclitaxel for 19 courses, followed by gemcitabine alone for 4 courses. After the addition of 6 courses of chemotherapy, a 60%dose of chemotherapy was administered for 13 courses due to severe neutropenia. The patient died 32 months after the first visit. The 60% dose of gemcitabine and nab-paclitaxel also inhibited tumor growth. These findings suggest the effective and safe long-term use of gemcitabine and nab-paclitaxel.

A man in his 70s was diagnosed with gastric cancer and underwent total gastrectomy with D2 lymphadenectomy. The final diagnosis was T3(SS)N2M0, Stage ⅢA. After surgery, S-1 was administered for 1 year. One year and 6 months after surgery, abdominal computed tomography showed a single liver tumor(S4: 30mm). Based on overexpression of the human epidermal growth factor receptor 2(HER2)protein in the primary tumor, we selected capecitabine plus cisplatin plus trastuzumab as the combination chemotherapy. After the second course, the therapeutic response was stable. S4 partial liver resection was performed. The liver tumor was histologically evaluated as Grade Ⅰb metastatic gastric adenocarcinoma. After surgery, capecitabine plus trastuzumab was administered for 1 year. One year after resection of liver metastasis, the patient is alive without any relapse.

Prothymosin alpha (ProTα) has been identified as an anti-necrotic factor from the conditioned medium of primary cultured of rat cortical neurons under the serum-free starving condition. ProTα is released in a non-vesicular manner from neurons or astrocytes by the help of cargo protein S100A13. Thus released ProTα is found to have robustness roles in the brain under the condition of neuronal necrosis or apoptosis. ProTα inhibits necrosis by plasma membrane-translocation of glucose transporters endocytosed by ischemia/starving stress, through an activation of unidentified G protein-coupled receptor and protein kinase Cβ. In the cerebral or retinal ischemia model, systemic injection of ProTα protects brain or retina from ischemic damages by converting necrosis to apoptosis, which is in turn blocked by neurotrophic factors. In the retinal ischemia model, ProTα prevents the damages by another mechanism through toll-like receptor 4 (TLR4) and downstream TRIF signaling. The direct interaction between ProTα and TLR4/MD2 is also evidenced by the study of molecular dynamics and protein-protein interaction. All these findings indicate that ProTα could be called a cytoprotective member of damage-associated molecular patterns (DAMPs) or alarmins. ProTα and its modified peptide fragment, NEVDQE (P6Q) show the vasculoprotective actions by itself in a model of cerebral ischemia as well as neuroprotective actions. The concomitant administration of these peptides abolishes the cerebral hemorrhage induced tissue plasminogen activator (tPA), which is treated late after cerebral ischemia models. Thus, ProTα and P6Q seem to have promising therapeutic potencies to directly protect neurons and inhibit the hemorrhage by late treatment with tPA against stroke.

A 62-year-old woman received chemotherapy for breast cancer with bone metastasis and malignant pleural and pericardial effusion. She was examined by imaging for progressive cognitive impairment and headache. Enhanced MRI findings showed multiple solid tumors on brain surface, and brain perfusion scintigraphy showed blood flow decrease in both parietal lobes. She was diagnosed with secondary dementia due to leptomeningeal metastases of breast cancer, and whole brain external irradiation was performed(30 Gy/15 Fr). After treatment, multiple tumors were decreased in size and her cognitive impair- ment was improved.

Here we report a case of a hemorrhagic gastric cancer patient with severe coronary artery disease, in whom the cancer was successfully resected with the support of intra-aortic balloon pumping(IABP). An 80-year-old man was referred to our hospital for further examination of his anemia and tumor around the pancreatic head. He was diagnosed with type 3 gastric cancer with multiple bulky lymph node metastases invadingto the pancreas(cT4b[LN-Panc], N3a, M1[LYM No.16a2int], cStage IV ). Tarry stools continued and blood transfusion was repeatedly required. To control tumor bleeding, we considered that gastrectomy should be performed prior to chemotherapy. Since he had a history of acute myocardial infarction, coronary angiography was performed, which showed severe coronary stenosis in 3 vessels. Preoperative percutaneous coronary intervention or coronary artery bypass grafting were inappropriate because of tumor bleeding. We performed palliative distal gastrectomy under the support of IABP. The postoperative course was uneventful and he could initiate subsequent chemotherapy smoothly. IABP may be a useful option for hemorrhagic gastric cancer patients with severe coronary stenosis.

A 74-year-old man visited our hospital with an awareness of anal mass and bleeding. He was diagnosed as adenocarcino- ma of anal canal with wide spreading skin invasion. After neoadjuvant chemoradiotherapy(radiationtotal 45 Gy/25 Fr; cape- citabine 825mg/m2)was performed to reduce the mass volume, laparoscopic abdominoperineal resection with large perineum skin resection and lateral lymph node dissection was carried out. The perineal defect was repaired with a rectus abdominis musculocutaneous flap. Six days after surgery, the rectus abdominis musculocutaneous flap necrotized, and second perineum reconstruction by the bilateral gracilis musculocutaneous flaps was performed after debridement of necrotic tissue. We reported a case of radical resection of local advanced anal canal cancer with skin invasion by performing combined modality therapy and perineum reconstruction.

Gemcitabine with nab-paclitaxel(GN)shows promisinganti -tumor effect and has been established standard regimen for metastatic pancreatic cancer(PC). Conversion surgery(CS), recently reported about initially unresectable PC with favorable response to non-surgical treatment, might provide long-term survival. The aim of this study is to evaluate the efficacy of multi-modal treatment includingCS after GN therapy for initially unresectable PC. From 2015 to 2016, 29 initially unresectable PC treated with chemotherapy includingGN were eligible for the retrospective analysis. Unresectability was defined over 180- degree abutment to major arteries(UR-LA)or suspicious small metastases(UR-M). CS was planed after clinical favorable response over 6 months of treatment duration. Median age of the patients was 62.5 years old, including 18 males and 11 females. Tumor in the pancreas head(n=20)was dominant. Eighteen patients were UR-LA and remaining1 1 were UR-M. CS was performed in 9 cases(31%)with no significant difference between UR-LA and UR-M. CS showed significant better survival with 67%of 2-year survival rate, compared to without CS(p=0.039). GN regimen effectively induced CS for initially unresectable PC. Multidisciplinary therapy includinginduction GN and CS might have survival impact on unresectable PC.

The patient is a 65-year-old woman with anemia. The multiple liver tumors detected by ultrasonography, it was diagnosed as neuroendocrine tumor(NET), G2 by biopsy. There was an ulcer at the bulb of the duodenum, so we diagnosed liver metastasis of duodenum NET. Because the liver tumors spreaded to both right and left lobes, we carrying out a transcatheter arterial embolization(TAE)twice to liver metastasis, and chemotherapy by octreotide was performed. 20 months after the beginning of treatment, a 4 cm tumor was remained in the left lobe but others were not detected by computed tomography, so we performed cytoreductive surgery. Duodenum bulb resection and left hepatectomy was performed and the specimens were NET, G2 in the pathological findings. We detected a lot of tumors less than 1 cm in the right lobe during the operation, so TAE was carried out for the right lobe after surgery. The disease showed no progression for 28 months after the first admission(post operation5 months).

A52 -year-old woman was diagnosed with ascending colon cancer with ovarian metastasis and peritoneal dissemination. Since the patient did not have symptoms with intestinal obstruction, mFOLFOX6 plus bevacizumab(Bmab)was performed for 12 cycles. After chemotherapy, the tumors of ascending colon and ovary were significantly shrunken and novel distant metastasis was not observed by CT scans. Therefore, the tumors were considered to be resectable and curative resection was performed. In the surgical findings, the peritoneal disseminations were localized, and right colectomy, bilateral oophorectomy and extirpation of the peritoneal disseminations were performed. R0 resection was pathologically achieved and adjuvant chemotherapy with UFT/UZEL was administrated for 6 months. The patient is alive without recurrence for 1 year. Since right sided colon cancer is less likely to have obstruction, upfront chemotherapy can be a strategy for locally advanced right sided colon cancer with distant metastasis.

We report a case of peritoneal metastasis of bile duct cancer that was successfully treated by surgical resection. A 70s man underwent pancreatoduodenectomy(PD)for bile duct cancer, and abdominal CT revealed a tumor in the peritoneum along the right kidney at 55 months after PD. As FDG uptake was seen at the lesion on PET-CT, he was diagnosed as recurrence of bile duct cancer or primary malignant tumor in the retroperitoneum. Because the tumor was solitary on CT and PET-CT, we conducted surgical resection of the tumor. Pathological diagnosis was well differentiated adenocarcinoma that was similar to the primary lesion, and the tumor was confirmed as recurrence of bile duct cancer. He remains alive without 2nd recurrence for 60 months since tumor resection(117 months since PD).

Chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD) are 2 major pulmonary comorbidities of primary lung cancer patients. The COPD patients are at risk for respiratory failure after a major lung resection when lung resection exceeds the patient's pulmonary reserve. It is important to assess a postoperative risk based on the patient's cardiopulmonary function. Cardiac risks are initially evaluated for all the candidates for lung resection, then, ppoFEV1% and ppoDLco% are calculated. If these 2 parameters are not satisfactory, cardiopulmonary exercise test is required to assess the risk. Adequate treatment for COPD should be given to the patients through the perioperative period. ILD is another major comorbidity of lung cancer patients, and its acute exacerbation (AE) is the leading cause of postoperative death. The Japanese Association of Chest Surgery proposed a risk scoring system for predicting postoperative AE. Currently there is no reliable management to prevent or ameliorate postoperative AE. Methylprednisolone pulse therapy is empirically performed as a treatment for AE with controversial evaluation. Pirfenidone and some other drugs are expected to reduce the occurrence of postoperative AE, however, further studies will be needed to confirm the efficacy and the safety.

We performed salvage surgery after chemoradiotherapy(CRT) in a patient with thymic basaloid cell carcinoma. A 46-year-old man with an abnormal chest shadow on X-ray findings was referred to our hospital. Computed tomography revealed a partially solid tumor along with a multilocular cyst in the anterior mediastinum with mediastinal lymph node swelling infiltrating to the superior vena cava(SVC). Positron emission tomography revealed FDG accumulation (SUVmax 7.94)in the tumor. Pathological findings of a tumor biopsy specimen obtained by thoracoscopy led to a diagnosis of thymic basaloid cell carcinoma. Following CRT (ADOC+RT:60 Gy), a complete resection (R0)with replacement of the SVC was performed. The postoperative course was uneventful, and the patient was alive at 20 months after surgery with metastasis to the cervical lymph nodes and bone.

Currently, various dietary interventions or supplements, including probiotics and prebiotics, are available for patients with Crohn's disease. Among these interventions or supplements, there is nothing showing significant efficacy. Although the evidence level is not high, the available data suggest that enteral nutrition is effective in both active and quiescent Crohn's disease. However, the therapeutic efficacy of dietary and nutritional interventions needs to be supported by well-designed trials in large cohorts of patients. Further, a significant limitation of enteral nutrition is inadequate patient compliance due to poor palatability of an elemental diet. One major challenge is to establish practical strategies for increasing patient adherence for long-term enteral nutrition.

A 20-year-old woman, who was suffering from appetite loss, weight loss and livedo reticularis for one and half months, was referred to our hospital. On admission, laboratory studies demonstrated proteinuria (1.0 g/g Cr), hematuria (erythrocytes': 50 - 99/HPF), ,.enal dysfunction (Cr : 2.09 mg/dL), elevated C reactive protein (CRP: 10.82 mg/dL), elevated MPO-ANCA titer (11.6 U/mL) and elevated pentraxin3 (PTX3: 24.05 ng/mL). Her kidney and skin biopsy revealed massive crescentic necrotizing glomerulonephritis and leukocytoclastic vasculitis, respectively. She was diagnosed with microscopic polyangiitis (MPA), and treated with 500 mg/day of intravenous methyl-prednisolone (mPSL) for 3 days followed by 40 mg/day of oral PSL, rituximab (375 mg/m² once a week for a month) and plasma exchange. When PSL tapered to 30 mg/day in 4 weeks, her renal function was only partially recovered, while the CRP level had been normalized and the MPO-ANCA titer was almost negative (3.6 IU/mL). To evaluate histological activity, a second renal biopsy was conducted, which showed fibrocellular crescents in 32% of her glomeruli. The PTX3 level remained high (14.82 ng/mL) at that point. Taken together, the vasculitis was considered to be active still. Steroid pulse therapy for 3 days was administered again, followed by oral PSL 30 mg/day. Her renal function completely recovered in 70 days. The PTX3 level also normalized in 161 days. PTX3 is one of the short pentraxins, produced by a variety of cell types in response to pro-inflammatory signals such as IL-1 and TNF-α. It was reported that PTX3 reflects activity of vasculitis independently from CRP. In the presenting case, when the second renal biopsy revealed a histologically active lesion of the vasculitis, PTX3 was elevated independently from CRP and MPO-ANCA, suggesting that PTX3 may be a more sensitive marker of the disease activity than other tests.

A 68-year-old man presented with type 3 advanced gastric cancer(Circ, tub2>por, HER2 score 3)in the antrum, with skip lesions in the duodenum. The tumor was cT4aN2M1(DUO)CY0, cStage IV . An XP plus trastuzumab regimen(1,000mg/m2 capecitabine[Xeloda®]twice a day on days 1-14, 80mg/m2 CDDP on day 1, 8 mg/m2 trastuzumab on day 1[second course- 6mg/m2])was administered every 3 weeks and repeated for 6 courses without severe adverse events. After 6 courses, the primary tumor and metastatic lymph nodes shrank by 31.7%(a PR according to the RECISTcriteria ), and open distal gastrectomy, D3 lymphadenectomy, and Roux-en-Y reconstruction(ante colic)were performed as conversion surgery(R0). During the administration of adjuvant chemotherapy with S-1, para-aortic, mediastinum, left supraclavicular fossa, and cervical lymph node recurrence developed. Four courses of weekly PTX plus trastuzumab as first-line chemotherapy and 11 courses of biweekly CPT-11 plus CDDP as second-line chemotherapy were administered. Because of prolonged adverse events such as Grade 3 diarrhea, the patient refused continuation of chemotherapy. The patient died 24 months after the start of preoperative chemotherapy.

We report a case of a 23-year-old womanwho developed pulmonary embolism(PE)during chemotherapy for advanced gastric cancer following total gastrectomy(R1). She presented with type 4 gastric cancer with peritoneal dissemination and positive washing cytology. Palliative total gastrectomy was performed(R1)and first-line chemotherapy with S-1(80mg/m2, days 1 to 21) plus CDDP(60mg/m2, day 8)(SP; every 35 days)was administered. PE occurred on day 15 of the 3rd courses of SP. Computed tomography(CT)revealed massive PE in both the pulmonary arteries, and ultrasonography indicated an increase in right-sided pressure. Thrombolysis using urokinase and heparin was performed immediately, and she recovered after 10 days in intensive care. Dehydration caused by the adverse event, as well as nausea and the anticancer drug itself, are risk factors for DVT and PE. Risk stratification, prevention, and early treatment are very important for PE.

We report a case of lymph node metastasis of intrahepatic bile duct cancer that was successfully treated using chemotherapy and radiation therapy.A man in his 70s underwent hepatic resection for intrahepatic bile duct cancer, and abdominal CT 1 year 8 months after surgery revealed lymph node swelling(25mm in diameter)along the common hepatic artery.He was diagnosed with lymph node metastasis and began to receive chemotherapy.We administered gemcitabine(GEM), cisplatin, and S-1 for 6 months, and GEM and S-1 for 1 year 4 further months as combination therapy.One year 10 months after the start of chemotherapy, the size of the lymph node decreased to 13 mm.However, as FDG uptake was seen on FDG-PET, radiation targeted to the lymph node was applied(50 Gy/25 Fr).After completion of radiation therapy, the lymph node has not regrown even in the absence of treatment, and the patient survives 6 years after the primary operation(4 years 4 months since the start of chemotherapy for recurrence).This case suggested that multidisciplinary therapy might be useful for lymph node metastasis of intrahepatic bile duct cancer.